International Journal of Art Therapy

Formerly Inscape

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Healing the inner child through portrait therapy:

Illness, identity and childhood trauma

Susan M. D. Carr & Susan Hancock

To cite this article: Susan M. D. Carr & Susan Hancock (2017): Healing the inner child through
portrait therapy: Illness, identity and childhood trauma, International Journal of Art Therapy,
DOI: 10.1080/17454832.2016.1245767

To link to this article: http://dx.doi.org/10.1080/17454832.2016.1245767

Published online: 03 Jan 2017.

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INTERNATIONAL JOURNAL OF ART THERAPY, 2016
http://dx.doi.org/10.1080/17454832.2016.1245767

Healing the inner child through portrait therapy: Illness, identity and childhood
trauma
Susan M. D. Carr and Susan Hancock

ABSTRACT ARTICLE HISTORY

This is a co-written case study by art therapist Susan Carr and patient-researcher (PR) Susan Received 10 April 2016
Hancock, one of seven people who participated in Carr’s PhD research project. Susan Hancock Accepted 29 July 2016
is a former university lecturer who was diagnosed with incurable cancer shortly after retirement;
KEYWORDS
her publications include The Child that Haunts Us: Symbols and Images in Fairytale and Miniature Portrait therapy; self-identity
Literature (2008, published by Routledge). In her PhD project, Carr researched portrait therapy as disruption; childhood trauma;
a collaborative art therapy intervention for people living with Life-Threatening and Chronic mirroring and attunement;
Illnesses (LT&CIs) who experience illness as a disruption to their sense of self-identity. Portrait inner child; life-threatening
therapy reverses the ‘terms of engagement’ within art therapy, using the art therapist’s ‘third and chronic illnesses; PTSD
hand’ to create portraits for patients, yet co-designed by patients. The focus of this article is an
exploration of the role portrait therapy plays in helping people living with LT&CIs to explore
and heal childhood trauma. We examine the therapeutic implications of transforming traumatic
memories and argue that through a process of mirroring and attunement, portrait therapy
enables people to develop an increase in their creative capacity to adapt to the way illness
impacts upon their inner child and to gain an increased sense of self-identity coherence.

Introduction
… to cover all this, she fusses, cackles and cajoles, but
behind the mask is the terrified girl, never sure, never
good enough, never secure …
(Binnie, 2015)
One of the findings from researching portrait therapy
(Carr, 2014, 2015) was the importance when facing a
Life-Threatening and Chronic Illness (LT&CI) of revisit-
ing childhood experiences in order to embrace,
support and heal the inner child self-identity. From a
total of seven participants, six spoke of early childhood
trauma, several for the first time, showing that trau-
matic events from infancy and childhood are often
imprinted on the psyche; ‘time does not heal the
wounds … time conceals them. They are not lost,
they are embodied’ (Felitti, in Lanius, Vermetten, &
Pain, 2010, p. xiii). These results suggest that traumatic
life experiences from childhood and adolescence are
far more common than usually recognised, and biome-
dical researchers have identified that these traumas
‘have profound and enduring effects on the neuroregu-
latory systems mediating medical illness, as well as
social behaviour from childhood to adult life’ (Felitti,
in Lanius et al., 2010, p. xiii).
The physiological impact of illness may also mean
that patients feel ‘childlike’ in their need for support
and help from others. This is sometimes termed
‘regression’, and Jung argued that a ‘patient’s regres-
sive tendency … is not just a relapse into infantilism,
but an attempt to get at something necessary … the
universal feeling of childhood innocence, the sense
of security, of protection, of reciprocated love, of
trust’ (Jung, 1993, p.32). The concept of ‘regression’
may also be referred to as ‘the inner child’ and the
needs of the inner child are particularly highlighted
during times of illness, when feelings of vulnerability
and the need for ‘love and compassion’ prevail
(Capacchione, 1991, p. 52). Also, the restriction of
physical movement caused by illness inhibits a
person’s way of being in the world (Carel, 2012,
p. 102) in a way that is similar to the restrictions of
childhood and uncovers a return to vulnerability and
dependence (Frank, 2000).
These issues are echoed within the autobiographical
photograph by Jo Spence and Tim Sheard, from their
series ‘Narratives of Disease’ (see Figure 1), within
which Spence (who describes herself as an ‘Educational
Photographer’) represents her own struggles with
cancer.
In this photograph, Spence depicts herself as a
newly diagnosed cancer patient, expressing her vulner-
ability, evoking images of the frightened child needing
to be comforted, saying, ‘I want to show you what I
think happens to a cancer patient when they go into
hospital … literally I was a tearful child holding her
teddy bear’ (Spence, quoted in Chambers, 2008).
However, a traditional medicalised approach by
health care workers to the ill person may also encou-
rage a childlike attitude of submission and obedience,
rather than promote agency and autonomy (Sumner &
Boyle, 1996; Zola, 1982, pp. 235–237). This attitude is
not surprising when one considers that the medical

CONTACT Susan M. D. Carr smc223@hotmail.co.uk

© 2016 British Association of Art Therapists
2 S. M. D. CARR AND S. HANCOCK
Figure 1. Jo Spence, from ‘Narratives of Disease (Included)’ by
Spence and Sheard (1990).
ethic of care was originally modelled on the maternal/
child relationship.
The findings of Carr’s (2015) study show that early
childhood trauma can be a complicating factor in the
impact of physical illness on a person’s sense of self-
identity, and the link may also be physiological. One of
the largest investigations conducted in the last 20
years in the USA was the Adverse Childhood Experi-
ences (ACE) study (1997). The study findings suggested
that adverse childhood experiences are a major risk
factor for self-destructive behaviours of all kinds, and
that there was a direct link between the severity of trau-
matic experience and the likelihood of a person devel-
oping an LT&CI in later life (van der Kolk, 2005, p. 2).
Within the following case study, patient-researcher
(PR) Susan Hancock will be referred to as ‘Susan’.
Susan requested that her real name be attributed to
this collaborative work. Portrait therapy carried out
with people living with LT&CIs is of necessity flexible
time-wise due to the unpredictable nature of illness,
and PRs were encouraged to take the lead regarding
how much time they dedicated to this intervention.
For Susan, the intervention consisted of 17 portrait ses-
sions lasting on average 1.5 hours, spread over a 12-
month period. All sessions took place at Susan’s
home, at her request. Susan had previously taken
part in art therapy sessions at the day hospice service
she attended, and was selected as a possible
participant in the portrait therapy PhD project by the
multi-disciplinary team.
Illness, childhood trauma and posttraumatic
stress disorder (PTSD)
Illness is both soul-shaking and soul-evoking for the
patient and for all others for whom the patient
matters. We lose an innocence, we know vulnerability,
we are no longer who we were before this event, and
we will never be the same.
(Bolen, 1996, p. 14)
Although Susan has never been formally diagnosed
with PTSD, due to her history of childhood trauma,
depression, anxiety and self-harm as a teenager, it
seemed useful to research this as a possible expla-
nation for symptoms experienced following Susan’s
life-threatening illness diagnosis. Traumatic childhood
experiences often result in a person developing PTSD,
which may remain undiagnosed until re-traumatisation
happens later in life and may be triggered by the
trauma of life-threatening or chronic illness.
A diagnosis of PTSD is often seen by those affected
as a ‘legitimization and validation of their psychic dis-
tress’, enabling them to make sense of their suffering
(van der Kolk, 2014; van der Kolk, McFarlane, & Wei-
saeth, 1996, p. 5), and asks not ‘what is wrong with
you’ but ‘what happened to you?’ This highlights a
focus on the meaning that patients ‘give to their
lived experiences, rather than a medicalised diagnosis
of “disease”’.
PTSD highlights the inextricable link between a
person’s ‘biology, conceptions of the world, and per-
sonalities’ and their inability to come to terms with
traumatic experiences that have ‘overwhelmed their
capacity to cope’ (Lobban, 2012, p. 2; van der Kolk,
2014; van der Kolk et al., 1996, p. 4). Rather than the
traumatic event itself driving the psychological and
biological aspects of PTSD, it is instead a disorder of
memories, with ‘intrusive and distressing recollections’
(Creamer, Burgess, & Pattison, 1992; Lobban, 2012, p. 3;
McFarlane, 1992; van der Kolk et al., 1996, p. 6). Trauma-
tised people who are haunted by memories that cause
an emotional and physiological response often organ-
ise their lives around avoiding anything that triggers
them (van der Kolk & Ducey, 1989), or they keep
these experiences from conscious awareness through
dissociation (Engle, 1997; van der Kolk et al., 1996,
p. 12).
There is, however, a paradox in PTSD that although
flashbacks and nightmares may intrude into a person’s
consciousness, many traumatised people have diffi-
culty remembering and relating exact details of the
traumatic experience, instead experiencing ‘sensory
elements of trauma without being able to make
sense out of what they are feeling or seeing’ (van der
Kolk & Fisler, 1995; van der Kolk et al., 1996, p. 10).

Susan reported difficulty in remembering specific inci-
dents from her childhood, instead remembering the
physiological aspects so that whenever thinking of
herself as a child she could always, immediately,
‘taste’ the salt of tears in her mouth.
Children who are traumatised may also develop a
specific worldview that incorporates their sense of
betrayal and pain, meaning they ‘anticipate and
expect the trauma to recur’ and respond to even
minor stresses with ‘hyperactivity, aggression, defeat
or freeze’ (van der Kolk, 2005, p. 11). When faced with
stressful stimuli, such children become ‘confused, dis-
sociated and disorientated’ and are constantly ‘on
guard’, and attempt to ‘organise their relationships
around the expectation or prevention of abandonment
or victimisation’ (van der Kolk, 2005, p. 11). If children
are powerless to control or do anything about the
trauma they are experiencing, they become ‘helpless’,
going immediately from ‘(fearful) stimulus to (fight/
flight/freeze) response without being able to learn
from the experience’, and when exposed to reminders
of the trauma they tend to behave as if they were re-
experiencing the original trauma itself (van der Kolk,
2005, p. 5).
It has been recognised that self-destructive activi-
ties, such as self-harming, often originate in ‘painful
encounters with hostile caretakers during the first
years of life’ (Simpson & Porter, 1981; van der Kolk
et al., 1996, p. 11) and become part of the patient’s
coping mechanisms. Susan reported using self-
harming as a teenager as a coping mechanism.
The physiological aspects of trauma have been
researched in recent years, with results demonstrating
that traumatic events can cause lasting damage to the
hippocampus, which is part of the brain’s limbic system
dealing with the modulation and consolidation of
memories (Lobban, 2012, p. 3). Changes are also seen
in the amygdala (also part of the limbic system),
within which memory, decision-making and emotional
reactions are processed. These changes cause the
amygdala to remain on high alert, causing a state of
hypervigilance to ensue (Lobban, 2012, p. 3) and trig-
gering the fight/flight/freeze mechanisms. However,
research has also shown that changes to the brain
can be reversed through a process of neuroplasticity,
whereby new neurons are generated, and that these
changes are influenced by both ‘internal and external
factors’ (Kays, Hurley, & Taber, 2012, p. 119).
According to van der Kolk et al. (1996, p. 17), there
are two vital aspects for successful treatment of PTSD.
These are enabling a person to ‘regain a sense of
safety in their bodies’ and to ‘complete the unfinished
past’. For most people, regaining a sense of safety in
their bodies requires engaging in activities that help
them deal with issues of ‘passivity and helplessness’.
This can include ‘play and exploration, artistic and crea-
tive pursuits, and some involvement with others’ (ibid.,
INTERNATIONAL JOURNAL OF ART THERAPY 3
p. 18). ‘Completing the unfinished past’ includes over-
coming the ‘fear of confronting their helplessness
and shame’, their ‘fear of the traumatic memories’
and ‘fear of involvement with life itself’ (ibid.).
There is a recognised correlation between disrupted
early attachments and difficulty with the construction
of a meaningful life narrative (Holmes, 2002, p. 150),
and also the building of a coherent sense of self-iden-
tity as this is also formed by our early attachment and
interactions with our main caregivers (Learmonth &
Gibson, 2010, p. 58; Winnicott, 1971). Gender can also
be an important factor in the development of coping
strategies for children who witness domestic abuse,
with girls tending to internalise and repress traumatic
and negative feelings (Higgins, 1994). There is a high
propensity for girls to disassociate from their painful
feelings, meaning that they neglect their emotional
needs, lack agency and tend to withdraw (ibid.). In
their early teenage years, girls often direct their anger
towards themselves and develop anxiety and depress-
ive disorders such as self-harming, eating disorders and
suicidal tendencies (Mills & Kellington, 2012, p. 4; Royal
College of Psychiatrists, 2004).
Portrait therapy
This research project and the theories underpinning
portrait therapy have been described previously
within a paper published in the International Journal
of Art Therapy (see Carr, 2014), however I will summar-
ise the project again here.
The collages, sculptures and portraits to be dis-
cussed are drawn from a qualitative, practice-based
PhD research project that utilised an in-depth multiple
case study design (involving seven PRs), multi-modal
creative data collection methods (resulting in 30 por-
traits and 80 collages and prose poems) and a phenom-
enological approach to data analysis (Gilroy, 2006,
pp. 101–104). The primary purpose of this intervention
was to develop and evaluate (through explicating the
lived experience of PRs) the process of self-identity
revisioning achieved through co-designing and
viewing the portraits of self-identity, painted for PRs
by the art therapist.
As the formation of self-identities is intrinsically rela-
tional (Grytten & Måseide, 2006; Wright, 2009), I have
used Wright’s (2009) theory of ‘mirroring and attune-
ment’ to underpin the use of portraiture as a way to
revision self-identities. Wright argues that the surface
of the canvas in a painting is ‘derivative, or “analogue”
of the mother’s expressive face in infancy, and func-
tions in a similar way as a responsive and mirroring
extension of the self’ or ‘surrogate adaptive mother’
(Wright, 2009, p. 13). I have developed these ideas
further to include the portrait painted for the PRs as
an embodied, mirroring device, which acts as the
attuning (m)other.
4 S. M. D. CARR AND S. HANCOCK
By utilising the art therapist’s artistic practice devel-
oped from art therapy pioneer Edith Kramer’s (1971,
1986, 2000) model of the art therapist’s ‘third hand’,
this intervention enables lending PRs the art therapist’s
‘good-enough’ artistic abilities to paint PRs’ (self-)por-
traits (Carr, 2014). Kramer described her ‘third hand’
technique as ‘a hand that helps the creative process
along without being intrusive, without distorting
meaning or imposing pictorial ideas or preferences
alien to the client’ (1986, p. 71). She writes about how
she painted portraits of her child clients, saying, ‘My
actions seemed to reassure them and to strengthen
their feelings of identity’ (1971, p. 40 [my emphasis]).
Portrait therapy protocol
The portrait therapy protocol (Carr, 2014, 2015) is
broken down into three phases. Phase one involves
using creative emotional distancing tasks, utilising fam-
iliar, non-anxiety-provoking materials (e.g. buttons,
Lego and photographs) in order to elicit PRs’ stories
of self-identity. This phase on average lasts between
one and two sessions at the beginning of the interven-
tion, although these techniques could also be used at
any stage to elicit further information. During the
second phase of the project, the art therapist creates
co-designed collages and prose poems as ‘response
art’ (Fish, 2012; Miller, 2007) containing ‘mirroring and
attunement’ (Wright, 2009), reflecting back stories of
self-identity PRs impart within phase one.
Phase two also involves a series of negotiations with
the PRs to form statements of intention for each por-
trait, sometimes using an album of portraits painted
by contemporary and historical, famous and non-
famous artists as a way to access the world of
portraiture.
Phase three involves the art therapist painting the
portraits and may include sessions where PRs are
painted from life and also a continuation of the co-
designing process, so that portraits can be adapted
or changed, the aim being the empowerment and
engagement of the PRs through this collaboration.
PRs are given the choice to be painted in a way that
reflects different aspects of their self-identity, which
might include how they look: in the present, prior to
their illness, or in their early life.
The amount of time spent working on collages and
portraits away from the PRs will vary, depending upon
the design choices of the PRs, but it was found that the
time devoted to this was important for the therapeutic
process as it demonstrated my ‘holding in mind’ of the
PRs when apart, to encourage feelings of self-worth
and trust. Some portraits took several weeks to com-
plete, while others took less than an hour. This
depended upon the size, medium and style requested
by the PR (e.g. a small cubist or impressionist style por-
trait could be achieved in a couple of hours, whereas
larger highly detailed work took several weeks to
complete).
Working with people diagnosed with an LT&CI does
have a holistic impact on the art therapist, and during
this project I (as the art therapist) felt an increase in
bodily-centred counter-transference (also called embo-
died vicarious-traumatisation) (McCann & Pearlman,
1990). This is described as physical symptoms such as
pain and discomfort, before, during or after working
with a patient (Booth, Trimble, & Egan, 2010, p. 285).
This may be combined with an experience of loss of
meaning and hope (ibid., p. 284). At different times
during the project, I felt increased tension in my
neck, shoulders, throat and chest, as well as a sense
of exhaustion and breathlessness. This can be
described as ‘listening with the body’ (Field, 1989),
and was an empathic reaction to, or unconscious mir-
roring of PRs’ symptoms. However, while painting the
portraits I noticed a marked relief from these symptoms
and I believe that creating images for the patient
enabled my body and mind to calm itself and to self-
soothe (Fish, 1989), which in effect equates to taking
our own medicine (Carr, 2014, 2015).
The traditional terms of engagement within art
therapy include an expectation that patients will
create the artwork and talk about this within the
session (and I do not suggest that this should in any
way change for the majority of clients). However, this
practice does have its ‘limitations’ and ‘problems’
(Maclagan, 2011, p. 8), particularly in palliative care.
Often patients are too disabled, unwell or fatigued to
make art, and (as with clients in other fields of art
therapy) for a variety of different reasons some
people are unwilling or unable to make art, despite
the expectation that they do so. There was an option
for PRs to contribute to the creation of the artwork
themselves, and one PR did help co-create a portrait
sculpture. Most, however, were content to direct me.
The importance of therapist/service user
collaboration in disseminating art therapy
interventions
Case studies written collaboratively ensure a focus on
the lived experience of those most intimately involved,
and avoids pitfalls such as projection (Wade & Tavris,
2000, p. 479), where the therapist may unconsciously
ascribe their own negative thoughts or feelings onto
another person who does not share these thoughts
or feelings. Through involving the patients’ views at
each stage of therapy and research, collaborative pro-
jects reflect a significant change from research carried
out ‘on’, to research carried out ‘with’ participants,
acknowledging their presence as valued co-researchers
in this process, and encouraging feelings of empower-
ment (Moon, 2002, p. 290) and reciprocity (Maiter,
Simich, Jacobson, & Wise, 2008). Also, case studies

written using service users’ own words enable their
voices to be heard, listened to and learned from (see
Learmonth & Gibson, 2010; Melliar & Brühka, 2010).
Empathic understandings between therapists and
clients may also be increased through the levelling of
the traditional hierarchy in therapeutic interventions
(Vick, 2000, p. 217). The collaborative approach within
portrait therapy enabled Susan to express personal
experiences of the intervention in her own words and
also to further reflect upon what the intervention
meant for her both as a patient and also as an aca-
demic. Working together with patients to report the
results of interventions underlines the potential for
user collaboration in every aspect of art therapy
research and its dissemination (Gilroy, 2006, p. 110).
The case study
Susan has also collaborated with and co-edited all
other aspects of the article. Susan’s words in this
article originate from self-edited responses to ques-
tions in an end-of-project semi-structured interview
from Carr’s (2015) PhD thesis. Susan engaged enthu-
siastically with the portrait therapy project and over a
10-month period we co-designed four portraits, five
portrait sculptures and 10 collages and prose poems
focused on stories of Susan’s self-identity.
Susan’s story: My memories of childhood and my
teenage years have always been memories of tears
and misery. My father was always angry and I lived in
fear of his seemingly-perpetual and unpredictable
moods when he raged at my mother and me and
found us worthless. I have a half-brother from my
father’s previous marriage—although I was essentially
an only child as my half-brother did not live with us,
having escaped to his late mother’s relatives, so that I
seldom saw him. Years later (in fact at our father’s
funeral), I learned that he was rescued by them, still
wetting the bed and stammering for fear of his
father. As a teenager, I experienced feelings of acute
depression, anxiety and suicidal ideation, and used
self-harming as a way to cope with and contain such
terrifying feelings. I kept all this to myself, feeling iso-
lated and unable to talk to anyone about it—afraid
that I might be mad.
On leaving school I studied accountancy by distance
learning and worked in that field, despite having
always wanted to study English Literature. I married
young in order to escape from home and was
blessed with two children; however, the marriage
ended in divorce and, sadly, my ex-husband later
died. I feel immensely lucky to have then met and
married my (wonderful) present husband (now also
my carer). Once my children were teenagers, with
moral support from my new husband, I returned to
studying and gained my BA, MA and PhD degrees,
beginning an academic career as a university lecturer,
and gaining recognition for my academic writing on
children’s literature and on Jungian psychoanalytic
criticism.
INTERNATIONAL JOURNAL OF ART THERAPY 5
I was diagnosed with incurable cancer several years
ago and have undergone radical radiotherapy and che-
motherapy treatments. Before diagnosis I was phys-
ically fit, and enjoyed travelling, walking and playing
golf with my husband and friends. Now these pursuits
are no longer possible since the disease and sub-
sequent treatment have severely affected my mobility;
I am only able to walk short distances with crutches,
and mainly use a wheelchair or motorised scooter.
My condition controls what I can do now as my
father controlled what I could do so long ago.
‘Getting out of that box’: recognising the
issues, shifting perspectives and increasing
adaption and agency
The goals of trauma therapy involve: providing a safe
therapeutic environment within which anxiety can be
minimised, avoiding overwhelming the client and
causing unacceptable levels of distress by facilitating
acceptable levels of exposure to the traumatic mem-
ories, and thereby enabling desensitisation to, and inte-
gration of the memories, to occur (Briere, 2004).
During the first few portrait sessions with patient-
researchers, I devised creative elicitation tasks that
had the benefit of creating emotional distance. One
of these was a ‘button task’, which involved creating
a pre- and post-illness ‘sculpt’ with the buttons.
Buttons were chosen for this task because they are
familiar, non-threatening, as well as being neutral and
ambiguous and easy to manipulate. In this task,
Susan was requested to choose buttons that rep-
resented aspects of her pre-diagnosis self-identity
and place these in any pattern on the baize board.
Susan was then asked to explain why she chose each
button. Overall shape/design of the button sculpt was
also noted and discussed. The process was then
repeated, asking Susan to choose buttons relating to
her post-diagnosis self-identity.
The aim of this task was to enable Susan to talk
about and remember aspects of her self-identity and
the impact of LT&CIs enabling tacit understandings to
be made manifest, as well as a sense of emotional dis-
tancing and reconnection to stories of self-identity,
acknowledging that ‘bringing emotional connected-
ness to a prior experience gives it a new perspective,
a possibility of meaning beyond that currently held’
(Lett, 1998).
Within Susan’s post-illness button task (see Figure 2),
she created a design that depicted the impact of illness
on her self-identity. Within the design, Susan identifies
her ‘self’ as the mermaid, ‘trapped’ within a metaphori-
cal ‘box’.
Susan described her post-diagnosis button task
design:
I am the mermaid in the middle of a box. The small
‘gap’ left at the top is a space where memories can
still ‘get in’ but which is too small for me to ‘get out’.
6 S. M. D. CARR AND S. HANCOCK
Figure 2. Post-diagnosis button task by Susan Hancock.
Seeing the mermaid in the ‘box’ enabled Susan to see
how ‘boxed in’ she felt, and we were able to link that to
feeling both over-protected and under-protected as a
child. Susan’s father blamed her mother for any tiny phys-
ical accident that befell her, so her mother was afraid to
allow her to do anything active, while failing to protect
her from his unpredictable anger whenever he perceived
the slightest threat to his controlling authority. This initial
theme of the ‘box’ became one that recurred throughout
Susan’s involvement in the project, with Susan develop-
ing creative and adaptive strategies to ‘get out of the
box’. Charmaz (1995, p. 657) suggests that adaption
within illness ‘implies that the individual acknowledges
impairment and alters life and self in socially and person-
ally acceptable ways’.
Figure 3. Back in that Box collage by Susan Carr, 2012.
The metaphor of ‘being boxed in’ was also exam-
ined within one of Susan’s collages and prose poems,
which I created for her as a form of response art
(Fish, 2012). Here the box becomes synonymous with
being confined to a wheelchair and also Susan’s
dislike of being photographed (see Figure 3).
This then led to further discussions and develop-
ment of the ‘boxed in’ metaphor into a 3D portrait
sculpture, Pin Hole Camera (see Figure 4). Within this
early co-designing phase, Susan and I were able to
adapt ideas to fit Susan’s thoughts and feelings and
Pin Hole Camera became symbolic of Susan’s traumatic
relationship with her father. One of the aspects Susan
highlighted regarding her relationship with her father
was his obsession with photographing her as a child.
Susan said:
Throughout my childhood my father was obsessed
with photographing me.
I learned to dread the camera coming out and the
orders to face the camera and smile, to face the sun
and not squint. Albums and albums of photos
remain, a testament to my father’s persistence and
my stoic acceptance and attempts to keep the peace
…
The multiple photographs of Susan bear witness to a
father objectifying his daughter in monochrome, and
yet he captures only the surface. Susan complies to
keep the peace, but only partially, and retains her sub-
jectivity within herself. The cost of this, however, is with-
drawal. In the photographs, Susan stands or sits doll-like,
pretty in pink and bows, trapped by the lens, her
coloured world converted into black and white. Psycho-
logically, each photograph is a ‘pin prick’ of discomfort,

Figure 4. Pin Hole Camera by Susan Carr (co-designed by Susan Hancock).
as her likeness is taken against her will, ‘snapped’, ‘cap-
tured’, ‘caught’, again and again and again. These are
not ordinary childhood snaps taken by a doting father
of his daughter. The photographic process involved
Susan having to be dressed in different outfits, her
hair curled or permed and then posed in different
locations, all of which could take hours. Susan said she
‘dreaded’ the camera being brought out. Literally thou-
sands of photographs were taken of Susan by her father
during these early years. It is only since the research
project that she has felt able to destroy some of the
albums.
Reflecting upon these photographs, Susan recog-
nised that having her photograph taken in the
present triggers memories of discomfort and the
fear of her father she experienced in her past. Susan
highlights the importance of Pin Hole Camera as a ‘cat-
alyst’ to connect to and to ‘let some of these things
out’, but also its ability to ‘hold’ difficult issues,
saying ‘it contains it and puts it away’. Susan also high-
lights the importance of my mirroring and attunement
within the portraits, saying, ‘and then I can see it made
into something that expresses what I wanted to say in
a way that perhaps even I didn’t realise’. Attunement
is key to developing a ‘vital and resilient sense of
self’ (Siegal, 2009), and the artworks can be seen as
containing ‘mirror fragments’ of personal truths and
knowledge (Learmonth & Gibson, 2010; van Lith,
2015, p. 9).
When creating the Pin Hole Camera portrait sculp-
ture, I was aware of the pins representing the pain I
felt tangibly between us as Susan spoke about her
fear of her father as a child and her desperate attempts
to keep the peace. Each pin represented the discomfort
of being photographed, and also each experience of
her father’s explosive temper and her own enforced
suppression of her academic prowess. There was also
a recognition of the self-harm Susan used as a teenager
to mitigate emotional pain through physical pain, and a
reflection upon the fact that pins, or needles, are used
INTERNATIONAL JOURNAL OF ART THERAPY 7
to ‘repair the damage’ and also are used in acupuncture
to heal.
Together, Susan and I reflected upon how exploring
the theme of being ‘boxed in’ has changed her lived
experience of agency, shifted perceptions and devel-
oped new self-insights. I asked Susan if, through the
portrait process, she was now finding ways to ‘get
out of the box’:
Yes, I think having recognised it, I’ve recognised the
steps that I need to take to change it. I don’t think
when we set out on this that I would have, I don’t
think I was fully aware of that feeling. I think articulat-
ing it made it visible to me, I think. I think that’s one of
the reasons that I’ve got the crutches, partly because
my back really hurts if I’m in the chair too long, but
the crutches are a positive step out of that, I think.
And, taking more care putting make-up on, nails, this
kind of thing, is saying that I’m not going to be in
that box if I can avoid it. So yes, I think that has
made a difference to stepping outside.
This correlates with Aita, Lydiatt, and Gilbert’s (2010)
research project carried out in Canada called Portraits
of Care: Medical Research through Portraiture, which
used the creation of drawn and painted portraits to
study the relationship between patients and their
carers. Aita et al. (2010) describe one of the participants
in their study saying that since being painted she has
found herself dressing up and ‘putting on make-up for
the first time since undergoing multiple surgeries on
her face’. Reflecting on the portraits enabled a change
of perspective and perceptions, and allowed new
insights into the self to form, with the artwork containing
a co-designed representation of a ‘shifting, emergent
sense of self’ (Melliar & Brühka, 2010; van Lith, 2015, p. 9).
Revisioning memories through portrait
therapy
When working through traumatic memories, van der
Kolk et al. (1996, p. 19) suggests that a process of
creativity is necessary as these memories need to
8 S. M. D. CARR AND S. HANCOCK
be ‘modified and transformed’, contextualised and
‘reconstructed in a personally meaningful way’, so that
the memories can become ‘acceptable’ as part of the
patient’s past. This includes a process of self-discovery
that enables the development of insight and self-reflec-
tion (Franks & Whitaker, 2007), as well as the processing
of repressed feelings, something that Greenwood (2011)
suggests alters implicit memory in the brain.
During the photo-elicitation sessions, Susan said that
as a child she was in a ‘catch 22’ situation with regards
to education and learning; her father was enraged if
Susan showed signs of being an academic or ‘too
clever’ (and therefore like her mother’s well-to-do
family), and equally enraged if she was ever ‘below
average’ in her school work, since she was his daughter
and any lack of ability reflected personally on him. Susan
said she had to hide her reading of academic and literary
works from him, and could still ‘taste the salt tears’ and
feel the anticipatory fear of his fury if he found out.
During our co-designing of Susan’s Catch 22 portrait
sculpture (see Figure 5), we initially discussed the idea
of depicting Susan as a child walking across a tightrope,
however we also felt that there needed to be ‘books’
involved. We also reintroduced the pins used in Pin
Hole Camera (see Figure 4) as a symbol of pain and
discomfort.
Within this portrait sculpture, Susan is depicted as a
small faceless child who attempts to ‘balance the
Figure 5. Catch 22 by Susan Carr (co-designed by Susan
Hancock).
books’, afraid to move, a heavy load on her young
head, one slip and she will be impaled on spikes of
steel. Within this ‘catch 22’ situation, Susan can only
be acceptable to her father by denying herself, and
she hides her academic self to keep the peace. As her
father’s daughter, Susan is not allowed to fail but also
not allowed to be too clever; she must therefore main-
tain a perfect balance or face the fearful storm of tears
and shame. As her mother’s daughter, Susan also hides
her true self and colludes with her mother to maintain
the façade of the idealised daughter, encouraged to
placate her father ‘butter him up, please butter him
up!’ to avoid both being caught in the storm of his
anger.
The three-dimensional work Susan and I co-
designed could be seen as representing ‘a growing
capacity to see from different viewpoints’ (Greenwood,
2011, p. 49).
This portrait sculpture demonstrated my mirroring
and attunement of Susan’s childhood distress,
showing how impossible the task of ‘keeping the
peace’ or ‘balancing the books’ was for such a small vul-
nerable child. As the project progressed, the idea of
‘balance’ within the collages became something
Susan focused on, making sure that there were an
equal number of both positive and negative collages.
We subsequently co-designed a portrait sculpture
that served to ‘balance’ the negatives in Catch 22; this
was The Cupboard of Imagination and Dreams
(Figure 6). The ‘portrait’ aspect is represented by a
Figure 6. The Cupboard of Imagination and Dreams by Susan
Carr (co-designed by Susan Hancock).

small child standing on a swing on the lower drawer
and relates directly to Susan’s recollections from her
childhood:
When I was a child my parents had a locked cupboard
with a glass front full of classic books [my mother’s] I
was not allowed to read … . One day I discovered
where the key was hidden and from that day on I sur-
reptitiously ‘stole’ the key and read all the books, one
by one, either hidden behind the settee while my
father was at work or late at night hidden under the
bedclothes. Despite my fear of the potential conse-
quences of being caught, I discovered a world of
freedom and adventure in my cupboard of imagination
and dreams.
In the cupboard of imagination and dreams is a world
where it is ok to take risks and explore. There is a land
free from guilt and anger, a land where you can be
yourself or an ‘other’, a land of magic, mystery and intri-
gue, a land without limits. Susan gains personal integ-
rity by engaging in her love of learning, but the cost of
this is her idealised innocent self, which slips from the
pedestal with each deception. Susan gains knowledge
of the world and learns she must hide her deception
and her evolving self. Through this deception, Susan
also comes to know her shadow self.
Susan ‘slipped’ a little from the idealised child ped-
estal with each deception; the portrait therefore
holds the dualities of truth and deception, under- and
over-protection, and hope and fear. Susan reflects
upon how the portraits helped her to find ‘balance’ in
the collages and through this process find a coherent
sense of self-identity:
It’s certainly helped to bring up the positive parts of my
childhood as well, because I probably would have … if
somebody had put me on the spot and asked me
about childhood, I probably would have remembered
a lot of bad things, but not how they were bad, what
made them so upsetting for me. I probably wouldn’t
have been able to consciously explore what it was
about the things that I hated. And then, also to coun-
terbalance them with things that were positive, more
than I had thought would be there. And I quite like
this idea of me still being me despite everything. So
yes, I think it’s been something that would have
been a lot more difficult to achieve, with simply
talking sessions.
It is therefore through the images and the reflective
space created that Susan finds a new understanding
of herself (Lett, 1998; O’Neill, 2008), suggesting that
through the mirroring and attunement inherent
within them, a personal recognition of ‘me still being
me despite everything’ is found.
For Susan, the portrait objects allowed her to see the
impossible task she took on as a child, trying to
‘balance the books’ and keep the peace, and recognise
the dualities of being under- and over-protected. Susan
described her experience of the portrait sculptures as
externalising objects, containing significant aspects of
INTERNATIONAL JOURNAL OF ART THERAPY 9
her self-identity, ‘holding’ and containing aspects of
hidden pain and suffering, enabling both connection
and emotional distancing to take place, and new mean-
ings to be developed:
I think you creating the collages and portraits helped
change the way I look at my past because if you asked
me for my life story, I wouldn’t necessarily have said
the things I’ve said. What we are looking at is an
emotional life story, which you have to find meta-
phors to express, which I think is what this does.
You know, I would perhaps concentrate on getting
the degrees and writing and you know, maybe,
meeting the Queen and all that kind of thing but
they are not my emotional life story. And my
emotional life story is much more important to
express. It’s nice for someone else to express the
emotions that you can’t.
Revisioning traumatic childhood memories,
adding metaphor, symbolism and aesthetics
The idea of revisioning comes from a belief that when
you create portraits that embody your story, you can
stand back from it and see it from a different perspec-
tive, changing it subtly in small but powerful and
meaningful ways. In Susan’s Saying Goodbye to the
Sea portrait (see Figure 7), metaphor and symbolism
are utilised to mirror both the enjoyment Susan felt
as a child being by the sea, but also her fear and trepi-
dation of leaving it.
Susan said:
Paint me as a child stood saying goodbye to the sea, I
would stand there and pretend to be Boudicca. My
father was always happier when we were on holiday
by the sea, and I always feared returning home,
where my father’s rages were uncontrolled.
In the portrait, Susan stands strong and defiant facing
the waves, shouldering the storm, safe inside her
imagination. However, Susan realises that she
cannot stay by the sea, as she must retain her ideal-
ised self through obedience and hide her true power-
ful self, symbolised by the stranglehold on the doll
she carries.
Susan’s reaction to seeing this portrait for the first
time was that it was ‘beautiful’, and by attaching
‘beauty’ as a metaphor for recovery and self-recla-
mation to this portrait, Susan was able to revision her
remembrance of this difficult time, capturing again a
sense of ‘balance’ and attaching these memories to a
sense of aesthetic resonance and coherence.
I asked Susan whether the portraits enabled her to
remember her past differently:
Yes, definitely. I get all good feelings of this, you know.
The sadness of saying goodbye to the sea is balanced
by being there in the first place, you know, to be there
and to be protected but to be protected in a nice way,
have things made for you [my mother made all my
10 S. M. D. CARR AND S. HANCOCK
Figure 7. Saying Goodbye to the Sea by Susan Carr (co-de-
signed by Susan Hancock).
clothes for example] and all the love that’s implied in
that.
Being Pandora: managing contradictions
and increasing self-love
When reviewing Susan’s portraits together, we became
aware of how they each held complex dualities. As a
child, Susan was subjected to extremes of dysfunc-
tional attachment styles, being idealised and over-pro-
tected on the one hand, and unacceptable and under-
protected on the other, with her mother being unable
to protect either herself or her daughter from Susan’s
father’s anger.
The dualities of idealisation and vilification, of power
and helplessness, of fear and courage, as well as her
father’s patriarchal views about femininity and edu-
cation, were all depicted within another of Susan’s por-
traits, Being Pandora (see Figure 8). Susan had
previously told me that her favourite genre of painting
was the Pre-Raphaelites and had talked about how
much she liked the ‘Pandora’ pastel painting by
Dante Gabrielle Rossetti. I therefore decided to paint
a pastel portrait of Susan in her teenage years as Ros-
setti’s ‘Pandora’.
Being Pandora combines the idealised child and the
troubled teenager who used self-harming as a coping
mechanism, as well as adding in the mystery and
grace that is the essence of Susan as I saw her in the
present.
Figure 8. Being Pandora (after Rossetti, 1828–82) by Susan Carr
(co-designed by Susan Hancock).
The idea of ‘the box’ is revisited within this portrait
—but this time Susan stands outside the box, holding
it shut in her hands, suggesting the power she now
possesses over it. In this portrait, Susan is portrayed
as a mysterious, mythical girl/woman, cast in the role
of beautiful femme fatale; betrayed by her curiosity,
she is blamed for releasing all ills into the world, yet
she is also bountiful all-giver, peace maker and
holder of hope and grace. This portrait highlights the
overt patriarchal domination within Susan’s early life
and the requirements to appear feminine and submiss-
ive as well as the inevitable ‘fall from the pedestal’.
However, there is a sense that even though Susan as
‘Pandora’ is ‘idealised’, she is also ‘uncapturable’,
despite falling victim to her own curiosity by
‘opening the box’, resulting in a loss of innocence.
Encapsulated within Being Pandora are the contradic-
tions of idealisation and vilification, but this conflict is
mitigated through the mirroring and attuning process
and the addition of aesthetic resonance. Good and
evil, power and helplessness are also explored, and
Susan is left literally holding hope within the box.
When Susan saw the Being Pandora painting, she
said she ‘loved’ it and that it was her favourite portrait.
Portraits are unique manifestations in that they are
objects that represent persons and as such they can
be touched, handled and reflected upon, and as an
empathic witness, I am also able to say that I too love
a portrait or a collage. This is an acceptable way of
expressing love for a patient, albeit again third hand.

Even so, the significance was not lost on the patient-
researchers, that their portrayed sense of self-identity,
which we had co-created together, was lovable. Other
PRs also talked freely about how much they loved the
portraits, collages and prose poems.
People often talk about ‘loving’ things, even trivial
things, but admitting love for something that represents
one’s self—particularly in the light of self-identity disrup-
tion and the stigma of illness—is significant. This is a
benefit of ‘third hand’ (Kramer, 1971) practice and
‘response art’ (Fish, 2012). Through making images for
patients, emotional distance is created, but also conversely
emotional connection. I have noticed in my art therapy
practice that if a client makes an image, they find it very
hard to look at it without seeing all the faults within it,
and one flaw (which no one else will ever notice) oversha-
dows the meaning of the image for them. However, when
I paint a portrait of a patient, the situation is reversed, and
they are free to ‘love’ the image, and do not seem to
notice the ‘flaws’ that I as its creator see all too easily.
Self-love is a necessary protective behaviour learned
in childhood (not to be confused with a narcissistic self-
obsession), and is linked to feelings of self-worth and a
coherent self-identity. The benefits of self-love are wide
and far-reaching, as has also been shown with ‘Paul’,
another participant in this project (see Carr, 2014),
through increasing self-care and pride in his appear-
ance and a renewed sense of agency. In her end of
project interview (EPI), Susan also notices similar
benefits and talks about ‘taking more care, putting
make-up on, painting her nails … ’.
Susan also said she had told me stories of self-iden-
tity that she had never told anyone else before, some-
thing also said by the other six participants.
One of the findings from the portrait therapy
research project was that all the participants reported
telling me stories of self-identity that they had never
told anyone before. These findings correlate with the
observations made by Mark Gilbert in his ‘Saving
Faces’ (Farrand, 2000) portrait project, whereby Gil-
bert’s sitters shared ‘details of their lives which they
shared with no one else’ (ibid.). I therefore suggest
that this could be a unique portrait effect (Carr, 2014,
2015). Susan describes her experience of this:
Yes, I felt perfectly free to say where I thought some-
thing didn’t work or did work so much freer, much
more comfortable … Yes so, in fact there’s a whole
raft of things that I’ve never told anyone before. In
the portraits, you’re turning negative memories
around into something that’s beautiful and lasting
and giving them back as something that’s not
tainted by misery or pain or anything else.
Discussion and analysis
Art therapy works on the premise that through making
the artwork, clients are able to externalise a problem
INTERNATIONAL JOURNAL OF ART THERAPY 11
into an art form, and by effectively controlling that
art form, the relationship of the client to the problem
can be changed. However, results from this project
indicate that using the art therapist’s ‘third hand’ to
create portraits for patients works well as an emotional
distancing/connection technique, despite the artwork
being created at one remove. Through the revisioning
process and the manifestation of aspects of self-iden-
tity within externalised objects, hidden pain and suffer-
ing are brought into being in the present, so that they
can be held, contained, moved, worked on and
reflected upon. Susan talks of her own experience of
this:
I think when it has been put into a portrait or sculpture,
fear doesn’t have such a hold over you. I think also that
you reflect on the effect on you, but when you see
something like the Pin Hole Camera sculpture, you
can see how you were vulnerable, that it was actually
somebody else’s issue and it affected you when you
couldn’t understand that. You know, you think about
how you felt but it takes it outside and puts the issue
with somebody else. It’s something that I shouldn’t
have to have felt but did, so yes it contains it and
puts it away. But understands it, it doesn’t put it
away by belittling the fear, it takes on board the fear
in all its manifestations I suppose and contains it
elsewhere.
Susan also talks about the difference this project
employs opposed to emotional distancing techniques
in ‘talking’ therapy. We believe that the mirroring and
attuning process contained within the portraits
creates this difference, by reflecting back stories of
self-identities to Susan that she needed to see, allowing
an intra-subjective validation of self-identity to take
place. Susan explains further:
By creating the portraits for me, you are lending me
your vision on my life. There’s a difference between
you asking me specific things that relate to the por-
traits … it was easier for me to say what I felt than if
you had simply said ‘did you have a difficult child-
hood?’ It was the catalyst that allowed me to let
some of these things out. It’s you taking things
hidden inside my head and making them visible to
me … and then I can see it made into something
that expresses what I wanted to say in a way that
perhaps even I didn’t realise. This seems to be a
much more effective way of dealing with hidden
pain and giving those who tend towards depression
the opportunity to recognise all the good parts of
their lives that can be overshadowed. It has helped
me to clarify how I felt and the connections that
have arisen because of my illness and it’s helped me
to understand myself better, understand the way that
I’ve responded to the illness.
One of the aims of portrait therapy is to enable people
to increase their ‘creative capacity to adapt’ to illness
(Reeve, Lloyd-Williams, Payne, & Dowrick, 2010) through
increasing agency and flexibility and changing percep-
tions of ‘control’. We describe our understanding of
‘creative capacity’ as similar to Higgs’ (2008, p. 551)
12 S. M. D. CARR AND S. HANCOCK
description, as ‘adaptive behaviour through imagina-
tive potential’. Susan talks about her experience of this:
The processes involved in portrait therapy allowed me
to express this emotional journey; I can look at it in a
pain-free way because I am intrigued about the
process and that takes the sting out of a lot of it. I
can see how illness ‘affects’ who I am now, but it
doesn’t ‘control’ who I am now. Looking at the portraits
helped me see that all of the things in between in my
life have helped me to cope with things now. Portrait
therapy gives you something that helps you function
in the world outside.
These stories of self-identity reflected in the portraits
were stories that patients had perhaps been waiting
a lifetime to tell, and according to Mullender et al.’s
study (2002), having ‘someone to talk to’ has been
cited as the second most cited need (after physical
safety) for children who have witnessed domestic vio-
lence (Mills & Kellington, 2012, p. 5). This suggests the
need for a ‘stabilising witness’ (Miller, 1990, p. 43;
Mills & Kellington, 2012, p. 3), something that we
believe is offered through the mirroring and attune-
ment within the portraits. This provides a supported
revisiting of the trauma and the revisioning of mem-
ories into an acceptable form, which can then be
reintegrated into a renewed, coherent sense of self-
identity. Susan describes the importance for her of
that ‘stabilising witness’:
It’s so important to have somebody understand you,
because most of the rest of the time with this you
are protecting the people around you from knowing
how you feel, because you know you don’t want to
put them through that, whereas you know I can say
things to you that I wouldn’t say to anyone else …
The construction of self-identity is made possible
during interpersonal interactions, where ‘other people
corroborate a person’s “me”’ (Grytten & Måseide,
2006, p. 196). ‘Self-stories’ are therefore told to others,
but also to one’s self, and the ‘act of telling’ therefore
becomes a ‘dual reaffirmation’ (Frank, 1997, p. 56).
I asked Susan if she thought that portrait therapy
would benefit other people experiencing a similar
illness or issues:
Yes, I think it would help. It helps people in my situ-
ation, but I think it would help a broader range of
people, I think it would be particularly important to
people suffering from depression, to try to create
something visual that would lift them … to see the
positive aspects of themselves, so yes, I would say
people with psychological illnesses and people psy-
chologically affected by physical illnesses, so both
sides of the coin. And a particular thing in the
hospice situation is where people know that their
own death is not a long way away, so that to help
people to feel that they have this kind of projection
into the future, that they’re not just going into the
hospice and dying and the world moves on and
forgets that they ever existed, it does give people
some kind of existence beyond that point, so that’s
another reason for it in the hospice context I would
think. However, I certainly see that it could also have
a lot of validity for people with other issues, such as
severe depression. So often treatment of illness
involves reducing patients to their illness, so that
there is nothing beyond, no recognition of a life
lived, no personal identity remaining.
Limitations and implications for future
research
Although this case study was part of a larger research
project, focusing on this single case and discussing it
collaboratively offers a detailed insight into the pro-
cesses involved in portrait therapy and Susan’s lived
experience of it. While it is not possible to generalise
results from one single case, it does, we believe, offer
an overview of the impact of LT&CIs on a person’s
self-identity, in particular those living with negative
effects of early childhood trauma. Through collabora-
tively reporting the outcome of this research project
and negotiating interpretations, we hope to have
avoided researcher bias and projection, and as Sullivan
(2010, p. 226) says regarding practice-based research,
‘it is often from experiences that are both simple and
complex, precise and uncertain, that the most insight-
ful outcomes are revealed, and the most important
questions arise’.
Studies have shown that early traumatic life experi-
ences are far more common than has previously been
recognised, and are linked ‘in a strong and proportion-
ate manner to outcomes that are important to medical
practice’ (Felitti, in Lanius et al., 2010, p. xiii).
We suggest that it is important for health care pro-
fessionals today to recognise the manifestations of
early childhood trauma in LT&CIs as a ‘second and separ-
ate etiological mechanism underlying many biological
diseases. Doing so will likely be the major public health
advance of our time’ (Felitti, in Lanius et al., 2010, p. xiv).
Further research into interventions for people who
experience illness as an assault on their self-identity
would build on the knowledge gained from this
study, as would further research into ‘third hand’ art
therapy interventions and the integrative use of aes-
thetic resonance. As Learmonth and Gibson (2010,
p. 56) say, ‘Recovery is not about making the past go
away, or undoing how the events of our life have
formed us: it is about the “resilience immunology” of
comprehensibility, manageability and meaningfulness’
(Learmonth & Gibson, 2010, p. 56).
In art as in life, changing our story also changes our
memories and how we feel about them, and we believe
that ‘the life of feeling is best revealed through those
forms of feeling we call the arts: that is their special pro-
vince … the arts provide access to qualities of life that
literal language has no great power to disclose’ (Eisner,
2008, p. 7).

Notes on contributors
Susan M. D. Carr is an art therapist who has been working in
palliative care for the past 10 years and completed her PhD
researching portrait therapy at Loughborough University in
December 2015.
Susan Hancock is a former university lecturer who was diag-
nosed with incurable cancer shortly after retirement. Her pub-
lications include The Child that Haunts Us: Symbols and Images
in Fairytale and Miniature Literature (Hancock, 2008).
References
Aita, V. A., Lydiatt, W. M., & Gilbert, M. A. (2010). Portraits of
care: Medical research through portraiture. Journal of
Medical Ethics and History of Medicine, 36, 5e13.
Binnie, K. (2015). I need security to survive. Life of Breath Blog,
October 28, 2015. Retrieved from http://lifeofbreath.org/
index.php/2015/10/28/i-need-security-to-survive/
Bolen, J. S. (1996). Close to the Bone: Life-threatening illness and
the search for meaning. New York, NY: Touchstone.
Booth, A., Trimble, T., & Egan, J. (2010). Body-centred counter-
transference in a sample of Irish clinical psychologists. The
Irish Psychologist, 36(12), 285–289.
Briere, J. (2004). Psychological assessment of adult posttrau-
matic states: Phenomenology, diagnosis, and measurement
(2nd ed.). Washington, DC: American Psychological
Association.
Capacchione. (1991). Recovery of your inner child. New York,
NY: Simon & Schuster/Fireside.
Carel, H. (2012). Phenomenology as a resource for patients.
Journal of Medicine and Philosophy, 37, 96–113. Retrieved
from http://jmp.oxfordjournals.org/content/37/2/96.full.
pdf
Carr, S. M. D. (2014). Revisioning self-identity: The role of por-
traits, neuroscience and the art therapist’s ‘third hand’.
The International Journal of Art Therapy, 19(2), 54–70.
Carr, S. M. D. (2015). Enabling self-identity revisioning through
portraiture, for people living with life threatening and
chronic illnesses: Paint me this way! (Doctoral thesis).
Loughborough University Library online repository,
Loughborough.
Chambers, E. (2008). Surgical portraiture and the hospital
environment as site and subject. Association of Art
Historians Conference paper.
Charmaz, K. (1995). The body, identity, and self: Adapting to
impairment. Sociological Quarterly, 36(4), 657–680.
Creamer, M., Burgess, P., & Pattison, P. (1992). Reactions to
trauma: A cognitive processing model. Journal of
Abnormal Psychology, 101, 452–459.
Eisner, E. (2008). Art and knowledge. In Handbook of the arts in
qualitative research. London: Sage.
Engle, P. (1997). Art therapy and dissociative disorders. Art
Therapy, 14(4), 246–254.
Farrand, P. (2000). Portraiture as therapy. Retrieved from
http://www.savingfaces.co.uk/index.php/media-mainmen
u-32/133-dr-paul-farrand-medical-psychologist.html
Field, N. (1989). Listening with the body: An exploration in the
countertransference. British Journal of Psychotherapy, 5(4),
512–522.
Fish, B. J. (1989). Addressing countertransference through
image making. In H. Wadeson, J. Durkin, & D. Perach
(Eds.), Advances in art therapy (pp. 376–389). New York,
NY: John Wiley & Sons.
Fish, B. J. (2012). Response art: The art of the art therapist. Art
Therapy, 29(3), 138–143. doi:10.1080/07421656.2012.701594
INTERNATIONAL JOURNAL OF ART THERAPY 13
Frank, A. W. (1997). The wounded storyteller: Body, illness and
ethics. Chicago, IL: University of Chicago Press.
Frank, A. W. (2000). Illness and autobiographical work:
Dialogue as narrative destabilization. Qualitative Sociology,
23(1), 135–156. Retrieved from http://www.ucalgary.ca/~
frank/Dauto.html
Franks, M., & Whitaker, R. (2007). The image, mentalisation
and group art psychotherapy. International Journal of Art
Therapy, 12(1), 3–16.
Gilroy, A. (2006). Art therapy, research and evidence-based
practice. London: Sage.
Greenwood, H. (2011). Long term individual art psychother-
apy. Art for art’s sake: The effect of early relational
trauma. International Journal of Art Therapy, 16(1), 41–51.
doi:10.1080/17454832.2011.570274
Grytten, N., & P. Måseide (2006). “When I am together with
them I feel more ill”. The stigma of multiple sclerosis
experienced in social relationships. Chronic Illness, 2, 195–
202. Retrieved from http://chi.sagepub.com/cgi/content/
abstract/2/3/195
Hancock, S. (2008). The child that haunts us: Symbols and images
in fairytale and miniature literature. London: Routledge.
Higgins, G. (1994). All children should be safe. Bristol: Women’s
Aid Federation.
Higgs, G. E. (2008). Psychology: Knowing the self through arts.
In G. Knowles & A. Cole (Eds.), Handbook of the arts in quali-
tative research. Thousand Oaks, CA: Sage.
Holmes, J. (2002). John Bowlby and attachment theory.
London: Brunner Routledge.
Jung, C. G. (1993). The practice of psychotherapy (2nd ed.). East
Sussex: Routledge.
Kays, J. L., Hurley, R. A., & Taber, K. H. (2012). The dynamic
brain: Neuroplasticity and mental health. The Journal of
Neuropsychiatry and Clinical Neurosciences, 24(2), 118–124.
Kramer, E. (1971). Art as therapy with children. Elek: Schocken
Books Inc.
Kramer, E. (1986). The Art therapist’s third hand: Reflections
on art, art therapy and society at large. The American
Journal of Art Therapy, 24, 71–86.
Kramer, E. (2000). The art therapist’s third hand: Reflections on
art, art therapy and society at large. In L. A. Gerity (Eds.), Art
as therapy collected papers: Edith Kramer (pp. 47–72).
London: Jessica Kingsley Publishers.
Lanius, R. A., Vermetten, E., & Pain, C. (Eds.). (2010). The impact
of early life trauma on health and disease: The hidden epi-
demic. Cambridge: Cambridge University Press.
Learmonth, M., & Gibson, K. (2010). Art psychotherapy, dis-
ability issues, mental health, trauma and resilience:
‘Things and people’. International Journal of Art Therapy,
15(2), 53–64. doi:10.1080/17454832.2010.523880
Lett, W. (1998). Researching experiential self-knowing. The
Arts in Psychotherapy, 25(5), 331–342.
Lobban, J. (2012). The invisible wound: Veterans’ art therapy.
International Journal of Art Therapy, 19(1), 1–16. doi:10.
1080/17454832.2012.725547
Maclagan, D. (2011). Between art and therapy: Using pictures
from the world of art as an imaginal focus. Art Therapy
Online, 2(2), 1–9.
Maiter, S., Simich, L., Jacobson, N., & Wise, J. (2008).
Reciprocity: An ethic for community-based participatory
action research. Action Research, 6, 305–325. Retrieved
from http://arj.sagepub.com/content/6/3/305
McCann, L., & Pearlman, L. A. (1990). Vicarious traumatization:
A framework for understanding the psychological effects
of working with victims. Journal of Traumatic Stress, 3(1),
131–149. Retrieved from http://link.springer.com/article/
10.1007/BF00975140#page-2
14 S. M. D. CARR AND S. HANCOCK
McFarlane, A. C. (1992). Malevolence, splitting, and parental
ratings by borderlines. The Journal of Nervous and Mental
Disease, 180, 258–264.
Melliar, P., & Brühka, A. (2010). Round the clock: A therapist’s
and service user’s perspective on the image outside
art therapy. International Journal of Art Therapy, 15(1),
4–12.
Miller, A. (1990). The untouched key: Tracing childhood trauma
in creativity and destructiveness. London: Virago.
Miller, R. B. (2007). The role of response art in the case of an
adolescent survivor of developmental trauma. Art
Therapy: Journal of the American Art Therapy Association,
24(4), 184–190. Retrieved from http://www.eric.ed.gov/
PDFS/EJ791443.pdf
Mills, E., & Kellington, S. (2012). Using group art therapy to
address the shame and silencing surrounding children’s
experiences of witnessing domestic violence.
International Journal of Art Therapy, 17(1), 3–12. doi:10.
1080/17454832.2011.639788
Moon, C. (2002). Studio art therapy: Cultivating the artist iden-
tity in the art therapist. London: Jessica Kingsley.
Mullender, A., Hague, G., Imam, U., Kelly, L., & Mellos, E. (2002).
Children’s perspectives on domestic violence. London: Sage.
O’Neill, M. (2008). Transnational refugees: The transformative
role of Art? Forum: Qualitative Social Research, 9(2). Art. 59.
Retrieved from http://nbn-resolving.de/um:nbn:d:0114-
fqs0802590
Reeve, J., Lloyd-Williams, M., Payne, S., & Dowrick, C. (2010).
Revisiting biographical disruption: Exploring individual
embodied illness experience in people with terminal
cancer. Health, 14, 178–195. Retrieved from http://hea.
sagepub.com/cgi/content/abstract/14/2/178
Royal College of Psychiatrists. (2004). Domestic violence: Its
effects on children. Mental health and growing up.
Retrieved from http://www.rcpsych.ac.uk/mentalhealthinf
o/mentalhealthandgrowingup/domesticviolence.aspx
Siegal, D. J. (2009). Mindful awareness, mindsight, and neural
integration. The Humanistic Psychologist, 37(2), 137–158.
Simpson, C. A., & Porter, G. L. (1981). Self-mutilation in children
and adolescents. Bulletin of the Menninger Clinic, 45, 428–438.
Spence, J., & Sheard, T. (1990). Narratives of disease. London:
Photographic Exhibition. Retrieved from http://www.
jospence.org/narratives_of_disease/n_o_d_6.html
Sullivan, G. (2010). Art practice as research: Inquiry in visual arts
(2nd ed.). London: Sage.
Sumner, L. W., & Boyle, J. (1996). Philosophical perspectives on
bioethics. Toronto: University of Toronto.
van der Kolk, B. A. (2005). Developmental trauma disorder:
Towards a rational diagnosis for chronically traumatized
children. Psychiatric Annals, 35(5), 390–398.
van der Kolk, B. A. (2014). The body keeps the score: Brain, mind
and the body in the healing of trauma. New York, NY: Viking.
van der Kolk, B. A., & Ducey, C. (1989). The psychological pro-
cessing of traumatic experience: Rorschach patterns in
PTSD. Journal of Traumatic Stress, 2(3), 259–274.
van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the frag-
mentary nature of traumatic memories: Overview and
exploratory study. Journal of Traumatic Stress, 8, 505–525.
van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (Eds.).
(1996). The effects of overwhelming experience on mind,
body and society. London: The Guilford Press.
van Lith, T. (2015). Art making as a mental health recovery
tool for change and coping. Art Therapy, 32(1), 5–12.
doi:10.1080/07421656.2015.992826
Vick, R. M. (2000). Creative dialog: A shared will to create.
Art Therapy: Journal of the American Art Therapy Association,
17(3), 216–219. doi:10.1080/07421656.2000.10129707
Wade, C., & Tavris, C. T. (2000). Psychology. Upper Saddle River,
NJ: Prentice Hall Inc.
Winnicott, D. W. (1971). Mirror-role of the mother and family
in child development. In D. W. Winnicott, (Ed.), Playing and
reality (pp. 111–118). London: Tavistock.
Wright, K. (2009). Mirroring and attunement: Self-realisation in
psychoanalysis and art. London: Routledge.
Zola, I. (1982). Missing pieces: A chronicle of living with disabil-
ity. Philadelphia, PA: Temple University Press.