Art Therapy With Neurological Conditions (PDFDrive)

‘If anyone needs confirmation that art therapy is the approach to
use in the treatment and recovery of neurological conditions this

is the book to read. Within these chapters the author practitioners
convey the extraordinary range and adaptation of interventions
available that enable increased access to therapy for patients, carers
and public services considering employing art therapists. I was
transfixed throughout both by the compassion of the case studies
but also the authority of knowledge embedded in each chapter.
A truly pioneering work, showing how the development of art
therapy knowledge and expertise has risen to a sophisticated level of
authority in delivery and awareness of the therapeutic contribution
it can make to such a complex subject.’
– Kate Rothwell, Art Psychotherapist, Head of Arts Therapies
in the Forensic Directorate of the East London Foundation
NHS Trust, Art Psychotherapist H.M.P Grendon
‘Art Therapy with Neurological Conditions is an interesting book,

ambitious in its aim as it covers diverse and complex clinical areas,
giving moving personal stories throughout and emphasizing the
importance of relationships to recovery. Connecting much of the
work are the links between neurological, emotional and cognitive
aspects of art therapy, in particular the ability of art and images to
activate “functional plasticity”, the capacity to recover by adaptation
and offer a chance to emotionally heal. Some of the chapters cover
topics which have had little or nothing written about them previously,
such as epilepsy and learning disability (Chapter 9). Other areas of
clinical work note the lack of psychological input for example in
stroke rehabilitation (Chapter 6). The book acknowledges the need
for more research and views the writing as initiating this through
the sharing of clinical practice.’
– Diane Eagles, Art Psychotherapist and Older Adult Mental
Health Arts Therapies Manager for CNWL (Central
North West London) NHS Foundation Trust
‘In dealing with the diverse aspects of art therapy, the making,
thinking about and working with imagery and tangible and symbolic
processing, this inspired and inspiring book shows how successfully
art therapists adapt their practice for people with many different
neurological conditions in a variety of clinical and community
settings. It will be an invaluable resource for art therapists and other
professionals in this field, and a vital source of information and
insight for trainee art therapists.’
– Deborah Gibson, MA Art Therapy Research, PG Dip Art
Therapy, RATh, Art therapist, Supervisor and Lecturer
‘This book should be read by everyone who is interested in the

interface between art therapy and neurology. It presents the
underpinnings of what could develop into a new theory of art
therapy.’
– Frances F. Kaplan, DA, ATR-BC, Art Therapist, Teacher
of Graduate Art Therapy Courses, Marylhurst University,
and author of Art, Science and Art Therapy
Art Therapy with
Neurological Conditions
companion volume
Art Therapy with Physical Conditions

Edited by Marian Liebmann and Sally Weston
ISBN 978 1 84905 349 5
eISBN 978 0 85700 911 1
of related interest
Art Therapy and Anger

Edited by Marian Liebmann
ISBN 978 1 84310 425 4
eISBN 978 1 84642 810 4
Art Therapy and Clinical Neuroscience

Edited by Noah Hass-Cohen and Richard Carr
ISBN 978 1 84310 868 9
eISBN 978 1 84642 839 5
Assessment and Outcomes in the Arts Therapies

A Person-Centred Approach
Edited by Caroline Miller
ISBN 978 1 84905 414 0
eISBN 978 0 85700 788 9
Neuroscience for Counsellors

Practical Applications for Counsellors, Therapists
and Mental Health Practitioners
Rachal Zara Wilson
ISBN 978 1 84905 488 1
eISBN 978 0 85700 894 7
Art Therapy with
Neurological Conditions
Edited by Sally Weston and

Marian Liebmann
Foreword by Jackie Ashley
Jessica Kingsley Publishers

London and Philadelphia
Excerpt on page 101 from Jan Phillips (2010) God is at Eye Level: Photography
as a Healing Act is reproduced with kind permission of Quest Books.
First published in 2015
by Jessica Kingsley Publishers
73 Collier Street
London N1 9BE, UK
and
400 Market Street, Suite 400
Philadelphia, PA 19106, USA
www.jkp.com
Copyright © Jessica Kingsley Publishers 2015
Foreword copyright © Jackie Ashley 2015
All rights reserved. No part of this publication may be reproduced in any material
form (including photocopying or storing it in any medium by electronic means and
whether or not transiently or incidentally to some other use of this publication)
without the written permission of the copyright owner except in accordance with the
provisions of the Copyright, Designs and Patents Act 1988 or under the terms of a
licence issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby
Street, London EC1N 8TS. Applications for the copyright owner’s written permission
to reproduce any part of this publication should be addressed to the publisher.
Warning: The doing of an unauthorised act in relation to a copyright work
may result in both a civil claim for damages and criminal prosecution.
Library of Congress Cataloging in Publication Data
A CIP catalog record for this book is available from the Library of Congress
British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN 978 1 84905 348 8
eISBN 978 0 85700 912 8
Printed and bound in the United States
Contents
Foreword by Jackie Ashley 11

Preface 13
Introduction and Emerging Themes 15
Sally Weston and Marian Liebmann
ADULTS
Part I Setting the Scene
Chapter 1 Neurology and Art Therapy 39
Debbie Michaels
Chapter 2 Beyond Limits: Art Therapy with People with Severe
Physical Limitations 62
Simon Bell
Chapter 3 The Janus Response: Coming to Terms with Changes Due
to Brain Injury or Other Neurological Condition 76
Iris von Sass Hyde
Part II Acquired Brain Injury

Chapter 4 Who Am I Now? Art Therapy, Identity and Adjustment
after Acquired Brain Injury 99
Carole Connelly
Chapter 5 Art Therapy at a Rehabilitation Day Centre for Adults and
Adolescents with Acquired Brain Injury 115
Anna Knight
Chapter 6 A Glimpse Beneath the Surface of Organisational Life: Art
Therapy in Brain Injury and Stroke Services 135
Debbie Michaels
Chapter 7 Art Therapy and Insight and Awareness after Brain Injury 152
Sally Weston
Part III Epilepsy
Chapter 8 Art Therapy after Acquiring Seizures in Adulthood 173
Quentin Bruckland
Chapter 9 ‘This is my Dream World’: Art Therapy with Young Adults
with Epilepsy and Learning Disabilities 187
Andrea Gregg
Part IV Dementia
Chapter 10 Reframing and Reconnecting: An Art Therapy Group for
People with Dementia 203
Elizabeth Ashby
Chapter 11 ‘My Coat or Yours?’ Generating Peer Support and
Interpersonal Relationships through Art Therapy for
Minority Ethnic People Experiencing Early Onset
Dementia Living at Home 220
Melody Golebiowski
Part V Other Neurological Conditions

Chapter 12 Have We Met Before? Images as an Aide-mémoire to
Restructure Self-identity with a Man with Korsakoff ’s
Syndrome 241
Jenny Wood
Chapter 13 What has Colour Got to do With It?
Art Therapy and Motor Neurone Disease:
An Anthroposophical Approach 256
Marion Green with Christopher Day
CHILDREN
Chapter 14 Art Therapy and Encephalitis 279
Mark Wheeler
Chapter 15 Art Therapy with a Boy Living with a Life-threatening Illness 298
Judith Ducker
PERSONAL REFLECTIONS
Chapter 16 Art Therapist, Heal Thyself ! 317
Mark Wheeler
Glossary 334
The Contributors 341
Subject Index 344
Author Index 350
List of Figures
Figure 1.1 Evolutionary structure of the brain. 44
Figure 1.2 The two cerebral hemispheres and lobes (top view). 46
Figure 1.3 Lobes of the brain (side view). 46
Figure 1.4 Structure of a neuron. 47
Figure 2.1 Spiral exercise. 70
Figure 2.2 In conversation. 71
Figure 2.3 Memories and reflections. 72
Figures 2.4 and 2.5 Energy and emergence of form. 73
Figures 2.6 and 2.7 Growth and transformation. 73
Figure 3.1 The sanctuary of boyhood. 82
Figure 3.2 First holiday in the Austrian Alps. 83
Figure 3.3 A stallion called Diamond Dancer. 84
Figure 3.4 The unopenable yoghurt pot. 86
Figure 3.5 Poster paint open vista by male patient with MS. 87
Figure 3.6 Foam roller brush hillsides by female patient with MS. 87
Figure 3.7 Pastel sketch of seascape by patient with head injury. 88
Figure 3.8 Poster paint image by patient with head injury. 88
Figure 3.9 Pushed out of the apartment window. 90
Figure 3.10 Looking at life without drugs. 91
Figure 3.11 Death of a significant other. 92
Figure 3.12 Addiction: An elephant never forgets. 93
Figure 3.13 Present hopes and future dreams. 94
Figure 4.1a Cut-down tree. 106
Figure 4.1b Scraping. 106
Figure 4.2 Walking through the forest of buildings. 107
Figure 4.3 Womb. 109
Figure 4.4 Burning tree. 110
Figure 4.5 Rosette. 112
Figure 5.1 The effects of disability. 116
Figure 5.2 Rebirth. 123
Figure 5.3 Ben: painting within a frame. 124
Figure 5.4 Ben: collage cards of cars. 125
Figure 5.5 A client’s mind map. 129
Figure 6.1 Shattered self. 137
Figure 6.2 Ambivalence. 139
Figure 6.3 Hope. 141
Figure 6.4 Anger and despair. 147
Figure 7.1 Shelf in art therapy room, with ram’s horn. 158
Figure 7.2 Tree and ram’s horn. (The outside world.) 164
Figure 7.3 First head and worked clay. 165
Figure 7.4 Clay heads together. 165
Figure 7.5 Heads rising up. 166
Figure 8.1 Maintaining forward motion. 179
Figure 8.2 Bad smell. 180
Figure 8.3 The war. 181
Figure 8.4 The big man. 182
Figure 9.1 Models of dogs. 192
Figure 9.2 The Wizard of Oz. 194
Figure 9.3 ‘I am upset and that is why I am crying.’ 195
Figure 9.4 ‘This is my dream world.’ 196
Figure 9.5 Two faces. 198
Figure 10.1 Nick: Imaginative village and landscape. 206
Figure 10.2 Steve: Riot of colour. 211
Figure 10.3 Greg: Pink car journeying. 214
Figure 10.4 Jon: Eagle flying high. 215
Figure 10.5 Jed: Jed’s exploration with colour. 216
Figure 11.1 The artist riding his bicycle. Blue brush pen on A4 paper. 232
Figure 12.1 Guitar player (1). 247
Figure 12.2 ‘The therapist’ and ‘No body’. 248
Figure 12.3 Guitar player (2). 248
Figure 12.4 Whole again! 250
Figure 13.1 Creation story, second day. 265
Figure 13.2 Eden. 265
Figure 13.3 Age 7 – leaving home. 267
Figure 13.4 Granny with angry spots. 268
Figure 13.5 Age 42–49 years. My horizons opened, but painfully. 269
Figure 13.6 The diagnosis. 274
Figure 13.7 Peace and hope. 274
Figure 14.1 Expressionist entry. 284
Figure 14.2 Corridor and outside world. 293
Figure 14.3 Distant Hulk. 293
Figure 14.4 Big Hulk. 294
Figure 14.5 Outside view of set and lens. 296
Figure 15.1 Postbox. 302
Figure 15.2 Scaffolding. 303
Figure 15.3 House without scaffolding. 304
Figure 15.4 Bed. 305
Figure 15.5 Hedgehog and Rabbit. 308
Figure 15.6 Fire station with handrail. 311
Figure 16.1 Ghost in the gallery. 320
Figure 16.2 Mark’s biking year book. 322
Figure 16.3 Brain damage in the Big Apple Box. 328
Figure 16.4 Barse in the West End Gallery. 331
Foreword
When my husband, the broadcaster Andrew Marr, suffered a serious

stroke in 2013 he immediately knew that some parts of his life
were lost forever. He was never likely to run again – hard to hear
for a man who regularly pounded for an hour round Richmond
Park. Even worse, he believed he would never paint or draw again,
because his left hand was left useless after the stroke.
He was delighted, not long afterwards, to realise that one of the
many therapists who called to see him in Charing Cross hospital
was an art therapist. Stroke patients were encouraged to draw and
to paint from very early on, and despite the motor difficulties they
experienced, with the help of a therapist they could achieve some
very positive results.
Andrew took up the challenge, working both with the art
therapist, and by himself, drawing in a notebook and on his iPad.
Drawing and painting had always been a huge part of his life: every
holiday we ever had together was spent trying to drag him away
from his oil paints after too many hours in the sun at his easel. Now
art was giving him something more: it was no longer just a hobby, it
was a means of dealing with what had happened to him.
One of his earliest drawings, post-stroke, was of himself,
wobbling around as he tried to stand, supported by a physiotherapist.
The image had been captured by a member of staff with a camera,
and he had then drawn himself from the photograph. His thinking
was that during those early days in hospital he felt vulnerable and
quite scared, but that drawing his vulnerability helped him to make
sense of it.
And so it has proved for many survivors of stroke or other brain
injuries. The science is there to show that parts of the brain ‘light up’
11
12 ART THERAPY WITH NEUROLOGICAL CONDITIONS
when people are enjoying art. It is undoubtedly helpful in making

emotional adjustments to a new and maybe disabled life.
Once Andrew left hospital, he decided to write a book about
drawing and what it has meant to him throughout his life. Part
of it, clearly, is distraction. He wrote that drawing involves ‘being
completely involved in an activity for its own sake. The ego falls away.
Time flies…It isn’t “chilling”. It isn’t relaxing…It sounds a lot like
meditation, a method of self-mastery, developed over many years.’
For someone recovering from a stroke, the ability to lose oneself,
to escape from the horrible reality of what has happened, is a
blessing. More than that, drawing or painting can help create a space
in which to process the confused thoughts you might have about the
situation, and the future.
Equally important, it has now been shown that drawing and
painting can help re-create neural pathways in the brain – the task
that so many stroke survivors are struggling with. Once certain parts
of the brain have died, it is the remarkable ‘plasticity’ of the brain
that enables it to re-learn tasks, using different routes.
For Andrew, art therapy enabled him to return to something
he has always loved. On a recent short break in Morocco, he was
back at his easel, covered in oil paint, reeking of white spirit and
happy as a bird. Not everyone who is offered art therapy will have
much experience of drawing or painting. But even for those who
haven’t picked up a crayon or a paintbrush since their school days,
the therapy works.
It’s high time the value of art therapy is more generally recognized,
not just for stroke survivors, but for all types of brain injury, as well
as dementia and mental health problems. This inspiring book looks
at the science behind art therapy as well as offering case studies. It
should be given a wide circulation.
Jackie Ashley
London
March 2015
Preface
This book is a companion volume to Art Therapy with Physical

Conditions. The two books grew out of a successful conference run
by the British Association of Art Therapists, ‘Art and Wellbeing: Art
Therapy and Physical Conditions’ in 2009. This focused on work
done by art therapists in medical settings with people with physical
conditions. The conference was oversubscribed, as was the call for
papers the following year for an edition of the International Journal
of Art Therapy: Inscape on art therapy with physical conditions. This
showed that many art therapists were working in this field, with
experience, ideas and, in some cases, research to share. It became
clear that a book on the subject was needed.
Once again, when the call for chapters went out, there was so
much excellent material that there was enough for two separate
books – one on art therapy for people with physical conditions,
one on art therapy for people with neurological conditions. We have
included a range of practitioners, from those newly qualified to
those with many years’ experience. The books deliberately consider
the broad span of disease or injury to the body, rather than focusing
on one specific diagnosis. They focus on the importance of meeting
the emotional needs and the psychological journey taken when the
body suffers damage or disease; and the experience of becoming a
‘patient’ and undergoing ‘medical procedures’, which can be life-
saving but also often painful and invasive. A third element in the
books is the experience for art therapists of working in physical
health settings.
Both books contain many case studies, alongside ideas and
theories that therapists have found useful in developing their
practice. Case studies are important in developing practice and
research in new and complex fields. The books raise the question
13
of what is useful with particular conditions, and whether there is a

particular specialist practice for art therapists working in physical
health settings. Several chapters also document struggles by art
therapy to become established in this field.
There is a historical mind/body split in western thinking and
medicine, and this is reflected in the health service, resulting in
issues on both sides. Mental health services are underfunded and
physical issues are underdiagnosed for people with mental health
problems. Treatments for physical illness focus on the physical body.
Emotional reaction and psychological adjustment to sudden or
serious illness or injury are usually not seen as part of the business
of a general hospital. When they are specialists are not employed in
large numbers. Much support has also traditionally been given by
nurses, but they have less time for this as shortages result in more
pressure. Nevertheless, art therapists are to be found working in
a wide variety of settings, with many clients and patients taking
advantage of their services.
There are three particular areas where art therapy has become
more established: dementia care, neuro-rehabilitation and cancer
services. Other less well-known fields of physical illness are now
using art therapy, as these books show. These are all areas where
people have pressing issues, but medicine does not always have
answers. Art therapy can be a place to process the experience of pain,
loss and change, facing unknown territory, including the imminence
of death. It can give people time and space to absorb and come to
terms with their journey, wherever it may lead.
The introductions to the two books draw attention to some of
the themes and strands emerging in this area of art therapy practice
– an area coined in the USA as ‘Medical art therapy’. The individual
chapters then explore these themes in more detail.
Introduction and Emerging Themes
Sally Weston and Marian Liebmann
This book draws together the experience of art therapists across

the United Kingdom working with adults and children with
neurological conditions. This includes brain injury acquired from
external injury, internal bleeds including stroke, and conditions such
as motor neurone disease (MND), multiple sclerosis (MS), epilepsy,
dementia, including early onset Alzheimer’s disease, Korsakoff’s
syndrome, encephalitis and brain tumour.
When I started work in a neurological rehabilitation unit in
1997, there was little written about art therapy with this client
group. Neurology is a specialism in itself, sitting somewhere
between mental and physical health, and services are located in
general hospitals, not psychiatric hospitals. As art therapists we were
often the only professionals with a brief to work therapeutically
with people’s mental and emotional health. It was a relief when
a national neurology and art therapy special interest group was
formed and we could discuss the issues we were encountering.
How was it best to work with people with physical limitations or
with speech difficulties? How could we be sure that clients with
cognitive issues consented to therapy? What was art therapy’s role in
the goal-focused environment of physical, cognitive and functional
rehabilitation? How should we communicate with colleagues? The
stories we shared were often inspiring, as we described clients able
to use sessions to express deep feelings, or, over time, to adjust to
changes unimaginable before the onset of the injury or condition.
Dave Rogers, an art therapist who had been working in the field for
some years, said, ‘Loss and coming to terms with it. That’s the main
issue in brain injury’ (1998).
15
Reading the contributions in this book, this is still the core of

what art therapy can contribute, whether after sudden traumatic
changes and losses after brain injury, or the gradual loss of ability
and choices in the progression of a neurological disease. Art therapy
offers a space and tools for fragmented, traumatised people to process
their feelings and begin to put themselves together again.
Seventeen years after the art therapy and neurology special interest
group started, there is now more literature on this work. Frances
Kaplan’s Art, Science and Art Therapy (2000) called on art therapy to
apply a more scientific analysis to its work. This was followed by
Noah Hass-Cohen and Richard Carr’s informative book Art Therapy
and Clinical Neuroscience (2008), which brings detailed knowledge of
the complex relationship between art, creativity and interpersonal
neurobiology. Cathy Malchiodi’s Art Therapy and Healthcare (2013)
includes a chapter on brain-injured clients and rehabilitation. There
are chapters on Parkinson’s disease, Huntington’s disease and
Alzheimer’s disease in Diane Waller’s Art Therapy and Progressive
Illness: Nameless Dread (2002). There have also been randomised
controlled trials (RCTs) showing that art therapy groups for patients
with dementia are successful in maintaining function (Sheppard et
al. 1988; Rusted, Sheppard and Waller 2006). There will hopefully
be further systematic research to help us understand how art therapy
actually affects us at the neurobiological level and how it might help
people with brain injury and long-term neurological conditions.
However, in the meantime, there is still a need for us to share
our practice and ideas on working with clients with neurological
problems. The art therapists’ interventions are often necessarily
innovative and complex, and the case studies convey this. We hope
the wealth of experience and ideas in this volume will contribute to
the developing theory and practice in this specialism, and encourage
others to consider both working in and researching this valuable and
rewarding field.
Theories and ideas

In addition to the art therapy literature and knowledge from the arts,
the authors draw on broadly three fields.
1. Neuroscience to provide evidence and explanation for the

work and the potential for physiological change. There is an
emphasis on the art within the therapeutic relationship as a
vehicle for promoting neuroplasticity, with increasing evidence
of lasting changes.
2. Medical explanations of each condition or issues arising
from them (e.g. memory) are included in each chapter. An
alternative medical model is outlined by an art therapist and
client using an anthroposophical approach (Chapter 13).
Further alternative models of ill health are touched upon in the
description in Chapter 11 of beliefs in a multicultural group. In
the companion volume to this book, Art Therapy with Physical
Conditions, the first chapter, ‘Does Your Body Mind? Does Your
Mind Matter?’ outlines recently developed holistic models
of human health and explores some of the limitations of the
western medical model.
3. Psychotherapy and psychology. This includes attachment theory,
with special emphasis on the role of the arts and attachment
when there are problems with memory or insight (Chapters 7
and 12). Phenomenological ideas (intersubjectivity) are used
to analyse the place of the relationship with the therapist
(Chapters 7 and 11). Intrapsychic learning in groups is covered
in Chapter 11, and psychoanalytic ideas on organisational
dynamics in Chapter 6.
Neurology: brain, body and mind

It is generally agreed that some knowledge of the brain and
neurological conditions is helpful to work with clients in this
field. In the first chapter, ‘Neurology and Art Therapy’, there is
an overview of neuro-anatomy, and each subsequent author also
includes information about their clients’ conditions. Chapter 1
also outlines the history of understanding how our brains function
and the impact of recent neuroscientific developments on this
understanding. Some of this helps to explain the physiological effect
of the arts and psychotherapy, as neuro-imaging shows the brain
‘lighting up’ as human beings respond to relationships with others,

or to engaging in the arts. Evidence of neuroplasticity and the brain
changing and developing through life, is encouraging for those with
brain injury, because there is the potential to develop new pathways
and find new ways of thinking.
Settings and team work

Art therapists describe work in a variety of settings, including a
residential home via a referral from psychiatry (Chapter 12), in an
NHS mental health unit (Chapter 10), day centres (Chapter 11), in
children’s services (Chapters 14 and 15), through learning disability
and epilepsy services (Chapters 8 and 9) and in clients’ own homes
(Chapters 2 and 13).
A number of authors working in rehabilitation services write
about the complexities of fitting into specialist teams (Chapters
4, 5 and 6), while Chapter 7 describes art therapy’s interactions
with other disciplines in a multidisciplinary team. Several chapters
mention Garner’s ‘Neurological art therapy triad’ (1996) – art
therapists work with the neurological, cognitive and emotional
elements all at the same time, and note that this is the same complex
process needed for recovery.
The authors in Chapters 3, 4 and 6 set up their art therapy services
within hospital neuro or stroke multidisciplinary teams from scratch.
They describe establishing the special role of art therapy, but also
ways of adapting practice so that art therapy contributes to meeting
neuro-rehabilitation goals. In Chapter 4 an innovative approach
using an arts project is described, which involved staff, patients and
relatives in establishing an identity with each other and the centre.
This also demonstrated the powerful nature of participating in the
visual arts.
Art therapists are often the only workers with the brief of
treating the emotional pain of the impact of the condition, and may
feel marginalised within the team. Chapter 6 looks at the dynamics
of teams dealing with trauma and loss, using theories drawn from
organisational dynamics to examine some of the subconscious
processes that can operate in organisations when staff are dealing

daily with distressed clients.
Emotional issues
Grief, loss and adjustment
Grief, adjustment and finding hope after trauma and loss – these are
the themes dealt with by most authors.
The stories in this volume of people struck by sudden brain
injury or living with degenerative conditions indicate the extent of
trauma and the adjustment faced. It is well documented that people
with long-term conditions have significant adverse psychological
responses and high levels of depression once back in the community.
This also happens to people with severe memory loss, who may not
be able to account for their feelings, and there are several examples
of such clients being helped by art therapy. Chapter 12 examines in
depth the link between memory loss, identity and depression in the
case of a younger man stranded in an older people’s home. Another
client described in Chapter 7, who was disorientated and lacking
insight into her condition, was able to admit in the process of art-
making an otherwise unacknowledged sense of foreboding and that
something was very wrong with her.
The author in Chapter 3 identified a pattern of adjustment in the
recurring themes in the images of 100 people she worked with over
four years. She calls this the ‘Janus response’. Janus is the god facing
both ways, symbolising transition. She suggests that art therapy can
be a place of transition, a place to connect to the past before adjusting
to change and going forward to make a new life. This chapter also
identifies the particular psychological issues encountered by people
who came by their injuries after an assault rather than an accident.
Two chapters show clients perceiving art as a joyful experience,
leading to transformative experiences in dealing with previously
unbearable pain. A client in a long case study (Chapter 4) finds the
art room ‘a haven’ within the intensive rehabilitation programme.
Another client (Chapter 13) describes how, after a period of many
years finding art therapy helpful and absorbing, the art-making
enabled him to come to an important resolution, linking his feelings

at the time of diagnosis with trauma from the past. He and his art-
making are shown moving into a new phase.
Art-making can be a means of expressing anger and other
strong feelings, which arise at times of grief and unwanted change
(Chapters 3 and 4). The author in the final chapter argues strongly
from personal experience that good recovery is possible, if there is
good rehabilitation, including long-term art psychotherapy.
Children’s emotional reactions and struggles with their condition
can be manifested through difficulties at home or school (Chapters
14 and 15). Art therapy can offer a way of exploring their distress
and experiences symbolically. This is conveyed expressively in
the film set made in the ‘noir genre’ by a boy with encephalitis,
described in Chapter 14 – a perfect vehicle for him to convey the
altered perception and other effects of his brain injury.
Identity and self-esteem

Confidence and self-esteem are often affected, with issues of identity
coming to the fore as people come to terms with dependency,
hospitalisation or being unable to resume their work and social lives.
Relationships are often affected, as seen in many chapters (3, 7, 8, 12,
16). Issues include people developing a sense of shame about being
a burden on others due to the effects of epilepsy (Chapters 8 and
9), while changes in physical and cognitive abilities and appearance
cause self-confidence to plummet (Chapter 4). Changes in and loss
of relationship following brain injury are a theme for many people.
Groups providing peer support for sufferers of dementia and their
carers are described in Chapters 10 and 11, showing helpful effects
on confidence and self-esteem.
Stigma, assumptions and exclusion

There are discussions of how social exclusion and stigma affect
people with physical disabilities (Chapter 2), learning difficulties
(Chapter 9), epilepsy (Chapters 8 and 9), and dementia sufferers
and their carers (Chapters 10 and 11). The struggle to get support
for social isolation is outlined in Chapter 2, while the final chapter
tells how low expectations of professionals can affect outcomes and

relationships with others following brain injury.
Philosophical/spiritual issues and mortality

Finding meaning following the immediate and often long-term
disruption to the life they were living before their brain injury is
a big issue for many. There may also be a heightened awareness of
mortality or of nearly losing their lives. Chapter 15 describes work
with a child with a brain tumour facing mortality. Chapters 9 and
15 outline the extra challenges faced by children and young people
in negotiating normal development and life stages. Others (for
example, the long case study in Chapter 3) re-assess life and make
positive changes in the light of awareness of being close to death.
People with degenerative conditions face the prospect of further
changes and losses due to their condition. The help and support
offered by group art therapy in facing together similar challenging
issues is conveyed by the positive feedback from participants and
carers in both groups for dementia sufferers (Chapters 10 and 11).
Art therapy is seen as an accessible and encouraging form of therapy
for this client group – a meaningful self-directed activity for people
whose choices have become increasingly limited.
Coming to some sense of resolution or peace with living
with serious conditions is described in the client’s own words (in
Chapter 11). Chapter 8 explores ideas from ‘illness representation’
as a means of moving towards some acceptance, enabling a client to
move forward emotionally.
The function of art-making

An exciting undercurrent in the book is the way art therapists
use art-making in providing therapeutic help. The case studies
include several techniques that patients with particular impairments
have found useful, e.g the repetition of mark-making for patients
with tremor; prompting and visual cues for clients with cognitive
difficulties; limiting choices if the person struggles with divided
attention. Chapter 5 explores many of these art-based techniques
and Chapter 15 illustrates effective ways to work with a client with

limited sight.
There is increasing evidence that art-making stimulates the brain,
helping to form new neural pathways, and many authors pick up
on this. Chapter 7 outlines Garner’s (1996) idea that art-making is
uniquely placed to deal with the complexity of the issues faced by
those with neurological problems. The reason for this is that making
art operates simultaneously on cognitive, emotional and neurological
levels, just as a person does. Neuro-imaging shows the brain to
be active in many different areas when engaged in art-making, as
already mentioned on pages 17–8.
Of course the art-making described is done within the containment
of the therapeutic relationship. Recent British Association of Art
Therapists (BAAT) conferences on neuroscience, attachment and the
arts (2013, 2014) have explored the potential of the ‘triangular’
therapeutic relationship (art, client and therapist) to make positive
physiological changes in the brain.
Memory and cognition

Chapters describing art therapy in neuro-rehabilitation all show
how cognition improves and is supported by art therapy sessions
as recovery progresses. Aspects of art-making – concentration,
attention, planning, initiation – are all recognised as helpful to
rehabilitation.
A number of chapters (7, 10 and 12) include case studies
where a client’s severe memory loss is supported by the art therapy
relationship. For example, the client in Chapter 12 was able to use
his art portfolio as an external memory. The concrete, visible nature
of the images enabled him to piece together a narrative of his life
in a way his very short-term memory could not. This chapter also
examines how the activity of making and doing things he was
familiar with tapped into undamaged procedural memory. Similarly,
the autobiographical Chapter 16 describes reconstructing the year
lost to retrograde amnesia with the help of friends, photographs and
a scrapbook.
Chapter 12 also argues that the repetition of making marks, form
and line actually stimulates memory. Chapter 10 refers to Bagan
(2012), who found that regular use of visual art processes forms
new neural pathways in the brain. Both authors working with
clients with dementia find that, over the course of a medium-term
art therapy group, clients with dementia retrieve memory, develop
concentration, and increase or maintain brain function.
The role of the senses

Art employs all the senses. In Chapter 7 the environment of the art
room is described as a sensory experience in its own right and the case
study focuses on people no longer able to understand their bodily
experiences. This and Chapter 11 use the phenomenological idea of
intersubjectivity to explain why sensory experience is so valuable for
this client group. Just as infants first interact with the world through
their senses, people unable to think clearly or use so-called higher
executive functions (the ability to plan and execute ideas) still have
access to and understanding of their sensory experience. Chapter
11 uses ideas from Schore (1994) about early attachment: through
body language, movement, engaging in mark-making, the client and
the attuned art therapist both have access to communication and a
meaningful relationship.
Different media engage different senses, playing to individuals’
needs, strengths or abilities. The sensory qualities of certain materials
(e.g. clay, see Chapter 7) seem to have a direct connection with
disturbed or absent experience of their physical body. In contrast,
a man with epilepsy, whose body and life felt out of control, found
planning precise artwork suited him (Chapter 8). For others, using
paint or messy or flowing media is a way to let out or express strong
feelings previously kept in (Chapter 3).
Access to the poetic imagination,

metaphor, symbol and style
For people in hospital for a long time or whose lives have become
restricted because of disability, access to imagination and culture
can be both difficult and a lifeline. Chapter 2 outlines how severe
disability can restrict life to a single room.
There are many examples of how clients use artistic expression to

make sense of their inner lives and altered experiences in the world
(Chapters 3, 9, 13 and 16). Examples include Chapter 3, which
shows how images convey progress in the rehabilitation process,
while Chapter 4 draws our attention to the work of Rita Simon
(1992, 1997) who specifically links changes in artistic style with
inner emotional states. Simon shows how this can help therapists
‘read’ and understand the inner lives of people unable to use words
to convey their inner lives.
Access to the imagination, symbol and metaphor can bypass
problems of rational thought or verbal expression, so it is particularly
useful for people with impairments in speech and/or cognition.
Many of the case studies show clients with these difficulties. The
art therapist as a professional with artistic training is perhaps
especially well placed to help and can employ ‘specialist skills honed
through our own art making – observation, analysis and reflection’.
(Golebiowski, Chapter 11).
Hints for practitioners of art therapy with

people with neurological conditions
Useful pointers include:
• Remember the importance of being ‘holistic’. This is in two
senses:
1. working with others, carers, team members, especially if the
person is classed as a vulnerable adult
2. working with the whole person: body, mind, spirit and
member of society.
• Find out about the condition and how it affects people.
• Research on the person’s biography, especially if they have
communication difficulties or memory problems. The life lived
before brain injury is an important part of them, but they may
not be able to connect with this, or their own account may
conflict with historical ‘fact’. The injured person may well
wish to know the objective truth, and others may need to help
develop ways to support this.
• Be aware that cognitive issues can mask emotional difficulties,
and vice versa. For example, a client’s denial of difficulties (e.g.
‘There will be no problem in going back to work as soon as I’m
home from hospital’) may be due to either emotional reasons
or cognitive issues (e.g. memory or perceptual difficulties).
• Be prepared to structure sessions to enable participation.
This can include adapting equipment or the environment,
and finding a good medium or techniques to accommodate
physical, cognitive or sensory impairment. Help from others
may be needed.
• Bear in mind that cognitive, neurological and emotional issues
will all be interacting in sessions and your client may focus on
all or any of these.
• Your client may or may not have pre-existing unresolved
emotional issues. If they have, they may or may not need to
focus on this in their current circumstances.
• Art therapy offers both sensory and the practical ‘doing’
element of art-making. Both of these are immensely valuable
in the process of encouraging neuroplasticity.
• Be flexible. The author in Chapter 5 describes her approach
as an ‘eclectic’ one and includes many practical techniques,
including using the sessions as cognitive assessment.
• Therapists may also have to be flexible in the settings they
work in. Examples in the book include clients being taken out
into the community (Chapter 12) and art therapists going out
into clients’ homes (Chapters 2 and 11).
• Value your experience as an artist. The arts themselves have
much to offer and can be greatly appreciated, especially in
institutional settings. Chapter 4 describes a highly successful
pop art portrait-painting project; the history of portrait
painting is linked with artists tackling questions of identity.
The art therapist in Chapter 14 is a photographer himself,
and uses his knowledge of the film noir genre. Chapter 7
describes clients for whom art-making stimulated memories of

previous cultural interests. Chapters 11 and 13 both describe
the observational skills and knowledge gained as an artist, as
invaluable nonverbal skills encouraging intrapsychic learning
and attunement in client and art therapist.
Where next?
The arts therapies are accessible to most people with long-term
neurological conditions and recent brain injuries, whatever their
disabilities, and there is plenty of evidence that patients and carers
value and want more emotional and psychological support. So it is
to be hoped that arts therapies will be more widely considered as an
option for this client group. There are already some good examples
– Meningitis Now offers art therapy nationally as emotional support
for children who have had meningitis; in some regions arts therapists
are employed by the National Health Service (NHS) or in third sector
organisations, including Headway (the brain injury association),
Stroke Association, Multiple Sclerosis Society and Epilepsy Society.
Equally, people with brain injury may find their way to art therapy
through mental health or forensic services. Several authors in this
book include the process of setting up art therapy in hospital,
residential and community settings.
We hope that the chapters in this book will add to the increasing
literature on the topic, and will encourage art therapists to make a
case to set up services and to conduct further enquiry and research
into art therapy for people with long-term neurological conditions
and brain injury.
Overview of chapters
1. Debbie Michaels: ‘Neurology and Art Therapy’
This chapter covers the history of neurological understanding of
the role of the brain, including modern scientific developments. The
section on the anatomy and physiology of the brain includes structure,
organisation and function, communication, connectivity, plasticity
and the impact of damage or disease. The chapter goes on to outline

the current psychosocial philosophy driving neuro-rehabilitation,
and the value of psychotherapeutic approaches in rehabilitation.
Finally the chapter looks at research evidence and literature on the
arts therapies and long-term neurological rehabilitation, including
the influence of neuroscience.
2. Simon Bell: ‘Beyond Limits: Art Therapy with

People with Severe Physical Limitations’
This chapter describes the importance of art therapy for people who
are severely restricted in movement and speech, to help them express
their inner emotional and cognitive life, which often remains intact
even though they have difficulty expressing it. A short case study is
included of a man in the advanced stages of motor neurone disease,
who held pencils and brushes in one corner of his mouth, and a
longer case study covering four years, of a man who suffered a stroke
and had lost the use of language and his hands. The chapter shows
how, with graded exercises and encouragement, this client was able
to reach the stage where he was able to continue his artwork on
his own.
3. Iris von Sass Hyde: ‘The Janus Response:

Coming to Terms with Changes Due to Brain
Injury or Other Neurological Conditions’
This chapter is based on an analysis of more than 100 patients’
images produced by patients with acquired brain injury or multiple
sclerosis who used art therapy in a neuro-rehabilitation unit over a
four-year period. Illustrated by a representative selection of images,
a long case study and a number of shorter vignettes, patients are
shown in processes of realisation, grieving and adaptation. Image-
making works alongside and sometimes instead of words. Repeated
themes arise from the spontaneous art-making in the art therapy
sessions.
The author calls the overall process ‘the Janus response’. Janus is
the Roman god with two faces traditionally set at the gateway to the
walled city – looking inwards and outwards at the same time. The
stay inside protected ‘walled city’ of the art therapy sessions enables
clients to connect with their previous life before venturing out into
the world again. The chapter uses Jungian ideas and suggests that
the mythical, cultural and imaginative content of art therapy is
important to recovery after severe trauma.
4. Carole Connelly: ‘Who Am I Now? Art Therapy,

Identity and Adjustment after Acquired Brain Injury’
This chapter describes setting up an art therapy service within the
interdisciplinary Northern Ireland neuro-rehabilitation service. The
author worked with issues of identity affecting clients after brain
injury, using the idea of pop art portraits, in collaboration with an
arts worker. This project linked the tradition of the portrait with the
individual and a shared identity for all at the centre – a place where
you are understood. An individual case study over five months
shows a client engaging with a process of grief and denial, facilitated
through the art-making process. He regarded the art therapy room
as a haven and the author speculates how art-making involves the
limbic system, and how tapping into a joyful experience may be
helpful when experiencing devastating loss and change, and seems
to facilitate adjustment.
5. Anna Knight: A‘ rt Therapy at a

Rehabilitation Day Centre for Adults and
Adolescents with Acquired Brain Injury’
This chapter outlines art therapy work in a voluntary sector
rehabilitation day centre, Headway, with adults suffering from a
wide range of acquired brain injuries (ABI). The work includes two
strands: work with those trying to come to terms with recent injuries,
and longer-term work improving clients’ wellbeing and quality of
life. Skills developed in art therapy are shown to be transferable
to everyday life. There is a need for a broad range of art therapy
techniques, to cover the wide differences in physical, cognitive and
emotional problems. The chapter shows how art therapy can effect
change through providing the brain with stimuli that can help adjust
and rebuild life after ABI, and contributes some examples of art
therapy techniques for specific disabilities. A case study shows how
this can work in practice.
6. Debbie Michaels: A
‘ Glimpse Beneath the
Surface of Organisational Life: Art Therapy
in Brain Injury and Stroke Services’
This chapter looks at the way the culture of organisations can both
affect and be affected by the experience of clients and arts therapists.
Drawing on the work of the Tavistock Institute of Human Relations
and Kleinian understanding of unconscious processes, the author
examines her experience of clients in two roles: trainee therapist
and supervisor of another therapist. This demonstrates how clients’
feelings of isolation, worthlessness and ambivalence can powerfully
affect those working with them. This in turn can influence
organisational dynamics, sometimes negatively. Art therapists,
however, can use their own feeling responses and reflective processes
to understand what may be happening in themselves and in the
organisation, and help clients through these dark places. The case
material shows how the client’s emotional states shifted during the
time they were in therapy.
7. Sally Weston: A
‘ rt Therapy and Insight
and Awareness after Brain Injury’
This chapter looks at art therapy with people who, after recovering
consciousness from severe brain injury, have no insight about what
has happened to them. Such clients cannot connect with ‘reality’
so cannot progress well in their rehabilitation. However, the author
noticed that such clients seemed to value art therapy and to show
evidence of changes in cognition and memory. Case studies from two
clients in a neuro-rehabilitation unit show them bringing cognitive
and neurological as well as emotional issues to art therapy sessions.
There is discussion about learning through the senses within the
therapeutic relationship and how the art-making and the art room
itself may facilitate this.
8. Quentin Bruckland: A‘ rt Therapy after

Acquiring Seizures in Adulthood’
This chapter describes the difficulties faced by people diagnosed
with refractory epilepsy – that is, seizures that cannot be controlled
by medication. These difficulties include physical trauma and facing
a totally new life, full of unpredictability, as they do not know when
to expect seizures. This affects people’s identity and self-worth,
and brings into question all their previous plans for their lives. In
addition they feel a sense of shame, due to the often public nature
of seizures, and may feel stigmatised by the label of epileptic. The
chapter includes a case study of a 28-year-old man referred for art
therapy to help him adapt to his diagnosis and recover his sense of
self. He was able to use the art materials to do this, and to begin to
envisage a meaningful life despite his condition.
9. Andrea Gregg: ‘“This is my Dream

World”: Art Therapy with Young Adults
with Epilepsy and Learning Disabilities’
This chapter starts with a discussion of types of epilepsy, then
focuses on three clients with epilepsy who also have learning
disabilities. A common theme was the use of fictional characters in
the artwork and identification with these characters as a means of
increasing self-esteem. The opportunity to create, experiment and
communicate within the therapeutic context allowed each client
to be understood, which led to them feeling more confident and
more able to communicate effectively with the important people in
their lives.
10. Elizabeth Ashby: ‘Reframing and Reconnecting:

An Art Therapy Group for People with Dementia’
This chapter starts with an introduction to the eight members of a
weekly art therapy group for people with dementia run by the author.
Three types of dementia are explained, with their devastating effects
on people and on their families. The chapter goes on to outline
some of the benefits of art therapy for this group, and the support
needed to achieve these. Themes emerging during sessions include

acceptance of their diagnosis, loss of some aspects of life, physical
impairment, bereavement, increasing memory loss, and the way
these impact on families too. Sharing these in the context of the art
therapy group provides a much-needed sense of relief.
11. Melody Golebiowski: ‘“My Coat or Yours?”

Generating Peer Support and Interpersonal Relationships
through Art Therapy for Minority Ethnic People
Experiencing Early Onset Dementia Living at Home’
The first part of this chapter looks at early onset dementia (ages
50–70) from a cross-cultural perspective, providing several scenarios
where cultural influences shaped responses to situations. Reference is
made to the evidence base for this work. The second part describes
the formation and running of the group, in which the emphasis
was on developing peer support and interpersonal relationships.
It includes vignettes of selected sessions from the 24 sessions that
took place, and a description of a method of reminiscence recording.
The Finale provides reflections on the process, and discussion of
evaluation and the National Institute for Clinical Excellence (NICE)
guidelines.
12. Jenny Wood: ‘“Have We Met Before?” Images

as an Aide-mémoire to Restructure Self-identity
with a Man with Korsakoff’s Syndrome’
This chapter describes how a man with Korsakoff’s syndrome,
suffering from extreme short-term memory loss and depression,
engages with art therapy and recovers a sense of himself.
Although the client could not remember his therapist or recall one
session to the next, looking at his own images stimulated memory.
The art therapist was then able to develop a therapeutic environment
which supported and reinforced the client’s autobiographical
memory. This meant that he could reconnect with his past, grieve
his losses and develop again his sense of self. He emerged from his
depression and was able to engage in a more active life again.
The chapter includes a description of Korsakoff’s syndrome and

a definition of the differing memory systems. It also draws on ideas
from hypnotherapy and neurology which make use of experience
stored in the senses.
13. Marion Green with Christopher Day: ‘What has

Colour Got to do with It? Art Therapy and Motor
Neurone Disease: An Anthroposophical Approach’
Marion and Christopher worked together using indications
from Margarethe Hauska’s anthroposophic art therapy training;
in an anthroposophical clinic. There is a clear description of the
anthroposophical medical model of health based on the work of
Rudolph Steiner. Marion describes her working methods as an
art therapist trained in anthroposophical methods. This involves a
holistic approach to health and the person. Colour is seen as an
important element in art therapy, as is careful observation of the
client’s presentation as a clue to their state of mind and body and
their needs. There are examples of various adaptations made to enable
people with physical limitations to find means of artistic expression.
This is followed by an account of Christopher’s work in art
therapy sessions over several years of short admissions to the clinic,
and later at his home where he worked through difficult emotions
associated with diagnosis and physical limitations, finally finding
beauty and meaning whilst living with this progressive illness.
14. Mark Wheeler: A

‘ rt Therapy and Encephalitis’
This chapter follows the journey of a boy aged 14 and his family
struggling at home and school with significant cognitive and
relational deficits following encephalitis contracted at the age of six.
He was referred to art psychotherapy in a Child and Adolescent
Mental Health Service.
The client engaged with the therapist using media that resonated
with his view of the world post encephalitis e.g. Nintendo DSi and
film noir. The case material is presented in the form of a film script,
using visual imagery and blocks of time in the form of ‘scenes’.
With validation and understanding the boy’s confidence grew and
problems decreased, as his concentration, empathy and sense of

humour returned.
15. Judith Ducker: A‘ rt Therapy with a Boy

Living with a Life-threatening Illness’
This chapter describes art therapy work with a seven-year-old boy
with a life-threatening tumour that affected his sight and mobility.
He was referred to art therapy because of his frustration and angry
outbursts. He had low self-esteem, feeling he was a burden to others.
He was unable to take part in the usual active pursuits of boys of his
age. In art therapy he made three-dimensional models which were
metaphors for himself, and was able to work through his feelings
about his tumour.
The art therapy also helped him adjust to changes in his family
circumstances. Puppets were used to explore relationships between
him and others, and between different parts of himself. As he reached
the age of ten, his tumour stabilised and the art therapy then helped
him to consider a future for himself.
16. Mark Wheeler: A

‘ rt Therapist, Heal Thyself!’
This final chapter describes the long road to recovery for an art
therapist following a severe traumatic brain injury. He begins by
describing the lengthy journey through life-saving interventions,
hospital treatments and rehabilitation. He then extracts a series of
useful lessons for professionals, as learnt by someone who has used
their services. He also includes research findings about long-term
recovery. He describes the use of music, photography and the support
of friends and therapists, including psychotherapy, which helped his
journey to recovery. He and another brain injury survivor who had
psychotherapy and the arts as part of their treatment over a number
of years, both made a significantly better recovery than two others
who did not. He argues strongly for the psychological, cognitive and
neurological help that art therapists have at their disposal and for
their place in multi-disciplinary teams.
Notes
All clients’ and patients’ names and some personal details have been
changed to preserve confidentiality, apart from those who asked us
to use their real names.
The terms ‘art therapy’ and ‘art psychotherapy’ are used
interchangeably in this book, according to contributors’ preferences.
References
Bagan, B. (2012) ‘Aging – what’s art got to do with it?’ Aging Well Magazine. Accessed
on 30 August 2012 at www.agingwellmag.com/news/ex_082809_03.shtml.
Garner, R.L. (1996) ‘The Nat Model: Factors in Neuropsychological Art Therapy.’
American Journal of Art Therapy 34, 107–111.
Hass-Cohen, N. and Carr, R. (eds) (2008) Art Therapy and Clinical Neuroscience.
London: Jessica Kingsley Publishers.
Kaplan, F. (2000) Art, Science and Art Therapy. London: Jessica Kingsley Publishers.
Malchiodi, C. (ed.) (2013) Art Therapy and Healthcare. New York: Guilford Press.
Rogers, D. (1998) Discussion at the art therapy and neurology special interest group.
Rusted, J., Sheppard, L. and Waller, D. (2006) ‘A multi-center randomized control
group on the use of art therapy for older people with dementia.’ Group Analysis
39, 4, 517–536.
Schore, A. (1994) Affect Regulation and the Origin of the Self: The Neurobiology of Emotional
Development. London and New York: Taylor and Francis/Psychology Press.
Sheppard, L., with Rusted, J., Waller, D. and McInally, F. (1988) ‘Evaluating the use
of art therapy for older people with dementia: A control group trial.’ Alzheimer’s
Society, Brighton Branch.
Simon, R. (1992) The Symbolism of Style. London and New York: Routledge.
Simon, R. (1997) Symbolic Images in Art Therapy. London and New York: Routledge.
Waller, D. (ed) (2002) Art Therapy and Progressive Illness: Nameless Dread. Hove: Brunner-
Routledge.
Adults
PART I
Setting the Scene

CHAPTER 1
Neurology and Art Therapy

Debbie Michaels
Introduction
The study and practice of both neurology and art dates back to
ancient times, but whilst the therapeutic potential of art has a long
history, art therapy (aka art psychotherapy) is a relatively new
profession in which work with brain injury and other long-term
neurological conditions is a developing area.
Over thousands of years humans have strived to makes sense of
the workings of the brain and its effects on mind and body, as well
as our interactions with the world. More recently we have begun to
understand how the interpersonal and social environment can affect
neurological development as well as the progress of neurological
conditions and recovery from brain injury. This chapter aims to offer
a brief overview of this immensely complex area and its relevance
for art therapists.
The development of neurological understanding

From ancient times to the twentieth century
Humans sense, process and respond to the internal and external world
in ways shaped over millions of years. Much of our knowledge about
the structure and functioning of the brain has come about through
observing and studying what happens when different parts are
damaged or diseased. Evidence from prehistoric times that the brain
39
may have been given a special role is based on the discovery of skulls
with holes deliberately cut in them (trepanation) in various Neolithic
sites across the world (Finger 2001). The Egyptians were the first
to document the effects of head injuries. However, as in many other
cultures, the heart stood above the brain on the Egyptian ladder of
importance, being considered the seat of the soul. Diseases such
as epilepsy were thought to be caused by witchcraft or evil spirits
and treatment involved calling upon omnipotent deities, magic or
narcotics to rid the body of demons.
In Greek times humoural theory provided a new framework for
understanding disease states. This paired the four elements (earth,
air, fire and water) with a specific bodily fluid (humour) which, in
turn, was associated with a specific bodily organ. Treatment involved
restoring the humours to a harmonious balance. With head injury,
this often involved trepanation or craniotomy; the belief being that
releasing intracranial pressure would restore humoural balance. The
Greek philosopher Aristotle adhered rigidly to the heart as the seat
of intellectual and perceptual functions. However, Hippocrates and
his followers observed that minds were altered when people suffered
internal damage to the head in a way that does not occur with any
other organ. This led them to regard the brain as a control centre
for the body, with conditions such as epilepsy seen as naturally
occurring brain diseases rather than signs of demonic possession.
Despite his reverence for Aristotle, the Roman physician, Galen,
agreed with Hippocrates. He saw the brain as the seat of intellect
and contended that imagination, cognition and memory could
be affected independently by injury and disease. Galen combined
humoural theory with astrological beliefs and, like many others
of his time, relied on cupping, bleeding and leeching as forms of
treatment (Finger 2001).
Scholarship and new learning stagnated in the west through
the Middle Ages, but the work of Hippocrates, Aristotle and Galen
was kept alive by Middle Eastern scholars, who based their own
medical books on these and other classical sources. In the west, the
first real revolution in neurology and anatomy came about with
human dissection and anatomical drawing during the Renaissance
(fourteenth to fifteenth centuries). Localised regions of brain function
Neurology and Art Therapy 41
were identified in the mid-seventeenth century with the naming of

‘hemispheres’ and ‘lobes’, and Descartes presented his ideas about the
brain as a reflexive machine. The use of humoural and astrological
theories continued into the seventeenth century, with the belief that
most large brain injuries were hopeless as they permitted the air to
‘overcool’ the brain. However, during this period the use of electricity
as a treatment gained credence. With the Industrial Revolution of
the eighteenth and nineteenth centuries the use of humoural theory
in the west diminished, whilst electrotherapy advanced rapidly,
being recommended for a variety of disorders including paralysis
and aphasia (Finger 2001).1 Some claims were extravagant, and
imaginings about electricity’s life-giving force manifested in Mary
Shelley’s fictional 1818 novel Frankenstein (Shelley 2008). However,
by the end of the nineteenth century neurologists, including Freud,
were questioning these claims. The idea of ‘re-education’ after brain
damage emerged, with the theory that other parts of the brain could
be trained to take over lost functions. This led to the development
of speech therapy for people with ‘aphasia’: an impaired ability to
understand or produce spoken or written language (Finger 2001).
An understanding of neurological disease began around the turn of
the eighteenth and nineteenth centuries. Most neurological disorders
were categorised on the basis of a single feature, such as paralysis or
a tremor. However, due largely to the contribution of Jean-Martin
Charcot (1825–1893), and his work at the Salpêtrière Hospital in
Paris, such features were finally looked upon as observable signs and
symptoms. These were correlated with observations of anatomical
damage, becoming formalised into the clinico-anatomical method
(Finger 2005). Charcot’s work greatly influenced the developing
fields of neurology and psychology, and is associated with multiple
sclerosis, Parkinson’s, and motor neuron disease.
Before the mid-1800s, when technological advances led to the
description of neurons, there was little understanding of what the
brain did, except that nerves transmitted sensations and controlled
movement. The famous case of Phineas Gage, who survived massive
damage to the frontal lobe in 1848, was perhaps the first to suggest
that damage to specific parts of the brain might affect personality,
his physician reporting that it was as if ‘the equilibrium or…
balance between his intellectual faculties and animal propensities,

seems to have been destroyed’ (Harlow 1869, p.13). Gage’s case
particularly influenced nineteenth century scientific discussion at
a time when theories concerning hemispheric specialisation along
with personality and behavioural deviance were emerging. The idea
of a ‘split personality’ or an uncivilised, irrational right hemisphere
and a moral, intellectual left hemisphere is also illustrated in Robert
Louis Stevenson’s popular literary character of the time, Jekyll and
Hyde (Stevenson 2013 [1886]).
In the late 1800s, neurologists Paul Broca and Carl Wernicke
identified particular areas of the left hemisphere which affected
expressive speech and language comprehension. These discoveries
opened the way to further clinico-anatomical correlations, making
it possible, over time, to ‘localise’ different brain ‘centres’ with
particular mental functions. Although a rich period in neurological
history, it became evident towards the end of the nineteenth
century that this sort of mapping, or scientific ‘phrenology’, was
too simplistic. At the turn of the twentieth century opposing ideas
argued for a more holistic view of the brain as a finely integrated
unit, not simply a collection of autonomous parts. Freud, who
had studied with Charcot, was at the cutting edge of neurological
research at the close of the nineteenth century. His 1896 hypothesis
that brain cells communicated with one another across spaces
linked with research by Charles Sherrington who, a year later,
termed these spaces ‘synapses’ (Wilkinson 2006, p.2). This formed
the beginnings of our understanding of what we now call neural
‘plasticity’ (Finger 2005).
Key twentieth century discoveries

The early twentieth century brought the discovery of chemical
‘neurotransmitters’ where previously it had been thought that
there was only electrical excitation. The case of the American
HM, who had both hippocampi surgically removed in 1953, also
revolutionised our understanding of the hippocampus and its critical
role in the organisation and functioning of memory; particularly
the storage and recall of different aspects of sensory experience. In
the UK in the 1950s, Roger Sperry’s ‘split-brain’ research began to

shed light on the functional differences between the hemispheres
and the relationship between them (Finger 2001). Prior to this the
right hemisphere had been neglected in neurological history, being
regarded as more ‘primitive’ than the left (Sacks 2011). However,
more recently the model has been one of differing systems with
constant and widespread interaction, ranging across different levels
of consciousness.
The impact of modern scientific developments

Along with a greater appreciation of the role of neurotransmitters
in diseases of the nervous system, the twentieth and twenty-first
centuries have seen the development of increasingly sophisticated
methods of looking at the brain. Since Freud’s time there have
also been significant psychosocial insights into the ways that the
environment affects our development and relationships, and growing
evidence that the insights of psychotherapy have a sound biological
basis (Kaplan-Solms and Solms 2000; Solms and Turnbull 2002).
Through neuroscientific research we are learning more about
the intricate relationship between the brain, human physiology,
rationality and emotions (Damasio 2005; LeDoux 2003; Panksepp
2003) and the impact of trauma on memory; and the importance of
early attachments, human connections and the social environment
on neurological functioning throughout life (Schore 1994; Siegel
2006; van der Kolk, McFarlane and Weisaeth 1996). Neuroscience
has also redefined our understanding about the plasticity of the
brain and its ability to organise, change and form new neural
pathways in response to interpersonal and socio-emotional learning
and experience (Doidge 2007; May and Gaser 2006). This offers
the potential for altering the patterns of brain activity as well as a
person’s emotions (Restak 2004; Siegel 1999). New imaging and
scanning techniques are also enabling scientists to make a visual map
of the brain’s activity when emotions are experienced.
There is still much about the complex interactions within the
brain that we have yet to understand (Wilkinson 2006). However,
recent neuroscientific developments may offer new insights into
how elements of the brain function and respond, as well as unique

observational methods for investigating art therapy practices
(Belkofer 2008; Zaidel 2010).
Basic anatomy and physiology of the brain

Structure, organisation and function
The organ of the brain is the enlarged anterior end of the spinal
cord, which is the pathway for most neural connections to and from
the brain. Together the brain and spinal cord make up the central
nervous system. Over millions of years newer parts of the brain
have developed and become superimposed above and around the
older parts, reflecting the shift of priorities from those driven by
survival needs defined by nature, to those defined by psychosocial
determinants (Carr 2008).
Figure 1.1 Evolutionary structure of the brain.

If we imagine an archaeological site, the oldest structure is the

brain stem and cerebellum, which form the hindbrain (Figure 1.1).
They ensure survival and are the most metabolically active in the
newborn baby (Gerhardt 2009). Over this ancient amphibian-
reptilian core evolved a midbrain, which is involved in the relay of
sensory and motor information and includes the limbic system, which
is responsible for social emotional processing. These structures were
then covered by the cerebrum, and the densely folded cap of the
cerebral cortex or forebrain. This links information from other parts of
the brain and deals with sophisticated social cognitions. The cortex
is the newest in evolutionary terms and most highly developed in
humans. Unlike the brain stem, it is underdeveloped at birth and is
shaped, most importantly, by experience (Siegel 2006). This area
has been described as the thinking part of the brain, where sensory
and emotional experience is regulated (Gerhardt 2009).
Whilst brain structures are sometimes referred to as ‘low and old’,
or ‘high and new’, reflecting evolutionary development, Damasio
(2005) suggests that ‘nature appears to have built the apparatus of
rationality not just on top of the apparatus of biological regulation,
but also from it and with it’ (p.128). In other words, the newer parts
of the brain cannot function independently of the older, more
primitive responses.
The cerebrum is divided from front to back by a longitudinal
fissure creating two separate, but connected, cerebral hemispheres
(Figure 1.2). Although asymmetric in shape, they match each other
but, in general, each receive information from the opposite side of
the body. Whilst specific functions are often attributed to right and
left hemispheres, when fully functioning, both hemispheres are
active and integrated with each other; sensory and other types of
information are transferred between the two, via a bridge of nerves
called the corpus callosum.
Figure 1.2 The two cerebral hemispheres and lobes (top view).
Each hemisphere is further divided into four separate lobes
(Figures 1.2 and 1.3). Parietal, temporal and occipital lobes form
the association cortex. This functions to forward information to the
frontal lobes, which organise sensory information into a coherent
perceptual model of our environment.
Figure 1.3 Lobes of the brain (side view).

Communication, connectivity and plasticity

The brain of each individual evolves and adapts throughout life,
initially developing as a result of the complex interaction between
internal and external stimuli from the early care-giving and
psychosocial environment (Siegel 2006).
Figure 1.4 Structure of a neuron.

The basic building blocks of relational connectivity are nerve
cells (neurons; Figure 1.4). These are electrically excitable cells
that process and transmit information. Each neuron has a nucleus,
tendrils (dendrites) that receive messages from other neurons, and
axons that transmit the messages to neighbouring cells. Experience
creates the activation, or ‘firing’ of neurons, which causes the release
of chemical messengers (neurotransmitters) into the space between
adjacent neurons (synapse). Through electro-chemical conversations,
neurons form circuits via synaptic connections. These, in turn, form
the complex neural communication networks that make up the
sensory nervous system. Some neural pathways are local, but others,
which are covered by myelin sheathing, pass electrical signals quickly
and smoothly between the brain and the rest of the body.
The establishment of functional neural circuits mediates sensory
and motor processing, and underlies behaviour. Frequently repeated
sequences of neuronal firing help to thicken dendritic connections
and establish learning and memory formation. This is the basis of

neural plasticity. New connections are not created as entirely new
entities, but rather are added to pre-existing ones. This, in turn,
results in ‘heavier’ brains which, it has been suggested, are less
vulnerable to neurodegenerative diseases and can better compensate
for brain injury (Hass-Cohen and Carr 2008).
The impact of damage or disease

Neurological disease or damage makes it more difficult for the
brain to communicate with other parts of the body, upsetting a
previous state of balance. Just as specialised areas of the brain do
not function as totally autonomous units, damage to a particular
structural area or network of the brain, as well as personal history
and psychosocial factors, are likely to influence the level of impact
and impairment experienced, as well as the progress of a condition
and prognosis. Whatever the cause, the diagnosis of a long-term
neurological condition often marks the beginning of profound
changes for a person’s life and relationships. Impairment may be
sudden, as with traumatic or acquired brain injury, spinal cord injury
or stroke, and followed by partial recovery. It may be intermittent
and unpredictable, as with epilepsy or early multiple sclerosis, where
relapses and remissions lead to marked variation in the care needed.
Or impairment may be progressive, as with motor neuron disease,
Parkinson’s disease, later stages of multiple sclerosis or Alzheimer’s
disease, where progressive deterioration in neurological function
leads to increasing dependence on care from others (DoH 2005).
Aspects of sensory perception, bodily functions, physical and
cognitive capacity, communication and comprehension, behavioural
and social skills, as well as emotions, may all be affected. Some people
may display confusion, loss of spatial and self-awareness, agitation,
angry and aggressive behaviour, and even psychotic symptoms
(Girvan, Knight and Weston 2009). Anosognosia (unawareness
of deficit), and anodiasphoria (lack of concern) are also common
features following traumatic brain injury (Evans 2003; Prigatano
1999; Weston 2005). Both are associated with poor motivation in
rehabilitation, which can negatively affect treatment, care and future
prospects, with more people ending up in supervised settings (Malec
and Moessner 2000; Murrey 2006).
Most treatment approaches now include a variety of professional

disciplines which seek to support a person in achieving their potential
in terms of recovery, as well as with the challenges of living with
a long-term neurological condition. With support many people do
learn to achieve a new equilibrium, even if this is fragile. However,
some people may continue to find it hard to manage their behaviour,
sustain close relationships, or accept the diagnosis, prognosis, level
of change, disability and loss (Miller 1999). This can result in
high levels of anxiety and depression and make it harder to plan,
adjust and adapt to long-term environmental and social demands
(Murrey 2006).
Psychosocial rehabilitation
Historical context
Sacks (2011, p.6) writes that:
A disease is never a mere loss or excess…there is always a
reaction, on the part of the affected organism or individual,
to restore, to replace, or to compensate for and preserve its
identity, however, strange the means may be.
Historically, many people were stigmatised, shunned and even
imprisoned. Phineas Gage made a good physical recovery from
his brain injury, but so radical was his personality change that
friends reported that he was ‘no longer Gage’ (Macmillan 2008,
p.829). There is little doubt that his brain injury had a considerable
psychological effect. However, Macmillan challenges the popular
myth, which has Gage transformed from a reliable, mild-mannered
and affable man to a restless, unpredictable and aggressive one until
his death in 1859. He argues that Gage’s later work as a stagecoach
driver would have required motor, cognitive and social skills and,
with this in mind, speculates about whether someone or something
offered enough structure to his life for him to regain some lost social
and personal skills.
Although modern neuroscience has outgrown the speculations
prompted by Phineas’ case, it is still a part of the medical folklore
and education. Up until recently a diagnosis of ‘organic brain
dysfunction’ excluded many from psychotherapy (Judd and Wilson

2005) and there is an ongoing struggle to find successful treatment
methods for brain-injured people with severely impaired insight and
awareness and/or severe psychological problems (Murrey 2006).
Attitudes may be changing, but the fear and social stigma associated
with mental illness and disability mean that there are still barriers
to accessing psychological/emotional support, particularly where
treatments are dominated by pharmacological regimes (Strand and
Waller 2010). This can leave those affected and their carers feeling
socially and emotionally isolated.
Psychotherapeutic approaches to rehabilitation

Although the systematic investigation of the unconscious mind is
relatively new, the origins of dynamic psychotherapy can be traced
back in time through a long line of ancestors and forerunners
(Ellenberger 2008). In the west, this broke through at the turn of the
twentieth century with Sigmund Freud and psychoanalysis. Around
the same time the Gestalt movement in neurology emerged, based
on the Greek idea that the ‘the whole is something else than the
sum of its parts’ (Koffka 1999, p.176). This challenged localisation
theories with a more holistic approach which emphasised the self-
organising tendencies of the brain. During World War I, a German
Jewish neurologist and psychiatrist, Kurt Goldstein, worked with
many brain-injured soldiers and developed a holistic theory based
on Gestalt. He gave the focus of the brain damage and the remaining
brain equal importance when constructing a picture of a person’s
symptoms, which he understood as responses of the organism in
the face of challenging environmental demands (Miller 1999). The
work of Freud and Goldstein influenced Russian neuropsychologist
Aleksandr Luria during World War II, who similarly emphasised
the person’s strengths or ‘preserved components’ in the treatment
of brain injury (Glozman 2007). Live music was used in treatment
programmes during both wars and in the late 1940s the pioneers
of British art therapy began to emerge (Edwards 2004). As
neurological research concerning theories of recovery developed in
the early twentieth century, the importance of motivation was also
recognised. This stimulated the growth of multifaceted approaches
towards rehabilitation, with an expansion of specialised brain injury

programmes in the 1980s, both in America and in Britain (McCann
1998). However, despite the pioneering work of the 1940s there
remained a presumption, as with learning disability, that impairment
of cognitive, emotional and linguistic functioning would prevent
people from taking full part in the psychotherapeutic process (Judd
and Wilson 2005).
Before the 1990s little was written about psychological treatment
with people who were living with a long-term neurological condition.
However, the work of American psychologist, George Prigatano,
has contributed greatly to an understanding of psychotherapeutic
approaches in the treatment of brain injury (Prigatano 1999).
Influenced by Freud and Jung, amongst others, Prigatano argues that
a person’s ‘subjective perception of their rehabilitation experience
can be a powerful influence on how they actually behave or cope
with neuropsychological impairment’ (1999. p.24). His work is of
particular interest for arts therapists as he suggests that the challenge
for the clinician is to find concepts, symbols and analogies that will
address the individual’s experience of brain injury (Prigatano 1991).
The arts therapies and long-term

neurological conditions
The arts therapies in neuro-rehabilitation have become well
established in the USA. In the UK specialist art therapy services
can be found across different sectors; in hospital-based and
community rehabilitation units, behavioural units, residential homes
and voluntary organisations (Girvan et al. 2009). However, service
provision remains patchy and integration of the arts therapies from
acute services through to community support is rare.
Most arts therapists work within the context of a multidisciplinary
approach. Significant issues include the need to address trauma and/
or loss alongside the impact of neurological damage on aspects of
physical, cognitive, behavioural and emotional functioning. Overall
aims are generally psychosocial and include: issues of adjustment
and change; resolving the tension between the person’s previous
function and their current functioning; restoring/maintaining a
sense of balance and wellbeing; working towards an acceptance of

deficits with a focus on strengths; re-establishing a sense of identity
and dignity; and building/maintaining relationships with others
and community (Weston 2004, 2008). Some people may be faced
with the need to address end of life issues, and music therapists,
particularly, may work with people who are minimally conscious,
where the aim is to stimulate behavioural, physiological and
expressive responses as well as sensory and relational connections
(Magee 2005).
There are clear differences in descriptions of American and
British art therapy practice (Weston 2005). American art therapists
stress specific clinical goals, and use treatment plans and directed,
theme-based sessions (McGuinness and Schnur 2013; Wald 2003).
The diagnostic potential of the artwork and work with behavioural
issues is also emphasised (Silver 2007). Garner (1996) proposes a
neuro-rehabilitation approach, placing emphasis on environmental
factors and the need to develop approaches that incorporate an
understanding of cognitive, psychological and neurological processes.
This is in contrast to a more psychodynamic and less directed
approach in the UK, which emphasises psychological, emotional
and social aspects as well as expression, nonverbal communication
and symbolic meaning (Cregeen 1993; Michaels 2010; O’Gorman
2001; von Sass Hyde 2000; Wisdom 1997). However, despite
differences, both advocate a flexible and adaptable approach. This
acknowledges cognitive, neurological and psychosocial factors
alongside emotions, and emphasises the importance of the art-
making process in stimulating the imagination and meeting multiple
and individual needs (Peisah, Lawrence and Reutens 2011; Strand
and Waller 2010; Wood 2002). It is also clear from the literature
that ‘lack of insight and awareness’ is not a seen as a barrier to
meaningful engagement in the psychotherapeutic process (Prigatano
and Johnson 2003; Weston 2005).
The influence of neuroscience

Whilst the brain imprints of early childhood lay a strong foundation
for later patterns, neuroscientific research indicates that new neural
pathways continue to develop throughout life. This is particularly
relevant for arts therapists working with long-term neurological

conditions (Hass-Cohen and Carr 2008; Levine-Madori 2009;
McGuinness and Schnur 2013). Recent art therapy literature
also cites extensive research which offers us new insights into
neurological phenomena related to: memory; how images influence
emotion, thoughts, and wellbeing; and how the brain and body react
to images and the experience of making art (Belkofer 2008; Kaplan
2004; Malchiodi 2012; Stewart 2004; Zaidel 2009). Art-making is
a complex neurological task involving sensory, cognitive, emotional
and motor pathways, characterised by the nonverbal expression of
sensations, perceptions, feelings, thoughts, ideas and experiences
(Lusebrink 2004; Lusebrink, Mārtinsone and Dzilnar-Šilova 2014 ).
Belkofer (2008) argues that art has a neurological foundation in its
perceptual properties, the emotions evoked from making, and from
viewing it. There is evidence to suggest that emotional responses and
many basic affective tendencies may survive damage, even though
cognitions may be impaired (Panksepp 2003), and that artistic
endeavour is resistant to brain damage (Zaidel 2010), remaining
accessible in spite of neurological diseases such as Alzheimers
(Cummings et al. 2008; Ehresman 2014). This is supported in music
therapy literature, where multisensory stimulation is understood to
facilitate connectivity between key regions of the brain, and may
be particularly beneficial for people with a neurological impairment
(Zimmerman and Lahav 2012).
Neuroscientific research also indicates that the development of
new neural pathways takes place especially in the context of enabling
relationships (Siegel 2006). In a multi-modal study McGuinness
and Schnur (2013) argue that the manipulation and purposeful
grasping of different colours, textures and forms stimulates visual
and kinaesthetic sensory responses (Lusebrink 2004), channelling
the flow of physical and mental activity and mirroring it back to
the maker. The attuned presence of the therapist helps to hold
the relational self in mind while allowing for the expression of
emotions and motivations. Alongside this, higher cortical functions
may be performed through viewing and talking about the art (Hass-
Cohen 2008). McGuinness and Schnur suggest that mirroring is
a fundamental part of relational interaction which can promote
recognition, anticipation and empathy, and improve executive
functions such as processing abstract thoughts and ideas; regulating

emotions and managing social interaction.
The evidence base

The complex and diverse range of abilities and difficulties presented
by people with a long-term neurological condition requires that
therapeutic approaches are tailored to the individual’s needs. However,
explaining the art therapy process can pose difficulties (Lusebrink et
al. 2013), and raises the research dilemma of how best to capture
the qualitative nature and complex individualised nuances of arts
therapy interventions, whilst also being able to quantify benefits on
a broader scale. Historically, much of the published literature is case-
study based, which perhaps reflects this dilemma, but the number of
systemised studies across both art and music therapy has increased
over recent years (Raglio et al. 2010; Rusted, Sheppard and Waller
2006). Results are generally positive; however, attempts to quantify
outcomes have, in some cases, led to discrepancies when compared
with qualitative feedback (Stafstrom, Havlena and Krezinski 2012).
The past 20 years have seen a significant rise in the number of
arts therapy publications concerned with this area of clinical practice.
Whilst the emphasis here is on art therapy, it is important to note
that music therapy has an extensive research base that demonstrates
its effectiveness with a range of long-term neurological conditions
(Aldridge 2005). By far the largest increase in art and music therapy
literature concerns dementia and Alzheimer’s disease. Gilroy (2006)
offers a helpful overview of significant art therapy research with
dementia, from the UK and USA, which indicates a reduction in
depression, with improved attentiveness, sensorimotor skills, social
interaction, mental acuity, physical competence and calmness. These
findings were largely supported by the first British systematic
randomised control trial which offers evidence of positive and
durable benefits for those living with moderate to severe dementia
(Rusted et al. 2006). Subsequent evidence supports the use of arts
therapy approaches to help stimulate cognitive function (Levine-
Madori 2009), facilitate communication and reduce isolation
(Peisah et al. 2011), and promote resilience (Galbraith, Sabrina
and Ross 2008). While art therapy interventions may not change
the neurological course of the illness, there is evidence to suggest

that they may improve quality of life through stimulating brain
connections and facilitating communication (Ehresman 2014),
providing culturally sensitive opportunities for control, choice and
management of emotions (Johnson and Sullivan-Marx 2006), and
offering a sense of hope (Safar and Press 2011).
Stroke rehabilitation has received considerable attention in the
UK with the National Stroke Strategy (DoH 2007) and NICE
guidelines for stroke rehabilitation (NICE 2013). In a review of
international art therapy literature Reynolds (2012) suggests that,
whilst the available evidence is limited, it indicates that art therapy
may address multiple objectives and many of the diverse cognitive,
emotional and functional needs of people disabled by stroke. The
NICE guidelines for stroke rehabilitation acknowledge the need
for long-term emotional support for people living with stroke and
their carers, but does not include the arts therapies within its scope
of reference. However, the NHS London Allied Health Professions
Stroke Toolkit (NHS London 2012), does identify the arts therapies
as contributors at the prevention stage, working to maintain
emotional health, and in relation to long-term gain, where they
are identified as being able to help with emotional issues related to
living with stroke.
Whilst receiving less attention in the public eye and literature,
recent research into the effectiveness of art therapy with Parkinson’s
disease suggests that the manipulation of therapeutic art forms may
contribute to a decrease in tremors, all levels of depression, obsessive-
compulsive thinking, phobia and stress (Elkis-Abuhoff et al. 2013;
Strand and Waller 2010). There is also evidence to suggest that
both art and/or music therapy may offer significant psychosocial
and emotional benefits for people living with multiple sclerosis
(Ostermann and Schmid 2006; Sterz et al. 2012), and for children
and adolescents who have epilepsy (Havlena and Stafstrom 2013;
Mondanaro 2008; Stafstrom et al. 2012). There is little published
about the role of the arts therapies in the treatment of motor neuron
disease. However, a case study presentation illustrates how someone
living with the condition can experience great joy and creativity and
reclaim a sense of purpose and achievement with the help of music
therapy (Mackinnon 2011).
Conclusion
This chapter provides an overview of the development of
neuroscientific ideas and the relevance of this to arts therapists
working with long-term neurological conditions. Ever since the
brain has been identified as the seat of thought processes, we
have attempted to relate its structure and function to physical
and psychological activities. Recent expansion in neuroscientific
knowledge and increasing understanding of neuroplasticity have
brought greater insights into how the brain develops, its capacity
for adaptation, and the complex integration of physical, sensory,
emotional, cognitive and social functioning.
In clinical practice we meet people for whom experience may
make little sense and words may have little meaning. To quote Oliver
Sacks (1991, p.8) this requires us, as practitioners and researchers, to
be ‘co-explorers in a land beyond the bounds of common experience,
and to seek images, analogies and metaphors to assist in bringing
the unthinkable into the realm of the thinkable’. Neuroscience offers
one such metaphor which, alongside other frames for understanding,
may help us to describe the sensory, nonverbal phenomena we
observe and experience in our work.
As arts therapists we draw on a range of theoretical, metaphorical
and symbolic frames to help us understand the personal and the
psychosocial contexts for therapy, to engage our clients in the
therapeutic process, and to make sense of the nonverbal processes
and narratives that emerge within the therapeutic relationship.
Knowledge about how the human brain functions, and the impact
of damage or disease, is helpful for understanding the experience of
those living with or caring for people with long-term neurological
conditions. There is still much that we don’t understand. However,
neuroscientific insights may, alongside other frames of reference, offer
new research opportunities which could help to support a developing
evidence base for the emotional, cognitive and psychosocial benefits
of the arts psychotherapies with this client group.
Acknowledgement
My thanks to Iris von Sass Hyde for her contribution to the writing
of this chapter.
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CHAPTER 2
Beyond Limits
Art Therapy with People with
Severe Physical Limitations
Simon Bell
Holism and interiority

When considering art therapy and people with severe physical
limitations, I would like to start from a holistic point of view.
The holistic approach incorporates the psychological, emotional,
spiritual, physical and social aspects of the human experience. Each
area of need is given equal value and importance (Bell 2008; Wood
and Pratt 1998). I would also like to consider disability first from
the interior, emotional and psychological dimension, and then work
towards the external, outward expression of this experience via the
body. The interpretation of what is happening is often based on the
presentation of these inner experiences through complex physical
movements within the limits of mobility. The art therapist is focused
on the total experience of disability, particularly when working with
those whose disability is the result of a life-threatening illness and
surgical or pharmacological treatment. The focus of attention is the
inner world of the person adjusting to a terminal illness and the
disabling consequences of many degenerative conditions.
Many of the physical, emotional and cognitive limits are
insurmountable restrictions reflecting the finite nature of the
human body. These restrictions may be not only the result of actual
physical disabilities, but also the extent to which the environment
62
Art Therapy with People with Severe Physical Limitations 63
and technology facilitate access to opportunities for overcoming

them. As a non-disabled person, I can experience these limitations
suddenly and abruptly. I can only reach so far before many things are
beyond my grasp, literally and metaphorically. Yet in many instances
I am not prevented from realising my potential to the same degree
as my disabled neighbour. Many disabled people may not be able to
achieve their potential for freedom of movement and communication
because of poor resources, a failure in others to understand their
needs and requirements, or the very real limits caused by many
forms of physical impairment and disability.
When considering limitations from the inside of the body to the
outside of the body, there is first a valuing of all inner faculties.
There is the recognition of the inner life despite extreme physical
limitations. If there is a sufficient level of neurological functioning,
then there is likely to be a sophisticated and complex awareness
of self, of the environment, the actions and communication of
others. There will be language in thought and a rich realm of the
imagination, even when verbal communication is no longer possible.
The mind and the emotions are fully alive and active. For instance,
Jean-Dominique Bauby (2008) and Stephen Hawking (Ferguson
2011; Hawking 2008) both overcame the almost total paralysis
of their bodies to communicate their experiences and express their
intelligence and sophisticated inner lives to the world. Their example
is a reminder of the complexity of thought and emotion that resides
within, even when physical function is reduced to the twitch of a
cheek or the wink of an eyelid, or even minimal registrations of
brain activity.
The use of music therapy

Examples of music therapy with people who have experienced
traumatic brain injury (TBI) illustrate how a creative approach can
yield surprising therapeutic results. Gibertson and Aldridge (2008,
p.37) describe the outcomes of a study using a ‘therapeutic narrative
analysis’ research approach. Their work shows how, within the
context of a neurological rehabilitation service, music therapy can
offer a mode of connection with a person in a coma. It can also
provide a means of translation and interpretation of the deep psychic

realities of such patients in the early stages of rehabilitation. This is
applied within an integrated system of care and offers a further layer
of understanding of the needs of people recovering from TBI. There
are many unique aspects to the use of music therapy that cannot be
replicated by other therapeutic interventions – however, the broad
principle of exploring the response to music in this context is similar
to opportunities for people with severe physical limitations to use art
materials and create visual images that reflect their physiological and
inner emotional realities. This challenges a purely functional view
of the care of the person impaired and disabled by, for example, a
stroke or brain tumour.
Being able to express ourselves in a relationship, to communicate
our needs and establish a mutuality of meaning, is central for
establishing our autonomy and for maintaining meaningful
relationships. This promotion of meaningful expression is an
important part of rehabilitation. It is not simply functional but
reflects what it is to be a functional human being. (Gibertson
and Aldridge 2008, p.50)
The use of art therapy

My PhD research (Bell 2008) focused on the meaning-making
that takes place in art therapy at the end of life. This is a context
where rehabilitation in palliative care has the goal to improve overall
quality of life, and not necessarily the recovery of functionality
or increasing longevity. The progression of a terminal cancer or
degenerative illness, when there is no longer a cure and prognosis is
poor, often requires an emphasis on addressing concerns related to
dying, loss, grief and maintaining identity and relationships.
There is always the danger that (as a non-disabled person)
I may not accurately interpret the level of psychic activity and
depth of emotional awareness that a physically limited person is
experiencing, particularly in the context of life-threatening and/
or life-limiting illness. It is therefore imperative in the context of
palliative care (which includes multiple sclerosis, motor neurone
disease, heart disease, stroke, brain tumour or other long-term
degenerative illnesses), that healthcare professionals help disabled

people to communicate and express their most profound inner needs
and desires. It is important that there is a good understanding of
the debate relating to disability and that current approaches to the
support and care of disabled people are considered (Barnes and
Mercer 2011; Shakespeare 2006). Art therapy is a useful way of
enabling a person who is experiencing the gradual loss of mobility
and increased disability, to continue finding creative ways to
communicate their experiences from a holistic perspective. When
mobility is minimised to the slightest movement of the hands, feet
or mouth, if a pencil or brush can still be held, there continues to
be a means for a person to be creative and express some aspect of
their world.
Peter’s story
When employed at a hospice in Sheffield, I worked closely with Peter,
a man in his fifties in the advanced stages of motor neurone disease.
The only mobility he still had was some movement in his neck, mouth
and eyes. His hearing was not impaired and his eyesight was still good.
He moved about with an electronic wheelchair, using a joystick with
his cheek to maneuver it around his home and any other environment
capable of accommodating it. I first met him at his home following a
referral from the specialist nurse. He was very low in mood at this
time and extremely frustrated with his routine. He could manage
some speech with great effort and much concentration from anyone
listening, which was a source of exasperation for him. He wanted to
paint and draw, and so began an experiment in facilitating this with
only the use of his mouth to hold a pencil or brush. The first attempts
involved a small easel clamped to the kitchen table, with brushes and
pencils wrapped in cotton wool and surgical tape, so that he could
grip them in the corner of his mouth. He navigated his wheelchair as
close to the easel as possible, and I held the paint palette and water at
the level of his head, so that he could learn to dip his brush in a pot of
water, strike the paint, mix a colour and daub the paper in front of him.
Peter took many weeks to perfect his technique, with many failures
of execution. However, he had a deep and unrelenting determination.
He built up his dexterity with his mouth painstakingly over weeks and
months. At one point he announced that he had commissioned his
brother to design and build an easel that he could drive up to at any
time. This frame had devices to hold brushes and pencils so that he
could grab them with his mouth. Pots and paints were suspended at
appropriate angles to allow him to find colours, mix and apply the paint.
He worked with watercolours, as they could be revived when dry, and
he could control the amount of water he added to the mixture. Peter
perfected his skills to the extent that he began producing delicate and
intricate watercolour paintings of plants, flowers and still lifes from
around his home. Each image was a composition of tiny daubs of paint
constructed delicately over long periods of time. Peter could only
work for 10 to 15 minutes at a time before he became exhausted.
I witnessed him recover a sense of purpose and meaning in his
routine, and he viewed his disability as a means to achieve a new
skill and overcome his limitations. There were often times when he
struggled, but he had discovered a new channel for his inner world.
The therapeutic benefits to him were immense, and as we worked
together, he shared his thoughts and feelings as well as he could
through slurred and sometimes indefinable speech. Engaging together
in this process established a nonverbal mutual understanding.
Art therapy has its roots in the appreciation of the nonverbal
dynamics taking place around the artwork and the process of making
drawings and paintings. It is concerned not only with the aesthetic
and practical aspects of art-making but with the meaning-making
that takes place too. This is where the personhood of the individual
is validated and given worth. It restores a sense of purpose, improves
and sustains quality of life.
To work with Peter and witness him achieve so much was an
incredibly rewarding experience. However, his experience is not
representative of the many people living with the impact of long-
term degenerative conditions. Often they do not live in homes with
level access, and may have to negotiate environments that are not
easily adapted to a wheelchair or other aids and adaptations. There
may not be the level of family support to facilitate greater mobility,
and economic circumstances may limit the installation of a stairlift
or technology to aid communication. The use of digital devices
or computer programmes to help with communication may be
beyond some people, as they require knowledge and skills in using
complicated IT procedures. I have worked with patients who are
confined to a downstairs or upstairs room in the home, where any
move to another area of the home or outside the home environment
would be a major logistical event, requiring much planning and
coordinating. These added limitations relating to socio-economic
circumstances and family context can have devastating constraints

on the inner emotional and psychological world of people with
neurological problems. It is therefore vital to discover creative ways
of entering the environmental and/or psychological spaces of people
with debilitating neurological conditions. Thus there is an important
role for art therapists as part of support services.
Tony’s story
I worked with Tony from the end of 2001 to May 2005. Tony and his
wife became known to the hospice during an admission for respite
care. They had worked through much of the initial distress following
Tony’s stroke over 12 months before his referral to art therapy by a
social worker based at the hospice. Tony was in his early fifties and
still adjusting to many life changes following the stroke, which had
seriously reduced much of his physical capacity. He was no longer
able to speak, although he could reply with ‘yes’ or ‘no’. His general
comprehension was good and he understood much of what was
said to him. The cognitive impairment was at the level of language;
he did not recognise words and could not always match them with
the objects to which they referred. He had been left with a right-
sided weakness and was unable to walk or move his right arm and
hand. Tony had become wheelchair-dependent. His wife was his main
carer, and together they managed his lack of mobility extremely well,
with his motorised wheelchair enabling frequent trips away from the
family home.
Prior to his stroke, Tony had led an academic life, and he continued
to have a sharp and responsive mind, despite the problems with
communication. At first Tony and I met weekly, then towards the end
of our contact we met once a month. When I first met Tony, he was
extremely low in mood, tense and frustrated. He had not recovered
as well as he had hoped, and his condition remained the same, with
little improvement in communication. Due to the loss of speech,
Tony was unable to communicate all his needs and experiences. He
could not write letters or words in any understandable order with
his left hand, so expressing thoughts, choices and feelings in writing
was almost impossible. He had very good facial expression and could
demonstrate his pleasure or disapproval. Later, he became more subtle
in his nonverbal body language, and his ability to respond to closed
questions improved. He also developed the ability to write single
words with his left hand, although this remained limited.
A speech and language therapist had supplied Tony with an

electronic communication system, which provided a word-and-picture
process for composing short sentences. He rarely used this during our
meetings, as he found the process too slow and demanding, preferring
to focus on the art materials.
Tony and I began a steady and longstanding working relationship
that focused around the art-making, based largely on nonverbal
communication. Tony responded positively to the use of art materials
and soon developed a capacity to use his left hand to create drawings
and paintings. Our contact finished when Tony decided that he no
longer needed art therapy and could manage on his own. His health had
remained stable and the imminent threat of another life-threatening
stroke had subsided. He had made good progress emotionally and
psychologically. He was far less frustrated by his new circumstances
and had overcome much of the earlier depression and despondency
at the beginning of our work together. Tony also wanted to develop
his new-found interest in art as an activity outside art therapy. In
discussion with Tony and his wife, we agreed that Tony no longer
needed art therapy, and that he would continue drawing and painting
for his own pleasure.
The sustained contact helped Tony recover his confidence and
sense of self-worth. He was able to use the art-making as a way of
working with feelings, overcoming his physical limitations and extending
his communication skills. He had established an attitude and outlook
on life that focused on his successes and achievements. He had gone
through a long process of adjustment. The lengthy contact had been
necessary to help Tony integrate huge losses into his life, recover his
sense of wholeness, and adapt to life with a permanent disability.
During our work together, I discovered a lively, enthusiastic
person who enjoyed humour and was able to share his successes
and frustrations. The art-making became a largely nonverbal dialogue
between us and we discovered different ways of communicating
through drawing together. We did not always understand each other,
and we were both often left bewildered and unsure of each other’s
intentions. There were times when Tony felt utterly dejected, and
exasperated at the lack of understanding from others of his feelings
and needs. However, he rarely expressed resentment and tended to
control and suppress his angry feelings. There was little he could do
physically to dispel these feelings, due to his level of disability. In this
sense, the art-making was cathartic, helping him to release the pent-up
emotions that he experienced.
Using art materials

My initial visits to see Tony took place in his family home, first in the
living room. I placed a board over the arms of Tony’s non-motorised
wheelchair, and a few drawing materials at his side. We then progressed
to a table that he could negotiate comfortably in his wheelchair to
reach the materials from his sitting position.Tony later moved to a flat,
another major adjustment for him. At this time he began to use a more
sophisticated, electronically operated wheelchair, and we worked at a
table he could drive up to and access with relative ease and comfort.
These first meetings were a little tense as Tony was uncertain as to
what he might achieve, and I was nervous about him experiencing an
early sense of failure. I encouraged him to use his left hand and arm, as
he still had enough strength and power to reach for and hold objects.
He discovered that he could control the use of a pencil and a brush
held firmly in the grip of his fingers. Tentatively he started to create
simple marks and shapes. Often I would draw with Tony, to establish his
confidence and help him discover the range of marks he could make
unaided. His mood was very low and he appeared troubled and in
conflict with himself. He responded well to my initial encouragement
and began to be more convinced by the potential of doing artwork.
At first, I provided fairly simple exercises that gave him the
opportunity to develop the motor coordination required to use the
materials. He gradually received some positive feedback as he realised
what he could achieve, and saw for himself how he could manipulate
the pencil to attain his intended goal. Simply getting the pencil to move
from one point to another was a success. He went on to develop
more versatility with this medium and discovered new ways of drawing
and painting.
Visual narrative
Tony’s drawings and paintings contained a wide range of themes, from
portraits of himself and his wife to abstract shapes and forms. Due to
his loss of speech and difficulties in communication,Tony was unable to
explain or describe the full meaning of each of his images. The content
of his images was arrived at through a joint effort. Many times we
would have a conversation through line. Tony made a mark and I then
followed by adding my mark to his. We created many drawings using
this simple process that would often last for 20 minutes or more.
Relationship, physical proximity and facial expression became
intrinsic to our mode of being together. The content of the images
emerged out of spontaneous engagement with the art materials. The
art-making became a space for having a visual conversation. Tony also

created images without my direct involvement, and approached this
with certainty and a sense of purpose.
Tony engaged with the art-making process in a sustained and
deeply committed way. He continued to draw and paint long after
he decided to end our meetings. It became an important mode of
creative expression and a source of pleasure for him.The drawings and
paintings below provide a sample of the images he created and their
potential meaning.
Figure 2.1 Spiral exercise (see colour plate).

In the early stages of working together, Tony tried exercises that
enabled him to discover the level of control he could have when using
simple drawing materials. Figure 2.1 was created in one of our first
sessions. I created a grid and asked him to draw several spirals, and
then to try and use a coloured pen to follow between the lines. Tony
was able to handle the physical movement required for this with skill
and great concentration. Here he was breaking new ground with the
use of his left hand, and the exercise gave him the initial confidence
and reassurance needed. He controlled the medium well and from
his wheelchair discovered a potential in these initial experiences that
carried us along through many hours of concentrated silence together.
Tony sometimes drew simple portraits, often of his wife, executed
in double-quick time. He expressed delight with his efforts and
responded with laughter. These images expressed the tremendous

significance of his relationship with his wife. They had a very close
bond and he tried to communicate the tensions and difficulties that
arose between them. On occasions he drew a self-portrait, which I
felt was his attempt to discover and reassert his identity and sense
of autonomy. The portraits symbolised his way of maintaining a sense
of self and connectedness with those who were of most importance
to him.
Our joint images took place in silence, and Tony often initiated
interaction by encouraging me to make the first mark. We soon became
absorbed together in this dialogue, using lines to create shapes and ideas
that neither of us could understand. He was frequently amused by any
error or hesitation with my choices of mark-making. The emotional
intensity and concentration felt like a test of my commitment to him.
He wanted to be assured of my undivided attention and continuity of
support. The long silences in our meetings were filled with nuances of
facial expressions, eye contact, nods and shaking of our heads as we
struggled to understand each other.
Figure 2.2 In conversation (see colour plate).

The dialogues with images are illustrated by Figure 2.2. These
interactions took the form of my making a small mark, then Tony
following with his mark, and so on, until the conversation ended. The
linear shapes and forms seemed to have an intellectual and cognitive

purpose to them. Sometimes Tony added numbers and letters, as in
Figure 2.2, as if attempting to recover his numeric and language skills
within the network of lines. These images formed structures and
networks that seemed to create a unique constellation of links and
points of connection.
We occasionally returned to more conventional themes and
Tony drew or painted something he remembered from nature or his
domestic environment. He enjoyed discovering the fluidity and use of
colour when using paint. After the success of gaining control of the
pencils and felt-tip pens to make drawings, painting provided him with
greater flexibility and spontaneity in his expression. This progression
lifted his mood and led to a general emotional improvement and
increased self-worth. These images suggested his enjoyment and
observation of the world around him (see Figure 2.3).
Figure 2.3 Memories and reflections (see colour plate).

With time Tony developed a wide range of skills that he used to
communicate, often with great difficulty, the thoughts and feelings
that he experienced. Tony seemed to have discovered a mode of
expression and communication that was almost poetic and symbolic.
I learnt to tolerate the mystery as to the full and complete meaning
of these images, and trust that their importance was intrinsic to the
imaginative engagement with the art-making.
The following series of images relate to one meeting. During
this meeting, Tony worked with energy and purpose. He chose soft
charcoal, a medium he had not tried so far. He began making quick and
energetic marks across the page (see Figure 2.4). He worked with a
determination and concentration that had a feeling of urgency about
it. He continued on to Figure 2.5. In Figures 2.4 and 2.5, the energy
was intense and focused.Vertical marks in Figure 2.4 changed in Figure
2.5 to circular movements and spiral shapes with dense black spots
as he pressed hard with the charcoal. Sometimes pieces of charcoal
crumbled from the stick, which gave him a few moments of pleasure
and mild amusement. In these two images, he seemed to express
energy and vibrancy through the charcoal with its soft, grainy feel that
obeyed his intentions.
Figure 2.4 and 2.5 Energy and emergence of form.
Figure 2.6 and 2.7 Growth and transformation.

Tony then moved on to the third image, and slowed down as he

created the forms in Figures 2.6 and 2.7. There was a feeling of fertility
and growth about these forms, like plants about to emerge from their
buds. It reminded me of Maclagan’s reference to ‘inarticulate form’
(2001, p.62), as if the first two images were the expression of chaotic,
undifferentiated energy, out of which forms emerged.The fourth image
looked like two heads in flight, with great ears or wings enabling them
to take off. I felt this image reflected our relationship, and how we had
been able to take flight imaginatively through our visual dialogue. The
emergence of these images seemed to indicate a transformation in
articulating form and meaning. The flying heads also suggest a pictorial
realisation of the psyche relating to self and other, free from physical
constraints.
Conclusion
As with many patients I have worked with, who were coping with
cognitive or physical impairment due to disease (such as a brain
tumour) or treatment (surgery, for example), there is often a desire
to reach beyond limits. As healthcare professionals in general, and
especially as arts psychotherapists, it is our response to these efforts
that can be critical in affirming self-worth and connectedness. This
response looks beyond criteria of functionality and attempts to reach
deeply injured and traumatised psychological and emotional areas of
need. This can have an enormously positive impact on the recovery
of communication and the expression of emotion. A sense of
participation can be established that affirms familiar and commonly
held realities and reduces isolation. This sense of connectedness
is often built on fragile threads of meaning, and requires creative
solutions and conditions in which to flourish and grow.
The achievements of the Paralympic Movement (Wood 2011)
illustrate how impairment and disability can be overcome. However,
many people whose impairments and disability are the consequence
of an acquired illness, accident or grievous bodily harm, often
struggle to secure adequate emotional and psychological support.
These case vignettes show how art therapy is an effective response to
the complexities and subtleties of the inner world and deep psychic
needs of people living with severe physical limitations.
References
Barnes, C. and Mercer, G. (2011) Exploring Disability: (Second edition.) Cambridge:
Polity Press.
Bauby, J.-D. (2008) The Diving-Bell and the Butterfly. London: Harper Perennial.
Bell, S. (2008) ‘Drawing on the End of Life: Art Therapy, Spirituality and Palliative
Care.’ Unpublished PhD Thesis: University of Sheffield.
Ferguson, K. (2011) Stephen Hawking: His Life and Work. London: Bantam Press.
Gibertson, S. and Aldridge, D. (2008) Music Therapy and Traumatic Brain Injury: A Light
on a Dark Night. London: Jessica Kingsley Publishers.
Hawking, J. (2008) Travelling to Infinity: My Life with Stephen. London: Alma Books Ltd.
Maclagan, D. (2001) Psychological Aesthetics: Painting, Feeling and Making Sense. London:
Shakespeare, T. (2006) Disability Rights and Wrongs. London: Routledge.
Wood, C. (2011) The True Story of Great Britain’s Paralympic Heroes. London: Carlton
Books Ltd.
Wood, M. and Pratt, M. (eds) (1998) Art Therapy in Palliative Care: The Creative Response.
London: Routledge.
CHAPTER 3
The Janus Response

Coming to Terms with Changes Due to Brain
Injury or Other Neurological Condition
Iris von Sass Hyde
Introduction
Janus is the Roman god who faces both ways, the god of gateways,
and after whom January is named. In Rome the Janus gates were
opened in time of danger to allow the troops to storm out to deal
with the crisis. They were closed again when the crisis was over, and
people could focus again on their own life and pleasures.
In September 1996 I began work in a newly created art therapy
post working with neuro-rehabilitation patients on Ashby Ward
in Lincoln Hospital. Three years later I undertook a research MA
at Sheffield University in which I evaluated the images created by
100 patients. In this thesis I looked in depth at the patients’ work,
assessed their individual personality types and considered their
personal relationships. I traced these patients’ psychological and
emotional rehabilitation on the ward and in the community. I also
looked at the different use of time whilst engaging in the art therapy
process, according to their neurological and physical state. All the
patients gave their written consent.
I found that a pattern emerged in the patients’ art therapy
images, which mapped their inner journeys during rehabilitation.
‘The Janus response’ is the term I developed to describe the distinct
76
Changes Due to Brain Injury or Neurological Condition 77
stages I saw in the patients’ images and the work they did in the art
therapy sessions.
Patients usually started by remembering the person they were,
their past life and their significant others. They then focused on
present issues and demands, significant relationships, and interests
in the ‘here and now’. Finally they were able to look towards their
future and their discharge – closing the gates in their Janus response.
The work of the unit

In the western world, road traffic accidents (RTAs) are the most
common cause of spinal cord and traumatic head injuries. More than
half of these occur in the 15-to 25-year-old age group. Lincolnshire
is a large county with a low population, but an above-average rate of
severe RTAs and fatalities. Most Lincoln-based head-injured patients
are referred to our unit after their acute care.
These patients often sustain other injuries and fractures, which
complicate their recovery, and the physical injuries may well be
accompanied by a host of other difficulties. These can include
considerable communication problems, reactive depression, dysphasia
and amnesia. Patients often feel loss and bewilderment at their injury.
They may have no memory of the accident, initial hospitalisation or
surgery. They may not remember others injured, perhaps fatally, in
the accident and they may not even recognise or remember members
of their own family. Loss of a sense of self, in the deepest sense, is
the very real handicap to recovery and rehabilitation for all these
patients. Those whose injury has been caused by an assault on their
person by another have the added trauma of a personal attack. This
casts a long shadow on their psyche, and leaves additional deep
psychological scars. The fact that someone wanted to harm them
needs sensitive working through in the safe space of art therapy.
All members of the multidisciplinary team aspire to handle
patients with sensitivity. However, art therapy is the treatment that
provides a safe place where they themselves have the opportunity
to piece together the fragments of what has happened to them and
their families.
Patients with neurological diseases, such as multiple sclerosis (MS)

or motor neurone disease (MND), have different issues. They do not
become severely ill overnight. They often have an insidious onset
of transient symptoms that, for a long time, may be elusive. They
may face the problem of being ‘fobbed off ’ or not being believed,
so that they themselves become suspicious of their own symptoms.
MS is the most common neurological disorder of young adults in
temperate latitudes. It is more prevalent in women than in men, in
a ratio of 3:2. The peak age of onset is around 30 years, but can
range from 15 to 45 years. Other neurological diseases treated on
the unit include Parkinson’s disease and brain tumours. The different
character of each disease affects the individual patients, dictating
their needs, their capabilities, and how art therapy can help them.
The art therapy service

Both the neurologically injured patients and those with neurological
disease were seen on a one-to-one basis. The role, purpose and
confidential nature of sessions and images produced was discussed
when I first met the patients. One-to-one input helps the patient
concentrate and allows them time and space to come to terms with
their changed condition and its effect on them and their family. It
also enables the therapist to be sensitive to individual needs and
personal situations, and to maintain confidentiality. Anne Gray’s An
Introduction to the Therapeutic Frame (1994) was of great help to me in
setting up the right therapeutic framework for different individuals.
Timescales
I saw the patients recovering from head injury for art therapy for a
period of three to seven months, occasionally longer. However, I saw
the patients with neurological diseases such as MS for one to two
weeks during their brief admissions, and every four to six months
during their respite or re-assessment admissions. Occasionally, if they
required longer hospitalisation, I extended the art therapy sessions,
but this was rare. The length of time working with these patients
was short, but because they knew it was the only time available, and
that it would be continued on their next admission, they generally

engaged in the art therapy process well.
For all patients, the plan was to allocate 50 minutes – the
‘therapeutic hour’. However, some patients in the early weeks were
only able to take part in the activity for 15–20 minutes. For the head-
injured patients, this might be due to cerebral irritation, leading to
a shorter attention span. Patients with MS may find their memories
affected by cerebral plaques or general fatigue. Both groups can suffer
from visual problems, or have difficulties in holding art implements
for a variety of reasons. By offering shorter time and accepting their
need to finish and leave, the patient’s sense of acceptance and self-
worth was maintained. As the patient improved, the length of session
could increase week by week to the full therapeutic hour. But for
those unable to increase their therapy time, the shorter periods were
used fully.
The therapeutic journey

All patients who come to the unit need to have the facility to attempt
to work through their loss, and their problems – past, present and
future. This can be offered in art therapy. For some patients the task
has complications.
Premorbid factors
The way in which patients respond to art therapy is partly dependent
on their core personality or premorbid state. This, in turn, is affected
by their early attachments and early relationships. There are some
patients whose past casts a darker shadow, more fearful than their
present medical condition. Their Janus response is a pressing need to
‘open the gates’ in their art therapy sessions and focus on past events,
relationships and traumas. Only then can they reflect on their altered
present, and their unknown future.
Separation and attachment

Patients who have known separation or experienced difficulties in
maintaining relationships within their own families may mirror
this on the unit with staff and patients alike. Indeed, they may be
disruptive during their rehabilitation admission and may be referred
to art therapy for this reason. John Bowlby (1973) has much to say
of relevance about such patients. He clearly demonstrates the links
between deprivation of consistent closeness of someone’s principal
carer in their early years and the inability to forge close bonds in
later life. This can lead to lack of trust in others and disruptive
behaviour, and could be a real block in these patients’ rehabilitation.
Such patients needed the space to allow their anger, rejection
and heartache to find expression in their images within the safe,
accepting art therapy sessions.
The emotional outcome of injury and disease

A few people can never accept their changed condition and future
limitations, nor can they accept the past pain. Others who appear
more resigned and submissive may actually give up trying, even
with the things that they can do. These patients can turn inwards
and become deeply depressed, or turn outwards to those around
them, and lash out at their remaining family or carers. So while
some patients and their families will stick with each other through
thick and thin, others disintegrate, destroying what they have and
what still could be. The effects of family leaving them or incidental
cruelty towards those who can no longer look after themselves are
a bitter reality for some patients. This adds greatly to their misery
and humiliation, harming them more than the pain of their injury
or disease.
Whatever the diagnosis, each patient is unique and responds in a
unique way. Their progress and limitations are their own. They need
to be accepted for the people they are and offered accompaniment
for their individual journeys of ‘individuation’ within the art therapy
encounter. Carl Jung, who developed the concept of individuation,
said, ‘I use the term individuation to denote the process by which
a person becomes a psychological individual, that is, a separate
indivisible unity, or whole. Individuation does not shut one out from
the world, but gathers the world to oneself ’ (Jung 1979, p.228).
The patients thus face their past selves, their changed future, and
all that the present contains. This is the Janus response.
The research
Themes and stages revealed in the images
All the 100 patients’ art images were carefully assessed in a sensitive,
comprehensive, confidential appraisal of each piece and how it was
created. What the patients said about them was significant and taken
into account. Comparison of the 100 patients revealed the following
archetypal patterns in subject and content: significant others, present
issues, wide horizons. Archetypes, also an idea developed by Jung,
are repeated themes and images that recur personally or universally,
echoing shared images, events or themes. They occur frequently
in the patient’s dreams or life. Some would say they are part of
everyone’s DNA.
1. SIGNIFICANT OTHERS
This may be an image of a significant person, pet or companion,
place or event. All these are memory-based, building up the patient’s
sense of their past selves and former reality. They may recall strong
attachments and significant events or places; each is meaningful to
the patient.
2. PRESENT DAY-TO-DAY ISSUES AND LIFE NOW

The images show how the patient’s world has often become the
hospital unit, with its own dynamics, friendships and tensions. Ward
issues may become, at this time, more real than their former life and
hold their full emotional focus. Good or difficult issues are included.
3. WIDE HORIZONS
In this last group of images, patients generally show a remarkable
change from whatever has occupied them previously. The images
reveal wide, open, lyrical horizons. They reflect an internal change
in focus and outlook from past places and past relationships, through
the present ward dynamics, to the horizons of life outside and the
longed-for discharge.
The patients covered all these distinct stages, spending varying time
in the different areas, and sometimes returning to one previously
visited. They looked at their past, dealt with their present situation
and relationships, and then were able to face their changed future.
Each journey was intensely personal and meaningful.
Case material: the Janus response

Significant others: place
The first image (Figure 3.1) is from one of the first patients I saw
on Ashby Ward and whom I continued to see for art therapy during
his biennial MS admission. He was a quiet, courteous man, who
had been a master builder. His company had been sad to let him
go when his MS was finally diagnosed. However, double vision,
numbness and loss of balance sadly made it inevitable. Now he was
wheelchair-bound, and at home went out very little, becoming a
self-made recluse. Nevertheless, on the unit, where other patients
were also in wheelchairs, he felt accepted amongst peers with
similar problems.
Figure 3.1 The sanctuary of boyhood.

In early art therapy sessions he used pastels to create a vibrant image

of his favourite place to fish, both as a young boy and as an adult.
He remembered it with great affection; especially as later he had
shared that place with his son. This was his sanctuary, his special
place, at Woolsthorpe near Belvoir. His face softened when he spoke
of it. Perhaps in that image he felt he was back there. It had both
meaning and significance, and continued to do so whenever the two
of us reviewed his work. This was his significant place.
Significant others: place, event and living creatures

This image (Figure 3.2) was created by a patient involved in a
serious road traffic accident. He had been working temporarily
as a taxi driver, while waiting for a job to start after a period of
unexpected unemployment. He lived in rural Lincolnshire, where his
accident occurred. His initial treatment had been in a Lincolnshire
hospital before being taken by helicopter to Addenbrooke’s
Hospital, Cambridge. He had complex fractures and head injuries.
Three weeks later he was transferred back to Lincolnshire to our
Rehabilitation Unit.
Figure 3.2 First holiday in the Austrian Alps (see colour plate).
Because of his injury, this patient could only use his right hand for
short periods, and he resorted to using his left hand when his right
hand was tired. His vibrant image almost covered the entire page of
blue sugar paper. He sketched in a turquoise lake, the clear colour
still a potent memory after 30 years. He sketched in the brown
mountains with summer snow on the highest peaks. Around the
lake on three sides he carefully placed dark green pines and swaying
grass with lovely wild flowers too fragile to include in this image,
all canopied by the intense blue alpine sky. This alpine lake was his
significant place, discovered on his first holiday abroad. He then
created another pastel sketch of the horse he so pined for during his
long hospital admission (Figure 3.3). This was Diamond Dancer, a
stallion that missed him. The stallion too was restive. He did not let
anyone else ride him, and could not understand his owner’s absence.
How does one reassure a pining horse? His significant other was
his horse.
Figure 3.3 A stallion called Diamond Dancer.

Fortunately the patient’s progress continued, the external fixator
holding his broken leg was removed, and a weekend at home was on
the horizon. Then he and Diamond Dancer would be reunited. For
this patient his ‘significant others’ were threefold – a place, an event,
and a four-legged friend. All had significant empowering effects as

he began the long journey towards changed options and lifestyles.
Present day-to-day issues and life now

At times patients only wish to focus on the ‘here and now’ of their
ward life, with all the dynamic issues that arise. One such patient
was a woman in her fifties with MS. In general she was coping well
with the hard adjustments and curtailments to her life. This included
ending her musical career as a pianist.
On this admission she had to have a supra-pubic catheter inserted,
and had to accept having a hoist installed at home. But it was little
difficulties that really upset her. Once, when supper was served, she
chose a yoghurt for dessert. The unopened yoghurt was placed in
front of her with a teaspoon. The member of staff left the room,
unaware that the patient could not open the lid of the yoghurt pot.
In frustration she left the dessert unopened and uneaten. She was
very upset by this trivial but humiliating incident.
Her Conté pastel sketch held that difficult moment (Figure 3.4).
The patient was aware that others had more serious problems and
how fortunate she was to have the support of her husband and
family. But in spite of all that, it was the closed yoghurt pot that
defeated her and reduced her to tears. It was her ‘Achilles heel’ and
she needed to focus on this hurt in the safe space of the art therapy
room before carrying on with all the pressures of daily living. It can
be the little things that stop our patients in their tracks and really
demoralise them, underlining their losses.
Figure 3.4 The unopenable yoghurt pot.
Wide horizons: going home

Each patient creates their own agenda in the art therapy room.
Each may need to dwell on different parts of their Janus response.
But, however they have worked, once they have their discharge
date, their outlook and images often change radically. Typically,
they suddenly create rolling landscapes. These images were often
entirely imaginary – archetypal scenery with open skies and wide
horizons. Sometimes it was only after their landscape was finished
that they told me of their discharge date. They little realised that
their images had revealed the fact already. Patients were optimistic,
sometimes unrealistic, but most shared an archetypal hope as they
were given the date of their discharge from hospital back to life in
the community.
Of these four examples (Figures 3.5–3.8), three are in poster
colour, and one in pastel. Each reflects the wide, open horizons
of discharge.
Figure 3.5 Poster paint open vista by male

patient with MS (see colour plate).
Figure 3.6 Foam roller brush hillsides by female

patient with MS (see colour plate).
Figure 3.7 Pastel sketch of seascape by patient

with head injury (see colour plate).
Figure 3.8 Poster paint image by patient with head injury (see colour plate).
Individual case history: Traumatic head injury caused by assault

Brian was a young man, looking younger than his 23 years. He had been
pushed out of a high apartment window in Nottingham by four local
young men. His girlfriend owed them £40 for drugs, which they both
used. He was initially treated in the intensive care unit in Nottingham.
However, he lived in Lincoln, so was transferred to Lincoln Hospital
and then finally to our unit.
On arrival, his tracheostomy was still in place to assist his breathing,
and he had a metal ‘halo’ to support his cervical spine. He was now
paraplegic due to the severity of injury to his lumbar spine on impact,
and was totally wheelchair-dependent. He was a slight young man,
fearful that his attackers might return to finish teaching him the lesson
they planned for those who did not pay their dues.
He had been referred for art therapy by one of the ward sisters,
because the assault on his person and resultant paraplegia had
resulted in severely changed life options and future prospects. He was
responsive when I made myself known to him and discussed starting
art therapy on a regular basis. I spoke to him in simple terms of the
nature, purpose and confidentiality of art therapy within our unit. He
spoke of his background, of his parents and their divorce, and of his
sister and himself being abused by his father at an early age.
On a later occasion, he told me that it was his father who had
introduced him to drugs at the age of nine. Smoking ‘grass’ had led
him to the use and abuse of other substances, from which emerged a
pattern of dropping out of school, aggressive behaviour, and funding his
new habit by many a scam. This escalated to shoplifting to the value of
£200 a day, which made him known to both police and stores. But now
he really felt that he had been given a second chance – a new start – by
surviving the attack, in spite of his considerable permanent disabilities.
He saw this as the one positive edge to his terrible assault. He wanted
to commence art therapy immediately, and set out then and there to
paint his first image in poster colours (Figure 3.9). This was of himself
being pushed out of the apartment block window, and of the base of
the tree where he landed. The sensation of landing was very real to
him, a state of terror and pain.
Figure 3.9 Pushed out of the apartment window.

This first emotive image was quickly, indeed compulsively, created. He
also told me that he had not told the police that he remembered
everything, although he did, in fact, recall it very distinctly. Revealing
names, he felt, could mean more harm to him and his girlfriend.
In intensive care he had gone ‘cold turkey’ from all the drugs he
had been using. Having survived, he was determined not to return to
his drug habit, but was really afraid that his attackers might return to
silence him. This fear was very present and he needed to focus on the
attack in the safety of the art therapy room, and not be hurried in any
way until he was able to ‘move on’.
In this first image, Brian used poster colours and brushes with
simple, direct strokes and quite rapid hand movements. He was able
to use his right (dominant) hand and worked for about 15 minutes on
this image, then spent about 10 minutes discussing issues arising from
it. Having finished, he wanted to go back to his own room. We fixed his
next session and he left the art therapy room in his wheelchair.
In these early sessions, because of his many complex fractures,
his tracheostomy and spinal injuries, his concentration time was
limited. He could only manage short sessions of about 25 minutes. My

uncommented acceptance of these short, suddenly ending sessions
was part of the simple ‘holding and acceptance’ in the safe space of the
art therapy process.
Brian came to his second session on time, finding his own way
to the art therapy room from the main body of the ward. He was
anxious to tell me all that had happened over the previous weekend.
He had had an important visitor and had still kept to his intention
to stay away from drugs and his former life. His visitor had been his
girlfriend, who had created the incident in which the assault had been
committed. She had come offering to supply Brian with heroin and
anything else he wanted. He had said that he had decided to stay off
drugs, and therefore ended their relationship. He did this so that he
really could remain clean from drugs permanently – a significant and
courageous decision.
His second image was again in poster colour, on blue sugar paper.
It showed a white, mask-like face with a blue-edged crown, on which
was painted, in green, the word ‘BANG’. To the right of the mask-like
face was a crudely outlined syringe, full of some recreational drugs.
Beneath this he had written in black letters the word ‘WITHOUT’
(Figure 3.10).
Figure 3.10 Looking at life without drugs.

Brian was adamant that he did not want to return to his former life
of drugs and crime, and continued to be aware of what he called his
second chance of life. Even life in a wheelchair had more options than
his former life, he felt. The reality of this was visible on the unit, where
more than 90 per cent of patients were wheelchair-dependent.
In all, I saw Brian for 25 sessions over a period of six months.
During the early weeks of his admission his great grandmother died
in the adjacent radiotherapy unit. Her funeral was at the crematorium
a week later. Brian did not create an image that week, but showed me
a photograph of himself aged 12, with his grandmother. It was a much
worn, cherished photograph. While his parents were splitting up, he
and his sister turned to her and she was always there for them. He felt
her loss very deeply.
He took up Conté pastels and created his own tribute to his ‘Nan’,
whom he had loved so much. This image had the wooden coffin with
its own plinth in front of a blue curtain. In mauve letters above the
coffin he wrote ‘We all love you Nan’. Below he wrote ‘Goodbye Nan’
(Figure 3.11). A little paper boat, such as she had taught him to make,
was sailing away into the unknown. Brian was very affected by this
event. He also realised that it could have been his own funeral, and it
made him take stock of his past life.
Figure 3.11 Death of a significant other.

The following week, Brian had his silver tracheostomy tube taken
out and resumed normal speech and swallowing. This was a positive
milestone for him. The length of the art therapy sessions increased
gradually to the full therapeutic hour and he experimented with
different art materials and methods. He created one particularly
powerful image using wet paper and abstract application of poster
paint to create fluid, abstract tones. The page was folded to create
a mirror picture (Figure 3.12). This created a poignant image of a
suffering, haunted face. Brian named this image ‘An elephant never
forgets – addiction’. He felt that it mirrored the despair and dark side
of addiction and that he, like the painted visage, would never forget
what addiction had done to him.
Figure 3.12 Addiction: an elephant never forgets (see colour plate).

Brian occasionally went to his mother’s house over the weekend. This
was a significant transitional stage in his rehabilitation. Back on the
ward he continued with various therapy programmes. In physiotherapy,
he was learning to walk between parallel bars. In occupational therapy
sessions he was encouraged to cope in a kitchen. He was even thinking
of attending North Lincolnshire College for courses to set up a
business with an able-bodied friend.The fact that he was thinking about
a realistic future was good. He realised that he could not live with his
mother when discharged. Therefore, with the occupational therapists,

he visited several nursing homes for young disabled adults. Finally, he
selected one ten miles north of Lincoln. He would have his own room
and there were good facilities for individual and group activities.
I visited him twice in the early weeks of his admission to his nursing
home. This enabled art therapy to act as a bridge in the transitional
stage as he came to terms with his new environment and lifestyle.
However, I was aware that the earlier openness was no longer there –
perhaps it was no longer needed.
On the occasion of his last art therapy session on Ashby, he created
a lively poster image. The spectrum of colour was bright and strong,
different from his earlier images. It contained three horizontal bands
of azure, prussian blue and gold. On the gold sand he had painted
himself, centre stage in his wheelchair. He had his feet on the floor,
as he often did, ‘walking the chair’. He had really caught the essence
of himself. Then, on the far distant sea edge, he painted an image of
himself, without the chair, walking on water (Figure 3.13).
Figure 3.13 Present hopes and future dreams (see colour plate).
This showed how, almost as amazing as walking on water, he had left
his past life of crime and drugs behind and made a new beginning, with
a new sense of self and possibilities for a future.
Brian worked through many of his problems, but his case showed
the scarring effect of what John Bowlby called ‘present absence’ and
‘absent present’ parenting (Bowlby 1973, pp.42–44). Brian’s father,
absent in fatherly roles, was present enough to abuse him and his
sister, and to introduce Brian to drugs at the age of nine. Their young,
vivacious mother, with whom they lived, was too focused on her own
life and pleasures to bother with the daily needs of her children. She
was present, but absent to their wants and needs, although they adored
her. His Nan had been there for him.
Inadequate parenting played a significant part in Brian’s emotional
make-up. As Bowlby describes in his book Attachment and Loss (1976),
recognisably negative behaviour arises where there has been an
absence of nurturing and attachment in the early years. This can lead
to aggression within a peer group and towards authority. I feel that
this may have been a strong factor in Brian’s peer group difficulties at
school and even on the unit with some of the patients and staff.
In spite of these difficulties Brian made real strides in all aspects of
his rehabilitation. He did not return to his old ways of drug-taking and
crime. He continued to live at the nursing home, where he remained a
loner. He attended North Lincolnshire College the following autumn.
Conclusion
Within this reflective research study I witnessed much. I saw in most
patients’ artwork and therapeutic encounters a clear ‘Janus response’
that mirrored their personal, psychological and emotional recovery.
Patients needed to look back at the person they had been, or to
remember meaningful events or places. They had to deal with the
daily challenges that they faced in their changed or changing lives.
They did this by remembering their past, dealing with their present,
and facing their changed future ahead.
There were patterns to the pace and timing of the therapy.
Head-injured patients required a slowly rising scale of art therapy,
commencing with brief sessions and building up to the full
therapeutic hour in a sensitive way. Patients with neurological
disease, however, such as MS, needed to reduce their sessions as their
disease progressed or relapsed. But whatever the course of therapy,
all the patients’ images were a rich harvest that taught me about the
purpose and scope of their individual response.
The Janus gates were open in time of danger, and this mirrored
the patients’ openness to their therapist at difficult times. The Janus
gates were shut in peacetime, reflecting their independence and
lesser need of the therapist when things were going well.
References
Bowlby, J. (1973) Separation: Anxiety and Anger. London: Pimlico. (Originally published
1973 by Hogarth Press and the Institute of Psychoanalysis.)
Bowlby, J. (1976) Attachment and Loss. London: Pimlico.
Gray, A. (1994) An Introduction to the Therapeutic Frame. London: Routledge.
Jung, C. J. (1979) Word and Image. Bollingen Series. Princeton, NJ: Princeton
University Press.
Van Dijken, S. (1998) John Bowlby, His early Life. London, New York: Free
Association Books.
PART II
Acquired
Brain Injury
CHAPTER 4
Who Am I Now?
Art Therapy, Identity and Adjustment
after Acquired Brain Injury
Carole Connelly
What makes us who we are? Our unique DNA code, family

experiences, socio-economic status, good and bad life experiences,
gender… How do we define ourselves? By what we do, via
relationships, through our interests? Now imagine, whatever your
view of yourself, that an unpredictable event occurs and everything
changes… From doing whatever we want to requiring help, from
autonomy to dependence. These personal and relationship change
issues were addressed in Micheal Sucsy’s film The Vow, released on
22 January 2012 (Williams 2012). The film is based on a book
about an American couple, Kim and Krickitt Carpenter. It is about
Kim trying to be a good husband to a wife who has no recollection
of their past, and Krickett trying to be a convincing wife although
not knowing her husband.
This chapter outlines how persons, following acquired brain
injury (ABI), utilise art media to re-establish personhood and a sense
of agency and autonomy. It describes an illustrative project and a
single case study.
99
Service context
The Regional Acquired Brain Injury Unit (RABIU), Belfast
Health and Social Care Trust, is a 25-bed, purpose built, specialist
rehabilitation unit situated within the grounds of Musgrave Park
Hospital, Belfast, Northern Ireland. The unit accepts persons with
ABI. They range from those in low level consciousness to those who
are independently mobile but have major cognitive deficits. Most
patients are able to participate in patient-focused rehabilitation.
Outpatient rehabilitation for patients attending on a daily basis is
also provided. Following initial assessment a rehabilitation aim is
set by the team in conjunction with the patient and their family/
carer. Each patient’s rehabilitation programme is devised in order to
maximise their level of independence and minimise carer burden.
Persons may be admitted from any of the five current integrated
health and social care trusts within Northern Ireland (estimated
population 1.8 million). Neuro-rehabilitation is provided via an
interdisciplinary team model and delivered by nursing, physiotherapy,
occupational therapy, speech and language therapy, dietetics,
neuropsychology and social work, with additional part-time input
from music and art therapy under the direction of a consultant in
rehabilitation medicine.
Establishing an art therapy service

Setting up a new art therapy service in the RABIU was challenging.
The unit was officially opened in May 2006, but two years elapsed
before I was appointed. On my arrival, significant changes were
taking place within health and social care trusts in Northern Ireland
(in Belfast alone, six trusts were amalgamating to become one large
trust). A small, L-shaped room had been allocated for art therapy,
with one table and no materials. By the end of the first week I had
my first patient, an artist, and was given £50, taken from patient’s
comfort funds, to buy art materials.
Due to my feeling isolated in the unit, and unsure how art therapy
would fit into the existing structure of therapies, Dave Rodgers
(my art therapy supervisor) sent me an article entitled ‘Preventing
vicarious traumatisation of mental health therapists: Identifying
Art Therapy, Identity and Adjustment after ABI 101
protective practices’ (Harrison and Westwood 2009). This prompted

me to develop a link with the unit’s neuropsychology service, which
is now responsible for my clinical supervision.
In establishing the service, two main strands of work, namely
group projects and individual work, have developed to date.
Identity and loss are key areas people struggle with following a
traumatic brain injury, and I felt that one way of safely addressing the
issue of identity might be a group portraiture project. Portraiture can
be one way of looking deeply at oneself. Some patients had already
been drawing or painting themselves in my individual art therapy
sessions. I asked the Arts Care Artist in Residence if she would kindly
bring her skills to the group, as she is both an accomplished portrait
painter and owner of a special ‘Pop Art’ computer programme which
can be a mechanism to make portraiture accessible to previously
untutored or unskilled artists.
Portraiture
Making a portrait of someone is an honour and a privilege. It is
an opportunity to look deeply into another, to see the essence
of spirit as it sweeps across the surface.
(Philips 2000)
For centuries artists have produced self-portraits. One of the first
known was made by the Pharaoh Akhenaten’s chief sculptor, Bak,
in 1365 BC. Since the Renaissance, artists have used self-portraits
to explore identity and ask the question: Who am I? Our character
and identity is expressed by our face and its expressions. After brain
injury a person’s face may look different or damaged, and even if it
doesn’t, their sense of identity is different.
Many famous artists, such as Rembrandt, Munch, Lowry, and
Bacon employed self-portraiture to reveal something of themselves.
The famous Mexican artist Frida Kahlo, after a catastrophic
accident at the age of 18, painted numerous self-portraits throughout
her life. Some of these very graphically communicate and express
her painful experiences. Painting them may have helped her come
to terms with her trauma. Her self-portraits provide the ‘internal
dialogue’ of her life. Picasso’s self-portraits reveal complicated

psychological insights, both personal and profound, about his inner
state. Some artists who suffered neurological or physical diseases
have left self-portraits that have allowed later physicians to attempt
to analyse disruption of mental processes; notably, Paul Klee, Giorgio
de Chirico and Egon Schiele (Bogousslavsky 2010).
The ‘Pop Art Portrait’ project

The process of producing a ‘Pop Art Portrait’ entailed taking
a number of photographs of the person, from amongst which
their favourite image was chosen. This was then imported into a
computer program and a number of different colour combinations
were generated. These images were shown to each person, giving
an idea of what was possible and how they would ‘look’ in different
colour schemes. Each person chose their own colour preference.
Their image was then projected onto a large, 65cm square board,
making it easier to paint when someone has a weak arm or their
sight is affected.
After the project was started some staff showed interest, and the
decision was taken to include staff portraits. It was felt that this
might reduce any perceived barriers between patients and staff, and
promote a sense of inclusion. People painted alongside others in
the unit and each understood that their portrait would be displayed
with those of other patients and staff on a link corridor between the
brain injury unit and the main hospital. At all stages each patient (in
total 26) had the right to withdraw from the project and not to have
their finished portrait displayed. However, more patients and staff
wished to participate, and from small beginnings the project grew
to 48 portraits.
A cohesive rehabilitation unit in itself generally promotes a
sense of belonging. All those involved have a combined identity as
well as an individual identity, an identity within a group. In a real
sense, individuals were leaving their mark when their portrait was
erected and publicly displayed, denoting in part their importance as
a person. It is generally the rich and famous who have their portraits
displayed on public walls.
The official opening after one year of the project provided an

opportunity for those involved to meet up post discharge, along
with family members. This event was a focus for the achievement of
patients and the re-emergence of personhood following significant
brain injury.
Work on this theme of changing identity continues for new
patients in the form of two groups, one for men and one for women,
where more personal issues can be addressed.
Individual art therapy: A case study

Art therapy was like a little haven where I was surrounded by
beautiful images, a getaway place, a secret tree house. It was
like having a visitor in prison. In my head you need an art room
where you can come in and make a mess and leave it. (Martin
Campbell, 2010)
Martin was 46 years old when he suffered a brain stem stroke and was
initially diagnosed as having locked-in syndrome. (This is a condition
where the person is paralysed but largely intellectually intact,
imprisoned inside his own body, unable to speak or move.) He had
been observed to be in this condition for the first two weeks post
stroke. When I met Martin he was reading Jean-Dominique Bauby’s
memoir entitled The Diving Bell and the Butterfly (Bauby 1997). He
needed to speak at length about this time and how he had felt being
imprisoned inside his own body, listening to staff talking about him and
being unable to respond – ‘it was Hell’, he said.
At the time of his stroke Martin was working as a project manager
in the Middle East and spent 11 weeks in an intensive care unit there
before being transferred to Northern Ireland. He was to spend a
further four weeks in an acute hospital before transferring to RABIU.
During this time he had an image of the rehabilitation unit as ‘cutting
edge’ – a NASA-like environment where he felt he was going to be
cured. Speaking of this later, Martin reflected on the mythical quality the
unit had held for him and how his imagination could go into overdrive.
When Martin arrived in the unit he had a tracheostomy (trache)
tube. This had been inserted following his stroke, as he was unable to
breathe for himself. When his trache was removed, he had low-level
volume speech (dysarthria) and compromised swallow (dysphagia).
His recovery was expected to be slow and prolonged. Initially his
stay in the unit was to have been between two and three months.
However, he remained an inpatient for five months until he was able to
be discharged to a self-contained flat with a care package in place. He

was cognitively intact, had good vision in his right eye, the use of only
his left hand, and reduced left-sided hearing. Martin had his left eyelid
sewn shut to minimise the risk of developing an ulcerated cornea.
Following his discharge, Martin agreed to share his work and
comments for this chapter. I chose to ask him for permission to write
about his art therapy for a number of reasons. From the start he was
committed to art therapy and after his initial assessment session he
enquired, ‘Please can I come again, it is great to come to hospital to
enjoy myself.’ He found art therapy resonated with him and was an
instant match.
Frances Kaplan (2000) points to the work of the leading
neuroscientist V.S. Ramachandran, who postulated that very early
in evolution certain visual areas were directly linked to limbic
structures to produce a pleasant sensation, since this would enhance
the animal’s chances of survival. Martin also felt his images helped
him access parts of his hidden life. Martin seemed to sense that
the images he was making were symbolic and contained not only
memories he was aware of and could illustrate pictorially. He was
aware of unconscious elements residing within his pictures.
Thus a word or an image is symbolic when it implies something
more than its obvious and immediate meaning. It has a wider
‘unconscious’ aspect that is never precisely defined or fully
explained. (Jung 1978, p.4)
This case study will demonstrate how Martin used art for coming to
terms with his acquired brain injury, by looking at his previous life.
Using a very tactile method to make visual images, incidents from
his past were revisited and he started processing the immense loss of
self he had experienced.
Claudia Osborn, an American doctor who sustained a severe
head injury, says in her autobiography:
Every person has their own path, their own very personal way
of dealing with their head injury, sometimes we have to look
back and become aware of our loss in order to move forward
with our life and reconstruct a new self. (Osborn 1998, p.196)
Speaking of her head injury, she said it produced a shattered sense

of self and in rehabilitation, art therapy assisted with constructing
a new image and a new sense of self. Similarly, it is worthwhile to
draw on the seminal work of Elizabeth Kübler Ross (1969) who
identifies five stages of grief and adjustment:
1. Denial, with a refusal to accept facts and the reality relating to
one’s situation.
2. Anger, where a person realizes that the change is real, and looks
to blame someone or something for making it happen to them.
3. Bargaining, when a person tries to find a way out of the situation.
4. Depression, when awareness comes of the losses associated with
the change in circumstances, and of what has to be left behind.
5. Acceptance, when a person realises their life is not going to
be the same again and develops a sense that they must get on
with it.
During his time in art therapy Martin completed a total of 27 images
over five months in our weekly individual sessions. He liked to use
off-white cartridge paper. His first five images were 42cm x 30cm,
and from the fifth session onwards his images were all executed
on paper size 59.5cm x 47cm. His first image was made using chalk
pastels, but his preferred choice of medium was poster paint, which
he squirted out of the plastic bottles onto the page then worked with
his fingers. This was a joyful and sensory experience. It took him time
to understand that this alone was not going to meet his ego needs.
Satisfaction of those needs might have to come from other sources. In
Martin’s case, it seemed as if art was a good vehicle for him, giving him
a sense of intellectual pleasure and achievement and bridging, at least
in part, the emotional chasm between himself and others.
Speaking of his artwork later, Martin reflected that two themes
appeared repeatedly in his images: one of a bursting, circular shape that
continues constantly, and the second like ‘brain patterns’ – a strong
flow of thoughts from right to left – like trying to do something you
cannot do and digging your way out of something.
Figure 4.1 (a) Cut-down tree (see colour plate). (b) Scraping
During our initial session Martin made two images. Using his non-
dominant hand, his first image, using chalk pastels, was a circular,
wheel-like structure with spokes radiating out from the centre – the
beginning of his two recurring themes. Later he said, ‘In the centre of
the circle, something always seems to be happening, almost like I am
bursting from something. Whether it’s one’s heart that is bursting or
whether it is a bursting out of one’s physical, perceived, broken body
– or whether it’s an explosion of the mind.’ The image reminded him
of a cross-section of a tree trunk. He talked of having spent a lot of
his time thinking in cross-section in his job; also of his MRI scan being
thin cross-sections of his brain. When speaking about his image Martin
perceived the many layers behind it, and said to give one explanation
would be to limit it. He initially said it was good to use materials he
was not used to; later he said the image was rubbish and that he hated
the pastels!
Martin commenced his second image by squirting paint from the
bottle, which he mixed on the page and proceeded to lift off using
his fingernails, ‘like a life going on which gets interrupted’. He said the
colours were all muddy, his life felt in a mess. He was unsure about his
present and future. Commenting on the time we spent together he said,
‘Don’t know why I am doing this – it hasn’t progressed as I intended.’
Martin then spoke of how very angry it made him when people used
the past tense in speaking with him about his professional life, saying
he was an architect, when, as he understands, he still is an architect.We
spoke about his profession being a large part of his identity. At this
stage denial was an inevitable stage of the grief process.
Martin felt then that he could not afford to waste his limited and
precious energy on grieving. He wanted to pass through his time in
rehabilitation as fast as he could and return to being a successful
architect as soon as possible. The most important goal for him was to
walk, to be able to stand on his own two feet unaided, and walk around
without his wheelchair, to stand at equal height with those around him
and not be seated with people looking over him. Martin was soon to
begin to walk via his painting: using his fingertips he would walk across
the landscape depicted in a scene from his past.
Figure 4.2 Walking through the forest of buildings.

In his second session, Martin spoke of his image reminding him of the
experience of visiting a shaman and of using a hallucinogenic mixture
of plants. The lime green he used reminded him of the ‘halo’ he saw
around his good friend when he awoke from his trance-like state.
Similarly, his present situation felt unreal to him, like a dream from which
he should awake to find himself able to walk again, and be like before
his stroke. This could be viewed as the first stage of the grief cycle.
Martin’s images visually expressed the various stages of grief, namely
denial, anger, bargaining, depression and the beginning of acceptance.
Clearly, it is possible to occupy different stages at different times and
even move back to stages we have been in before. Grief stages can last
for different periods of time, and may either replace each other or
exist side-by-side at times, all of which are normal reactions.
At this time the neuro-rehabilitation team considered that Martin
was somewhat unrealistic in his expectations of getting back to work
within the next year, and it was decided that his consultant would
speak to him frankly about the nature and extent of his brain injury.
This discussion took place immediately before his third session with
me. He was devastated. When he was in the quiet and safety of the
art therapy room, he exclaimed, ‘I am a lot worse than I realised. I can
deal with the loss of use of my right arm and hand, but I cannot deal
with the possibility that I may never walk again.’ This may have been
the stage of bargaining. The red paint he used first stood for his life
blood, he said (see Figure 4.2). Next, the yellow he used was his feet.
He dotted the yellow paint across the page, right to left, symbolically
walking with his feet; he smeared the red and the yellow together
in frustration, disbelief and non-acceptance of his situation. This was
a way to express his myriad of inexplicable emotions. At the end of
the session he said he did not mind if I shared his artwork with the
team; however, he wanted no interruptions in his sessions. Given this
safe space and the time to begin to explore his situation, he wished to
work quietly, undisturbed. Prior to this, two other team members had
come into the room uninvited and interrupted our session. From now
on I placed a ‘please do not disturb’ notice on the door.
Martin missed his next session, as the nursing staff were unable to
get him up in time, so I went down to speak to him on the ward and he
proudly showed me his two daughters’ artwork. He wanted to know if
one of his daughters could come into the art session. As it happened,
this never took place. Next he chose to paint an image of a field in a
rural area of Ireland – with gold corn and a solitary red barn. Perhaps
the solitary barn depicted some aspect of himself. He had very happy
associations with the scene, it was a time of carefree happiness at the
start of his first marriage. Every so often he closed his right eye to
recapture the memory.
The following week he said his images from the previous week
were rubbish and that he had no idea what he was going to do. He first
squirted red paint onto the page, then yellow, mixing them to produce
an orange area to which he added a green line on top, then a line of navy
below (Figure 4.3). Then he exclaimed, ‘Oh God, it’s a womb!’ There
is a foetus in the womb (like his needing to develop in rehabilitation)
and only one egg in the right fallopian tube. On reflection later, he felt
that it was a storm brewing and symbolised both his wish to return to
the womb and his feeling of being reborn now as a different person –
someone who had been told he might not be able to walk again, and
consequently seeking to define ‘who am I now’.
At the beginning of our seventh session Martin’s breathing was
noticeably heavy and strong, as if something had disturbed him. Before
starting to paint, he referred to his previous images as ‘the workings

of a deranged mind’. Martin appeared at first to like, then to rubbish
his images. It seemed he was working through denial and acceptance
in his attitude to his images.
Figure 4.3 Womb (see colour plate).

Martin then spoke of Liam Neeson, whose wife died the day after a
skiing accident that resulted in a brain injury. This disturbed Martin. He
realised he too could have died, and he felt afraid of his own future. He
squirted yellow paint onto his page (Figure 4.4), followed by navy blue,
red and green in a deliberate order, pausing for a few seconds before
stabbing at the paint with his hand. Each colour, he commented, had
significance for him. Yellow symbolised the sun and brightness; dark
blue, he said, was good, it was a colour ‘you could go into’; and red
was his life force, his blood. He felt that his image became a burning
tree. His attribution of significance to the colours reminded me of the
account of Dibs, a young boy struggling to find a sense of self through
the process of psychotherapy (Axline 1964). Dibs used different
colours to convey his emotions and like Martin, he needed to establish
his identity and sense of ‘Who am I?’
Figure 4.4 Burning tree (see colour plate).

A tree is often used as a symbol for self and it seemed to me that
Martin could be burning with anger, as he began to process the
immense change in his life. This image was also a departure from his
previous work. It is consistent with work described by Simon (1992)
as the ‘archaic massive’ style of painting; it is full of feeling, involving
the spontaneous use of materials with strong colours. Simon (1997)
discussed this change in style as heralding unconscious shifts inside a
person and assisting with emotional integration.
The spontaneous creation of an image brings it into consciousness.
Speaking of artwork, Simon states that the symbolic image and style
in which it is represented often relate to a particular stage in the
integration of painful experiences. As the image and the style change,
so does the individual, who discovers previously untapped sources of
creativity and inner strength. Indeed, Simon (1997, p.87) comments:
‘I have found that the spontaneous creation of Archaic Massive
images can focus the resources of patients whose self-image has been
confronted with damage to their body.’ I felt Martin was truly utilising
art to express his strong emotions.
At the following session he said that he found some female members
of staff in the unit ‘quite feminist’.We discussed his feelings around this,
and the fact that the majority of staff in the unit were female, including
me, and that we were working with him at a vulnerable time.
After this he began to explore his masculinity. In a subsequent

image he carefully dotted each colour on the page in a colour wheel,
which he said depicted him walking away from his previous life. Soon
after, an image on the noticeboard in my room reminded him of a very
beautiful Indian woman he knew, and he produced five images of eyes.
He worked with five of the seven chakra colours (red for balance of
the physical body; orange for sexuality and release of tension; green for
protection, harmony and love; yellow for subconscious emotion; blue
for creative expression), thoughts of transcendence and ‘the third eye’.
Many people consciously or unconsciously have associations with
colour, and following an acquired brain injury some people have a
heightened sense of colour (Osborn 1998). Subsequently Martin
returned to scraping the paint from the bottom to the top (describing
this as how his stroke had interrupted the flow of his life), after
first using his thumb to smear lines of different colour horizontally
across his page. He said he was working on his stroke, re-evaluating
his life; later admitting that he was redefining personal relationships,
particularly with important women in his life. (This response highlighted
the importance of choice of images in the art therapy room, as the
same image had to be taken down when a woman experienced it as
menacing. Images can affect each person differently, and association
with an image can be very personal. We art therapists should be
constantly mindful of the power that an image can hold.)
In his final session, which occurred just prior to his discharge, Martin
asked me to draw a large circle, as he was thinking about mandalas.
The circle is a symbol of perfection, eternity and completeness. Chakra
symbol mandalas are used to facilitate growth and healing. After
squirting on the paint he made another wheel of colour (Figure 4.5,
page 112), including the last two chakra colours, indigo and magenta,
symbolising integration. He likened his image to the iris in a person’s
eye, and after ‘walking’ the colours with his finger he left the centre of
his circle white.
It was also like a rosette, given as a reward for completing
something (he had been to a local agricultural show a few weeks
previously); he said he was rewarding himself for completion of his
time in rehabilitation. On leaving he said, ‘I don’t do good-byes, see you
again,’ and drove his wheelchair out of the room without looking back,
almost as if he had decided this point was the end of a chapter in his
life and he was eager to move on.
Figure 4.5 Rosette (see colour plate).

Following his discharge, Martin has returned to the unit, with my
support, to deliver his ‘insider’ perspective on rehabilitation to an
interdisciplinary neuro-rehabilitation training forum. In addition, he has
also been involved in the professional training curriculum of dieticians
and clinical psychologists.
Conclusions
Within neuro-rehabilitation, art therapy is able to tap into and
explore the emotional aspect of a person’s rehabilitation, rather
than simply the resumption of physical functioning. Kaplan (2000)
argues strongly for the benefits of art-making. She reflects on
the work of cognitive scientist Donald D. Hoffman (1998), who
emphasized the comparative importance of visual intelligence by
pointing out that the brain systems responsible for vision occupy
nearly half of the cerebral cortex – controlling thought processes
(such as memory and learning) and motor functioning. She states
that available evidence indicates that art-making and creativity are
inherent aspects of being human.
From an alternative perspective, there is a Native American adage,

‘Tell me, and I will forget. Show me, and I may not remember. Involve
me, and I will understand.’ This is one of the tangible benefits of
art therapy in rehabilitation – namely, that it involves a person. The
person is being assisted to resume control of their life as they make
their choices about the materials they use, subject matter, colour, size
of image, and when the current drive to make known or externalise
the present thought and/or emotion conveyed by the visual image is
satisfied (even though the image may not necessarily be completed).
Spontaneous image-making bypasses the conscious mind, allowing
unconscious material to surface. Instead of consciously deciding ‘I
am going to paint a flower’, or copying an image, the playful use
of paint, collage, tiles, clay, etc., allows an image to rise up from
seemingly nowhere – this place we are not conscious of, but which
nevertheless defines, at least in part, who we are.
Acknowledgements
I would like to acknowledge the people who have engaged with
the art therapy service, particularly those who have graciously
given permission to write about them and their artistic endeavours,
especially considering the serious nature of brain injury which they
have survived. I consider it a privilege to have travelled therapeutically
alongside these people as they endeavoured to come to terms with
their brain injury during a vulnerable period in their lives.
With special thanks to Dr. Colin Wilson, Consultant
Neuropsychologist; also Drs John McCann and Sheena Caldwell,
Consultants in Rehabilitation Medicine, for their advice and editing.
References
Axline, V. (1964) Dibs: In Search of Self. London: Penguin Books.
Bauby, J.-D. (1997) The Diving Bell and the Butterfly. New York: Alfred A. Knopf.
Bogousslavsky, J., Hennerici, M.G., Bäzner, H., and Bassetti, C. (2010) Frontiers of
Neurology and Neuroscience Series, Vol. 27: Neurological Disorders in Famous
Artists – Part 3. Basel: Karger Medical and Scientific Publishers.
Harrison, R. and Westwood, M. (2009). ‘Preventing vicarious traumatization of

mental health therapists: Identifying protective practices.’ Psychotherapy 46, 2,
203–219.
Hieb, M. (2005) Inner Journeying Through Art Journaling. London and Philadelphia, PA:
Hoffman, D. D. (1998) Visual Intelligence: How We Create What We See. New York:
Norton.
Jung, C. (1978) Man and his Symbols. London: Pan Books Ltd.
Kaplan, F. (2000) Art, Science and Art Therapy. London and Philadelphia, PA: Jessica
Kingsley Publishers.
Kübler Ross, E. (1969) On Death and Dying. London, New York, Toronto, Sydney,
Wellington: Tavistock Publications Ltd.
Osborn, C. (1998) Over my Head: A Doctor’s Own Story of Head Injury from the Inside
Looking Out. Riverside, NJ: Andrews McMeel Publishers.
Phillips, J. (2000) God is at Eye Level: Photography as a Healing Art. London: The
Theosophical Publishing House.
Simon, R. (1992). The Symbolism of Style. London and New York: Routledge.
Simon, R. (1997) Symbolic Images in Art Therapy. London and New York: Routledge.
Williams, S. (2012) ‘Can couples learn to love a second time?’ Sunday Telegraph,
22 January.
CHAPTER 5
Art Therapy at a Rehabilitation Day

Centre for Adults and Adolescents
with Acquired Brain Injury
Anna Knight
Introduction
This chapter focuses on art therapy at a rehabilitation day centre in
the voluntary sector for adults with acquired brain injury (ABI). I
will document how and why art therapy provides a valuable service
for this client group and outline two significant approaches:
1. the art-based pragmatic approach to stimulate the neuro-
plasticity of the brain
2. the use of art therapy to help clients come to terms with
adjusting to their traumatic life change.
These approaches also provide the opportunity to address any
underlying issues clients may have had prior to their brain injury.
I will describe how art therapy has proved beneficial to clients
with brain injury. I will consider the necessity for a reliable and
steadfast environment for clients and staff (Stapley 1996). I will
discuss assessments adapted to differing aspects of brain injury,
covering the physical, cognitive and psychological effects of ABI.
Finally I will consider the most effective ways of working with ABI
sufferers in art therapy.
115
Long-term rehabilitation for

people with brain injuries
Figure 5.1 shows another client’s way of expressing the effects of
disability.
Figure 5.1 The effects of disability (see colour plate).

The rehabilitation centre has been carefully designed to provide
post-acute-stage clients with an environment where they feel secure
and safe. The centre is a spacious building with a number of purpose-
built areas for specific needs, aimed at reducing distraction, confusion
and frustration, thereby creating an environment conducive to
continued recovery.
During 2012–2013 the centre extended its services from general
support to focus much more clearly on treatment of specific areas of
ABI. It has also developed an initial assessment and review process that
allows therapists to target individual development needs, as well as
monitor progress toward recovery and the maintenance of skills. The
aim is also to raise awareness by introducing compensatory strategies
designed to overcome emerging issues and maximise autonomy.
There are two components to the service:
• The first supports those who have recently travelled through
the inpatient clinical pathway directly following their injury,
and are now at home and beginning to come to terms with the
realities of their impairment.
Art Therapy at a Rehabilitation Day Centre 117
• The second is the long-term, ongoing provision that helps to

support social and wellbeing needs, leading to further progress
and greater quality of life for clients and carers.
The therapeutic community provides a safe and nurturing environment
that encourages continuous, self-managed recovery. The centre offers
a holistic, person-centred approach that follows on from a formal
rehabilitation programme. This provides the opportunity for people
to come to understand the full extent of their injury and how it will
affect their everyday life in a range of complex social environments.
The physical, cognitive and

psychological effects of ABI
Physical
Loss of coordination, muscle rigidity, paralysis, impairment of fine
and gross motor skills, sensory disturbance (loss of sight, smell,
touch, taste, hearing), fatigue, sexual problems, pain, epilepsy.
Cognitive
Problems with attention, concentration and memory (visual, verbal,
recall, recognition), low tolerance to noise or stressful environments,
loss of insight and initiative, visual perception difficulties (object
recognition, communication difficulties), various forms of aphasia
(language difficulties), hemispatial neglect (ignoring one side of the
page).
Psychological: emotions and behaviour

Emotional disturbance: anxiety, depression, fear, sense of grief, loss
of motivation, difficulty with controlling anger and impulsivity,
disinhibition, effects of losing independence, post-traumatic stress
disorder, relationship difficulties, suicidal ideation, the impact of the
clients’ ABI on family and friends.
Of course, these sets of issues all interact with each other (Garner
1996).
Knitting life back together after brain injury

The key to the success of the centre is that it enables a safe
and comfortable environment where individuals’ problems are
understood. Clients can be themselves, make new friends, and
explore new tasks before taking them out into everyday life. These
tasks include:
• adapting to a new way of living
• developing a new identity
• learning strategies to adjust and cope with change
• learning to be aware and cope with various forms of disinhibition
• restructuring life, everyday living and communicating.
During initial and subsequent assessments, therapists set development
targets to help clients reach their full potential, and tutors and
therapists then support clients to achieve these. Attendance at the
centre and participation in activities, such as paying for lunch,
learning to manage disinhibition, coping with changes to plans,
being able to sort facts logically – these are all skills which can be
developed in the centre’s safe environment.
Therapies and activities used in this process include art therapy,
music therapy, speech therapy, art classes, pottery classes, woodwork
group, cookery group, gardening group, information technology in
everyday life, creative writing, cognitive exercises and yoga. These
are run by therapists or tutors, as appropriate. More therapies and
activities are planned for the future.
How therapies and activities can

overcome the effects of ABI
Problems with understanding or using language
One in four clients has difficulty speaking, writing or understanding
spoken or written language. For many clients their time at the centre
may be the only time they communicate with anyone outside their
home. Group work and games encourage interaction and develop
confidence in the use of verbal and nonverbal skills.
Paralysis and/or motor control

Several of the activities listed above encourage the use of limbs and
develop functionality, leading to the ability to carry out everyday
activities without support.
Sensory disturbance including pain

This can be addressed by individual therapy aiming to develop
clients’ self-awareness and coping strategies, which can then be
shared in group sessions.
Problems with thinking and memory

The assessment process together with cognitive exercises and
individual or group therapy sessions raise and maintain self-
awareness, and support the achievement of realistic goals.
Emotional disturbance
The therapy sessions help clients to explore and come to an
understanding of their situation. All the activities support the
recovery process, but it is the friendships made, the sense of
belonging and purpose, and the therapeutic interventions that make
the centre family important to those who attend. A major element of
returning to daily living is re-engaging with community activities,
and for some clients and their families the social events at the centre
provide the first opportunities to participate.
The contribution of art therapy at the centre

Art therapy can help with the task of ‘knitting life back together’
after brain injury in several general ways:
• improving memory
• lessening the feeling of loss
• helping to reacquire a ‘sense of self ’

• improving self-esteem
• improving confidence
• increasing self-awareness
• improving social skills and empathy
• improving energy
• increasing organisation skills
• stimulating brain deficits
• improving independence
• reducing post-traumatic stress
• family art therapy helps family dynamics.
Art therapy can also help with specific problems, described in the
next section.
Benefits of art therapy

As the brain is able to compensate for damaged areas, therapeutic
approaches that stimulate the brain to repair connections are crucial.
‘Neuroplasticity’ is the brain’s ability to reorganise its functions
based on new information and experiences. I have observed that after
brain damage some clients have produced high standards of artwork,
never having shown any interest in art before their ABI. According
to the International Network of Neuroaesthetics (2014), exploration
of the impact of the brain and neural degeneration on producing and
appreciating art, has revealed that activities and experiences are not
related to a single brain region or hemisphere. Rather, they emerge
from the interaction of activity taking place in many different brain
regions. Stimulation of the brain by opening awareness to sensing
and paying attention to new things, i.e. creativity during art therapy,
opens windows into connecting the neural functions of the mind.
Below are some examples of ways in which these aspects of art
therapy can help with specific problems.
Improved fine motor skills for those

who have suffered paralysis
The client may learn to use their non-dominant hand after paralysis
of the dominant hand. The exercise of drawing with the eyes shut
prevents self-criticism. (Edwards 2001). Wet-paper technique is
another way of decreasing self-criticism, as there is little preconceived
idea as to what will happen. The art therapist may act as the ‘third
hand’ during various creative processes, being directed by the client
to mix or apply the paint.
Improved speech for those who have difficulties

Aphasia can affect understanding or expression in speech, reading
and writing. In the words of a client, ‘It’s like dropping the thesaurus
on my brain’s floor and picking up the wrong words or not being
able to find them.’
I find that speech can start to ‘flow’ if the client is directed to use
their whole arm, if appropriate, in a wide arc while saying a word
– for example, drawing a circle at the same time as saying ‘circle’.
This often results in the client’s surprise at being able to say the
right word.
Improved memory
Question: ‘Who did that painting? It’s very good.’ Answer: ‘You did!’
Everyday experiences become a nightmare of confusion without
strategies to manage or compensate for the effects of short-term
memory loss. Problems may include forgetting people’s names or
faces, losing a train of thought, getting lost, repeating or forgetting
past conversations, misplacing objects, and difficulty learning
new skills.
Improvement in hemispatial neglect

Hemispatial neglect means the neglect of one side of the page, or
one side of the body, due to the neurological effect on vision. The
client is reminded visually of this neglect in their artwork and can
learn to rectify the deficit.
Relaxation techniques for clients with epilepsy

Eighty per cent of clients with ABI have various forms of epilepsy.
Directing the client to draw a line in a rhythm mirroring brain waves
helps the brain to relax, and sometimes prevents seizures forming.
Peace and quiet is paramount.
Stroke victims can be monitored through

the analysis of art images
I have observed that a strong diagonal usually runs through images
after a stroke. As the client progresses, the artwork regains the
conventional perspective, demonstrating change visually.
Reduction in tremors for clients with Parkinson’s disease

When a client with Parkinson’s disease holds an object such as a
pencil and focuses on drawing, the tremor diminishes or even
disappears. Tracing can help the brain to focus, resulting in relaxation
that encourages free-flowing speech.
Improved sensory awareness for clients with loss of sight

The Turkish painter Esref Armagan, blind from birth, intrigues me,
as his brain seems to have adapted to enable him to deliver visual
representation. Alvaro Pascual-Leone, Professor of Neurology at the
Harvard Medical School, found that, during MRI scans, Esref ’s visual
cortex lit up during complex drawing tasks as if he were actually
sighted. There is much to be researched here (Pascual-Leone 2004).
Spirituality
He who has a why to live for can bear almost any how.
(Nietzsche cited in Frankl 2004, p.109; first published 1946)
Some clients have experienced near-death experiences or time in a
comatose state. Living close to death may strengthen clients’ beliefs,
or inspire some to spiritual curiosity. On the other hand, they may
accuse the religion that they once relied upon: ‘Why has God
allowed this to happen to me – what have I done wrong in my life
to deserve this?’ God seems to have become the projection of their
anger and their pain, the scapegoat. Anger may also be directed at
the therapist or the institution – or even politicians!
The confidential, quiet space of the art therapy room is a perfect
environment for reflection. Existential questions about the meaning
of life, the future and a search for significance and hope can be shared
in group and/or individual sessions. Art therapy can be used to
explore the present moment, noticing bodily feelings and emotions
during the process of art-making. Meditative practice during art
therapy can give clients new tools to change their perspective and
attitude to living. Focusing at a deeper level is sometimes a new area
for people who have led busy, structured lives before their brain
injury. Mindfulness techniques are beneficial when experiences are
painful or beyond words.
One client discovered relief through painting. She called her
picture ‘Rebirth’ (Figure 5.2) and said, ‘I felt that I had lost so much
and felt empty and confused. The flowing water symbolises a time of
cleansing, washing away the confusion with a friend supporting me.’
Figure 5.2 Rebirth (see colour plate).

Case study
Ben, now 28, suffered a bike accident at the age of ten, causing
extensive executive and parietal lobe damage, affecting organisational
skills and social interaction. Ben continues to need 24-hour care due
to his unregulated behaviour and cognitive difficulties. I have worked
with him over a period of ten years. Individual art therapy sessions
provided the structure, boundaries and containment required for
Ben’s behavioural and cognitive difficulties. Ben and I developed a
strong empathic relationship, helped by my calm Labrador dog, who
responded well to Ben’s attention.
Ben presented with global aphasia, and expressed himself with his
own unique type of sign language, together with uninhibited whines and
shouts of frustration that other members of staff found frightening. He
would symbolically ‘shoot’ some male members using his fingers, but
his aggressive behaviour was well handled by his carers, who always
accompanied him.
I decided to see Ben alone in the art therapy sessions, so that
he could appreciate some sense of autonomy. He demonstrated
affection and attachment to the dog, which helped our therapeutic
relationship. I modified his challenging behaviour by gently whispering
encouragement, distracting him and changing focus. Considering Ben’s
executive damage, I presented dry materials which would contain
his behaviour and help him to centre on organising, fine motor
skills, his speech and the ability to concentrate. He spent much time
enthusiastically and obsessively rearranging colours, sequencing
numbered and lettered cards, writing numbers and words in grid form,
and filling in well-defined images with coloured felt-tip pens.
Figure 5.3 Ben: painting within a frame (see colour plate).

Over time Ben learnt to modify his behaviour even when mistakes
were made, ordering himself to ‘calm down’. Eye contact and humour
arose out of Ben’s gaining confidence. Having established Ben’s
improved behaviour, I introduced wet materials such as paint and clay.
With help from me arranging the acrylic paint and brushes, he chose
bright colours – which quickly became brown, scrubbed into surfaces
with circular motions, then progressed to defined shapes. Boundaries
were needed in any project that he undertook – including time, and I
therefore drew boundaries around his images as a form of containment
(see Figure 5.3), which he then continued himself.
As he progressed from pre-verbal behaviour, Ben showed more
enthusiasm for learning academic skills. His carers explored new
sensory activities; his confidence rose, and speech and language
sessions were introduced. Soon he was shaking hands with the
members of staff he had pretended to shoot, and started to relate
with others at the centre.
After the work with clay, in which Ben made three-dimensional
objects, I introduced sand play. This offered Ben the opportunity to
explore symbolic communication that enabled self-expression. It also
allowed me to understand his relationships at the time, as certain
familiar names were hidden under the sand or on the surface in
various positions.
He progressed to making complex collage cards based on his love
of cars (see Figure 5.4). During current sessions he likes music, enjoys
rhymes to car names (e.g. ‘Hyundai, in the sky, fly fly fly’), and makes up
words and phrases, using my iPad and ‘Bananagrams’ (a word game).
He also likes to sign his name on my weekly written report for his
carers, showing his understanding of the process.
Figure 5.4 Ben: collage cards of cars.

He is now able to join a small woodwork group at the centre. He

has changed into a young man who can socialise to a fairly acceptable
standard and leads a fuller life with excellent carers (although constant
containment is still needed). Ben’s rapport with my dog led to him
attending Riding for the Disabled, to add balance, control and a
relationship with a horse – and this has proved beneficial.
With his progress in art therapy and various stimulating additions
to his life, Ben is continuing to make progress, much to the pleasure
of his parents.
Ways of working in art therapy with ABI

Neuropsychiatrist professor Barbara Wilson suggests, ‘If you stick
to one theory or methodology you constrain yourself – it’s too
limiting’ (Wilson 2002, p.241).
Art not only bridges the gap between the outer and inner worlds
but also seems to span the gulf between different theoretical
positions. (Anthony Storr in Rubin 1999, p.157)
According to the comparatively new field of neuroaesthetics, to
quote Semir Zeki, Professor of Neuroaesthetics at the University
of London, ‘the artist is in a sense a neuroscientist, exploring the
potentials and the capacities of the brain, though with different
tools’ (Huang 2009, p.125). Magnetic resonance imaging (MRI)
has contributed greatly to advances in understanding how the brain
responds while creating.
My work is based on a person-centred approach with empathy,
addressing the needs of the individual. A sound ‘holding environment’
(Winnicott 1971) is particularly important to enable clients to cope
with behavioural difficulties and for them to feel secure and able
to engage. From a vulnerable base, clients must feel that they are
accepted without judgement, and can communicate in speech and/
or through their artwork.
A psychotherapeutic approach is essential to help understand
and resolve underlying psychological issues, and a wide variety of
art-based tools are also needed. The importance of improvising in
order to strive for the best standard of practice in this environment
is paramount. Individuals with brain injuries respond in different
ways – according to the brain’s impairment and to their pre-morbid

personality and condition.
Two possible examples show the wide range of conditions
which may lead to a referral for art therapy. The first may be a client
with a stroke, paralysed on one side, and who has aphasia – who
was extrovert and physically and mentally very able prior to their
brain injury. The second may be a client with a frontal lobe head
injury sustained from an assault, who has subsequent disinhibition
and lack of insight into self and others – and who had an abusive
childhood and a history of addiction. Both are trying to adjust to a
new life, physically and mentally – but may need different tools and
approaches to achieve this.
To enable compensation for these deficits, I address all three areas
at the same time – the physical, the cognitive and the psychological
state of the client. Rick Garner, an educational psychologist and
art therapist who developed the Neuro-psychological Art Therapy
(NAT) model, remarks that ‘One area cannot be approached without
consideration of the other two’ (Garner 1996, p.4).
Ways of working with clients with ABI

‘There is no criticism or judgement in art therapy.’ This sentence
posted on the art room wall greets the clients coming for art therapy.
This is important, as self-criticism and lack of confidence can
prevent some clients from engaging. Clients are often too vulnerable
to accept direct criticism from others. ‘I’ve had a brain injury, but I’m
not stupid.’ This notice written by a client describes how they often
feel treated as if they are mentally deficient.
Initially clients have individual art therapy sessions, giving rise
to joining a small group when or if they are able. Group sessions
provide the opportunity to share and reflect, resolve issues and reduce
feelings of isolation. Art therapy uses various ways of working that
help to build up an individual’s cognition and emotional wellbeing
to enable change and progress. Some individuals may never be able to
join a group, owing to their challenging behaviour, comprehension
problems or other difficulties preventing inclusion. Low self-esteem,
lack of confidence and the extreme change from their previous
personality may prevent any ability to socialise. The sudden loss
of physical and cognitive function results in an extreme emotional

upheaval. As one client put it,‘Keeping myself together is important
to me – I have to feel in control.’
Clients may hide their vulnerability with an extreme defensive
response, which may present in a strong egotistical exterior, verging
on narcissism. The last thing clients want to explore is their vulnerable
‘self ’, and introspection at this stage in their development can be
difficult: ‘I just want to retrieve the person that I was – without being
asked to do things that I have never done before in my life.’
Some clients find the words ‘art’ and ‘therapy’ challenging, with
their associations with self-criticism and mental illness. Common
responses may be: ‘Am I good enough?’ and ‘These materials are far
too good for me to use.’ Some question the point of art. I explain
that art therapy may provide an opportunity to work through, with
support, the losses and limitations resulting from their brain injury
and, most importantly, find strategies to cope with these changes.
Explaining some neurological details concerning the merits of hand–
brain coordination in order to stimulate areas of the brain, may be
especially beneficial for those who tire of the term ‘self-expression’.
In addition to learning compensatory skills to deal with deficits,
validating a client’s pre-morbid skills and personality is particularly
beneficial to their sense of self. Simple therapeutic approaches
can be connected with abilities in everyday life – such as learning
sequencing, handling money, or even being able to apply toothpaste
on the brush.
Clients have also discovered new skills through creative writing,
poetry, and the addition of music in art therapy sessions – all adding
to the neurological stimulation needed for progression in the three
areas: physical, cognitive and emotional. I believe that the word
‘creativity’ can be construed as any creative change for the individual.
Holding workshops is beneficial for team members to understand
the process of art therapy, as sessions usually take place behind a
closed door. When appropriate, and with group members’ permission,
I also invite a team member to join and experience an art therapy
group session.
Within the environment of the centre, exhibiting clients’
artwork can give a profound sense of wellbeing and confidence to
the client, including assuring other centre members that they may
also participate in art therapy. The sculptor Alan Thornhill (2008)

suggests in his writings that ‘creativity acts as nourishment both
to the artist and to the beholder. Art strengthens our sense of
possibilities and broadens our horizons.’
Art therapy assessments

In order to assess and monitor a client’s ongoing development I may
use certain approaches in addition to the initial cognitive behavioural
assessments.
Mind maps
‘Mind mapping’ (Buzan 2000) is a useful addition to formal
assessments. According to Buzan, the brain finds shapes, form and
colour more acceptable and relaxing than linear lists of words. I
invite the client to draw a circle and write their name in the middle,
to represent their ‘self ’. From the centre, they expand into other
circles depicting issues about their life, their needs and goals. Having
the opportunity to ‘centre’ on themselves is often a new experience
for clients, especially those with 24-hour care. This encourages
confidence without the anxiety of having to be ‘good at art.’ Mind
maps explore the client’s efficacy in fine motor skills, ability and
quality of writing and reading, spatial awareness, and the ability to
engage and to empathise. It can be adapted to their deficit.
Figure 5.5 A client’s mind map. (Name removed for confidentiality.)

House-Tree-Person (HTP) and Clock Face assessments

The use of pictures in psychological testing is a widespread practice.
I use appropriate Silver drawing tests (SDT; Silver 2007) and the
house, tree, and person (HTP), in which clients are simply asked to
draw these. A Clock Face assessment involves clients drawing a circle
and putting in the numbers. These assessments can identify clients’
emotional and cognitive issues such as depression, self-projection,
spatial awareness, sequencing and organisational skills (Silver 2007).
Body image
Creating or filling in a body image may offer the opportunity for the
client to demonstrate areas of pain, or insight into their brain injury.
Symbolic conversation
If the client is too frail physically or is mentally challenged or too
apprehensive to engage in any form of creating, I write or draw in
symbols, which describe or mirror our conversation. This validates
issues in a concrete manner, left safely in their private file. This is
often a start to a different way of viewing a conversation for the
client, as we focus within the triangle of the art therapy model –
the client, therapist and image. The detail is noted in concrete form
and is particularly useful for clients who suffer from short-term
memory loss.
There is no end to the complexities that can demonstrate how
the client is functioning on all three levels. A simple mark can be an
clue to their physical and mental state during rehabilitation.
Art therapy tools

Here I include some approaches that alleviate stress and enable
clients to engage in the art-making process, some of which are taken
from Marian Liebmann’s book Art Therapy for Groups (2004).
• Free association using words and/or images. This exercise
stimulates without stress.
• The iPad – there are many apps which clients appreciate for
memory, speech, relaxation and just for fun.
• Conversation on paper. Taking turns drawing on the same
paper stimulates response, imagination and interaction with
another person, especially useful for speech deficits.
• Music – listening and responding with words, poetry and
painting.
• Making collages using personal photographs and names of
people in their lives.
• Drawing a recent past incident in simple form, of the client’s
previous hours.
• A box of imaginative postcards is useful for memory and
stimulating the imagination. One simple exercise is to ask the
client to make two piles of cards, ones liked and ones disliked.
This stimulates speech or discussion, self-awareness and
imagination.
• The white board – this plastic surface is unchallenging as clients’
marks are not permanent and the surface is soft, enabling a flow
to their drawing. I ask the client if they wish me to photograph
their drawing – they usually accept with enthusiasm.
And of course there are many more – developed as I work.
Client testimonials
‘To survey my situation positively, my stroke has enabled me
to connect with my artistic side again. During my years of
work in business I did not touch it again until after my stroke.
Attending art therapy at the centre has enabled me to connect
with my creative side again – I cannot do without it.’
‘I like coming to group art therapy because it has made me

realise that others have the same problems. We have a good
laugh with each other.’
‘I’ve found new skills in art – my concentration – my speech

has improved.’
‘It is so much fun! Picasso!’
‘I found my skill in painting – I don’t suffer fools gladly – I am

confident – I can say what I think.’
‘I like coming because I have got my memory now, but I didn’t

have much before.’
Conclusion
Invisible lines
The world is held together by invisible lines –
You may think this is a story,
But I know it’s the truth
Houses huddle like families
Or stand proud like regiments of soldiers
With all eyes fixed on one distant point.
The world collapses without the lines
And we disappear into the vanishing point.
Poem by client at the centre, 2010.
This poem was written by a centre client who felt that art therapy
gave him a reason for living after his brain injury. The poem connects
with his need to learn perspective. The structured image became a
metaphor for the structure he needed in life, reminding me of a quote
from Joy Schaverien (1991, p.67) about ‘the picture within a frame’.
The client is ‘held’ within the symbolic frame of the therapeutic
environment in art therapy, connected with the supportive frame of
the centre, and life at home – and hopefully in the world outside.
Clients who attend the centre also attend other therapeutic
services. By bringing together charitable and public sector funding,
my hope is that appropriate services connect for the wellbeing of
the client. Health and social care budgets are stretched to breaking
point while demand for services grows. The situation is not going
to be sustainable unless clients can be supported to maximise their
independence through the centre’s rehabilitation process, thereby
minimising their demands on carers’ support and maximising their
quality of life.
Access to art therapy enhances rehabilitation – clients are locked
within themselves, and art therapy provides a medium in which they
can escape.
References
Buzan, T. (2000) Mind Mapping. London: Harper Collins.
Edwards, B. (2001) The New Drawing on the Right Side of the Brain. London: Harper
Collins. (Original book published in 1979.)
Frankl, V. (2004) Man’s Search for Meaning. London: Rider. (Original work published
in 1946.)
Garner, R. L. (1996) ‘Neuro-psychological Art Therapy Model.’ American Journal of Art
Therapy 34, 4, 107–111.
Huang, M. (2009) ‘The Neuroscience of Art.’ Stanford Journal of Neuroscience 11, 1,
24–26.
International Network of Neuroaesthetics (2014) www.neuroaesthetics.net. Accessed
on 1 May 2014.
Liebmann, M. (2004) Art Therapy for Groups. Hove: Brunner-Routledge.
Pascual-Leone, A. (2004) ‘Professor Pascual-Leone discussing Esref at University of
Wiconsin.’ Accessed on 24 April 2014 at www.esrefarmagan.com/alvaro
Rubin, J. A. (1999) Art Therapy: An Introduction. Philadelphia, PA: Brunner Mazel.
Schaverien, J. (1991) The Revealing Image: Analytic Art Psychotherapy in Theory and
Practice. London: Jessica Kingsley Publishers.
Silver, R. (2007) The Silver Drawing Test and Draw a Story: Assessing Depression, Aggression
and Cognitive Skills. New York and London: Routledge.
Stapley, L. F. (1996) The Personality of the Organisation: A Psychodynamic Explanation of
Culture and Change. London and New York: Free Association Books.
Thornhill, A. (2008) Art in the Park. Exhibition statement www.jonedgar.co.uk/alan-
thornhill-thoughts-on-creativity-2008.
Wilson, B. (2002) ‘Rehabilitation without error.’ The Psychologist 15, 5, 240–241.
Winnicott, D. (1971) Playing and Reality. London: Tavistock.
Further reading
Battleheim, G. (1958) The Poetics of Space. Boston, MA: Beacon Press.
Bolte-Taylor, J. (2008) My Stroke of Insight. London: Hodder and Stoughton.
Bowlby, J. (1998) Attachment and Loss Trilogy. London: Pimlico. (Originally published
1973 by Hogarth Press and the Institute of Psychoanalysis.)
Broks, P. (2003) Into the Silent Land: Travels in Neuropsychology. London: Atlantic.
Doidge, N. (2007) The Brain that Changes Itself. London: Penguin.
Gilroy, A. (2006) Art Therapy, Research and Evidence-based Practice. London: Sage.
Hass-Cohen, N. and Carr R. (eds) (2008) Art Therapy and Clinical Neuroscience. London
and Philadelphia, PA: Jessica Kingsley Publishers.
Kaplan, F. F. (2000) Art, Science and Art Therapy: Repainting the Picture. London and
Philadelphia, PA: Jessica Kingsley Publishers.
Lusebrink, V. (2004) ‘Art therapy and the brain: An attempt to understand the
underlying processes of art expression in therapy’. Art Therapy, Journal of the
American Association of Art Therapy 21, 3,125–135.
Sachs, O. (1985) The Man who Mistook his Wife for a Hat. London: Picador.
Solms, M. and Turnbull, O. (2002) The Brain and the Inner World. London: Karnac.
Stoler D. and Hill, B. (eds) (1998) Coping with Mild Traumatic Brain Injury: A Guide to
Living with the Challenges Associated with Concussion/Brain Injury. New York: ETES
Publisher.
Waller, D. (ed) (2002) Arts Therapies and Progressive Illness. Hove: Brunner-Routledge.
Zaidel, D. (2005) Neuropsychology of Art. Hove, Sussex: Psychology Press.
Zeidel, D. (2010) ‘Art and brain: Insights from neuropsychology, biology and
evolution.’ Journal of Anatomy 216, 2, 177–183.
Zeki, S. (1999) Inner Vision: An Exploration of Art and the Brain. Oxford and New York:
CHAPTER 6
A Glimpse Beneath the Surface

of Organisational Life
Art Therapy in Brain Injury and Stroke Services
Debbie Michaels
Introduction
I first worked with brain injury and stroke as a trainee art therapist
on placement. This initial contact left a powerful impression on me
and I have continued to reflect on the potential role of art therapy
with this client group (Michaels 2010). Hinshelwood and Skogstad
(2000) suggest that where the physical body takes precedence there
may be little attention given to emotional and relational aspects.
This struck home when I represented the British Association of Art
Therapists (BAAT) at the National Institute for Health and Clinical
Excellence (NICE) Scoping Workshop for the Guidelines for Stroke
Rehabilitation. Despite the recognition that stroke could have a
‘devastating and lasting impact on the lives of people and their
carers’ (NICE 2010, p.1), I discovered that psychological therapies
were explicitly excluded from the terms of reference of the national
guidelines.
In this chapter I draw on two settings: the specialist stroke
rehabilitation day centre where I undertook my placement; and a
specialist hospital inpatient unit where, some years later, I acted as
clinical supervisor for a music therapist. My aim is to explore my
impressions of how unconscious anxieties, raised by close proximity
to the trauma of brain injury or stroke, may influence attitudes and
135
behaviour within organisations and teams involved in patient care.

Through the lens of psychodynamic thinking and my own reflective
artwork I examine my observations, subjective experience and
countertransference responses in order to explore various incidents
which I found puzzling.
Theoretical frame
I have found the ideas of Melanie Klein and the British School
of Psychoanalysis very useful in understanding organisational
functioning. Fundamental to psychoanalytic thinking is the anxiety-
defence model. This assumes that we experience conscious and
unconscious anxieties in relation to life, work and relationships,
and that we defend ourselves psychologically against these anxieties
in functional, and sometimes dysfunctional, ways. Klein viewed
our early defensive processes as the infant’s attempts to manage
complicated, confusing and painful stimuli, the unconscious aim
being to keep such frightening experiences separate from comforting
and calming ones. The infant cannot verbalise unbearable feeling
states, so induces those feelings in the caregiver, through projective
identification (Klein 1997 [1946]). In good-enough circumstances,
the caregiver’s sensory receptivity serves as a ‘container’ in which the
infant’s projected anxiety can be held, thought about and responded
to, without being identified with and defensively acted upon (Bion
2007 [1959]).
This model for individual psychology has also been applied
to organisational functioning, particularly through the work of
the Tavistock Institute of Human Relations (Bion 1998 [1961];
Dartington 2010; Hinshelwood and Skogstad 2000; Huffington
et al. 2004; Menzies-Lyth 1988 [1959]; Obholzer and Zagier-
Roberts 1994). The idea is that primitive defences, such as splitting,
projection and projective identification can also operate in social/
organisational systems, and that these systems may function as
emotional containers, in more or less defensive ways. In a seminal
study of a general hospital Menzies-Lyth (1988 [1959]) describes
how the social system was unconsciously influenced by its members
to support the psychological defences of individuals against
the anxieties brought up by their work. This, in turn, supported
Art Therapy in Brain Injury and Stroke Services 137
a defensive culture of denial which involved pushing anxiety-

provoking thoughts, feelings and experiences out of conscious
awareness (Halton 1997).
Working environments are shaped by factors including socio-
economic, political and historical sources. Different settings and
client groups evoke differing anxieties and corresponding defences,
and each individual also brings their own conflicts and defensive
techniques. Health and social care organisations are inevitably full of
conflicting human relationships and emotions which may be difficult
to articulate (Armstrong 2004). Those who work in brain injury are
often confronted with people who have experienced catastrophic
change affecting personality, identity, behaviour and emotions.
Some may have been catapulted back to a state of helplessness and
dependence, with a loss of awareness, insight and orientation, as
well as control over mind/body links and basic bodily functions
(Michaels 2010).
Figure 6.1 Shattered self.

The torn pieces of painted tracing paper are scattered and partially stuck down, but not
securely. The fragments appear disconnected. On the right I am reminded of a leg or arm
that seems to hang helplessly, not attached to anything. In the background are impressions
of the whole piece before it was ripped apart, along with scattered partial handprints.
The image in Figure 6.1 was made early on in my training placement

and offers an impression of working with the impact of stroke.
Menzies-Lyth thought that closeness to human suffering
resonated unconsciously with deeply rooted personal fears about
one’s capacity to do damage and doubts about one’s ability to repair.
In brain injury outcomes are unpredictable and clinicians may face
an acute sense of powerlessness and associated guilt. This may raise
intense anxieties about one’s competence and abilities, especially
when the worker’s self (as in relational or psychodynamic therapy)
is felt to be a tool for ameliorating someone’s distress (Hinshelwood
and Skogstad 2000).
Observing our subjective experience

Part of my learning has involved an attempt to grasp the unspoken,
unthinkable subtext that may be enacted within organisations,
through developing an intuitive sensitivity to the dynamics
observed (Maxwell 2000). As an art psychotherapist I also draw on
my countertransference to the art-making process and image. This
occupies a transitional space between conscious and unconscious
as well as subjective and objective experiencing (Schaverien 1995;
Winnicott 2005 [1971]). Art-making captures a physical and
mental impression of an emotional experience that may hold layers
of symbolic meaning and unspoken, unthinkable elements which
may not previously have been brought into conscious awareness
(Michaels 2010). This offers alternative ways of formulating and
communicating that experience, and ongoing opportunities for
reflection (Brown, Meyerowitz-Katz and Ryde 2007).
In therapy our initial impressions and ‘gut’ feelings may offer
vital nonverbal clues to core dynamics (Hinshelwood 1991). Whilst
using oneself as a research tool produces an inevitable bias, there is
evidence to suggest that the use of countertransference might offer a
deeper understanding of another’s experience (Jervis 2009) and that
sensitive attunement and alertness to irrational responses and the
emotional undertow of organisational life may be a powerful source
of information (Armstrong 2004).
Art therapy in a community-based

NHS stroke rehabilitation centre
My training placement involved setting up an art therapy
service within a multidisciplinary NHS community-based stroke
rehabilitation day centre. This had been initiated in response to the
team’s difficulty in engaging some patients with standard treatments,
including occupational therapy, physiotherapy, speech and language
therapy and psychology.
Figure 6.2 Ambivalence.

The black criss-cross charcoal marks feel defensive, harsh, cold and imprisoning…
The vague impression of a face in the background seems out of reach…
sad, angry, or is it screaming?…trying to keep me out or make me aware of
something? The image is messy to the touch. I wipe my fingers on the paper
to get some of the black off, but leave traces of fingerprints behind.
Case study
Norma was socially isolated and had a history of mental health
difficulties. A stroke had left her partially paralysed, but she had refused
to engage with recommended treatments, and an air of despair and
frustration surrounded her. My first impression was one of rawness
and vulnerability, as if she had a very thin skin. Early on Norma’s
attendance was erratic and she could only tolerate a small amount
of contact. She always made an image, but my attempts to engage her
in verbal reflection often resulted in her ending the session. I would
be left feeling clumsy and insensitive, as if I had touched a raw nerve.
Figure 6.2 is a reflective image that I made after a missed session.
One week, I left the door open as usual and waited for Norma to
arrive. Time passed. I was intensely aware of the wall between us, but
felt simultaneously paralysed in mind and body and unable to move. I
felt inept and dejected. By the end of the hour I had given up hope, but
suddenly she appeared in the doorway and told me she would see me
next week. I felt relieved, but also frustrated with the in–out quality
and sense of a barrier between us. Reflecting on it in supervision,
I decided to try to speak with her before the next session. Finding
an opportunity for privacy in the open environment of the centre
was difficult. However, at an appropriate moment I approached her.
I acknowledged how strange it may have felt the previous week and
how hard it might be for her to come to therapy. We sat together
for a while and I felt a great sadness as she spoke of her depression
and how she missed aspects of her former life. Norma described an
image she had in mind. She agreed that I would come and tell her
when it was time for the session, and that she could come when she
felt ready, within the allocated hour. Norma attended regularly and as
time passed we were able to sit together for longer periods. She took
increasing ownership of the materials and gathered a considerable
body of images which evidenced her work in therapy. Walls, doors and
structures that enclosed, linked or separated spaces formed a powerful
theme, particularly earlier and later in therapy. In the middle more
abstract, colourful and playful images emerged with rich symbolism. It
was during this period that I began to feel more hopeful and made the
reflective image in Figure 6.3.
Figure 6.3 Hope (see colour plate).

The painted marks are more fluid, and the bright, lively colours mix and blend
into one another. The central triangular shape offers a structure of sorts and is full
of warm reds and oranges with cooler colours around the outside…merging and
penetrating through in places. The black felt-tip speck offers a focus for the eye
but it seems rather incongruous, as if it sits uncomfortably in its surroundings.
At the centre where my work with Norma took place, there was
a congenial, friendly atmosphere. However, as time went on, I felt
increasingly isolated, as if taking up valuable time and space. Intrusions
into the therapy room, followed by apologies for forgetting I was there,
frustrated me. I scheduled a workshop for staff members and several
signed up. No-one came. I felt forgotten about and angry, but also
confused. No explanation was offered and I struggled not to act on a
powerful impulse to turn away and shut the door on the placement.
With support from external supervision, personal therapy and prior
training I was able to reflect on the dynamics, repair the rupture and
integrate myself more fully in the team.
Reflections
It is understandably frustrating to negotiate with someone who
isn’t engaging, and whose behaviour is puzzling and hard to
comprehend. Feelings of depression, isolation and worthlessness
may have made it difficult for Norma to make meaningful contact
with more creative opportunities. Refusal of treatment presents a

major ethical challenge in psychotherapy with adults experiencing
neurological impairment. Norma’s ambivalence could be understood
as an attempt to exercise some assertiveness, autonomy and control
over her privacy, but could also be thought of as an unconscious
attempt to communicate intense feelings of helplessness, fear and
rage (Gordon 1999).
Those in the staff team were often puzzled and intensely frustrated
by patients who seemed ‘stuck’ in their rehabilitation (Michaels
2010), and art therapy referrals were often associated with feelings
of hopelessness and despair. Accommodating art therapy meant
finding both physical and mental space for an unfamiliar approach
within a long-established culture. Intrusions into the art therapy
space and non-attendance at the workshop suggested forgetfulness
of my presence. This may be understandable, given the temporary,
part-time nature of the placement. However, it may also reflect a
tension between inclusion and exclusion, and an unconscious
conflict between, on the one hand, opening up a space for a different
way of thinking, and on the other hand defending against the
intrusion into an established organisation. Halton (2004) suggests
that ambivalence and envy towards creativity, in its most ordinary
sense, means that it can be seen as a nuisance, exposing us to loss,
risk, mess, uncertainty and possible failure. In the organisation this
seemed manifest in negative attitudes and devaluing of art therapy’s
presence as a luxury rather than a serious endeavour (Waller 2009).
The impact of brain injury can raise intense anxieties concerning
loss of control and body integrity, fear of dependence, imprisonment
and mortality (Gordon 1999; Weston, Knight and Girvan 2009).
For the team, it was as if mental space for getting in touch with
anxieties associated with the reality of the patients’ situation, and
for expressing concern, sadness and guilt, was unconsciously closed
off, behind a veil of surface friendliness (Skogstad 2000). Whilst
art therapy offered a different way of containing painful emotional
issues it also seemed, at times, to symbolise a receptacle for the
‘unbearable’ feelings embodied in people like Norma, who could
then be split off and pushed out of mind, and ultimately out of the
organisational body.
Had I unconsciously identified with this projection and begun
to isolate and exclude myself, as if responding to pressure to close
off a ‘reflective space’ for thinking (Hinshelwood 1994)? My

countertransference seemed to reflect a difficulty with communication
that could not be articulated (Gordon 1999). Through supervision
and reflective art-making the potential symbolic meanings of the
barriers between Norma, me and the staff, and my sense of paralysis
became clearer. Over time I was able to adapt my approach, which,
in turn, opened up different communication patterns.
Music therapy in a hospital inpatient setting

Some years later I acted as clinical supervisor for a music therapist
with a temporary position in an inpatient unit for brain injury. Art
and music therapy had been embedded in the multidisciplinary
team for many years; however, the unit was undergoing a process of
organisational and cultural change.
As Karen’s supervisor I struggled to keeping track of her
patients’ comings and goings. She, in turn, reported her difficulty
planning therapy due to the emphasis on functional recovery and
early discharge. She felt a pressure to work quickly, and reported
some hostility towards addressing longer-term emotional issues.
In supervision, Karen presented carefully considered, thoughtful
narratives describing the detailed movements, rhythms and patterns
of the therapeutic process. She spoke openly about her struggle to
empathise, and her guilt and concern about this. In her description
of one session, the heaviness and immense loss seemed palpable. She
expressed some puzzlement at having given a patient an exercise,
which was not her usual approach. We wondered whether a shift to
exercising the person’s arm might have offered a brief escape from
thinking about the impact on their life as a whole.
Case study
Henry was minimally conscious. James was conscious and fully aware,
but unable to move or speak due to extensive paralysis. Both states
were acutely painful to hold in mind; however, James’ position seemed
unbearable to contemplate. Karen reported his distress on the ward
and his wish to die. She felt an acute sense of despair and inadequacy,
and questioned the point of doing anything. I had been struck by the
sensitive attunement of the musical instruments, as well as Karen, and

how important this might be for those with severe impairment and
limited capacity for reflection.
We discussed the potential music therapy offered for nonverbal
communication and meaningful contact and relationship at a sensory
level, even through tiny movements. This seemed to offer some
hope. Karen also intuitively felt that therapy would offer some
breathing space away from the busy, noisy ward. However, during one
supervision session she reported several occasions when neither
James nor Henry had been got out of bed, ready for therapy. She
felt angry, but also puzzled. There seemed no apparent rational
explanation. I found myself wondering about the unconscious impact
on the team of having these two very severely injured people on the
ward. Karen described high levels of uncertainty concerning their
potential for recovery and a cheery bustle around James without any
real engagement. Acknowledging the stressful, traumatic nature of the
work, we wondered whether avoiding close proximity to James and
Henry might also represent a way of unconsciously avoiding emotional
contact with the unbearable sense of helplessness this stirred up.
With the support of the team, James made considerable progress,
and later was able to reflect on the terrifying experience of feeling
trapped in his body and unable to respond. Crying, almost like an
infant, had been his only way of communicating his sense of isolation
and distress and his anger about the low expectations of the team.
Reflections
Severity of injury, for many of Karen’s patients, meant that links
between mind and body were often severely disrupted, resulting
in some loss of sensation, feeling and consciousness. The people
with whom Karen worked, and their families, faced the immense
challenge of adapting to a different way of living and unpredictable
recovery outcomes. However, moves towards functional treatment
and speedier discharge seemed to deny the value of the longer-term
emotional work of grieving as part of adaptation to life after injury.
Karen had tremendous respect for the team and acknowledged the
value of functional approaches. However, this emphasis limited her
ability to use the specialist skills that differentiated music therapy.
Karen had an intuitive sense of the value of offering a reflective
space away from the pressurised environment of the ward. Her anger
was felt in relation to emotional and relational considerations being
devalued and forgotten about. Although often misunderstood and
perceived as undesirable in many western cultures, anger is one of
many complex reactions that needs expression and understanding
after brain injury (Weston 2008). As someone trained in being
attuned to emotional states and nonverbal communications, Karen
may well have been sensitive to some unspoken anxiety and anger,
on the part of both patients and staff, in response to loss of resources
and autonomy as well as reflective space and creative opportunity.
Karen’s struggle to hold onto hope despite feelings of despair
and inadequacy may have reflected intense anxieties in the staff team
about competence and ability to empathise with massive trauma and
loss. Zagier-Roberts (1994) describes the psychological pressures
for teams caring for ‘incurables’, to defensively split positive from
negative feelings; resulting in institutional tendencies to either
deny full damage and distress, or the full potential of those in their
care. Waller (2009) also identified primitive institutional tendencies
which revolved around intense fear and helplessness, with staff
affected by emotions that they could not easily express in response
to the work and organisational changes. This may explain workers
‘forgetting’ to bring patients to sessions. The cheery bustle around
James is reminiscent of manic denial (Klein 1998 [1935]), manifest
in turning away from the human suffering by physically looking
away or turning to jolliness (Skogstad 2000). Faced with James’
distress, there may have been an unconscious wish in the team for
an end to his suffering, so that the unbearable feelings would cease.
Such unthinkable and unspeakable thoughts may lead to extreme
feelings of guilt and shame, resulting in superficial jolliness, but also
in emotional numbing and disconnection – as if in defence against
‘knowing’ about terrible trauma and loss (O’Gorman 2001).
Discussion
Both Karen and I entered these organisations for limited periods,
so were not embedded in the culture. We each experienced
powerful countertransference responses to the clinical work and
organisational dynamics, a tension between hope and despair, and,
at times, impulses to act in ways that were out of character, indicative

of primitive projective processes. Weston et al. (2009) highlight the
reliance on concrete communication for brain-injured patients, and
the importance of seeing behaviour as an emotional communication,
to be understood rather than simply modified. Over a decade later
the image in Figure 6.2, made in response to Norma, still leaves
its mark, reminding me of the tension between allowing painful,
messy emotions into consciousness and keeping them out. Whilst I
view this struggle as part of the human condition, I am mindful that
denial, along with lack of insight and awareness, is a central issue
in work with brain injury (Langer 1999; Weston 2005, 2015). For
patients, denial may be an important coping strategy early in the
recovery and adaptation process. For those in a caring role it is also
necessary to employ psychological defences in order to manage tasks
of daily living. Prigatano draws a useful distinction between ‘denial’
as representing an attempt to cope, and ‘impaired self-awareness’
as a failure to recognise the need to cope (Prigatano 1996, as cited
in Langer 1999). Sorting out emotional factors from cognitive and
neurophysiological issues is complex and challenging, compounded
because a brain-injured person may appear to ‘know’ about a deficit
one moment and ‘not know’ the next (Langer 1999, p.82). The
tension between ‘knowing’ and ‘not knowing’ also seems implicit
in the initial exclusion of any psychological provision in the NICE
Scope for Stroke Rehabilitation, as if there were a lack of awareness
that there could be any deficit (Evans 2003), as well as an avoidance
of associated mental connections (Langer 1999).
Hinshelwood and Skogstad (2000) link a lack of containment
with the high level of defensiveness found in healthcare institutions.
Health professionals and organisational bodies are under
considerable pressure to be creative in the face of severe cuts to
resources. However, in a cold economic climate, playful, reflective
and imaginative thinking may be perceived as dangerous rather
than healthy, and spaces where anxieties about survival may find
expression and containment are liable to be frozen, paralysed or split
off (Halton 2004; Huet 2012). I am mindful of my own struggles to
hold complex, conflicting emotions in mind, and of the value of the
creative and reflective spaces of supervision, therapy and art-making
to help contain my rage and despair, as well as my anxieties about
‘not knowing’.
Figure 6.4 Anger and despair.

This reflective clay piece from early on in my placement remains a potent
image. It is reminiscent of Waller’s (2002) analogy of a baby’s frantic cry
of terror and abandonment and the need for such torment and rage to be
expressed and acknowledged. I would suggest that this applies not only to
individuals who suffer trauma as a result of brain injury or neurological
damage, but also to those who live or work with them in a caring capacity.
The brighter, more fluid and integrated form suggested by Figure

6.3 offers a warmer, more hopeful perspective, but only when
viewed in relation to the torn remnants of Figure 6.1, the colder,
more defensive marks of Figure 6.2 and the despair evoked by
Figure 6.4. Conflicting issues of hope, denial and awareness give
rise to some of the most complex and anxiety-provoking challenges
in the treatment of brain injury. Psychotherapeutic work involves
holding the hope alongside the despair, until the person is able to
engage again with the parts of life they can pick up for themselves
(Weston 2012). Hatfield (2006) argues that those living with illness
and disability need us to be open to ‘containing’ the distress and
anger that is too unbearable to be thought about, and to ‘survive’
it. An emphasis on the body and physical functioning might spare
the mind the burden of anxiety and conflict related to contact with
human suffering, but may result in a culture of exclusion and neglect
of emotional life, for both patients and staff (Dartington 2010;
Skogstad 2000; Waller 2009).
Despite acknowledgement that ‘cognitive and communication

impairments…often compound difficulties by compromising people’s
abilities to participate in standard evidence-based psychological
therapies’ (NICE 2013, p.35), nonverbal psychotherapies remained
excluded from terms of reference for the NICE Guidelines for Stroke
Rehabilitation. Art therapists often work with vulnerable people
who are excluded from verbal psychotherapies. My placement had
been initiated in recognition of a gap in resources for helping people
living with stroke who were struggling to engage with standard
treatments. Feedback was positive; however, the door to further art
therapy training placements remained closed for nearly a decade.
The music therapy post at the brain injury unit no longer exists.
Conclusion
This chapter endeavours to offer a glimpse beneath the surface of
organisational life in work with brain injury and stroke. Seen through
a psychodynamic lens, there is a focus on unconscious processes,
anxieties and psychological defences. Whilst these processes exist
to some extent in all caring work, there are striking parallels in
the narratives and images presented which reflect central themes in
psychotherapeutic treatment for brain injury, including some of the
barriers. They include dynamic tensions between hope and despair,
awareness, insight and denial, inclusion and exclusion. Most notable
within the organisational dynamics was the puzzling ‘forgetfulness’,
as if there was an unconscious, unspoken assumption that it might
be preferable to be minimally conscious and ‘not know’ rather than
to be fully conscious and aware of emotional trauma, pain and
vulnerability.
A glimpse is inevitably limited in the view it offers. However,
allowing framed spaces for imagination, wondering and speculation
may offer valuable and surprising insights into unspoken,
unthinkable aspects of interpersonal and organisational culture that
might otherwise remain hidden and out of conscious awareness. This
chapter argues that the evidence of our sensory, subjective human
experience offers a perspective that is too important to be discarded.
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CHAPTER 7
Art Therapy and Insight and

Awareness after Brain Injury
Sally Weston
Introduction
Soon after starting work as an art therapist in a neurological
rehabilitation unit, I developed an interest in the role of art therapy
with people with severe cognitive difficulties ‘lacking in insight
and awareness’ after recent brain injury. The unit offers early
rehabilitation to people after moderate to serious brain injury.
Patients are medically stable but generally at the very beginning of
their rehabilitation process. Often they are flat on their backs, unable
to sit up. Their time on the unit can lead to a dramatic recovery,
but also to a realisation of the changes and losses that often follow
brain injury. These encompass the physical, cognitive, neurological
and social.
The team is multidisciplinary with nurses, doctors,
physiotherapists, occupational therapists, speech and language
therapists, arts therapists and psychologists using their specialist
skills to assess and treat the patients. There is good communication
and an understanding of the different roles within the team. The
role of the arts therapists (established in the team six years before
my arrival) is to work with patients in emotional distress and those
whose feelings or behaviour get in the way of engaging with their
rehabilitation goals. People with communication issues are seen as
particularly in need of the special resources of arts therapies.
152
Insight and Awareness after Brain Injury 153
Issues brought to the art therapy room include: the shock

of waking up in hospital with a sudden injury; memories of past
physical or psychological trauma triggered by the injury; worry about
relationships and dependents at home. For some the most upsetting
thing is loss of control of physical functions, or of the ability to get
on with life. As patients became more aware of their difficulties, they
often become depressed, their motivation decreases and they appear
to be making less progress. But from a psychological perspective,
this is actually a healthy process – grieving as part of adjusting to
losses. From a general rehabilitation point of view, it is healthy too
– knowing there is something wrong is essential before being able
to put it right. Arts therapists can support the work of the whole
team as well as the patient, by offering a space for acknowledging
whatever feelings might arise as awareness of the consequences of
acquired brain injury unfolds.
However, some people continue to show no awareness of the
effects of their brain injury, or much insight into the problems there
might be. Some of them come to art therapy. One client, a relatively
young man, made a good physical recovery, but when taken for an
‘outdoor mobility’ assessment, was found to have very poor road
safety awareness. Unable to see this or to understand why he could
not drive, he was thought to be a danger to himself and possibly
others. In the unit patients are not held under the Mental Health Act
and are free to leave, but the team was keen to offer him more time
to assess and work on his cognitive problems.
He came to art therapy willingly and appeared to find the
sessions enjoyable and meaningful. While making drawings and
models, he told stories about his life. As he became more settled,
he agreed to go to other therapies. However, he still discharged
himself before the team thought he was ready, and I was left with
an unfinished model of a bird, three quarters of a metre across –
its wings outstretched, perfectly balanced on delicate wire feet and
looking ready for flight! The bird remains in my room and provided
me with food for thought: its maker had demonstrated that he was a
practical man who could construct things that worked. Those extra
weeks on the unit undoubtedly gave him a bit more time to be ready
for the outside world. I felt sure that art therapy played a part, and
continued to offer art therapy to such clients.
Literature review
The term ‘lack of insight and awareness’, a catch-all phrase
commonly used in neuro-rehabilitation, is a common feature after
acquired brain injury. It is usually defined as unawareness of deficit
or the inability to recognise reality (Sacks 1985). While many clients
recover gradually with time, others with more severe brain injury
(Weisenburger, quoted in Malec and Moessner 2000) have a very poor
future prognosis, including a lack of motivation for rehabilitation.
This can have significant impact on families and carers, and can
lead to high incidences of anxiety and depression amongst both the
brain-injured and their carers (Wallace and Bogner 2000).
The causes of lack of insight and awareness are generally seen in
neuro-rehabilitation literature as involving combinations of damage
to memory, perception, and cognitive and motor ability (Evans
2003). Recently psychological processes, particularly psychological
defences against conscious realisation of unbearable loss, have also
been seen as part of the picture (Kaplan-Solms and Solms 2000;
O’Gorman 2003; Prigatano 1991; Prigatano and Schacter 1991).
Langer (1999) writes of the differences between denial due to
psychological defences and denial due to cognitive issues (poor
memory or attention span, or the lack of ability to marshal thoughts
logically). She suggests that therapists need a keen awareness of these
differences (both of which may exist in one person), as different
therapeutic approaches are needed.
The multiple losses and major adjustment issues following serious
brain injury suggest that psychotherapeutic help might be needed as
part of rehabilitation towards recovery. For a long time, brain damage
was classed as contra-indicative for verbal psychotherapy. This has
now changed with the establishment of the neuropsychoanalysis
movement and especially the work of Solms and Turnbull (2002). In
the 1980s Prigatano, a pioneering psychologist and psychotherapist
in this field, recommended psychotherapy with art as part of the
treatment in the newly-established head injury rehabilitation units
in the USA. Arts therapists have worked with brain-injured clients
in rehabilitation settings since the early 1980s in the USA and in
Britain since the late 1980s.
When I started work in this field in 1997, I struggled to find
much writing by art therapists about their work in brain injury. I
found the argument of the American art therapist and psychologist

Garner (1996) useful: following brain injury, people need to address
neurological, cognitive and psychological issues’ simultaneously.
Garner argues that, because of the complexity of art-making, which
involves many different regions of the brain, art therapy is uniquely
placed to help. I was also struck by the work of Maureen Del Giacco
(2014), a Canadian art therapist who runs a structured programme
of art-making which addresses specific cognitive issues for brain-
injured people.
There was even less literature about clients who lacked insight
and awareness, though it was clear that therapists worked with
brain-injured clients at all stages of rehabilitation. An exception to
this was Wisdom (1997), who wrote in vignette form about a client
entirely lacking in awareness that she had had a stroke or that her
husband had died, and showed how art-making and song could
be used to help her grieve her losses symbolically. American art
therapists Wald (1989) and McGraw (1989) both described work
with clients in this state as expressive and creative art therapy as
opposed to insight orientated art therapy. I was uncomfortable with
this distinction as I did not feel my practice was radically different
with clients lacking insight.
I noticed stages of recovery: clients generally prioritised first
physical recovery, then cognitive issues, and finally allowed in
thoughts and feelings about the consequences of having acquired a
brain injury. I tried to offer a space where they could feel safe and
confident enough to bring whatever pressing issues they had – and I
tried not to make assumptions about what those might be. And in the
quiet of the art therapy room, insights emerged – sometimes spoken,
sometimes symbolic. I continued to think about ways in which
clients like the bird-maker seemed to be using art therapy to enable
them to work on a different level from the rest of their sessions. Were
they employing different functions of the brain, different levels of
consciousness? The art-making seemed to hold the key and I turned
to art therapists writing about this – for example, Maclagan (2001)
on the aesthetic, and Hyland Moon (2002) on studio art therapy. I
also remembered Jung’s encouragement of his often psychotic clients
to use dance, art or storytelling in their psychotherapy sessions, with
the idea that the therapist’s task was to support the mind and the
body’s natural attempts to restore themselves to health (Jung and

Jaffe 1963).
In the early days I was helped by literature from art therapists
working in learning disability and dementia, notably Angela Byers
(1995) and Ian Osler (1988), as they were also dealing with clients
with cognitive and memory issues. Valerie Sinason (2010) writes
about people with learning disabilities being enabled to think
complex thoughts within the support of the psychotherapeutic
relationship.
In 2001 Sally Skaife’s paper on intersubjectivity was published
in Inscape. Using ideas put forward by the phenomenologist Merleau
Ponty, Skaife explored the use of the senses in perception and the
importance of ‘right-brain activity’ to our knowledge of the world
outside ourselves.
Ponty considered the question ‘How do new things become
known?’ He argued that perception of what is not yet known, is
located not in the mind or the eye, or language or deduction, but is
experienced in the whole body. If that is true, then it is through the
senses that new things become known – and this highlights the role
of the arts, which use sensual experience to connect mind, brain and
body with the outside world.
This provided me with a theoretical perspective to explain how
and why art therapy is helpful for severely brain-injured clients
lacking ‘contact with reality’ or insight. Faced with the task of
reconnecting with the world after brain injury, their cognitive
problems (in planning, remembering, initiating activity, verbal
reasoning) mean that they can no longer rely on their lifetime
experience of understanding the world. The philosophical question
‘How do new things become known?’ is a central one.
The answer seems to be that the arts are not a peripheral or
diversional activity for this client group, but a central means of
mediating with an unknown world and unknown self. How this
actually works is being explored further through neuroscience, by
arts therapists and those interested in the neuroscience of the arts.
McGuinness and Schnur (2013) use the term ‘creative apperception’,
developed by Winnicott (in Abram and Hjulmand 2007) to describe
the combination of art-making and attentive relationship in art
therapy. This provides the right conditions for new learning to take
place and new neural pathways to be made, bypassing the damage

and deficits. In an EEG study, Kottlow et al. (2011) (in Preminger
2012) found decreased alpha waves during various drawing tasks,
suggesting that somatic memory and object recognition are enhanced
during this process.
Working in the art therapy room: first sessions

Art therapy is often seen as involving a triangular relationship –
client, therapist, art. In addition the art therapy room provides
both an experience of space and an opportunity for action. It is an
environment which can be experienced through the senses, including
sixth and seventh senses – the vestibular and proprioception. (The
vestibular system explains the perception of our body in relation to
gravity, movement and balance. Proprioception is the sense of how
our body is positioned in space and how we plan our movements.)
I want now to look at the part the sensual and sensory might
play in therapy for people lacking insight, and to convey something
of the complexity of the process. I will start with two accounts of
a client’s first visit to the art therapy room. Both had had severe
brain injuries, and had made good physical improvements, but
were not initiating activity, and showed little awareness of any
difficulties. Both had strong but contrasting responses to their first
art therapy session.
Luke
Luke was a carpenter, close to retirement age, admitted to the unit for
rehabilitation following a ruptured aneurysm (a bleed in the brain). He
was soon able to sit in a chair during the day, but had problems with
balance, initiation and perseveration (repetitive actions). He did not
initiate activity or conversation himself, but increasingly responded to
what was asked of him. His mood seemed low and he was referred
to art therapy. I visited him on the ward, introduced myself as an art
therapist, and told him that there was an art room on the unit. He
looked interested and said he would like to visit. I timetabled a session
and took him down to the art therapy room in his wheelchair.
Once in the room, he looked dazed. I asked if he was surprised to

be there. After a long pause he said (with a faint smile) ‘I’ve just woken
up!’ He sat looking at his fingers, moving them slightly. He stopped
when they were interlocked. Reading the notes now, I have a painful
sense of my difficulty in communication. Luke’s responses seemed
very slow. I began to realise I might not be letting him have enough
time to reply. I was trying to let him know what art therapy was all
about, whilst allowing him to adjust to a new environment and to
communicate with me.
Figure 7.1 Shelf in art therapy room, with ram’s horn (see colour plate).
Luke looked around the room and asked ‘What is that?’, pointing to
a ram’s horn, kept on the shelf for people to draw or look at (Figure
7.1). I gave it to him. He held it and started stroking it. I asked him
what he thought it was and after a long pause he looked at me and
said, ‘I reckon it might be a ram’s horn.’ I felt as if I had asked a rather
stupid question. Luke seemed to be dealing with his situation and with
me with a kind of humorous irony. He kept holding the ram’s horn,
stroking it repetitively, and it seemed easier for him to talk with it in
his hands.
He was obviously interested in and aware of things in the room and
they prompted feelings and memories. He told me that a Kandinsky
picture on the wall that attracted his attention seemed ‘sinister’. He
looked at a picture of hills and then cried briefly when I asked if he
liked walking. He tried to get up out of his chair, which I had to prevent,
as I knew from the team that he was at risk of falling. I took him over
to look at the art materials and we discussed what he might like to

use if he decided to return for another session. He said he would like
to come again.
At the end of the session, as I wheeled Luke out of the room, he
put his hand out to investigate one of the musical instruments by the
door, the xylophone. I paused and let him take his time. He continued
to hold onto the xylophone. We were now unable to move through
the doorway. I could hardly hear his voice, but I think I heard him tell
me that he ‘got stuck’. I was not sure if this was about the xylophone
being in the way or a more general comment. I asked if he was saying
this kept happening to him. He seemed to nod. Could this be an insight
into his perseveration? I took it as a promising sign of a developing
awareness.
Fran
The second client, Fran, had also had an aneurysm. She was married
with grown-up children and had been a teacher. She lacked initiation,
and sat all day long doing nothing. In non-neurological settings, lack
of initiation after brain injury is sometimes mistakenly diagnosed as
depression, as the presentation is similar. She responded when spoken
to, but did not remember faces, nor know where she was or what had
happened to her.
An art therapy session had been booked on her timetable the
previous week, but had been cancelled as it clashed with a medical test.
To my surprise, Fran seemed to be aware that there had been a missed
appointment. She told me she had decorated her room specially,
because I was coming. She said she should have spent time with her
children and they were wondering where she was. But it was OK and
they all had a nice tea. It was hard to know how to respond – I knew
that Fran had been in hospital for weeks and that her children had long
since left home. Her story or ‘confabulation’ was clearly not entirely
factual, but made her feelings very clear – that she felt let down and
inconvenienced. She was quite cross, and I felt she was letting me
know that she wanted to be treated with respect.
With difficulty she used some paints and made an image, which
she said was the colour of her walls she had decorated at home. She
seemed pleased with this and agreed to return the following week.
Later that day feedback from another team member indicated that
the session seemed to have helped her thinking and awareness: Fran
had talked about going home, showing an awareness for the first time
that she was in hospital.
Further art therapy sessions – engaging all faculties

People approach art therapy in different ways. For some, relating to
the therapist is the first step to engaging with therapy. For others,
their first step is to be involved with a task. For yet others, it is the
room itself. The art therapy room offers an opportunity to experience
an environment that remains more or less constant. There may be
sunshine coming though the window one week, or the sound of
water coming down the drainpipe the next. Ambulance sirens or the
noise of nurses laughing in distant corridors may claim attention.
But otherwise there is some regularity, reinforcement, certainty.
There is plenty of sensory input – objects to muse on as Luke did,
which made connections for him, reminding him of the countryside,
and a bit later in the session enabling him to express some sorrow
that may have been part of his low mood. There are things to engage
with: art materials to use. Fran seemed to be using the whole room
as a way of discovering a context for her experience. Was it perhaps
mixing ‘the colour of my wall’ that made the connection for her that
she would not go back home in the evening?
As the therapist, I am also using sensory information to help
me make sense of what is happening for the client and how I may
best help. Sometimes this is practical – I brought Fran’s chosen art
materials to the table, and as she did nothing with them, demonstrated
how the paints could be mixed in the palette. Sometimes I share
my observations, if I think it will help the team assessment. In the
second session Fran picked up a fir cone which was part of a display
and began to put paint on it. I realised she had not recognised this
prosaic object, or perhaps had lost the sense that she had paint
and brush in her hands. This made me suspect that she was having
problems with proprioception or object recognition. I let the team
know so that they could compare this with their observations.
Luke: reflections
I will now look in more detail at my role and reactions in Luke’s
first assessment session. I was trying to help him find out how
he could use the materials. I was aware that he had been low in
mood, and hoped that the sessions would help him feel able to
explore and express his feelings. In order to do this, I tried to assess
Luke’s cognitive, communication and neurological difficulties and
strengths. The speech and language therapists had told me his speed
of processing was slow but that he understood one idea at a time. I
tried not to put too many ideas forward at once and gave him plenty
of time to answer. I noticed that both his sense of touch and what he
saw seemed to be stimulating his memory.
The session felt very slow and I had to balance accepting his lack
of initiation and perseveration with a need to move things forward.
People who initiate no activity themselves can be ‘prompted’ or
cued into action by words or a demonstration. On the other hand,
neurological symptoms may not be purely pathological, and may
also have emotional or psychological significance. I try to hold
both in mind at once. Perseveration involves strange mechanical
repetition – I usually find it hard to bear and want the person to
stop. The neurological explanation is that such movements (or speech
patterns) come from the autonomic nervous system, so are actions
which bypass conscious control. With Luke, I wondered if I could
make any sense of it psychologically. I thought about the quality of
obsessive touching – perhaps this was a need to make tactile contact
with the world after being in a coma? After the session I summed up
my notes by writing, ‘Has been depressed. Quiet excitement about
the art.’ This was confirmed the following week when I met him
being wheeled down to the session. ‘I’m off to the artists’ studio.’ he
said with a smile.
Fran: further sessions

Fran was also stimulated by the room and used the contents to convey
her emotional state and establish a relationship with me. During her
next two sessions, her perceptual difficulties worked alongside letting
some of her defences down, as she continued to let me know how she
felt. In the first of these, the art-making became a focus of discomfort.

She said she was going to draw a picture of a ‘bowl of fruit’, but only
made a few marks. I asked her if she had a favourite colour. She said,
‘No, I’m a waste of space.’ She added, ‘There’s a lot wrong inside.’
My tentative attempts to explore how she felt were clearly repulsed
at this stage, and I felt I had been insensitive and intrusive. I realised
I needed to tread very carefully around her psychological defences.
She had been an efficient, capable person with a job and a family she
had looked after. How could anyone face up to her current degree of
deficit and dependence?
The relationship with me continued to be the driving force of the
therapy, yet the materials and the endeavour of making something
(albeit reluctantly) appeared to be the catalyst (enabled by the
safety of the art therapy room) for the important growth of a little
‘awareness of deficit’ (Sacks 1985). The following session Fran came
into the room and asked cheerfully, ‘What shall we do? Paint?’ This
time, I got out a paint box, simpler to use than paint in tubes. She
asked me what colour she should use, telling me firmly, ‘I’d like you to
decide.’ I asked her what sort of mood she was in and if any colour
suited it better than others – she chose green. She looked at the two
greens – leaf green and bottle green. She used both, but dipping the
brush solely in the water, so that the paint became fainter each time.
She had lost the connection between the water and the colour in the
box. Assuming this was a cognitive problem, I showed her how to
use more water to make a bright colour. This intervention seemed to
irritate her. She didn’t continue with the greens, but used two other
colours together – brown and black – which she told me were the
colours in her wardrobe.
She said that black was a bad colour, depressing. Then she said she
was trying to make the same colour as her trousers. ‘When you asked
me earlier, I didn’t know what you meant.’ (Later I found out that
the nurse who had helped her dress that morning had asked her to
choose between different clothes, which she had been unable to do.)
She worked in the middle of the paper, now and again initiating marks
as she talked. I asked if the marks reminded her of anything. She said,
‘No it’s an experiment,’ then said, ‘a flower’ and then ‘trouser legs.’ She
then painted a little red shape and finally some blue in the middle. She
spent the final ten minutes of the session looking closely at the objects
and pictures on the shelf – she remarked on the shape of the ram’s
horn and the pine cone, and said, ‘No black along here.’
The following week she came into the room in a calm mood, and
looked intently at the same objects. She said, ‘I like it here. I remember
it. I remember all those things and nothing’s changed.’ Dubowski

(1984) points out that when the linguistic and iconic systems combine,
children make exciting leaps in their understanding. Fran’s use of visual
media seemed to have had prompted emotion and memory, making
connections which enabled her to solve a problem, which she was
then able to express in words.
Articulating the thought about getting dressed and the feeling
about the colour black somehow solved Fran’s problem with
initiation. Her difficulties with painting seemed to evaporate. Without
prompting from me, she had purposefully chosen two new colours and
successfully completed her task. She seemed to have made a picture
of getting dressed.
I suspected the other reason why she was unable to think, was that
the implications of her thoughts were too terrifying. If it was true that
she could do nothing for herself, she might indeed have fallen into the
blackest of depressions. The resistance I was experiencing may have
been part of a process of denial – horrible feelings thrust out in the
direction of the unreasonable art therapist or nurse asking ridiculous
questions or making impossible requests.
In the session she seemed to feel safe enough to feel the qualities of
the black/depression for at least as long as it took to put the paint on
her brush and the marks on the paper. As she initiated her final marks
herself, choosing two quite different colours, she had both completed
a task and briefly admitted the depth of her distress. The aesthetic
resolution of the picture coincided with a therapeutic resolution. And
she was able both to think and to allow herself to feel whilst she made
her painting – the iconic and linguistic working simultaneously.
Luke: regaining a sense of the body

The sessions with Luke were less emotionally charged than with Fran
– his thoughts and feelings were channelled into the artwork. For three
sessions he made rapid progress in his artwork. This series of pictures
clearly shows the extent of damage and then the rapid recovery of
spatial and perceptual skills. Figure 7.2 shows his first image, based on
things in the room – a picture of a landscape and the ram’s horn he
had picked up and handled. He clearly enjoyed the sessions, although
he did not remember what he had done from one session to the next.
Figure 7.2 Tree and ram’s horn. (The outside world.) (see colour plate)
Luke’s condition continued to improve through a combination of
natural healing and rehabilitation. Based on my work with other
clients whose insight was gradually returning, I thought he might use
the sessions to express his feelings of loss and grief. However, a more
pressing issue came to the fore – his cerebellum and therefore his
balance had been severely affected by the injury, had then improved,
but suddenly became a problem again. When first on the unit and
still in bed, he had resisted nurses’ and physiotherapists’ attempts to
move him, by gripping firmly onto his bed. At night he was unable to
relax enough to fall asleep. He was eventually able to tell staff that
he thought there was no bed there to support him. He had lost the
sense of where his body was located in space, and felt he was falling.
However, as his balance improved, his panic subsided. In the third
month this suddenly came to the fore again. He leant down to get
something from a cupboard and was unable to get up. Shaken by this,
rehabilitation was knocked back. He became reluctant to leave his
chair and attend therapy sessions.
When he returned to art therapy two weeks later, he started
working with clay (see Figure 7.3). He made a head; he then continued
working with the rest of the clay, but left it. He continued using this
medium, producing a series of heads (see Figure 7.4). These sessions
seemed to move the therapy into a different phase, with Luke totally
absorbed in the art-making, becoming increasingly motivated and
technically skilled. The final head was very realistic. My role was
minimal once the clay was out and he was sitting safely at the table.
It was as if he had found the medium he needed, and his work was
obviously intensely meaningful.
Figure 7.3 First head and worked clay.
Figure 7.4 Clay heads together.

It took my supervisor to point out something that happened with

Luke’s clay figures. As time passed and recovery and rehabilitation
progressed, Luke’s figures became more sophisticated – and had
gradually risen up until the final one was almost upright (see Figure
7.5)! They mirrored Luke gradually regaining his balance. Neither Luke
nor I had noticed this.
Figure 7.5 Heads rising up.

I will end with Luke’s final session, as he articulated in words things I
had only been able to surmise while he was working so intently that
I didn’t like to interrupt. I asked him what the art therapy had meant
to him. He said that he had ‘been able to go into myself – you know,
when everything is going on outside.’ I asked if he was thinking, or just
concentrating on the work. ‘Oh yes, I was thinking all the time.’ He
looked through his work and laughed in disbelief that he had made
the early figures. I told him my memories of how ill he had been, how
little he had been able to do compared to how he was now. I remarked
on the realism of the last head he had worked on, compared to his
earlier pieces. He grimaced and agreed. I said that change often feels
uncomfortable. He said, ‘Back to reality.’
Conclusion
An important part of the work of neuro-rehabilitation on the ward
is to discover the deficits and losses that brain injury has wrought.
This is often a collective endeavour, for the patient, relatives and
friends, and rehabilitation staff. In the early stages it is more likely
to be the relatives who are experiencing grief and trauma about
the brain injury – worries about the future, responsibilities suddenly

unattended to, bills unpaid, and more.
Patients themselves are more likely to be struggling with
difficulties with proprioception, like Luke, trying to negotiate and
understand a world where he no longer had a sense of where his
body was in space; or Fran, supposing herself to be in another other
time with young children living at home, unable to process the clues
that might have told her she was in hospital.
The art therapist’s delicate task at this time is to create an
environment where the patient can safely explore and express their
sense of reality and their feelings. I have explored how patients
‘lacking insight’ can be supported by the combination of art-
making, containment of a consistent room and relationship with
an attentive therapist. Drawing and art-making are complex tasks
involving the physical, neurological, cognitive and emotional
functions, consequently using many different areas of the brain. And
the process of trying things out can create new neural pathways.
The work done with the two clients above shows something of
the mechanics of the process, while the ideas I have explored in
relation to them go some way to explain how people after brain
injury, apparently ‘unaware of deficit and out of touch with reality,’
can use art therapy neurologically, cognitively and emotionally
to begin to work out who and where they are, to remember their
history, to begin to discover their difficulties and to begin the long
road of adjustment to the changes of brain injury and recovery of a
sense of identity and purpose.
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PART III
Epilepsy
CHAPTER 8
Art Therapy after Acquiring

Seizures in Adulthood
Quentin Bruckland
Introduction
In this chapter I will be looking at how art therapy supported a
person after being diagnosed with refractory epilepsy. First I explain
this condition, then I look at adaptation to diagnosis. I discuss the
awareness of emotional and illness identity, and look at coping,
illness representations and how psychotherapy (including art
therapy) can help.
I will draw on a case study of a man in his late twenties who
acquired epilepsy from an encephalitic attack, and hope to show the
benefits of using art therapy in the adaptation process. Art therapy
may help a person with epilepsy to:
• increase an adaptive approach, and reduce self-defeating
emotional responses to living with seizures and the diagnostic
label of epilepsy
• reach a meaningful self-representation of the condition through
a better understanding of the illness
• cope better with the disturbing and unpredictable effects of
epilepsy.
173
Refractory epilepsy
Refractory epilepsies are those which are resistant to control of
seizures by prescribed medication. Seizures can be frequent and
unpredictable, and include associated symptoms that can affect
people in physical and emotional ways, often intrusively. Attitudes
about the lack of controllability, or the label of epilepsy, by self or
others, can often leave the diagnosed person feeling vulnerable and
helpless (de Oliveria et al. 2010).
This often causes a burden of shame, helplessly facing a lifestyle
change and seeing oneself negatively in public (Räty, Soderfeldt
and Harman 1999; Räty et al. 2009). The prospect of never fully
recovering can add a further feeling of powerlessness to an already
shaky self-confidence. This leads to ruminating worries associated
with the diagnosis and the long-term future health effects of the
condition itself. In addition there may be hidden progressive
symptoms that can upset the quality of life (Suzuki 2009).
Coping and adaptation

The role of emotions is central to the adaptation process, and
any stresses relating to the condition have the potential to trigger
negative self-worth. This is often the result of life-altering losses,
shame and anxiety (Räty et al. 2009). The intrusive daily upsets of
seizures affect the basic human need to feel a sense of control over
one’s body and daily life.
Adapting to living with epilepsy is described in the literature as
a sudden life-changing experience, in which one’s severely altered
perceptions of health, self-efficacy and control lead to uncertainty
about many desired personal goals (Livneh, Lott and Antonak 2004;
Livneh and Antonak 2007; Räty et al. 2009).
The loss of one’s previous identity is the result of the fundamental
change to daily living (Travis and Ryan 2004). The sense of identity
and self-esteem of people with epilepsy are challenged by the
recurrent uncertainty of life with frequent seizures (Jacoby, Snape
and Baker 2005). This can also trigger a vulnerability to shame
(Räty, Soderfeldt and Larsson 2007, Räty et al. 2009), which can
Art Therapy after Acquiring Seizures in Adulthood 175
be difficult to acknowledge, and is often concealed due to a fear of

being misunderstood and of being stigmatized as epileptic.
This can lead to a vicious circle of negative self-worth, leading
to changes in identity and then more negative self-belief, and so on
(Räty et al. 2009). The initial impact of the diagnosis often leads to
strong emotional feelings about short-term and long-term changes,
some of which may be permanent, in both personal and public areas
of daily life (Livneh et al. 2004; Räty et al. 2009).
Miller (1994) states that, in epilepsy, the therapeutic method
needs to centre on reintegrating a sense of self and altering the
distressing sense of fragmentation, alienation and seclusion. After
diagnosis, this can be helped by seeking a meaningful quality of
life beyond the adverse effects of epilepsy (Livneh et al. 2001;
Livneh et al. 2004). This requires a period of adjustment and an
understanding of the emotions involved and the reality of living
with epilepsy (Räty et al. 2009).
Illness representations
Illness representations are made up of diagnosis, symptoms and
beliefs about controllability, and help in understanding the effect of
the illness on the person’s life (Kemp, Morley and Anderson 1999).
Making illness representations in an art therapy session provides a
shared communication towards the acceptance and meaningful sense
of self needed after acquiring epilepsy. The client being present and
actively involved in understanding the current health situation helps
integrate the experience into a renewed sense of self. This also helps
to modify negative core beliefs underlying the illness (Räty et al.
2009), and is vital to the adaptation process.
Acceptance of the diagnosis can help people start to cope with
the frequent daily insults when living with seizures. It can also help
to develop some awareness of the person’s relationship to their illness
identity and the wider psychosocial effects (Livneh and Antonak
2007). The relationship to their illness identity can also indicate the
best path for treatment (Goldstein et al. 2005a; Mittan 2009).
Psychotherapy
Miller (1994) and Goldstein (1997) talk about the therapeutic benefit
of psychotherapy to help patients identify and relieve unresolved
emotional triggers when living with an acquired diagnosis. It can
also help to build an integrated, meaningful sense of self to adapt
to and modify the stresses resulting from epilepsy. Velissaris et al.
(2007) talk about cognitive strategies following newly diagnosed
seizures, improving a sense of self and perceived control, and so
improving quality of life (Guekht et al. 2007; Räty et al. 2009).
Goldstein et al. (2005b), Kemp et al. (1999) and Kemp and Morley
(2001) highlight the importance of psychosocial reorientations,
which can have a significant impact on both coping styles and
psychological health related to living with epilepsy. Small (1980)
states that psychotherapy must focus on the reality of seizure patterns,
and accept the wider effects of the condition on the individual’s life.
Goldstein (1997) and Mirnics et al. (2001) highlight the importance
of psychotherapy to modify negative beliefs from the effects of
treatment and psychosocial and emotional problems.
Art therapy provides a way of working with the stresses and
difficulties of illness-related experiences when words alone feel too
challenging or painful. It can help to make sense of these experiences
in a visual way, and achieve a sense of control.
Improving self-esteem and self-efficacy beliefs can make a
difference to how people with an imposed illness experience their
feelings, and can help them make efforts within reach of their
abilities (Haddad 2010; Nahum 2012).
Case study: Dan

Dan was a 28-year-old man referred to art therapy after a medical
assessment and diagnosis of epilepsy. The aim of the referral was to
support an adaptive approach to modify his negative self-beliefs, which
resulted from restrictions and changes to his previous quality of life.
The aim was to improve his self-belief, acceptance and adaptation to
the condition.
I was mindful that it was highly unrealistic to expect an alleviation of
all the difficulties he was experiencing. Our initial aim was to develop
a meaningful and purposeful quality of life beyond the intrusive effects

and restrictions of living with seizures. His seizures were refractory
(resistant to medical treatment). This led to emotional uncertainty
and frustration, with a shift in self-concept. He felt an overwhelming
sense of shameful powerlessness to stop or change his health situation.
These feelings affected his self-efficacy and previous sense of self –
including relationships, daily uncertainty and meaningfulness of life.
Dan talked of the helpless worry of waiting for a seizure, which left
him with a constant distressing burden, and additional underlying doubt
about his sense of worth and self-belief, which in turn dramatically
changed his outlook on his future health needs. He described this as
a ‘plate of spaghetti’, hard to unpick or even find where this struggle
of a journey started or might end. This was an apt way for Dan to
describe his experience of total lack of control. He said he felt in limbo,
forever trying to digest, grasp and normalise any purpose or meaning
in the significant changes he experienced. He found himself clutching
at things, including his previous quality of life. He said he ‘needed some
head space’ from the never-ending and relentless seizures. Ironically,
this was the one thing he could guarantee would not happen.
The art therapy sessions

Dan arrived saying the only way he could describe his experience was
‘It feels like I’m falling away from everything I know, in my way and
attitude to life, but curiously I feel like I’m standing still while on this
never-ending journey.’ He continued, ‘I have nothing but time on my
hands, I feel like I’m in the desert. Is it me that is standing still while
the world I knew moves further away?’ He described watching family
and friends carrying on with their lives, while he fell further away from
feeling connected to where and who he was.
He described not having a sense of control or anything to stop him
falling, both metaphorically and physically, in the event of a seizure. He
felt the disruptive seizures, with their intrusive demands, shamefully
affected any way he tried to maintain a sense of control, resulting
in continual, wearing effects on his self-worth, and a sense of being
powerless to stabilise his life. These changes led to strong, anxious,
emotional reactions which resulted in several idiosyncratic behaviours,
such as social avoidance, due to the amount of time he spent thinking
about when he was going to have a seizure.
One statement Dan used a lot was, ‘People just do not understand
what it is really like to live my life. People should walk a mile in my
shoes before judging me and what I live with.’ The hidden self-appraisal
was frustrating and painful for Dan to experience, especially in public,
when he felt a lack of understanding added to his shameful frustration

about being viewed as ‘an epileptic’.
Dan approached art-making by often including his unique viewpoint
in a narrative. He was very aware of the altered pieces of his former
identity and the many aspects of his acquired illness identity. The
complexity of this often needed to be broken down to make a focused
sense of meaning at any one session. His art-making was precise,
controlled and thoughtfully planned; completely opposite from the
sudden and unpredictable nature of his seizures. Dan consciously
craved a capacity to hold onto a sense of control and meaning. Art-
making led his thoughts towards a more positive, autonomous and less
self-defeating way to communicate. He was very practised in covering
any weaknesses with a protective layer, to avoid being shamed further
by his condition.
On a bad day he arrived dazed, in pain, bruised and weary from a
night of disturbed sleep, saying, ‘I’m in bits today. Got a right kicking
from bone-shattering seizures last night and I’m not sure what is
going on.’ This fragmented state reduced clarity of functional thinking,
leaving him with an apprehensive, sliding scale of confusion in his sense
of time and whether he had a session with me at all that day. These
periods ushered in a shameful self-questioning cycle of low self-belief,
compromising his ability to make choices about what he should be
doing. This further undermined his sense of security and ability to
combat seizures and their symptoms. He wanted to protect those
close to him from witnessing the subtle but chronic effects involved
in his sudden life change. He had no previous experience by which to
gauge the hidden, intrusive undercurrents that ran into every facet
of his life. These hidden effects and reactions were an impossible
challenge to take on alone. His lack of confidence and clarity with
decision-making was continually affected by intense emotional feelings
of helpless vulnerability. These took up valuable mental space that was
needed for processing important coping strategies.
We spoke about being defined by the effects of living with epilepsy,
and trying to let go of what felt uncontrollable and the perpetual fight
against the all-consuming disorientation. Our aim was to modify these
negative effects, to enable Dan to achieve a realistic sense of control
and purposeful quality in his daily life.
He told me that, after a seizure, he often physically ran in any
direction, ‘to get away from the intrusive and frequent feeling the
seizure left in my head’. This was the only way he felt he could cope
with the horrible feelings and intrusive after-effects left in his head and
body. These enactments allowed us the opportunity to reflect on his

need to tear off and leave behind, run away and side-step the intense
feelings and vulnerability felt in his head.
Figure 8.1 Maintaining forward motion.

Being seen visibly out of control in public places was a huge culture-
shock, as was suddenly living with the shame and uncertainty of the
inevitable. ‘People just don’t want to see me seizing. It’s not nice, it’s
too intrusive.’ His first image (Figure 8.1) was of his primary need
to maintain a forward motion, despite the recurrent limiting effects
of living with epilepsy. These cyclical effects involved revisiting intense
emotional reactions to the daily events, and he realised he needed
to maintain an ongoing life regardless of the epilepsy. Dan’s fearful
perception of his epilepsy was due not only to its intrusive effect on
him, but to its potential to be unpleasant for people witnessing seizures.
This created a fear of being a burden to others. He felt helpless to
control his past, present and future hopes. The image was a marker
for the constant need to be moving forward in dealing with the effects
of his condition.
There was often a tension between new and old ideas that
generated surprise and difference. Dan’s second picture (Figure 8.2)
showed his desire to avoid life serving up ‘more shit on a plate’. This
was a humorous mixing of new and old, bringing out something
unpalatable, smelly, and leaving a nasty taste in his mouth. Privately Dan
viewed himself as frail, unappealing, unhealthy and even unfit socially
and economically.
Figure 8.2 Bad smell.

He had huge concerns about his vulnerability while having a seizure,
the lost time and not being able to get this time back. ‘Anything could
happen to me at these spells, seizing on the floor, and it’s my time
and life that has gone forever. A loss of life without knowing what
happened, I will never know what really took place or what I was doing,
and it’s time I will never get back.’ The lost chunks of time supported
and nurtured the recurring vulnerable, unstable self-image.
He sometimes arrived and stood for a quarter of the session,
talking intensely about the enormity of living; what felt like dominating
feelings of powerlessness resulting from the ongoing experiences
of his fundamental life change. There were sessions when he felt
overwhelmed by the sense of being alone with his experience of living
with this invisible mental suffering and how dark this could be. He
wanted a release from watching life just go by without something whole
or meaningful. Then he sat down in relief at our acknowledgement of
his perception of the stark facts. As he put it: ‘My diagnosis makes
pretty bad reading, enough to sober up anyone.’ In other sessions he
brought an intensity on arrival, with a large puff of his cheeks or a sigh.
He described a need to live with epilepsy without fighting a never-
ending battle 24/7. ‘Saying it is what it is.’
Figure 8.3 The war (see colour plate).

Figure 8.3 depicts Dan’s personal conflict and war, where neither he
nor anyone else could defeat the enemy by controlling his seizures, or
win the war by curing epilepsy. There was a true sense of not wanting
to continue with this fruitless battle that could not be won. His
seizures being resistant to medical intervention, the narrative was a
fruitless collection of battles, events and skirmishes, and the recurrent
experience of the overall war against epilepsy and its negative effects
on his life. Part of Dan wanted to live in peace and master some part
of his life that did not involve the epilepsy, while another part of him
wanted to ‘stop the condition, win the battle against it and eradicate
it from my life’.
Dan used images borrowed from the film Apocalypse Now (see
Figure 8.3), of travelling down a river on a long, secret, unclear and
difficult mission, to understand better the often hidden, recurrent
uncertainty of feeling out of control. This resonated with his own
journey that he faced on a daily basis. This image was returned to
many times, and worked as an ongoing indicator of how Dan felt about
himself, his wellbeing and ability to move forward in his life. It helped
him reach a willingness to go on a long, difficult journey despite the
anxiety he felt, to resolve his conflicts and emotions.
This narrative allowed us the opportunity to uncover many personal
and silent adverse assumptions. We were able to acknowledge setbacks
and recognise the many changed pieces of his identity. These included
inferior self-beliefs involved in the deep and personal battle with his
sense of self. His own emotional perception of the medical diagnosis,
and the social reality of living with the debilitating unpredictable effects
on his quality of life, were what truly mattered to his sense of wellbeing.
Despite all this, Dan needed to focus on coping with his condition and
what might still be possible ‘while still having to hit the deck’.
This offered us a chance to understand the complex efforts to
normalise the daily aspects of his changed identity, self-image and
shame associated with the lack of control. His shame was often felt as
a running battle and a hurdle to be overcome as a result of the sudden
changes in his bodily functions, his low self-image and loss of pieces of
his identity, either left in limbo or frozen. Art-making became a verbal
and nonverbal indicator of his emotions about these issues, and he
made several images on these themes.
Figure 8.4 The big man.

Figure 8.4 shows a new departure for Dan. This art piece took a
number of sessions to complete, starting with wire mesh and then
plastering over the wire structure in a measured and methodical way.
As he was working on this, there was much discussion about self-
perception, control and meaningful roles. Working together on this
strengthened our relationship. Building a functioning frame helped Dan
to understand and re-appraise his sense of self.
This was Dan’s three-dimensional representation, acknowledging
and owning all the complex, unpleasant parts, and restoring the echoes
of his previous self. It was a celebration of Dan’s personal rhythms, the
fragile along with the beautiful, embracing all of him as he was now.
He felt comfortable with his embodied self-image, clearly stable and
determined, on his own two feet, regardless of the fear of uncertainty.
The covering and bandaging of his previous self, and the emergence
of a new part of Dan’s sense of self, showed him surviving to create
a firm identity. This artwork enabled us to balance Dan’s experiences
with his new ability to negotiate what to expect when they happened
again. This was important for him, as it had been a ‘thorn in his side’,
having all the time in the world, but not having the mental space or
realistic approach to accept his situation. Art-making helped him to
achieve this adaptation and adjustment in wellbeing. He included the
words ‘The beat goes on’ to show his need for a meaningful sense of
progression, regardless of the ever-present uncertainty.
By embarking on this work together, we revealed and acknowledged
Dan’s need to hide from unpleasant psychosocial and physical realities
by cocooning himself. Encouraging self-efficacy and empowerment was
vital for Dan to regain his own ability to believe and trust himself as
the ultimate authority on his own body, and define a real, independent
sense of self. We reconstructed his identity bit by bit (Figure 8.4),
which ultimately allowed him to make his first empowered steps
towards having an informed quality to his life on a daily basis.
Conclusion
Our work involved communicating about Dan’s need to understand
his daily reactions to the chronic change in his health, and the
accompanying intrusive, negative, ruminating thoughts. These
were difficult for Dan, first to acknowledge, then make sense of
and understand, then be able to put into words, and finally enact a
representation of the condition and of his sense of self. The more
emotionally informed and secure he felt, the more it enhanced his

sense of self, enabling him to respond to difficult experiences and
feelings on a daily basis.
One of the most difficult aspects of this for Dan was the emotional
impact of enduring the abrupt, comprehensive and distressing sense
of change. The burden of epilepsy, both the diagnosis and the effects,
affected how Dan appraised and then re-appraised himself in daily
life. Dealing with these in the short term was vital in enabling Dan
to develop a more positive long-term attitude towards adaptation.
This was crucial in helping him to understand potential triggers
of vulnerability to health and wellbeing, and to achieve a healthy
attitude to living with epilepsy. He managed to develop a true sense
of meaning from the shattered parts of his identity, resulting in a
better sense of control.
Dan was able to understand his direct experiences as well as his
fears of never fully recovering, being healed or living a life free from
refractory epileptic seizures. He gained an awareness of the potential
of further impacts, learning to live with and adapt to the negative
effects on his sense of belonging, self-image and daily living skills.
This enabled him to be confident and aware of who he was, and to
live an informed and effective life. Our shared creative experience
inspired Dan to continue art-making after our work together ended,
using a reflective journal as a tool for making sense of difficult
periods when they arose.
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CHAPTER 9
‘This is my Dream World’

Art Therapy with Young Adults with
Epilepsy and Learning Disabilities
Andrea Gregg
Introduction
This chapter looks at the effectiveness of art therapy with young
people who have epilepsy and learning disabilities, and who are at
risk of death from seizures. Through the exploration of three cases,
I describe my clients’ search for their identity, looking at all three
clients’ use of and identification with fictional characters. I came to
understand this identification as a way for my clients to hold onto
their self-esteem and to protect their vulnerable and damaged sense
of self and body image.
Each case demonstrates the client’s search for identity and self-
image against the backdrop of living with a life-threatening condition.
In all three cases the identification with a fictional or fantasy character
helped the client to achieve prestige and status. I came to view this
identification as a metaphor for courage, adaptability and creativity,
rather than as a symptom or pathological defence. Trust, self-esteem
and creativity developed through the use of art-making, play, and
my ability to attune to the clients’ subjective reality.
187
The setting
I work for an independent company which provides specialist care
for young adults with epilepsy. The clients are seen in a residential
unit that is home to six adults with epilepsy and associated learning
difficulties and behaviours. A therapy room within this unit is set
aside for art and music therapy sessions. Clients are seen here from
this unit and from other units managed by the company.
Epilepsy
Epilepsy is the most common neurological condition in the UK,
with one in every 131 people having the condition, and over
40 different types of epilepsy currently categorised. Epilepsy has
been steeped in myths, interpretations and superstitions over the
centuries. In ancient times it was interpreted as a form of possession
by demons, or a punishment for angering the gods. In medieval
times the symptoms of epilepsy were given supernatural status. To
this day some cultures have shamans and witch doctors that use
seizures to prophesy, communicate with ancestors and reveal divine
inspiration. In the early twentieth century psychoanalytical thinkers
viewed the epileptic seizure as an expression of unbearable and
inexpressible emotion, a defence against thinking. Freud (1927) and
Ferenczi (1996 [1919]) understood seizures as unexpressed rage and
a withdrawal to a pre-birth state.
The current medical profession categorises two types of epileptic
seizure: partial and generalised. Partial seizures can affect the person’s
five senses, the person can be conscious but experience twitching of
the limbs, intense emotions or uncharacteristic behaviours such as
smacking the lips or rubbing the hands. It is the generalised clonic-
tonic seizure, involving loss of consciousness, that affects all three
clients discussed in this chapter. This type of seizure has two stages.
The body becomes stiff and then the legs and arms begin twitching.
The person then loses consciousness and sometimes bladder control.
Clonic-tonic seizures normally last between one and three minutes.
This is the most common type of seizure, accounting for 60 per cent
of all seizures experienced by people living with epilepsy. Clonic-
Young Adults with Epilepsy and Learning Disabilities 189
tonic seizures are typically what people are referring to when they
use the term ‘epileptic fit’.
There is still very little written specifically about art therapy
and epilepsy. The art therapist Simon Cregeen explores the anxiety
of living with this unpredictable condition in his papers ‘Making
sense: Brain trauma, epileptic seizures and personal meaning’ and
‘Seizure as symbol’ (Cregeen 1992, 1996). American art therapist
Connie Naitove (1983) has written about the impact of a diagnosis
of epilepsy with particular regard to the law, and the impact this has
on her clients.
The three cases that I will explore in this chapter focus on
clients with epilepsy who also have learning disabilities of differing
degrees. I noticed that a theme common to all three cases was the
use of fictional characters in the artwork and identification with
these characters as a means of increasing self-esteem. This appeared
to offer clients a status that allowed them to tolerate interaction with
me, which in turn allowed them confidence to use art materials and
explore feelings. In two cases the clients were able to shift from
over-identification with the fictional character to a more realistic
acceptance of themselves, by externalising the fictional characters
and putting them on paper to be viewed and explored as ‘other’.
I met each client to help with their particular journey at that
point in time. The intention was to offer them an open and relaxed
dialogue that respected their use of fantasy and the role that it served
as a defence against feeling disempowered, controlled and without
positive identity, as a young person with a life-threatening condition
and learning disabilities. I found I needed to develop an ability to
attune to the client in an open and receptive way, accepting the use
of fantasy, and celebrating its function as a way of forming identity
and preserving self-esteem. With time, the individual’s skills and
personality emerged and gained status.
Learning disabilities
According to the White Paper Valuing People (Department of
Health 2001, p.14), a learning disability includes having impaired
intelligence, a reduced ability to cope independently and impaired

social functioning.
Adults with epilepsy and learning disabilities may have similar
wants and needs to those without. They may want a job, a partner
to fall in love with, their own home, and to develop their own
interests and hobbies. Since publication of Valuing People, there has
been a drive to make society more inclusive of adults with learning
disabilities, including support to access paid or voluntary work.
Supportive adults, such as carers, parents and tutors, often encourage
young adults with learning disabilities to take college courses that
might lead to work. However, in reality and in the current economic
climate, it is rarely possible for adults with learning disabilities
to obtain paid employment, despite government legislation and
society’s attempts at inclusion.
As a society we are surrounded by advertising and media
showing us a picture of a successful life. Young adults with epilepsy
and learning difficulties are no different in their identification with
‘social goals’, but unlike their more independent peers, they often
lack opportunity to meet partners, or may face judgement from
family about their capacity to make safe choices regarding love and
sexual practice. Sometimes they struggle even to be viewed as an
adult by those nearest to them.
Case study 1: George

George was a young man of 23 with difficult-to-treat epilepsy and mild
learning difficulties. He was at risk of death from seizures. George had
his first seizure aged 8. He attended mainstream school until age 15
but struggled and was bullied. George’s parents were both dead, his
mother had died of epilepsy when he was in his early teens. George
attended a residential school from age 16 to 20 and then moved into
the care of the company where he lived and attended therapy. He lived
in a house with six other male occupants, all with epilepsy and learning
difficulties. George was referred to art therapy for urinating in his
bedroom, withdrawing from the rest of the household, fabricating the
truth and being dishonest with staff about day-to-day matters.
George appeared overconfident and brash during his assessment.
He wore a football shirt and baseball cap pulled down, obscuring his
eyes. He slouched in his chair and played with his mobile. He quickly
told me he was ‘on call’ from his job with the RSPCA and showed me
his phone.
During subsequent sessions, George began to talk about his life and
to explore the art materials, always making reference to his profession
or identity as an RSPCA inspector to increase his confidence. I knew
that George did not have a job with the RSPCA, although at first I felt
uncertain about this as George spoke so convincingly. I didn’t want
to let George fabricate the truth to such a degree that he would feel
persecuted or overwhelmed by shame at being found out, but at the
same time I was able to admire the way he boosted his confidence and
self-esteem by inventing this identity. The question was how George
could channel this within his sessions in a creative and helpful way.
Being careful not to affirm or deny his stories, I listened to George
talk about his work. George described how he would rescue animals
from danger and abandonment. He took on a super-hero persona
as he described saving an unfortunate dog or sick cat from disaster.
During one session he stopped and pretended to take a call from a
colleague. He said he was off to work straight after the session.
Running parallel with his conversation about being an RSPCA
inspector was another dialogue about the difficulties George faced in
his life. He spoke about his mother who had died of epilepsy; so had
other family members. He disliked living with six other men in the
unit as he felt that there was a power struggle for top position. He
had a girlfriend but no private time to see her, as the rules in the unit
stated that guests were not allowed in clients’ rooms after a certain
time in the evening. George described not being allowed to spend any
time alone with his girlfriend without the gaze of one of his carers
upon him. He spoke of how his seizures robbed him of his dignity and
memory.
As George spoke he tried out the paints, making marks and
mixtures, exploring the art materials as if conducting an experiment.
He read the labels and scrutinised the bottles of paint as if looking
for the first time at objects from another planet. He was awkward at
times; angry at himself and critical if he couldn’t take the lid off a pot
or control a line he was painting. But quite quickly he began to relate
positively to me and to the art-making.
‘I didn’t think I had it in me to make all this, I didn’t know I could
do it,’ said George after a few weeks of attending art therapy. He had
begun to value his identity as someone who could make, paint and
experiment. I felt the time was right to make a suggestion that perhaps,
rather than speaking about the dogs and the rescue missions he went
on as the RSPCA inspector, he might like to make some models of
the dogs using the materials on offer. George never looked back. The
stories about his job decreased and then stopped altogether as his
models took on increasing importance.
Figure 9.1 Models of dogs (see colour plate).

In Figure 9.1 we can see the range of different dog characters that
George made during the course of his therapy. He created two dogs
that he called ‘the couple’.The couple went on to have smaller ‘babies’.
He made several more dogs: a dog that was the joker of the pack, a
naughty one, a small one that was picked on and some other ones
that he called robot dogs.The small dog got elevated to the important
position of leader of the pack, he called this dog ‘little George’. George
acted out scenes from his life and his home situation with his models.
The pack mentality of the dogs mirrored his own life in the unit
where he lived, with all its power struggles and issues over dominance.
Sometimes the dogs got sick or fell over and George revealed his fear
and disgust at seeing this vulnerability that appeared to mimic his own
illness and seizures.
I saw George weekly for two years. He continued to make more
dogs, to make homes for them from boxes and to play with them and
narrate stories. His skills at manipulating the materials improved too

and this pleased him. He became able to talk about his epilepsy and
how it felt to have seizures. He found he could share the feelings of
anger and frustration about having lost consciousness and of having
done things he could not remember. He also shared his ambition to
work with animals and he finally got a voluntary job working at a
city farm.
At this point his therapy ended. He had stopped urinating in his
room, which could be seen as a form of ‘territory marking’ and was
more settled in his position within his home. He no longer used fantasy
to gain status, he had obtained his wished-for job with animals, and his
self-esteem and identity were greatly elevated. He had found a creative
identity as someone who could make and play. His defence against
feeling worthless had caused him to create the identity of someone
he deemed important, a person who was needed and could rescue
and protect. This was hopeful, as when channelled into making and
storytelling with actual models he was able to explore his life, regress
and play within the gaze of myself, the therapist. With his confidence
increased, George was able to take the opportunity to work with
animals and turn his fantasy into reality.
Case study 2: Nadia

Nadia was a 19-year-old young woman with moderate learning
disabilities, difficult-to-control epilepsy and risk of death from
seizures. She was referred for ongoing support for self-esteem and
communication needs. Nadia had recently moved into a 12-bed unit
and was referred for support with the adjustment and the many
different transitions she was experiencing at the time.
Nadia presented as a shy, quietly-spoken young woman, although
confident enough to tell me that she enjoyed painting and drawing and
was good at it. During her first three sessions she drew confidently,
talking continuously about what she was making, leaving little room
for me to interject or ask questions. Nadia mentioned her epilepsy
early on, as she had a seizure and missed a session. She spoke with
her head down and said that the seizures made her sad and angry.
As the sessions progressed she appeared more irritable and at times
defensive and agitated.
In session 7 she told me about a conversation on the phone with
her father that had upset her. However, she added that it was OK,
because in her head she was a princess and that although she knew this,
no one else did. We explored this over the next few sessions, which
led to Nadia revealing that she loved Disney films and characters, and
had a vast collection of the films. Nadia explained that her father felt
that she was too old for these films now. He had sanctioned her use
of them, restricting her to viewing only one film at the weekends,
and the staff at her unit complied with this. Nadia found it helpful to
imagine herself in the role of a Disney princess and liked the power
that it gave her to identify with her fantasy role models without her
father knowing. Nadia also revealed that she felt lonely and found it
hard to make friends with peers. One of her main goals was to get
a partner and she found this very difficult. Her seizures meant that
she required supervision 24 hours a day, leaving her with no private
time. In art therapy her images consisted mostly of patterns, flowers
and rainbows.
Nadia often spoke about her need to identify with princesses, and
as it was a strategy that she was already using, I felt it would be helpful
to encourage a creative exploration of this. So I encouraged Nadia to
explore her identity as a princess and her fascination with heroines in
Disney films through her artwork. I hoped that, through art-making,
she might find a safe way to explore her identity. I did not feel this
was going against the unit’s or Nadia’s father’s wishes, and my feedback
and reports to the unit manager were accepted. Nadia took up my
suggestion and depicted scenes from some of her favourite films. She
was particularly keen on Beauty and the Beast, but also drew scenes
from The Wizard of Oz (see Figure 9.2), Grease and Harry Potter.
Figure 9.2 The Wizard of Oz (see colour plate).

In each drawing, Nadia depicted the female heroine wearing glasses.

In Figure 9.2 we see the characters from the film The Wizard of Oz
with Dorothy, the female lead, wearing glasses, as Nadia did. In other
pictures, the female leading ladies such as Beauty, Hermione and Sandy
were all drawn wearing glasses similar to the ones Nadia wore. Nadia
explained that by adding the glasses, she could be the star in each of
her favourite films. It was her secret code in the pictures and I found
it wonderful to see Nadia’s confidence grow as she drew a different
scene from these films during each session.
While drawing, Nadia discussed her frustrations, her hopes and
her use of fantasy, and how this helped her survive and feel attractive.
There was a sense of her experimenting with roles and personas
through the artwork and in the way she was relating to me. Nadia was
in transition from teenager to adulthood, and appeared both alarmed
and excited by this.
Figure 9.3 ‘I am upset and that is why I am crying.’

Mid-way through her therapy Nadia drew a very different picture, see
Figure 9.3. This direct communication as to how she felt was drawn
and delivered in a very matter-of-fact way but felt incredibly moving,
as a very real and vulnerable part of herself had been revealed. Nadia
depicted herself as she looked in reality for the first time. She had
nothing to say about the image, but I felt it required little or no verbal
language to deliver its message.
However, Nadia did want to talk about her seizures, how it felt
physically to experience them, and also how it felt to live day-to-day
with epilepsy. Sometimes she spoke with a very young-sounding voice
and appeared sad. At other times she spoke in a more adult tone
and was clear in her descriptions and explanations. There was a sense
of her feeling ashamed and angry about how epilepsy took away her
sense of control and made her dependent and vulnerable.
Nadia continued to take her inspiration for her artwork from films
and then in session 36 she drew a picture of herself going for a walk.
The picture was surprisingly ordinary. Nadia depicted herself again as
she looked in reality without the disguise of a fantasy character. She
told me that over the weekend she had gone for a walk with a young
woman who had started work at the unit where she lived. This young
woman was Nadia’s new link worker and Nadia was very pleased, as
she liked her and could relate to her. This seemed a positive shift for
Nadia, signifying an ability to identify with a real person and show a
true image of herself.
Figure 9.4 ‘This is my dream world’ (see colour plate).

Following on from this came a picture called ‘This is my dream world’,
Figure 9.4. In this image Nadia drew all the things she wanted from
her life. She drew a toy shop, a bakery, a drink shop and a game shop.
She drew herself with a husband and children, two boys and two girls,
floating on a magic carpet above the street. At the centre and bottom
of the picture, Nadia drew a castle and a guard to protect her world.
This was Nadia’s very own vision of how she would like her future to
look. She included everything she hoped for; it had a fantastical and
magical element to it, and I found it hopeful that she could use her
creativity to show just what she wanted.
I saw Nadia weekly for a year and a half. Then Nadia got a part-time
voluntary job in a charity shop and it clashed with the day she came for
therapy. This provoked a discussion about ending our work together
and we both felt that it was a positive time to end her art therapy
sessions. Nadia was still looking to form a special bond with someone,
but had begun to socialise more with her peers. She had more control
as to what films she watched in her own flat, thanks to a supportive
link worker and her increased assertiveness and confidence. Nadia
took her folder of artwork home with her at the end as she wanted
to decorate her flat with some of the images.
Case study 3: Clive

Clive was a 19-year-old young man from an African-Caribbean
background with difficult-to-treat epilepsy and at risk of death from
seizures. Clive was also autistic, with limited verbal communication,
and was referred for art therapy in order to have an outlet for self-
expression, communication and an opportunity to create and relate
in a one-to-one setting. Clive lived in the unit where I was based and
provided art therapy. He had lived there since leaving school a year
previously.
When I first met Clive he referred to himself as ‘Soldier’, ‘Marley’
and ‘Michael’. Michael Jackson and Bob Marley were Clive’s heroes and
he had a real passion for their music, often carrying around pictures of
them. For this young black man, these role models offered visual images
of successful, talented black men. These characters soon appeared in
the work that took place during his art therapy sessions.
Clive began to make large faces using paint or pens. He called
these characters ‘Marleys’ and took my hand and said, ‘Make Marley,’
indicating that he wanted to go to the therapy room to do artwork.
In session 22 he used yellow paint and called the face ‘Yellow Marley’.
He then painted a face called ‘Soldier’ which he identified as himself. I
wondered if I was ‘Yellow Marley’, having blond hair, and suggested this.
But Clive did not respond – he rarely did if asked a direct question.
These characters appeared in most of his paintings and drawings

throughout his therapy.
Figure 9.5 Two faces.

In session 30 Clive painted two faces in bright green paint, see Figure
9.5. They were not his usual ‘Marley’ characters. Clive began to hit the
face on the right of the picture, saying, ‘Go to your room.’ He then
took my hand and gestured for me to do the same. It felt confusing
as to what he was depicting and acting out, so I remained cautious
but interested and encouraging. Clive then said, ‘Go to bed, Marley,’
and again hit the character he was painting. This theme continued in
his sessions week after week. The characters interchanged between
‘Soldier’ and ‘Marley’. His sentences increased. He would shout ‘Turn it
down,’ or ‘Don’t you do that,’ and then take my hand and gesture for
me to hit the character. I said gently that I wasn’t going to do that, but
that I was watching what he had to show me. These communications
and the content of the images were recorded in my reports and
discussed with relevant staff members responsible for Clive’s care.
Clive had shown increasingly aggressive behaviour towards staff and
other residents since moving into the unit. I was able to share with the
team some of my observations about Clive’s powerful identification
with his musician icons and his use of play and art-making with these
personas. Some of his sentences spoken in the therapy room had

begun to surface in his day-to-day interactions. These phrases were
interpreted as a call for help, and after investigation it was discovered
that Clive was not being kept safe when visiting his family at home. He
had been restrained whilst being given personal care and kept shut
in his room. Safeguarding systems were put in place to ensure Clive’s
safety; he was accompanied by a staff member from the unit when
visiting the family home, and was not allowed to stay overnight until
further investigations were conducted.Through the identification with
these strong role models, Clive had been able to bring this material
into the art room and re-enact it. This led to Clive being understood,
offered a vehicle for vital communication, and enabled him to be
helped. Clive also got a sense of pride and satisfaction from being
able to create images of his heroes and of his identification with these
strong, powerful men.
Conclusion
This chapter demonstrates how exploration, tolerance and the
discovery of a creative identity can lead clients to develop increased
self-esteem and an ability to discuss epilepsy and its impact. It can
be difficult to live with epilepsy. Clients can feel disempowered by
the lack of control they have over seizures and the level of care they
need to keep safe. This can lead to low self-esteem and depression.
Nadia’s father had worried about her identification with Disney
heroines and was concerned that this was not age-appropriate.
George had caused concern by fabricating the truth about his life
and creating stories about his identity and job. Clive was known for
carrying around pictures of his heroes and calling himself by their
names. Although all three clients were using strategies to cope that
were concerning to others at times, I felt there was also hope within
these defences or strategies. Art therapy can be a very accessible
form of therapy for those who have limited verbal communication.
It served as a vital tool for communication for Clive and enabled
him to be helped and understood. Nadia was able to play with and
experiment with her own identity on the page in front of her, in the
guise of princesses and heroines. George was able to gain status and
self-esteem by making and playing, by forming a creative identity,
and acting out his day-to-day concerns with his models.
When we look at these three cases together, we can see how

the opportunity to create, experiment and communicate within
the therapeutic context allowed each client to be understood.
Feeling understood led to feeling more confident, which in turn
allowed them to view themselves more positively and enabled them
to communicate more effectively with the important people in
their lives.
All three clients used art therapy to explore their experience of
the world. Their journeys, although different, all involved making
artwork with fantasy characters as the focus. At that vulnerable
time, transitioning from childhood to adulthood, the use of fantasy
characters in their artwork allowed them space to explore and
discover, act out and play. I was delighted to offer a space for these
young people to explore their issues using creativity and imagination
as tools for communicating, and to watch as it became an integral
part of their identity. All three clients were resourceful enough to
have made powerful identifications with positive fantasy figures
at times when they felt low in mood and stuck. The hope is that
through transforming fantasy into creativity and reality, the space
to play and create is one that remains within the client outside the
therapy room, a resource for them to draw upon in the future.
References
Cregeen, S. (1992) ‘Seizure as Symbol.’ Inscape, Spring issue, 17−26.
Cregeen, S. (1996) ‘Making sense: Brain trauma, epileptic seizures and personal
meaning.’ Psychoanalytic Psychotherapy 10, 1, 33-44.
Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the
21st Century. White Paper. London: DoH.
Ferenczi, S. (1996) The Correspondence of Sigmund Freud and Sandor Ferenczi, Volume
2 (1914–1919). Cambridge, MA and London: The Belknap Press of Harvard
University Press. (Originally published in 1919.)
Freud, S. (1927) An Autobiographical Study of Inhibitions, Symptoms and Anxiety and
Other Works. (Standard edition.) Volume 21 in the Standard Edition of the Complete
Psychological Works of Sigmund Freud, 1956–1974. London: Hogarth Press.
Naitove, C. E. (1983) ‘Where ignorance prevails: An arts therapist’s approach to the
epilepsies.’ The Arts in Psychotherapy 10, 3, 141–149.
PART IV
Dementia
CHAPTER 10
Reframing and Reconnecting

An Art Therapy Group for People with Dementia
Elizabeth Ashby
Introduction
An elderly person is struggling to know what to do with the art
materials. She doesn’t think she can make art. I tell her she can’t go
wrong – it is what it is. How can that be a failure or be wrong? It is
what they want it to be or what it turns out as. Reframing in this way
can be freeing for her and the other group members. This allows
acceptance, adjustment, and ultimately an increase in self-esteem,
reducing the effort needed for the ‘battle’ with dementia. The
process of making the image allows self-expression, and individuals
enter into a safe creative space, enabling them to reconnect with
and retrieve memories and develop concentration, increasing brain
function and improving wellbeing (Carr 2008).
This is part of what happens in the weekly art therapy group for
people with dementia that I have been running for several years. In
this chapter I will describe the difficulties faced by members of the
group as a result of dementia, and give a brief explanation of three
types of dementia diagnosis which affect the group members. I will
describe my therapeutic approach and the processes of the group,
and discuss the themes that have been addressed in sessions. The
chapter will also describe the patient outcomes, showing how art
therapy has helped the group members in various ways.
203
The art therapy group

The group membership is drawn from the older population and those
with younger onset dementia (YOD), and there are between five and
eight members at any time. There are usually two co-facilitators in
addition to me, a trainee art therapist and another member of staff.
(For three years a support worker from our YOD team held this role,
and was very valued by me and the group members.) The slow, open
nature of the group means that sometimes people leave the group
and other people join it, and the same process occurs with the co-
facilitators. I will introduce eight group members to you.
Jed is 63, and has been an accomplished artist, selling many
meticulously detailed paintings during his working life, but now
younger onset Alzheimer’s has resulted in a decline in his painting
skills. Jed finds this difficult but still feels a creative urge which he
is able to address in the group. His spatial awareness is particularly
badly affected, which means that sometimes he cannot tell where
the edge of the paper is and paints the table instead (but wearing his
glasses, if he remembers and can find them, does help a bit).
Martin, 76, has been a member of the group for three years; he
has multi-infarct dementia and many physical health issues which
cause him great pain. He has a surprisingly good memory for dates
but cannot follow dialogue on the television because somehow it gets
scrambled as he receives it. He frequently loses things, which he finds
very frustrating, although he laughs as he tells us about it, perhaps as
a coping strategy to hide his negative emotions. Martin plans what he
is going to paint during the week and brings this with him, painting
the image he has chosen during the session time. In so doing he has
found a way to carry over the benefits of the process by continuing the
engagement with his image-making throughout the week.
Jon is now 81 and has vascular dementia, as well as multiple
health issues, including a heart condition, high blood pressure and
epilepsy. He has discovered there is an ‘artist within’ himself through
joining the group, and he paints with tremendous enthusiasm and
imagination all sorts of ideas, from places he has visited to imaginary
scenes. These images develop and he speaks about them, and about
visiting his adult children in far-flung parts of the world.
Steve is 62, and has younger onset Alzheimer’s. He has run
his own business for many years and misses his working life. He is
Reframing and Reconnecting: People with Dementia 205
fortunate to have a very loving wife who supports him; she referred
him to the group. Having not had any experience of making art in
his life before, he was truly delighted to find he, too, had an ‘artist
within’, and after a tentative start he produced abstract images with
a highly individual style. Thus he gained confidence, new skills, and
a sense of being part of a community.
Dorothy, 74, has vascular dementia and her memory problems
are very problematic. She often feels that she is coming to the group
for the first time, though she settles quickly and connects with a
memory of the group at some level. She is very willing to try new
image-making techniques, but has very little self-esteem and often
makes negative comments about herself. She needs support with her
image-making but is becoming gradually more able to develop her
artwork, which gives her feelings of satisfaction.
Nick is the longest attending member of the group, and at 83
the oldest. He has a diagnosis of multi-infarct dementia which seems
to be quite slow in developing, so he retains a degree of apparent
independence. He is affected by mobility issues and has a tremor
in his hands, which hampers his image-making. Nevertheless
he paints imaginative villages and landscapes (see Figure 10.1),
having developed this way of working over time, and sometimes he
brings with him a picture of a place he would like to paint. Again
he demonstrates commitment, connection and a ‘carry over’ after
the group.
Greg, 75, has Alzheimer’s in addition to degenerative bone
disease which has resulted in his spine crumbling. This condition
makes walking difficult and life extremely painful. Greg started
making images in the group hesitantly, but as he gained confidence
in his ability, he began to make more imaginative images, which he
greatly enjoyed. He looks forward to attending the group every week.
Tina, 76, has younger onset Alzheimer’s, and has attended
the group for three years. During this time her skills have visibly
deteriorated, but she found that working on one image over a period
of time allowed her to experience a ‘dialogue’ with the image that
she could reconnect with time and again. She is a keen sportswoman
and likes to go running, but she gets lost, so she needs to be
accompanied by a like-minded friend.
Figure 10.1 Nick: Imaginative village and landscape.

The group is not for everyone. Some of the members who come, like
Jed, Nick and Tina, have had experience of making art in their lives
before dementia, and others, like Dorothy, have no prior experience
but a willingness to try. Some people attend the group once and then
declare that it is not for them and do not return, while others find
the artist within (as Steve, Jon, Greg and Martin have) and begin
an engagement with image-making that brings great delight into
their lives.
Dementia
I have noted three types of dementia that group members were
diagnosed with: vascular, multi-infarct and Alzheimer’s, as well as
younger onset dementia (YOD). Dementia is a degenerative disease
typically characterised by memory loss, mood changes, and problems
with communication and understanding. The most common cause
of dementia is Alzheimer’s, in which brain cells die due to the
development of protein ‘plaques’ and ‘tangles’ in the structure of
the brain. Some important chemicals are also missing, leading to
problems with message transmission within the brain.
The second most common dementia is vascular, and is caused

by problems with the blood supply to the brain cells. Vascular
dementia (also called small vessel disease) can cause difficulties
with the speed of thinking and with concentrating, depression and
anxiety, and memory problems. Seizures and symptoms of strokes
(such as muscle weakness or paralysis) can also be experienced, and
can lead to severe confusion. Other symptoms can include visual
misperceptions, changes in behaviour, difficulties with walking,
hallucinations, problems with continence and obsessive behaviour.
Another form of vascular dementia is multi-infarct dementia,
which is caused by a series of mini-strokes. The term refers to many
areas of the brain being damaged by loss of blood and consequent
lack of oxygen to the brain. The strokes may be very tiny and may
not even be noticed, but they cause brain cells to die.
‘Younger onset dementia’ simply means dementia that affects
people under the age of 65, and while the disease types are similar
to those faced by older people, the needs of younger people with
dementia differ. In my own practice I have noticed faster deterioration
in people with younger onset dementia.
Being diagnosed with dementia can be devastating for people,
and many struggle to accept the diagnosis. Prior to a diagnosis of
dementia, people may be experiencing mild cognitive impairment
(MCI), which is common in ageing and does not necessarily lead
to dementia. People with MCI are often fearful that they have
dementia, and a proportion of individuals will go on to develop it.
The symptoms of dementia can lead to considerable confusion
and fear, and consequent feelings of anxiety and depression.
Surprisingly, group members seem to have accepted their diagnosis
and to have been proactive in seeking help, whereas others who do
not accept that they have dementia seem to fight it more and suffer
more in consequence. A sense of humour seems beneficial for coping
with this destructive disease.
All the members of the group I have introduced to you have
partners who help them cope with their memory problems, but
families suffer greatly too. Eventually their loved one will not know
who they are, and the person they have known will be lost to them;
in the meantime, as the person gradually deteriorates due to the
progression of the disease, they are in a continuous cycle of loss.
Family members try to keep a brave face, but will sometimes tell
me of their struggles – with depression, for instance. Many would
benefit from art therapy themselves if it were available.
For people who do not have a partner or close relatives, the
progression of the disease will mean that greatly increased levels of
support by care agencies will be needed. If the individual’s needs
become too great, this may mean leaving their home when they
can no longer manage alone; this is very frightening and another
enormous loss for some individuals.
Art therapy processes

Image-making is the primary focus of the group, but the social
dynamics of the group are also an important source of support and
benefit for the members. They value the opportunity to discuss the
impact of dementia in their lives with others who experience the
same, or similar, difficulties. They value discussing current and past
world events (the 2012 Olympics and World War II, for instance),
memories of the past (such as their working lives, family life,
holidays) and memories of the local area where most of them have
lived for many years.
Group members also value companionable silence, which can
fall for some time during the image-making process while each is
concentrating intensely on their artwork. Half-way through the
session energy levels need reviving with cups of tea and biscuits,
and this usually heralds a shift in the dynamics. Some moving and
poignant discussions often take place during the second half of
the session.
My therapeutic approach is generally psychodynamic, with
humanistic and eclectic influences, and key to group work is an
understanding of group dynamics. I have a flexible, client-centred
approach and think of each group member as an individual with
a unique personality and particular difficulties that affect them as a
result of ageing and their dementia diagnosis.
Several individuals who share the same diagnosis may experience
broadly similar difficulties, such as memory loss, mood changes and
changes in behaviour, but the particular impact of their experience

of the disease can vary widely – for instance, in terms of its severity
and speed of progression. In addition, physical capacity can differ
greatly between individuals, who may have mobility issues, problems
with tremors, failing eyesight and hearing, or other health-related
issues connected with ageing rather than with dementia.
Important skills can be retained or recovered through image-
making processes, such as the retrieval of memories, an increased
capacity for making connections, and periods of intense concentration.
The processes of image-making require individuals to plan and make
choices that are complex and require both right and left hemisphere
brain activity to complete these tasks (Carr 2008; Hass-Cohen and
Loya 2008). Initial decisions about the materials and approach or
style to be used have to be followed by further decisions about
colours, shapes and organisation of the planned image. Further
decisions follow every step of the way during production.
These are skills that group members often cannot exercise in
other contexts in everyday life. As there is a greater emphasis on the
process of image-making than on producing an end product, there
is less of a sense of failure if the processes are a struggle and the
end product fails to live up to expectations. A sense of achievement
is gained when the process provides a much needed outlet for
self-expression and is enjoyable and unpressured. The safety and
emotional containment experienced within the group context is
paramount and further enhances the therapeutic impact of the group.
Regular use of visual art processes has been found to forge new
neural pathways in the brain; therefore making art can be very
helpful for people who have dementia, in positively contributing
to brain function and helping to develop alternative brain patterns
(Bagan 2012). Consequently, regular attendance and engagement
in the art therapy process can be very beneficial for group members
who have dementia. For an in-depth discussion about the value of
art therapy in terms of brain processes I would recommend Hass-
Cohen and Carr (2008).
The group cohesion, its lack of conflict and culture of non-
judgemental acceptance are all aspects of the group that are of great
value to its members. The art therapy room and the surrounding
environment contribute to the ambience and atmosphere that create
the sense of safety that individuals feel. In addition, I and the co-
facilitators make art within the sessions, either to model different art
techniques we are introducing to group members and encouraging
them to use, or to foster a creative working atmosphere. However, as
facilitators, we cannot ‘lose’ ourselves in our art during the session
as the group members can, as we must always be aware of the needs
of the individuals as the session progresses. For instance, we are alert
to the likelihood of Nick struggling to pour paint in a palette when
he begins to look for it, or Jed’s difficulty in seeing white paint in a
white palette (it is almost invisible to him).
The benefits of the group described above achieve patient
outcomes identified by the National Dementia Declaration for
England (Department of Health 2010).
Support levels in the group

I have found that the greater the difficulties that members of the
group experience, the more co-facilitators are needed to run the
group, though I have never had more than two in addition to my
own presence. Galbraith, Subrin and Ross (2008) recommend one
member of staff to every two group members for art therapy groups
with people who have dementia.
In my experience, higher-functioning group members need little
assistance except for some encouragement and some physical help.
Nick, for instance, needs a little assistance with pouring paint into
a palette and needs to drink his coffee with a straw, because of the
tremors in his hands. Steve benefits from being reminded that the
most difficult part of making an image (for him) is making the first
mark on the paper, and some ongoing encouragement as his image
gradually takes on form. Once he gets started, Steve is able to create
a riot of colour and imaginative markings that surprise and delight
him, such as Figure 10.2. Apart from these interventions Nick and
Steve need little assistance with their functioning in the group.
Figure 10.2 Steve: Riot of colour (see colour plate).

On the other hand, Dorothy needs constant assistance, first, because
she has not engaged in any image-making since she was at school,
so the art materials are less familiar to her; second, because although
she is willing, her short-term memory is so impaired that she is
unable to make the plans and choices necessary for image-making
without assistance. As a consequence she has a great sense of failure
that impacts all of her actions and results in extremely low self-
esteem. She tends to have a low opinion of her attempts at image-
making and is very apologetic. This led me to make an emphasis on
the value of all attempts at image-making that group members make,
whatever the outcome at the end of the session, and to promote the
idea that it is impossible to ‘do it wrong’.
I do pay careful attention to who sits where in the art therapy
room. We have place name cards on the table to assist those who
cannot recall names easily, and ensure that one member of staff sits
between group members who need higher levels of assistance. We
also try to ensure that group members are able to sit next to particular
people if they want to. However, without some initial orchestration,
group members drift into the room and sit where they want to, and
later find that they may not have a staff member near them to give
them the level of assistance needed.
Of these group members, Dorothy and Tina need the most
assistance during the session, and Nick, Martin and Jon need little
intervention once they are settled into their image-making. Steve
and Jed have fluctuating needs; sometimes (if they are having a
bad day) they need quite a lot of assistance, but in general they
only need spasmodic attention during the session. The group
functions well with one art therapist, one trainee art therapist and
one YOD worker.
The YOD worker has no experience of image-making but is
willing to contribute to the ambience of the group by making her
own images. She has extensive experience of people with YOD and
their difficulties, and her particular role is to support those members
in the group (currently Jed and Steve). Over the three years she has
assisted me running the group I have seen a development in her
artwork too, which has been exciting.
The balance of genders represented within the group changes
from time to time, as some members leave and others join. At the
start of the group some years ago there was an even balance between
men and women, but at other times there have been more men (as
there are currently), or more women. As all the facilitators are female
at present, this also makes a difference to the group dynamics and
has to be thought about.
Themes that have emerged in sessions

A number of major themes have become apparent during the life
of the group. Acceptance of the diagnosis of dementia has been
a struggle for all members of the group, and yet appears to be
important in enabling them to find happiness in their lives, despite
their diagnosis. Although partners have described emotional
responses such as head-banging and intense periods of crying,
group members tend to emphasise the need to stay positive in the
face of their difficulties, in order not to feel overwhelmed.
Loss is a major theme in work with older people, who experience

a gradual loss of many aspects of life they took for granted in earlier
stages of their lives, and therefore is often discussed in the group.
For instance, many older people struggle with the impact of having
to give up driving, which is a loss that all the group members have
had to face. This does not present quite so many problems when
their partner is still able to continue to drive, but does when both
become too infirm to drive or the other partner is not a driver, as
Greg has recently found. Access to all normal aspects of life becomes
difficult, particularly if mobility issues have become a problem,
and an increase in hospital appointments further compounds their
difficulties in living a normal life. Nick, Jon, Jed, Greg and Steve
have all talked about this issue from time to time, and Tina has
talked about her difficulties continuing to run, now that she cannot
do so alone.
Physical impairment is a major source of distress for most
members of the group, and yet they feel they have to show a brave
face to the world and their families. Martin and Greg found it helped
to talk about their chronic pain in the group, because when they are
having a particularly bad day, the group members and facilitators are
able to be more supportive. Sometimes group members are absent
for periods of time because of ill-health, but try to return if their
symptoms subside sufficiently. Some members are eventually unable
to continue to attend if their health becomes too fragile, and this was
the case for Jon and Martin.
Bereavement is an issue that affects all older people, as spouses,
siblings and friends die, and increasing loneliness becomes an
unwelcome burden in people’s lives. When group members die, their
loss is felt keenly by group members who can still clearly remember
individuals. Greg died quite suddenly the day after attending a
session, and this loss was a blow to those who remembered how
important his presence in the group had been. Greg’s increasing
confidence in his image-making capacity was reported by his family
to be important to him, and attending the group was a very positive
benefit to him in his last days.
Figure 10.3 Greg: Pink car journeying (see colour plate).

Figure 10.3, by Greg, was made over a period of ten sessions during
which it emerged, developed, and surprised us and him as it reached
its ultimate form. The pink car perhaps represents his latterly found
creativity, and is on a journey in a pleasant landscape beside a river
that flows under a bridge, that will eventually take him out of sight.
He was closer to death than any of us realised at the time.
The major themes of loss that are inherent in ageing are further
exacerbated by increasing memory loss beyond MCI. Dementia
gradually robs the individual of their freedom, their remaining skills,
their independence, and may ultimately take from them all that is
necessary for life. Commonly group members try to think positively
about the good things in their lives, such as family holidays they
have experienced recently, which was a subject Steve and Jed
recently talked about. They both derived tremendous pleasure from
having been able to travel, which they shared in the group. Others
then joined in to tell of their experiences of travel in different parts
of the world. Although we may have heard these stories many times
previously, the group members do not show if they remember.
The image in Figure 10.4 was painted by Jon and shows an
eagle flying high above the landscape. The eagle is a powerful
symbol and may represent a wish for freedom from his increasingly
incapacitated body.
Figure 10.4 Jon: Eagle flying high (see colour plate).

Although trying to stay positive is an approach all the group members
seem to adopt, they report deriving comfort from discussing their
struggles to cope with their loss of skills and independence with
others who have similar experiences and who understand the issues.
The losses of skills are all too evident to the facilitators as group
members visibly deteriorate, sometimes over time and sometimes in
a sharp decline, perhaps after a period of ill-health.
Jed’s wife told me that he had recently lost a lot of weight,
and that even having a cold caused a sudden deterioration in his
condition. Jed himself told me that dementia was a cruel disease.
His artwork is important to him, because as an artist he continues to
feel the creative urge. He was listening as I talked to Dorothy about
not being able to go wrong with her artwork, particularly if she
worked in an abstract style and allowed her image to evolve as she
made it, accepting each development as it emerged. This is a form
of dialogue with the image that many group members have found
particularly valuable, and Jed told me how freeing he found that
idea. He is no longer able to paint in the fine, detailed style he used
to be able to adopt so naturally.
Figure 10.5 Jed: Jed’s exploration with colour (see colour plate).
In place of the detailed and careful work he used to produce, Jed
found himself able to express something of his longing for past
freedoms in small watercolours that were reminiscent of landscapes
he remembered from walks in the country. Over time he became less
satisfied with these images, and as I talked to Dorothy, Jed thought
about how he could respond to this idea. He reframed his approach
to his image-making and felt able to discard damaging thoughts
of failure that had been dogging him for years in his approach to
painting. Jed had struggled to continue with landscapes but found
that he could let go of his preconceptions and enjoy exploring colour
without worrying about form, and when he stopped worrying he
enjoyed painting again (see Figure 10.5).
Deterioration due to the advance of dementia can be a reason for
members to leave the group, and it seems that for some there comes
a time when an individual’s capacities have so declined that they no
longer feel the same benefit from attending. In addition, awareness
of the deterioration of other group members can be distressing, as
they imagine they, too, may deteriorate in the same manner.
Tina worked on images for a number of weeks during the time
she was a member of the group. She had attended art school as
a young woman and so had a creative urge within that needed

satisfying, but she struggled to make art as her dementia developed.
As Tina’s dementia progressed and she increasingly lost capacity,
she became less able to hold a dialogue with her image, and
increasingly needed help to reconnect with her image. She found
it hard to start a new image, but if I made a faint outline on the
paper similar to the kind of marks she tended to make, she felt able
to use that as a starting point she could build on. Her prolonged
engagement with one image enabled her to pick up where she had
left off the previous week, as the image held connections for her
and she was able to maintain a creative ‘dialogue’ with her image.
Eventually Tina was unable to continue attending the group, and
in her last weeks she spent a lot of time apologising. It was heart-
rending to say goodbye to her.
It is not just the group members who experience enormous
loss through the process of dementia, but partners and families
experience loss of the personality and characteristics their loved one
used to have, which are gradually whittled away. Some partners have
to completely change their role in the relationship – for instance,
when a husband with a strong and controlling personality becomes
dependent on his wife for every aspect of his care. This can be very
difficult for elderly people who themselves may feel very unwell and
then become carers of their spouses.
Partners who are affected earlier than normal by dementia, in
their late fifties or early sixties, may miss out on the benefits of
early retirement that they had hoped for all their working lives. The
partners and carers of the group members all report that the person
who attends the group benefits from their involvement in art therapy,
and thereby, to some extent, so do they.
For the facilitators the loss of group members can also be very
hard and can be felt longer, because we are able to continue to
remember them even when other group members have forgotten,
or remember them only fleetingly. Losses within the group mirror
losses outside the group, and sometimes the impact on facilitators
can be a source of stress; support for one another is important at
such times.
Conclusion
Despite the degenerative nature of dementia and the difficulties the
disease causes those who experience it, the art therapy group impacts
the lives of its members and their partners positively. The art therapy
process draws on multi-dimensional aspects of brain activity which
enable group members to access skills they could not easily use in
other areas of their lives.
Image-making in the safe, contained and emotionally supportive
environment of art therapy facilitates self-expression, using whatever
materials and approach feels appropriate to each individual at the
time. This can change, as the dementia takes its course, reducing
the individual’s capacity to make use of the therapeutic process, at
which stage they can reframe their experience in another way, and
thereby reconnect with the process in whatever way they can still
manage. Image-making provides a medium for psychological escape
from incapacitated bodies, and this has been seen to be of benefit to
some members.
The experience of sharing deep personal pain in a context in
which they are understood, and this is shared with others, can be
immensely helpful to those whose skills are gradually ebbing away
from them as dementia progresses.
Further information
For more information on dementia consult the Alzheimer’s Society
(www.alzheimers.org.uk) and Dementia UK (www.dementiauk.org)
and other organisations who provide a great deal of information
about many aspects of dementia.
For more information about the impact of dementia on
individuals and their families, and about art therapy with people
who have dementia, see Waller (2002). For research into art therapy
and dementia, see Sheppard et al. (1998).
References
Bagan, B. (2012) ‘Aging: What’s art got to do with it?’ Aging Well Magazine. Accessed
on 30 August 2012 at www.agingwellmag.com/news/ex_082809_03.shtml.
Carr, R. (2008) ‘Sensory Processes and Responses.’ In N. Hass-Cohen and R. Carr
(eds) (2008) Art Therapy and Clinical Neuroscience. London and Philadelphia, PA:
Department of Health (2010) Quality Outcomes for People with Dementia: Building on the
Work of the National Dementia Strategy. Accessed online on 23 September 2012 at
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/DH_119827.
Galbraith, A., Subrin, R. and Ross, D. (2008) ‘Alzheimer’s Disease: Art, Creativity and
the Brain.’ In N. Hass-Cohen and R. Carr (eds) (2008) Art Therapy and Clinical
Neuroscience. London and Philadelphia, PA: Jessica Kingsley Publishers.
Hass-Cohen, N. and Carr, R. (eds) (2008) Art Therapy and Clinical Neuroscience. London
and Philadelphia, PA: Jessica Kingsley Publishers.
Hass-Cohen, N. and Loya, N. (2008) ‘Visual System in Action.’ In N. Hass-Cohen
and R. Carr (eds) (2008) Art Therapy and Clinical Neuroscience. London and
Philadelphia, PA: Jessica Kingsley Publishers.
Sheppard, L., Rusted, J., Waller, D. and McInally, F. (1998) Evaluating the Use of Art
Therapy for Older People with Dementia: A Control Group Trial. Brighton: Alzheimer’s
Society.
Waller, D. (ed.) (2002) Arts Therapies and Progressive Illness: Nameless Dread. Hove and
CHAPTER 11
‘My Coat or Yours?’

Generating Peer Support and Interpersonal
Relationships through Art Therapy for
Minority Ethnic People Experiencing Early
Onset Dementia Living at Home
Melody Golebiowski
Introduction
The focus of this chapter is a programme of weekly art therapy
group sessions for adults experiencing early onset dementia (EOD)
living at home in the community. Many of the group came from
minority ethnic communities, so in Part 1 of this chapter I consider
the influence of culture on therapy within the dementia context.
I highlight issues of difference and a rhythmic pattern within the
developing therapy, which I link to infant–mother interaction
observed in interpersonal neurobiology.
In Part 2 I describe how art therapy generated peer support
and interpersonal relationships between the participants, and how
a process of psychological change materialised whilst making a
‘VIRbal©’ (Verbal Image Reminiscence Recording).1
The ‘Finale’ discusses themes from the chapter as a whole, and
the title ‘My Coat or Yours?’ refers to playful occasions when group
participants left the session inadvertently wearing my coat, evoking
1 VIRbal© copyright Melody Golebiowski 2011. All rights reserved.
220
Supporting Minority Ethnic People with Early Onset Dementia 221
the sense of disorientation commonly experienced by those with

dementia.
Part 1
Working as a freelance art therapist, I have set up and facilitated
art therapy for people experiencing dementia within a variety of
contexts, including clients’ homes; residential care; day centres and
privately-hired settings within the community. The necessity to drive
to venues miles apart within the same day has meant adapting to the
role of ‘mobile therapist’, transporting art materials in a wheeled
suitcase, whilst discreetly drying the products of therapy (wet images)
in the back of my car. The duration of art therapy interventions varies
from weeks to years, depending on the referring agency. Indeed,
original members of a residential care group continue to attend after
four years; remarkable, considering that these are older people, some
with severe dementia. An interesting picture has emerged over time
of changes in the way they experience their dementia: a ‘dipping in
and out’ of clarity and confusion.
So what is ‘dementia’? The term represents different types of disease
involving progressive degeneration of the structure and chemistry of
the brain, affecting memory, reasoning and communication, with
complex outcomes for about 800,000 people in the UK (Department
of Health 2009; Lakey et al. 2012). The most prevalent forms are
Alzheimer’s disease, vascular dementia and dementia with Lewy
bodies, the latter sharing characteristics with both Parkinson’s and
Alzheimer’s disease. Amongst the less common forms is posterior
cortical atrophy, which affects cells at the back of the brain, with
implications for eyesight. Research continues and resources include
Tom Kitwood’s pioneering person-centred approach (1997); NICE
Clinical Guidelines 42 (2006); the National Dementia Strategy
(DoH 2009) and the Alzheimer’s Society web site.
Cultural influence
The population is affected regardless of gender, intellectual ability or
ethnicity, yet heritage and interpersonal relationships are influential
factors on quality of life (DoH 2009, p.29) and the stage at which
people experiencing dementia become known to health, care and
voluntary services (Patel et al. 1998, p.13). It is very clear to see
from the issues arising within my groups (fear of losing one’s sanity
and shame in being ‘found out’ by neighbours, for example) that
stigma associated with mental health issues abounds across cultures.
Noticeable, too, is the heterogeneous nature of dementia, so that
each person manifests their condition in a very individual way.
In my groups cultural identities present differently: overtly, for
example, through images, dress, references to food and religion; and
sometimes more covertly for various reasons, including a traumatic
past or assimilation into British culture. The importance of acquiring
insight into our clients’ faith, cultural and historical backgrounds
is highlighted by NICE (2006, 1.1.1.3; 1.7.1.1); the Health and
Care Professions Council (2013, 8.5) and therapists such as Joy
Schaverien (1999, p.56). This is vital within a dementia context
if we are to work with the fragmented communication that occurs
during therapy; develop capacity to hold participants’ emotions; and
move to deeper levels of engagement.
The fact that clients from minority ethnic backgrounds are using
the service at all is a measure of progress, since historically they
have been underrepresented. It is encouraging to read of more
than 6,000 ‘Black and Minority Ethnic’ people accessing dementia
support during 2007 in London alone (Alzheimer’s Society 2011),
as literacy and cultural incongruence have been described as the
greatest barriers to accessing services (Patel et al. 1998, pp.27, 45,
47). Employing bilingual practitioners under the auspices of the
Race Relations Act 1976 and Equality Act 2010 has improved this
situation. Some ethnic groups, however, still associate poor mental
health with something evil, holding the power to shame and exclude
an entire family from their community (Feeney Mahoney et al. 2005,
p.787): views which I found prevailing in 2012 amongst those in
the UK who are illiterate in their mother tongue, let alone English.
Although of white British heritage, I feel able to facilitate art
therapy and ‘reminiscence’ with minority ethnic people. Perhaps this
confidence stems from a lifelong fascination with different cultures.
Like most art therapists I am primarily a visual artist, inspired by
colour, form, pattern and rhythm, which occur across the arts cross-
culturally. An arts-based way of life invariably stimulates concomitant

learning. For instance, a study of Italian Renaissance art might reveal
how inextricably linked it was to the Catholic Church, whilst a study
of tessellating patterns could initiate an exploration of geometry
and Islam. Throughout history, artists have incorporated cultural
influences into their images: characteristics of African sculpture
appear, for example, in works of art by Picasso and Henry Moore.
Images by these two artists convey political messages too: Picasso’s
‘Guernica’ symbolises the terror associated with the Spanish Civil
war, whilst Moore’s lithographs capture Londoners sheltering from
air raids during World War II. Similarly, in art therapy groups, a single
image made by one person can resonate with all group members,
uniting and moving them to a deeper level of understanding and
commitment to each other. My background and art therapy training
(for which personal psychodynamic psychotherapy and clinical
supervision were mandatory) enabled me to have a non-judgmental
regard for people of cultural diversity experiencing dementia at
all stages.
Three scenarios capture cultural issues arising in my practice:
1. The theme of ‘difference’ was highlighted in a residential care
dementia context, where the presence of Saffanah, a young,
devout Muslim carer wearing the hijab, inadvertently evoked
fear and guilt in Maali, a lapsed Muslim and anglicised female
aged 84 from the Middle East. Having rejected her religion,
Maali now presented to art therapy a distressing image of
burning in hell as punishment at the time of death. Saffanah,
too, was upset at Maali’s response. Fortunately, the art therapy
session provided an opportunity to address these issues,
regulating Maali’s distress and bringing her end-of-life wishes
to the attention of managers. Saffanah also received emotional
support by staying in the session, revealing a non-judgmental
regard for Maali’s beliefs and concern for her spirituality. This
scenario raises the importance of a person-centred approach
where ‘difference’, if respected and incorporated into risk
assessments, need not have an adverse emotional impact on
carers or those being cared for.
2. Aadi, an Indian with dementia and no English language,

accessed individual therapy for eight weeks. With head
hanging low in shame, Aadi waited silently during our first
meeting whilst his wife explained via the interpreter his
symptoms, together with a suspicion that they were retribution
for some evildoing. Settling into the art therapy room alone
with me and our interpreter, Aadi shook his head sadly on
seeing the art materials, but by the end of the hour had begun
to engage with clay. The interpreter expressed astonishment in
the change perceived in Aadi, who by now was ‘making some
sense’ through verbal communication. Despite the language
barrier between Aadi and me, subsequent weeks were spent
using art materials spontaneously alongside each other. On
occasions when the interpreter was absent, we communicated
through art materials and body language. A definite change
had occurred in Aadi, who laughed during our sessions and
ended with his head held high.
3. Carlo was born illegitimately during the 1940s in Italy, at a
time when the Mafia and Catholic Church were particularly
influential. He had experienced stigma, shame and prohibition
from marrying. Starting afresh in the UK, it was ironic to receive
a diagnosis of dementia with renewed potential for stigma,
shame and exclusion. Kitwood (1997, p.83) describes exclusion
from one’s social group as a means of severe punishment in
some cultures.
Developing an approach
Reinforcing my approach across cultures and contexts is this
significant experience from past clinical practice:
Rolling a tiny piece of clay with my fingers held the watchful
gaze of a withdrawn, acutely unwell Malaysian patient seated
next to me. Slowly taking clay and rolling with her fingers, she
simultaneously rocked to and fro, matching my tempo, creating
a rhythm and a climax at which she suddenly chuckled, ‘rocking
chair’. Continuing together in this vein developed more language,
clay forms and deeper engagement as the session ended.
Astonishment at the verbal outcome of this rhythmic pattern

stimulated my research into neurobiology and language development.
From this I inferred that a psychodynamic, person-centred art therapy
approach has the potential to develop intrapsychic learning both for
individuals experiencing dementia and for the therapist, through a
rhythmic process of intersubjectivity relating to nonverbal infant–
mother interaction described by Stern (2004, pp.xiii, 49, 67, 100),
Trevarthen and Aitken (2001, p.4) and Schore (1994, pp.73, 76, 87).
The previous paragraph clearly portrays a person-centred
approach used in art therapy, with art therapists working at the level
and pace of individual participants. Thoughts and feelings begin to
emerge spontaneously as art materials are accessed: resonance may
occur, developing a sense of warmth and trust within the session.
It is this emerging material that I work with, similarly to Foulkes
and Anthony (1973, pp.57–58, first published 1957) enabling
participants to be ‘active’ in their therapy rather than ‘recipients’.
Within a dementia context, where agnosia (misperception,
mishearing) and aphasia (language difficulties) can form barriers
to participation in groups, I generate interpersonal relationships by
sensitively reflecting on individuals’ comments loudly and clearly
to the group as a whole. Rather than putting participants on the
spot (unless it is clear that names need to be used), I ask whether
anyone can share in the thoughts expressed. If participants have
been physiologically aroused by my gaze and attention as Schore
suggests (1994, p.73), then this invitation can facilitate verbal and
nonverbal interaction and cohesion within the group.
Sitting together around the table, a larger group of about 12
can ‘buzz’ occasionally whilst involved in image-making, but I
encourage participants to address the group as a whole rather than
their immediate neighbour, enabling all of us to focus on thinking
with the speaker. Occasionally humour arises as the sensation of
struggling for words and a lost theme resonates. Accustomed to being
exasperated and exasperating outside the safety of the therapeutic
environment, group members begin to relax, knowing that they are
not alone in their difficulties.
Safety of the therapeutic space does not occur by chance, however,
but as an outcome of knowledge and skills acquired from art therapy
training and clinical experience. These include implementation of
professional and psychodynamic boundaries; risk assessment of

physical and emotional hazards; application of relevant legislation
including ‘Protection of Vulnerable Adults’, Mental Health, Mental
Capacity and Data Protection Acts; observation of British Association
of Art Therapists (BAAT) and Health and Care Professions Council
(HCPC – the art therapy profession’s regulatory body) ethical and
professional standards of proficiency which protect the public; and
an approach informed by best and evidence-based practice.
Evidence base
Reviewing global dementia art therapy literature from the past ten
years, I came across a diversity of approaches, some very directive,
including a randomised controlled trial (RCT) where people
experiencing dementia were accompanied throughout by carers.
There may be advantages and disadvantages in the presence of
carers: an advantage, within a facilitated psychodynamic group, is the
opportunity to find a fresh perspective on their caring role through
recognising the individuality of their partner; a disadvantage is
that participants experiencing dementia lose their opportunity for
confidentiality. A compromise I have found useful is an occasional
group combining carers and cared for, in addition to the dementia
group. This can be a worthwhile form of psycho-education.
Art therapists practising within dementia contexts are fortunate
in being able to refer to an evidence base comprising a UK RCT
(Rusted, Sheppard and Waller 2006), guidelines (Waller and
Sheppard 2006) and a body of literature including Waller (2002)
and Byers (2011), all of which have influenced my practice.
There are some differences between my approach and that of
most global literature. The group that I devised, facilitated and
evaluated was a person-centred art therapy service for younger
adults aged between 50 and 70 years, diagnosed with early onset
dementia (EOD), living at home in the community. Instead of focusing
on psychometric scores or art as a diagnostic tool, my emphasis was
on developing peer support and interpersonal relationships. This
approach addressed Objective 5 of the National Dementia Strategy:
‘Development of Structured Peer Support and Learning Networks’
(DoH 2009, p.41).
My belief in facilitating emerging material enables images to

evolve spontaneously, providing the stimulus for all the thinking,
learning, communication and psychological change that, in the
following case study, occurred during each short hour. It was at the
end of the hour, as energised participants were getting ready to leave,
that they might inadvertently put on my coat, which was usually
slung across the back of my chair. My polite enquiry: ‘Is that my
coat or yours?’ sparked playful responses from this friendly group.
Part 2
Forming the group
Following discussions which included a PowerPoint presentation
providing evidence of my clinical practice, funding was gained for
a weekly, hour-long, community-based group lasting eight weeks.2
Prospective group members were living at home in the community
and selected according to referral criteria which I supplied, based on
clinical experience and concerns for safety and equal opportunities.
These included: suspected or diagnosed EOD; no history of mental
health issues such as substance misuse; ability to sit unaided and
upright for an hour; ability to feed oneself; ability to differentiate
between utensils and foods, which I felt would indicate capacity
to choose art materials and hold equipment. Verbal skills were
unnecessary. Additionally, I requested a group assistant who would
accompany group members out of the session or retrieve carers (who
remained on site in their own group) if necessary. Suitable participants
were identified by referrers; a venue conveniently situated for public
transport was risk-assessed, then hired, and invitations duly sent out.
Prior to therapy, I designed a consent form giving permission to
use photos for publication, for distribution to carers and cared-for
attending the assessment session together. Being aware of increasing
demands to demonstrate effective practice, I devised a questionnaire
to suit my context which the group assistant kindly agreed to
complete following each session, based on her observations.
2 This piece of work was carried out in association with the Alzheimer’s
Society and funded by the Department of Health through Hertfordshire
County Council. See Golebiowski (2011) for elaboration.
Attending the first session were four men: Aldo and Angelo
(Italian); Frank (English); Martin (German/Indian); and two women:
Sue (English) and Carol (Indian/English group assistant). All were
mobile, English-speaking and sitting with me around a table with
a range of non-toxic art materials. Until I knew my group members
well, scissors, pen caps and other small items were excluded in case
of harm.
Introducing myself and the group aims, I then invited each
participant to introduce themselves in turn. They responded with
little prompting, thus demonstrating a capacity to understand the
communication. Taking materials from the middle of the table, Sue
drew a house, using ruler and pens; Aldo a rectangle bearing four
circles; Angelo painted on A3 paper; whilst Frank, having drawn
geometric shapes, wrote: ‘I cannot draw to save my life as you
will see…’
Martin was drawing a horse’s head, using a brown brush pen. He
said he was having difficulty getting the nose right, then proceeded
to describe issues that were not ‘right’ in his life either. We heard of
the discrimination he had faced at school due to being dyslexic and
of mixed ethnicity. He was colouring with the brown pen and telling
us about being brown-skinned. He had felt out of place but had
overcome his difficulties. The horse’s nose was now taking shape.
Martin continued by mentioning an accident at work, following
which he had received his dementia diagnosis. He expressed anger
and guilt at the problems this had caused his family: there were
children to feed and, like many carers, his wife had left her job to
care for him. All group members, including the group assistant, were
now absorbed in painting and drawing, listening and responding
empathically, then telling their own story.
Emerging and universal themes included:
• Loss: of ability to communicate properly; confidence; self-
esteem; status (from breadwinner to dependent); driving licence
and independence; orientation: not knowing the date, time or
destination from one moment to the next and losing their way
if out alone
• Inadequacy: no longer able to fully meet the needs of their
children or ageing parents
• Burden: guilt at financial problems incurred within the family

• Isolation: due to lack of communication skills and feeling stupid
• Depression: due to loss
• Anger: why me?
• Relationship: positive comments of gratitude and affection were
bestowed on partners.
The following week a theme emerged of loss within their families,
bonding the group. However, conflict was discernible through
body language, as one person turned away when another spoke
repetitively. At this early stage in therapy and because of dementia,
participants were not able to be emotionally available for others –
they turned away to avoid difficult communication in a way similar
to infant–mother behavioural patterns described by Schore (1994,
pp.379–380). Nevertheless, I managed to draw participants back
into the group, so that they continued to attend. In addition they
met in a social group accompanied by carers. Variations on the horse
theme, increasing in strength of line and colour, occurred during the
next few sessions through images Martin copied from a magazine
that I supplied.
Immediate engagement in the weekly mark-making process
was becoming customary for all group members, evoking a sense
of containment and deepening commitment within the group as
a whole. In order to highlight these interpersonal developments I
will now describe them in greater detail and by the weekly stage at
which they occurred.
Developing empathy
Session 8
Mindful of the ending today, Frank’s carer had brought cakes to share.
However, we heard that the group would not end after all: we had been
reprieved for eight more weeks. We felt stunned but pleased. Changes
were apparent: one member was absent, but another surprised the
group by remembering the absentee’s name, commenting how quiet
the group was without them. Sue drew a house, for the first time
installing a figure; Martin, who had drawn a strong stallion rearing
on its hind legs, smoothed brown and red chalk pastel lovingly onto
the horse’s body. Frank (despite ‘not being able to draw to save his
life’) made an image of a tree and a ‘nightingale singing from Berkeley
Square’: vastly different images from our first week. Sadly, it was Sue’s
final session as she had made other commitments.
Session 11
Frank arrived after being absent for two sessions. He was surprised
to walk into the room and find us there, and even more surprised to
discover that he had been absent. He could not remember where he
had been, but laughingly commented that he hoped he had enjoyed it!
Session 12
Frank entered, remembering Martin’s name and associating him with
horses. Familiarity and recognition were developing: confidence too.
Session 13
Martin arrived a little late: Frank’s face lit up on seeing him. Carol
had been sitting next to Frank but moved to let Martin sit there. ‘So
I can be with my brother,’ commented Frank. He mentioned that he
had been to a day centre during the week, adding that he had seen
Angelo there.
Session 14
This week, with two more weeks still to run, I heard that we had
received yet another reprieve, and following a month’s break, would
have eight more weeks, taking us to 24 sessions in total. The group
was delighted. For the first time, Aldo took larger paper (A3). A shape
symbolising a horse emerged fleetingly before changing to a boat,
then another image with scratchy feet which he named a ‘primitive
creature’. I reflected inwardly that the boat resembled an infant’s crib
– and the scratchy feet? I wondered if they related to the fact that
Aldo had walked miles barefooted in his youth. Meanwhile, Frank had
drawn a solid oak door with a gravestone nearby; Carol had drawn
two flowers; Angelo an A3 image thickly painted in glowing ‘earth’
colours. Despite being absent, Martin was very much present in the
group today: appearing unconsciously and fleetingly through Aldo’s
image and possibly Angelo’s too.
Aldo: Reminiscence recording

Aldo’s dearest wish was to write his autobiography, so I wondered
whether he might care to record his memoirs. I had trained in
BAAT digital audio image recording and was able to adapt this to
the situation. Following discussions with Aldo, his wife, my manager
and my clinical supervisor, I arranged to visit the family at home for
a recording session. I had designed a permission slip for this purpose,
which Aldo signed. Then I sat with Aldo as he looked through family
photos and spoke towards the microphone. The session was relaxed
and spontaneous, and occasionally Aldo’s wife (who was present)
joined in the conversation.
Viewing the images made in art therapy reminded Aldo of making
the ‘primitive creature’. He had not known what it was: ‘It just came to
me that day,’ he said, before mentioning early childhood. Both he and his
wife then became moved by their memories, and a conversation ensued
between the three of us, drawing on my knowledge of the Catholic
Church, Aldo’s culture and life history, in helping the couple to think
through, resolve and assimilate a bitter family dispute. A momentary
pause occurred, during which I reflected on the astonishing power of
the ‘primitive creature’ in stimulating a process that had changed the
couple’s thinking.
As we continued to look through his images, Aldo mentioned how
much he had enjoyed attending the group, getting out every week and
meeting others with the same (neurological) condition. The recording
continued for about an hour, following which I edited audio and image
tracks together, returning a DVD to Aldo for personal use. It was agreed
that I could retain a shorter, anonymised extract from the recording,
as it demonstrated a fine example of participant feedback, and also the
change which emerged during the spontaneous art therapy process.
Elsewhere I recorded group members speaking together and
because of the emphasis on spontaneous reminiscence and images,
refer to the recordings as ‘VIRbals’ (Verbal Image Reminiscence
recording).
Following Aldo’s recording, we were fortunate in having ten further
group meetings, punctuated by a month’s break. I saw changes in group
dynamics: Aldo appeared more confident since the recording and
more interested in hearing others speak. His images now began to
portray change and strength, as olives grew on trees and boats became
robust; a tiny face appeared, and at week 17 he drew a bicycle with
rider, signed with a flourish (Figure 11.1).
Figure 11.1 The artist riding his bicycle. Blue brush pen on
A4 paper. (Signature obscured here to retain anonymity).
Towards a group ending

Session 17
Carol (the group assistant) finally left the group due to other
commitments: she had, after all, originally signed up for just eight
weeks. The group was most appreciative of her participation.
Session 18
With the change in group dynamics following Carol’s departure
and increasing frustration with their physical deterioration, anger
erupted amongst the four men that day, expressed through words and
aggressive-looking images. Paradoxically, image-making and listening
to others moved and soothed participants, each of whom appeared
highly attuned to the other. Within the group, I sensed psychological
belonging, described by Stern (2004, p.100). The group had become
implicitly experienced as safe and reliable.
Session 19
Only five weeks to go before ending: ‘How shall we cope?’ they asked.
There were no images that day.
Session 20
Frank drew runner beans growing up support sticks, stimulating
a conversation about food that he had grown and distributed. We
thought together about the support, growth and nourishment he had
provided for his family and the community: that he was performing
a powerful role that would have lasting effect. He was very taken
with this concept: that he could still be useful. We reflected on the
difference between this image and his first: ‘I cannot draw…’
Session 21
Angelo had been in hospital and shared his experience.
Session 22
Aldo drew a boat in distress, evoking endings.
Session 23
Penultimate session. A review of images initiated a quiet period of
reflection. Then, taking A3 paper, Aldo drew a person drawing water
from a well. He described great hardship during his youth: a lack of
running water, and walking miles in bare feet. The group listened
intently, moved to silence by the image and eloquent narrative. Deep
affection for each other was palpable as Frank solemnly described the
difficulties dementia was causing him and his family. Unlike on week
two, and despite their dementia, participants had developed language
skills and emotional capacity to be with each other.
Session 24
Final session: four men present. Angelo had used different media
during each session (pastels, pens, paint and clay) and was now painting
on A3 paper. Aldo drew shapes symbolising two boats and a Ferrari
containing two people. Praise for this powerful Italian car prompted
Frank to reveal that he had driven one, drawing the group closer
together through bonhomie. Copying the Mona Lisa (another powerful
Italian symbol) quietly from a magazine, Martin was now absorbed in
smoothing red and brown chalk pastel lovingly onto the portrait. Frank
said the group had been a lifeline for him and wondered what he would
do now that it was closing. Despite meeting up regularly (accompanied
by partners) outside therapy, and having plenty of networking plans
ahead, all participants expressed disappointment that the group was
ending, concerned that they could become isolated again. RCT studies
(Rusted et al. 2006, p.533) also found low mood at the end of the
intervention. I noticed that the group’s grieving, in anticipation of the
ending, was evident five weeks before the final session.
Finale
So here we have a community-based art therapy intervention
presented chronologically, as I wanted to convey a sense of the
group’s character and development over time. Originally planned for
just eight weeks, the extension to 24 sessions really suited this group
of people. Therapeutic engagement developed at a much deeper
level following the first set of eight weeks, with changes evident in
memory, confidence, language and empathy, implying that the extra
time was beneficial.
My approach to facilitating this group was informed by
evidence-based practice (Waller and Sheppard 2006) and developed
as a consequence of my clinical experience and the needs of these
particular individuals. In this group, each participant was mobile and
able to access materials independently, but this may not be the case
in other contexts and I therefore adapt my approach as required.
This has involved enhancing the materials to include items that are
fragrant or textured; photographic images that are meaningful to
individuals; and objects such as ethnic dolls, which are useful in
addressing difficult issues such as discrimination, attachment and
loss. Additionally I use the internet in therapy to search for images
that are suddenly remembered from the past; maps, too, enabling the
viewer to roam poignantly.
Fascinating, in my view, is the emergence of language from
those experiencing dementia as an outcome of using art materials
during art therapy. As with my Malaysian patient mentioned earlier,
I associate this process with a rhythmic pattern of intersubjectivity,
paralleling the bursts of language development described by Stern
(2004, p.49) and ‘psychobiological attunement’ (Schore 1994, p.87)
that develop during periods of optimal attention between infant
and mother (Schore 1994, p.73), resulting in a diversity of learning
processes.
In my opinion, the depth of engagement experienced by visual
artists when completely absorbed by image-making can emulate
optimal infant–mother attunement. Thus art therapists may have an
advantage, as specialist skills honed through our own image-making
processes – observation, analysis and reflection, for instance – can
reinforce our clinical approach.
Experience in using art materials was not required of participants:

four of the six mentioned in Part 2 had not used art materials before
and expressed anxiety as they gazed at the selection during their
first session. Despite this, all group members stayed, tentatively at
first (using ruler and pencil), but then engaged quickly, perhaps as
a consequence of feeling safely held by my facilitation. Helping
each other to overcome initial difficulties experienced during mark-
making may have contributed to a growing sense of attachment as
a group.
Trust and familiarity within this group developed during the first
eight weeks, possibly as a consequence of meeting regularly to focus
on mark-making, in the same environment, at the same time, with
the same people. Participants began to associate each other with the
content of their images, developing a sense of orientation and safety.
Being the centre of attention within a group may have enabled
individuals to regain self-esteem and confidence. This suggestion is
reinforced by Stern (2004, p.107) for whom the ‘eyes of others form
and hold ourselves together’.
Throughout the group’s life, signs of resonance occurred,
indicating group cohesion. The group laughed together at shared
experiences such as getting lost, while cultural signs and symbols
were often expressed unconsciously through images. These symbols
initiated verbal reflection and reminiscence from individuals, which
I facilitated amongst the group as a whole, such as the bicycle in
Figure 11.1, which elicited memories from Aldo’s youth. Most
flamboyantly, the Ferrari appeared on the final day, uniting the
whole group through laughter and happiness. Carol had commented
at Session 8: ‘You wouldn’t think they had dementia,’ illustrating
how participants felt ‘normalised’, regaining something of their
identity within this model of therapy. This comment also showed
how a diagnosis can influence our perceptions of others until we
come to know them well. Unfortunately longer-term outcomes of
this group’s therapy are unknown, as I was not allowed to maintain
contact following the end of treatment.
Evaluation
Finding a way to obtain feedback directly from people experiencing
dementia is subject to much global research (e.g. Moniz-Cook et al.
2008), so I was delighted that the VIRbal unexpectedly captured the
art therapy process in action during Aldo’s reminiscence. Gazing at
his images, Aldo was reminded of their spontaneity and the material
they evoked; was moved emotionally during the recording; then,
with my help, shifted his perception of a family dispute. Following
the recording, changes became evident through Aldo’s images and
manner and in the group dynamics, giving rise to ‘socio-emotional
development’, seen by Schore (1994, p.71) as an indicator of
effective treatment. So I conclude that the 24-week period of art
therapy successfully fulfilled the original target of addressing the
National Dementia Strategy (DoH 2009). Furthermore, I suggest
that this art therapy approach generates a model of speaking therapy
that fits the ‘Talking Therapies’ guidance (DoH 2011).
What of the NICE guidelines? These recommend psychotherapy
for carers distressed by dementia (NICE 2006, 1.11.2.5), rather
than for the people with the actual disease, which seems to devalue
their needs. From a reading of the NICE guidelines, potential for
psychotherapy appears to be limited (NICE 2006, 1.7.1.2; 1.8.1),
yet the group described in this chapter shows that an art therapy
intervention is highly effective and I propose it as a model of choice.
Why? Despite language barriers and different ethnic origins, people
experiencing dementia can access this psychological therapy at a
personally manageable level and pace. The different properties of
art materials enable movement between mess and control, whilst
the process of using them provides a channel for needs such as
expression, communication and contact; distance, too, by holding
the emotions of those feeling overwhelmed until they become more
acclimatised and able to trust their surroundings. It is very much an
inclusive therapy, where participants have a choice of verbalising or
being nonverbal, but are still able to communicate.
As I draw to a close, I recollect the pleasure I gained from
working with the people described above; with their culture and
difference; verbal and nonverbal communication and interpersonal
relationships. I was also delighted that evidence of psychological
change and the client’s voice appeared through the VIRbal. This
chapter surely portrays art therapy as a powerful, inclusive model
of psychotherapy where participants experiencing dementia thrived.
Now, is this my coat or yours?
Acknowledgements
Grateful thanks to my art therapy participants; to diligent draft
readers Kate Rothwell, Georgia Golebiowski, Jo Sandley, Barbara
and John Baker; to Anna Baines, Anna Golebiowski, David, Peter
and the editors for their patience; and to George Crocker, musician:
‘Thanks for the Memory’.
References
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alzheimers.org.uk/site/scripts/news_article.php?newsID=945.
Byers, A. (2011) ‘Visual aesthetics in dementia.’ International Journal of Art Therapy:
Inscape 16, 2, 81–89.
Department of Health (2009) Living Well with Dementia: A National Dementia Strategy.
London: DoH.
Department of Health (2011) Talking Therapies: A Four-year Plan of Action. Guidance.
London: DoH.
Feeney Mahoney, D., Cloutterbuck, J., Neary, S. and Zhan, L. (2005) ‘African-
American, Chinese and Latino family caregivers’ impressions of the onset and
diagnosis of dementia: Cross-cultural similarities and difference.’ The Gerontologist
45, 6, 783–792.
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Approach. Harmondsworth, Baltimore, MD and Ringwood (Aus.): Penguin.
(Original work published in 1957.)
Golebiowski, M. M. G. (2011) ‘Exhibition of Images by People Experiencing
Dementia.’ The British Association of Art Therapists Newsbriefing, Autumn, 40–43.
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Therapists Accessed on 13 August 2013 at ww.hpc-uk.org/assets/
documents/100004FBStandards_of_Proficiency_Arts_Therapists.pdf.
Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Maidenhead and New
York: Open University Press.
Lakey, L., Chandaria, K., Quince, C., Kane, M. and Saunders, T. (2012) Dementia 2012:
A National Challenge. London: Alzheimer’s Society. Accessed 8 July 2012 at www.
alzheimers.org.uk/site/scripts/download_info.php?downloadID=821.
Moniz-Cook, E., Vernooij-Dassen, M., Woods, R., Verhey F. et al. (2008) ‘A European
consensus on outcome measures for psychosocial intervention research in
dementia care.’ Ageing and Mental Health 12, 1, 14–29.
NICE (2006) ‘Clinical Guideline 42.’ Dementia: Supporting people with dementia and their
carers in health and social care. Accessed on 25 January 2015 at http://www.nice.
org.uk/guidance/cg42.
Patel, N., Mirza, N., Linblad, P., Amstrup, K. and Samaoli, O. (1998) Dementia and
Minority Ethnic Older People: Managing Care in the UK, Denmark and France. Lyme
Regis: Russell House Publishing.
Rusted, J., Sheppard, L. and Waller, D. (2006) ‘A multi-center randomized control
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39, 4, 517–536.
Schaverien, J. (1999) ‘The Scapegoat: Jewish Experience and Art Psychotherapy
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and Culture. London and Philadelphia, PA: Jessica Kingsley Publishers.
Schore, A. (1994) Affect Regulation and the Origin of the Self: The Neurobiology of Emotional
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Stern, D. (2004) The Present Moment in Psychotherapy and Every Day Life. London and
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Trevarthen, C. and Aitken, K. J. (2001) ‘Infant intersubjectivity: Research, theory and
clinical applications.’ Journal of Child Psychology 42, 1, 3–48.
Waller, D. (ed.) (2002) Arts Therapies and Progressive Illness: Nameless Dread. Hove and
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PART V
Other
Neurological
Conditions
CHAPTER 12
Have We Met Before?

Images as an Aide-mémoire to Restructure Self-
identity with a Man with Korsakoff ’s Syndrome
Jenny Wood
Introduction
In this chapter I present a case study about art therapy undertaken
with Frank, a man in his fifties diagnosed with Korsakoff’s syndrome
(KS), a debilitating condition affecting memory following the onset
of the condition, and commonly associated with a chronic history
of alcohol misuse. Frank was clinically depressed and his condition
prevented him from retaining information regarding the death of his
parents. Every time he heard of their death, it was as if for the first
time, rendering him unable to progress through the natural stages
of grieving. He had lost all sense of self-identity and was unable to
make connections with his past or to understand how he came to be
placed in residential care amongst elderly residents.
My clinical practice is informed by psychodynamic training
as an art therapist, primarily using the creative medium of art.
Additional training in clinical hypnosis influenced my approach
working with Frank. In this work I often found myself in conflict
with and questioning traditional psychotherapeutic approaches and
felt sure that organic brain dysfunction must have an impact upon
the therapeutic relationship between therapist, patient and art image.
Francis Kaplan in Art, Science and Art Therapy (2000) raises questions
about psychoanalysis in the light of neurological research findings,
241
which have appeased my unease. My focus in this chapter veers away

from the interpersonal dynamics, and instead I present my findings
in the light of an understanding of brain science and consider how
this influenced Frank’s use of art in the context of the therapeutic
relationship. Most particularly my enquiry sought to understand the
role art played in enabling Frank to retain new information and to
restructure his self-identity.
The referral
Frank needed specialist care and had been difficult to place. His age fell
within the adult range of mental health services, but the nature of his
condition was comparable to dementia, more commonly associated
with the elderly; hence he was placed in an elderly residential home.
Frank’s consultant psychiatrist was concerned about his spiralling
decline into depression and referred him for art therapy with a
view to seeing if he could use art as a means to find self-expression
and alleviate his depression. He was also concerned about Frank’s
deteriorating memory. I was employed on a private basis to work with
Frank, seeing him weekly at the care home for five months. As well as
not being able to retain the knowledge of his parents’ deaths, Frank
was divorced. His ex-wife still visited and he had some sense of their
separation, but not a full understanding of this. In his mind, they were
still married and he ‘suspected’ that she was having an affair, which
evoked feelings of immense anger and contributed to his depression.
Korsakoff ’s syndrome: clinical manifestations and impact on Frank

Frank had a previous history of alcohol dependency, which can lead
to KS when associated with a thiamine deficiency (Homewood and
Bond 1999). There have also been suggestions that there may be a
genetic predisposition to the condition in some individuals, as not all
alcoholics acquire KS (Kopelman, et al. 2009). A deficiency in thiamine
(vitamin B1) affects the brain and nervous system and is the result
of poor eating habits and heavy drinking. This causes physiological
changes in the stomach lining, rendering it no longer able to absorb
essential vitamins.
It became clear that Frank’s depression was largely due to the KS
feature of severe memory impairment, which prevented him from
progressing beyond the initial stage of grief, i.e. shock and disbelief
regarding his parents’ deaths, and from remembering his altered marital
status. Kopelman et al. (2009) offer a useful explanation of which
parts of memory are affected by KS, and although Frank remembered
Restructuring Self-Identity in Korsakoff's Syndrome 243
snapshots of his earlier life, anterograde amnesia impairs new learning

(memorising) of events occurring after the onset of the condition.
This impaired his ability to learn new names, faces, information and
events. Primary memory (holding information briefly) and aspects of
secondary memory (permanent and semi-permanent information)
are severely affected in KS. Episodic memory (personal memories)
is commonly affected, and learning new semantic memories (general
knowledge) is affected to varying degrees in the KS population. Key
to the therapy with Frank, implicit memory (not requiring conscious
recall) generally remains preserved.
The KS trait of confabulation (giving fictitious accounts of past
events, believing they are true), characterised by elaborate stories
often filling gaps in memory, was evident in therapy with Frank. Often
Frank’s confabulation was delivered with such conviction that both
he and I believed what he said wholeheartedly. Frank also telescoped
events, another common KS trait. He would describe something as
having taken place recently which actually occurred many years ago,
thus giving inaccurate chronological order of life events without
consciously being aware of it. This contributed to a sense of confusion
in the therapy. However, I customarily take the position that an
individual’s narrative has some kind of meaning to them at that given
moment in time.
The KS patient commonly is apathetic, with loss of initiative or
interest, and Frank was often flat in mood, with no emotional expression
and with lack of concern. Yet everyday events and conversation could
arouse in him emotions that were extreme and transitory, altering
rapidly at change in topic. Such extreme changes in personality were
challenging to be with and I never quite knew what to expect from
one minute to the next, nor how Frank might react to my reflective
feedback.
First session
First impressions can be very informative about the patient’s position
and relationship with the world around them and inform hypotheses
about the therapeutic intervention. An impressive Georgian façade
greeted me at the end of a long driveway, giving an impression of
grandeur, but as the front door opened the stale smell of urine stung
my nostrils and I felt sorrow for my patient. What stories of lived
experience could possibly have led to Frank being placed at such a
young age among elderly residents, and what role had alcohol played
in his life?
Frank had experienced compounded losses over a relatively short

period of time. He had lost his role and status (marital and financial) in
society, his career and associated skills, his family home and lifestyle, his
parents and, most significantly, he had lost his sense of identity and lost
his mind (I will elaborate on this shortly). Cantopher (1999) describes
a position of learnt helplessness in alcoholics, created over a period
of sustained losses. As an individual withdraws into a position of
helplessness and takes refuge in excessive drinking, a spiral of decline
further distances them from positive life experiences and only further
affirms the state of helplessness.
Frank’s state of helplessness greeted me as I was shown into a
dining room already set for lunch mid-morning and found him sitting in
a window seat, staring out into the garden. He was dressed in a manner
comparable to the elderly residents, in dark colours, corduroys and
baggy jumper, and his hair was dishevelled. My immediate sense of
Frank was of a man withdrawn within himself, lacking animation, and
having slipped insignificantly into the background. Frank turned to face
me and his vacant eyes appeared to stare straight through me; then he
focused upon my face and exclaimed:
‘Hello, my dear, have we met before?’ I replied that we had not.
I introduced myself and explained the concerns expressed by
Frank’s consultant that he might be feeling low in mood, and explained
how art therapy could help in such situations, if, indeed, he felt that
these concerns might apply to him? Suggesting that someone is
depressed, when they may be experiencing a rather better day than
perhaps other days, could immediately set us off on a wrong footing,
and instead I sat back and invited Frank to tell me a little about himself
and how he came to be here.
Frank’s response set the agenda for his therapeutic journey over
the coming weeks. He spoke spontaneously of his fear of the future,
demonstrating a sense of vulnerability and fear for his wellbeing and
safety as he considered whether or not he could stay at the home for
life; he had a sense of knowing and yet not knowing about his losses, and
expressed frustration (suggesting awareness at some level) at his poor
memory. I noticed feeling overwhelmed in my countertransference
response, recognising the extent of the anxiety and complexity of
emotions fuelled by the ‘not knowing’ Frank experienced.
At the close of the meeting I asked Frank if he would like to meet
with me again. He answered that he would, and I told him that I would
return the next day.
Frank’s story unfolds

The next day Frank was sitting in a drawing room. The KS patient lives
within a three- to five-minute time zone, having little access to memory
of recent events prior to this (Lezak 1995, first published 1976), so I
should not have been surprised that Frank did not recognise me.
He was biting his fingernails and I noticed a worried look in his
eyes as he turned to face me. I was struck by the vacant expression
and his rocking motion, which reminded me of the institutionalised
patient with no meaningful occupation of their time.
As I set about preparing the space in which we were to work
together, placing colouring pens, oil pastels and paper on the table, it
was as if I were denying feelings to protect myself from the reality of the
not knowing; but in so doing, I was also denying Frank’s communication
that ‘this is how it is to be me and how it is to be here’. I suddenly
connected with a sense of stupidity. I had exposed his memory loss.
Not only did he not recognise this crazy woman who presumed to
know him, but his anxieties heightened as I set out the art materials,
suggesting perhaps an expectation to draw. (Even though the role of
art-making had been discussed previously, he could not remember.)
I did not wish to remind Frank of our previous meeting directly,
thereby bringing up his memory deficit, but instead (re)introduced
myself. It was as if a slight connection was realised as Frank timidly
asked: ‘Have we met before?’
I replied that we had met once before and went on to talk about
my role as an art therapist. I invited him to tell me about his life, his
family, places where he had lived and his occupation. This evoked an
expression of feeling alone and fearing he might have no one and no
home to return to. I noticed a sudden vacancy in facial expression
and Frank became more sullen. I gave him a moment to stay with his
thoughts, then tentatively said I had noticed his altered expression and
enquired what was on his mind.
I was becoming attuned to Frank’s representational system (Battino
and South 2005, first published 1999), a concept very familiar to
hypnotherapists. This is the way expressive language which conveys
experience of the world is stored in sensory modalities such as images,
sounds, etc. Visual, auditory or kinaesthetic words, such as ‘I “see”,
“hear” or “grasp” what you are saying’, are used to describe experience.
Frank’s preferred representational system was kinaesthetic, so I used
this mode and asked him to covey his ‘gut feeling’ about his parents.
After a long pause, he said that he believed his parents were dead.
Whilst I did not wish to collude in denial of the truth, this early
stage in therapy was not the right time to explore unbearable truths
without first establishing a secure base. Confirming the reality of
Frank’s parents’ death might have prevented any beneficial therapeutic
relationship from forming and have risked re-traumatising the patient.
Frank spontaneously took a red oil pastel and held his hand poised
over the paper, cutting the conversation short abruptly, and said, ‘I
don’t know what to do – I can’t think!’ I understood the timing of his
actions as a diversion from the painful conversation, but equally his
words reflected his position in life of not knowing what to do. I said
that it can be difficult to think when faced with a blank canvas, so to
speak, and that it can be difficult to think about the future with so
much uncertainty hanging over him.
Themes began to emerge reflecting both positive and negative
memories, and Frank expressed a need for order and structure in his
life. I encouraged him to draw a symbolic representation to create
order in his mind, suggesting he draw and label boxes, perhaps to
contain different thoughts, feelings or memories. He drew a series of
boxes which he named as a ‘filing system’ for his emotions. Dissanayake
(1980) lists an array of meanings attributed to art by various writers,
such as creativity, self-expression and form and order, ‘the psychological,
perceptual and mental need to discover or impose a formal order
on experience’ (p.400). Sorting and organising is a common theme
when working with elderly people with dementia, and this intuitively
informed my purpose in suggesting the task to Frank. The boxes, with
lids in place, symbolically and psychologically held information which
had troubled Frank’s mind and, once done, this appeared to free him
from the immediate chaos of his internal world.
Kaplan (2000) critiques psychoanalytic theories of the unconscious
mind in view of evidence from neuroscience and genetics, and cites
Dennett’s view that ‘our introspective verbalizations serve to construct
meaning rather than uncover meaning buried in the unconscious’
(Kaplan 2000, p.42). The importance of art therapy was not based
entirely on a need to understand Frank’s unconscious mind and
relationships, for example, with alcohol; but instead to understand the
construct of meaning and affect of his lack of memory and the impact
this had on him in the here-and-now.
Frank went on to draw the head of a guitar player (Figure 12.1) but
said that he could not finish it. He spoke briefly about how he used to
play the guitar in a band in his youth. He abandoned the image, rather
like the abandoned (vacant) person before me. I wondered how much
his failing memory contributed to abandoning the image. Perhaps he

struggled to remember any more detail, or perhaps his own thoughts
had moved on, preventing him from processing his intentions of what
to do next – or possibly I had said something which had distracted him
from what he was doing.
Figure 12.1 Guitar player (1).

Over the coming weeks I had to reintroduce myself, as Frank would
forget my name and who I was. Frank had no recollection of our topics
of conversation, until one week I placed all of his previously produced
artwork in front of him. At this, he recalled almost every detail about
our conversations.
Directing change
With this finding in mind, I decided to use Frank’s ability to retain
memory through images as a means of developing the therapeutic
milieu, and ultimately to instil hope and change.
From now on I became more directive in my approach. I made
suggestions that addressed the agenda Frank had set at the start. I gave
priority to strengthening the secure base from which Frank’s fragile
ego could be developed before supporting Frank to grieve his losses.
I also wanted to somehow measure outcomes, not fully knowing
what these might be, and decided to use self-portraits, linking with
the idea of using figure drawings to measure self-esteem in personality
tests (Coopersmith et al. 1976), where a figure is presumed to be a
projection of the artist.
Self-portraits
I decided to be more prescriptive and asked Frank to draw ‘himself’.
Frank’s first portrait showed the top of his head and two marks
resembling eyes (Figure 12.2). I noted my observation to Frank of

the incompleteness of the figure, and he confirmed that the image
represented his feelings and how he saw himself. He stated that the
head is the most important part of the human being because it ‘has
thoughts and makes sense of things, and it talks.You don’t have to have
a beautiful body, but you need to have a beautiful mind!’ He described
himself as ‘a nobody’ – and there was literally no ‘body’ visually
represented. Frank conveyed fragmented memories and expressed
that without a sense of past life experiences and roots of origin, he
did not feel a ‘whole person’. He had so many unanswered questions,
he had lost his sense of identity, and had quite literally lost his mind.
To establish a benchmark for skill level in figure drawing, I asked
Frank to draw me. The key features were present, suggesting he had
sufficient drawing skills.
Figure 12.2 ‘The therapist’ and ‘No body’.

He drew another guitar player (Figure 12.3), but remained emotionally
distant from it, exclaiming that ‘it was not him’. However, it was more
animated, suggesting hope for movement towards change in beliefs.
Figure 12.3 Guitar player (2).

Creating ego foundations

I set about strengthening Frank’s ego by affirming the ‘roots’ that
he’d described as missing. As episodic memories were retrieved in
conversations in session, I encouraged Frank to record them visually
through drawings, writing or clay work. Positive life experiences
included memories of favourite pastimes – walking the dog, playing
in a band, brass rubbing, and visiting stately homes; of family events,
holidays, and people who were important to him. Memories recorded
in tangible form enabled Frank to retain aspects of the information.
Directed themes tested implicit memory and identified inner strengths
(for example, asking him to ‘create an island’, in which he instinctively
included all necessities to ensure his survival).
To complement the tangible art products that cemented his
autobiographical memory, affirming his past life experiences and
hence confirming his existence, it felt important to empower Frank,
to increase his sense of self-worth, in the here-and-now. Horticulture
is recognised to have therapeutic benefit, promoting mental wellbeing
(Fieldhouse 2003; Sempik,Aldridge and Becker 2005) and instilling hope
(Page 2008). Frank had previously been a keen gardener and, wishing
to utilise skills and knowledge acquired prior to the onset of KS, I
requested a plot of land to enable Frank to develop a vegetable patch.
Managing grief
Once his ego had become stronger, further utilising the visual theme
as an aide-mémoire, I used guided imagery, applying a hypnotherapy
technique as a means to explore negative memories. I invited Frank to
imagine a door, knowing that he would dislike what was on the other
side of the door, but also advising that there were other doors beyond,
to spaces which contained much better things.
I asked: ‘What do you see beyond the door?’
Frank stated that he could see ‘Two bodies lying on the floor!’
I enquired: ‘The bodies have not been laid to rest?’
Frank replied ‘Exactly!’
The subject of the door was discussed intermittently in subsequent
sessions, and I invited Frank to draw what he had seen, but he was
never able to draw the bodies on the floor. Each time, however, he gave
a more detailed account verbally, such as ‘the bodies were in boxes
without lids’, which reminded me of his earlier drawn boxes; some of
which had remained empty. We negotiated the possibility of it being
the right time ‘to close the lids and to move on’. Frank agreed and
drew the exterior of the door, which was clad in roses. It reminded me
of flowers placed, as a mark of respect, on a grave, and of a symbolic

representation of closure.
Frank went through periods of knowing, with conviction, about the
reality of his parents’ death, alternating with fluctuations of disbelief.
To help embed the reality, I used an approach familiar to Frank, that of
brass rubbing. I accompanied him to his parents’ graves and we made a
rubbing of the inscriptions. Again, once it was in a tangible form, Frank
was better able to retain the information. This facilitated the start of
the grieving process.
Evaluating the portraits

At the close of therapy, I requested a final portrait (Figure 12.4). Frank
took a black pen with confidence, and in contrast to the hesitations
I had witnessed previously, made his mark. He drew himself dressed
in a suit, with facial features, and excitedly confirmed his existence,
exclaiming: ‘I am whole again!’
Figure 12.4 Whole again!

Frank recovered from his depression, and his wish to remain at the
residential home, where he felt safe, was granted. He was supported
to maintain his vegetable plot until his death some years later. His
staff team were recommended to use images and writing to aid Frank
in remembering daily events, and were encouraged to continue to
develop a life-story book with him.
Theoretical understanding
When I first met Frank I was overwhelmed by the extent of his brain
dysfunction and felt the odds were stacked against him in terms of
any progress in restoring quality of life, in particular because his

condition was fuelled by other symptoms, such as anxiety and grief,
which further severely impair memory (Vance and Wahlin 2008).
Once we started work, I was curious to understand how Frank was
able to retain new information and what contribution art-making
and the visual image made to enabling Frank to restructure his self-
identity.
Whilst no studies have been found to date that specifically
measure outcomes attributed to the KS patient making spontaneous
art images to aid memory, Carlos Espinel reports his observations of
the artist Willem de Kooning, aged 82, diagnosed with Alzheimer’s
disease, with aetiologies of depression, alcoholism and KS, in
the medical journal The Lancet (1996). He values de Kooning’s
relationship with painting and its contribution in his recovery
process, recognising art and the brain as working ‘with and through
sensory pathways’ (Espinel 1996, p.1098) to facilitate de Kooning’s
restoration of his self.
Images have been used in KS clinical trials in picture recognition
tasks (Butters et al. 1983; Cermak et al. 1993; Markowitsch et
al. 1984) and it has been suggested that the KS patient takes
significantly longer to identify visually presented material, and is
slower to process information, than normal subjects (Oscar-Berman
1980). However, Butters and Cermak (1986) and Kopelman (1989)
suggest that the visual cue supports new learning, in particular with
material learnt before onset of the disorder. This connects with
Dissanayake’s (1980) view of art as a human behaviour, suggesting
that art is an innate knowledge hard-wired into the brain structure.
Art thus exists as an implicit memory, not requiring conscious recall,
established before the onset of KS.
KS studies undertaken by Edith Sullivan and colleagues, cited
by Buddy (2010), further conclude that visually presented stimuli,
with continual exposure, support new learning. Repetition is an
established way of learning (Dissanayake 1980). Hodgson (2000),
further supporting Dissanayake’s evolutionary perspective, reports
that repeated lines and geometric shapes are so appealing because
they are such an integral feature of brain formation. Art-making calls
upon the artist to make representational marks of what pre-exists in
memory. When infants explore mark-making for the first time, they
keep repeating the same lines, reaffirming what they now know. As
the developing child observes their surroundings, they practice their
new learning, recording what they see, in repetitive, representational
forms. The more mature artist calls upon what he already knows,
based upon infinite data received by the brain since birth, which,
combined with imagination, facilitates creative interpretations into
two- and three-dimensional form.
Conclusion
In this case example, art therapy has demonstrated its effectiveness
in supporting repair of a fragile ego and reconnecting Frank with
his autobiographical roots, re-establishing his identity and enabling
him to grieve. The repeated stimulation of making marks on paper,
in pattern, form and line, one mark leading on to another, combined
with bringing the artwork back to each session, and the tangible
form of the art product – all supported Frank’s memory. It is this
process that I believe enabled recovery of his sense of self, which
was evidenced in his progressive self-portrait images.
Creativity and the symbolic language of art was already well
established in Frank’s innate memory, before the onset of KS.
Accessing these prior creative skills and knowledge, such as making
rubbings of gravestones and tending a vegetable plot, further
contributed to developing his self-worth and self-esteem.
The commonality of memory loss has led to Alzheimer and
Korsakoff ’s subjects being merged in scientific studies. However,
there are differences, in terms of Alzheimer’s being progressive as
nerve cells die and the transmission of messages within the brain
decreases over time, whereas in contrast, the KS patient is not certain
to get worse over time and can improve with treatment with thiamine,
abstinence from alcohol, and support and changes in lifestyle.
Publications that review the correlation between art therapy
and neuroscience (such as Greene Stewart 2004; Hass-Cohen
and Carr 2008; Kaplan 2000), along with Frank’s case study, are
testament to warrant research into the value of art therapy with
Korsakoff ’s patients.
De Kooning and Frank were both creative in their own right prior
to onset of KS. I am not sure how significant this was in supporting
their recovery through the process of making art. Dissanayake’s
(1980) theory of art as innate human behaviour suggests that art
therapy has potential to access that given aspect of the brain, which
pre-exists before the onset of the condition, and thus serves potential
to all KS subjects.
Earlier, I referred to the value I place on listening to and accepting
whatever narrative the patient brings. Frank tended to confabulate
stories, but it was really neither here nor there whether they were
truth or fantasy. We are all prone to recount memories of emotionally
charged events with significant difference from what actually
happened (Vance and Wahlin 2008), such as exaggerating colours
or quantities. Frank’s confabulatory stories and his unknowing,
resulting from his condition, somehow become comprehensible
when we accept that it is human error to elaborate stories, and I
propose that the language of art makes all men equal and enables
the artist to call upon an innate knowing for truth and self-repair.
Acknowledgements
I wish to thank Frank’s family for their permission to allow this
case and images to be published. I am indebted to Frank for the
honour of having worked with him. Our journey fuelled my interest
in exploring the correlation between art and science, and has
influenced my continually evolving practice.
References
Battino, R. and South, T. (2005) Ericksonian Approaches: A Comprehensive Manual.
(Second edition.) Carmarthen: Crown House Publishing Ltd. (First published
in 1999.)
Buddy, T. (updated 30 October, 2010) New Hope for Alcoholics with Korsakoff’s Syndrome:
Affected Alcoholics Can Learn to Perform New Tasks. About.comGuide. Accessed on
3 August 2012 at http://alcoholism.about.com/od/dementia/a/blacer060422.
htm
Butters, N. and Cermak, L. S. (1986) ‘A Case Study of Forgetting Autobiographical
Knowledge: Implications for the Study of Retrograde Amnesia.’ In D. Rubin (ed.)
Autobiographical Memory. New York: Cambridge University Press.
Butters, N., Albert, M. S., Sax, D. S., Miliotis, P., Nagode, J. and Sterste, A. (1983) ‘The
effect of verbal mediators on the pictorial memory of brain-damaged patients.’
Neuropsychologia 21, 4, 307–323.
Cantopher, T. (1999) ‘The Philosophy of Treatment of People with Alcohol or Drug
Problems and the Place of the Psychotherapies in their Care.’ In D. Waller and J.
Mahony (eds) Treatment of Addiction. London: Routledge.
Cermak, L. S., Verfaellie, M., Letourneau, L. and Jacoby, L. L. (1993) ‘Episodic effects
on picture identification for alcoholic Korsakoff patients.’ Brain and Cognition 22,
1, 85–97.
Coopersmith, S., Sakai, D., Beardslee, B. and Coopersmith, A. (1976) ‘Figure drawing
as an expression of self-esteem’. Journal of Personality Assessment 40, 4, 370–375.
Dissanayake, E. (1980) ‘Art as a human behaviour: Toward an ethological view of art.’
The Journal of Aesthetics and Art Criticism 38, 4, 397–406.
Espinel, C. H. (1996) ‘de Kooning’s late colours and forms: Dementia, creativity and
the healing power of art.’ The Lancet 347, 9008, 1096–1098.
Fieldhouse, J. (2003) ‘The impact of an allotment group on mental health clients’
health and wellbeing and social networking.’ The British Journal of Occupational
Therapy 66, 7, 286–296.
Greene Stewart, E. (2004) ‘Art therapy and neuroscience blend: Working with
patients with dementia.’ Art Therapy: Journal of American Art Therapy Association
21, 3, 148–155.
Hass-Cohen, N. and Carr, R. (2008) Art Therapy and Clinical Neuroscience. London:
Hodgson, D. (2000) ‘Art, perception and information processing: An evolutionary
perspective.’ Rock Art Research 17, 1, 1–34. Accessed on 11 July 2012 at http://
home.vicnet.net.au/~auranet/cognit/web/hodgson.html.
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Syndrome: Failure to find memory impairments following non-alcoholic
Wernicke’s encephalopathy.’ Alcohol 19, 1, 75–84.
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Syndrome: Clinical aspects, psychology and treatment’. Alcohol and Alcoholism 44,
2,148–154.
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alcoholism.’ American Scientist 68, 410–419.
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Times 104, 45, 28–30.
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Therapeutic Horticulture in the UK. Bristol: Policy Press.
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(eds) Art Therapy and Clinical Neuroscience. London: Jessica Kingsley Publishers.
CHAPTER 13
What has Colour Got to do With It?

Art Therapy and Motor Neurone Disease:
An Anthroposophical Approach
Marion Green with Christopher Day
Introduction
This chapter presents working with anthroposophical art therapy
and patients suffering from motor neurone disease (MND). It applies
treatment indications for nourishment with colour and themes from
nature given by Dr Margarethe Hauschka. Christopher volunteered
his work for the chapter and we have collaborated closely throughout
the process. I am extremely grateful to him for his generosity, his
suggestions for shaping the work, and for his skilful editing.
Margarethe Hauschka (1896–1980) was a medical doctor
and one of the first anthroposophically trained art therapists. By
researching and developing art therapy exercises based on nature
themes and the study of colour, she realised she could assist patients
with art therapy as well as medicine. She established the Hauschka
anthroposophical art therapy training at Boll in Germany.
Context
I met the patients I will refer to whilst working at Park Attwood
Clinic, Worcestershire. It closed in 2010, but the medical model,
based on the work and indications of Rudolf Steiner, is available in
256
Motor Neurone Disease: An Anthroposophical Approach 257
some parts of the UK and other countries (see McLeod and Clarke
2007).
Patients entered an intensive treatment regime with a
multidisciplinary team. This included frequent, hour-long
consultations with doctors, a combination of art and/or sculpture
therapy, eurythmy therapy (a form of movement combining speech
and sound), massage and oil dispersion baths, physiotherapy
and counselling. Anthroposophical nursing treatment included
compresses, herbal limb washes, oilings, anthroposophic and
mainstream medications. Doctors, nurses and therapists were trained
in their modality according to the indications of Rudolf Steiner.
Therapists usually saw patients three times a week. The medical
team met each morning for the nurse’s hand-over, and twice weekly
at case conferences to ensure continuity of care; share observations
and questions; and determine the focus of the treatment plan.
Every effort was made to work with the patient, family and
carers to bring about a sense of wholeness, balance, harmony and
wellbeing. Many patients returned to the clinic several times over a
period of years.
Kitchen and household staff were vitally important, ensuring
that the meals and the environment were as nutritious and beautiful
as possible.
Anthroposophical medical approach

Anthroposophic medicine is very complex. For the purpose of this
chapter I will seek to simplify one aspect of it. For further information
I recommend the reader to Foundations of Anthroposophical Medicine
(van der Bie and Huber 2003.)
Anthroposophic medicine seeks to understand the human being
in terms of four interconnected bodies. The physical body is familiar
to us all. The etheric, also called the life body, relates to the movement
of body fluids. These are essentially repetitive, rhythmic processes,
and relate to time. Habits, such as waking and sleeping, mealtimes
and daily routine, are created by repetition and are therefore formed
by the etheric. ‘…death is marked by the moment when the life body
withdraws itself from the physical body’ (Mees 1990 [1983]), which
then becomes cold, stiff and lifeless. The astral body encompasses
the emotional life and qualities of soul; it is the vehicle of reaction
to life circumstances. The ego is understood to connect to the spirit
of man and how an individual makes sense of his/her destiny (or life
path). It is not the same as Freud’s ego, but closer to the superego.
Intrinsic to anthroposophy is an acceptance that there is a weaving
of events in a lifetime which may contribute towards fulfilling one’s
destiny. Such events include ‘accidents’ and illnesses.
In anthroposophic medicine art therapy enables (what lives in)
the astral body to surface; through the use of materials and themes
it can affect the soul. It is understood that by freeing and nourishing
the astral body there is an effect on the other interconnected bodies.
Through the release of suppressed or unconscious feelings some
people may experience beneficial effects on the physical and life
bodies. The etheric body, which mobilises the physical body, may be
restricted by the astral body. Under stress people often say, ‘I can’t let
go’. This ‘letting go’ refers to the release of the physical and etheric
from the astral body.
Two key principles of Hauschka art therapy are that colour is
healing, and that working through painting with the rhythms of nature
restores and balances the human soul and supports reconnection to
the wellsprings of life.
Motor neurone disease

I worked with three patients with advanced motor neurone disease
(MND) over a five-and-a-half year period. All needed assistance
from helpers and the aid of wheelchairs.
MND is as yet little understood by the medical profession. It is
degenerative, incurable and terminal. Motor neurons are protected
and insulated by myelin, which is made of lipids of protein. In
MND it seems that the myelin sheaths are damaged, causing a
communication problem from one nerve cell to another, resulting in
loss of motor control and spasticity. Motor neurone disease occurs
when motor neurons progressively lose their function. Motor neurons
are nerve cells that send signals from the brain to the muscles and
direct movement. They also help regulate many of the body’s

automatic muscular functions, such as breathing and swallowing.
MND affects muscle activity and leads to severe, progressive,
muscular atrophy. As the disease progresses, loss of tendon reflexes,
spasticity, cramps and spasms may occur. In simple terms, the etheric/
life body, of a person suffering from MND, is ‘cramped’. It has lost
its natural fluidity.
Patients may suffer fatigue, pain, shortness of breath and emotional
lability, including anxiety and clinical depression. They may suffer
from fear, stress, frustration, anger and loss of confidence. They
may also experience embarrassment and feelings of degradation as
well as guilt, grief and a profound sense of loss. MND patients are
increasingly unable to walk, talk or care for themselves. Relationships
are affected; relatives and carers need support and opportunities to
express themselves.
Sufferers usually have a short life expectancy that rarely exceeds
six years after diagnosis. Psychological and existential questions are
paramount (McLeod and Clarke 2007).
First impression
When one meets a person in a wheelchair with obvious physical
limitations it might be easy to focus on these and forget the
individual. Through training in Goethean observation1 (The Life
Science Trust), I learnt to sharpen my perceptions at the first moment
of meeting, to see beyond the physical and gain a fleeting glimpse of
the totality of the person beyond the illness. It is a kind of scanning
of the body and soul of the person entering the space. I find this a
very useful tool in my work. It is summed up beautifully in Rudolf
Steiner’s poem on loyalty, which was read out in the clinic at the
beginning of many individual case conferences:
1 Goethean Observation is a four-fold form of observing phenomena. The

practice of Goethean Science is a way of reading and learning from nature:
‘the physical attributes of an organism, the processes by which it grows and
evolves and its spiritual characteristics are all investigated by and unified
within the Goethean scientist.’ For further information please refer to The
Life Science Trust Website.
Loyalty verse
Create within you a new concept of loyalty.
What people call loyalty becomes so easily
meaningless.
Try to make this your loyalty:
You will find that there are fleeting moments in
your experience of your fellow-man,
when he appears filled and illumined by his true
Spirit-Being.
Then other moments will come: possibly long
periods of time when his being is as if clouded.
At such moments you must learn to say:
The Spirit makes me strong.
I remember my friend’s true being, which once I
was allowed to glimpse.
No outer delusion or deception can ever take it
from me.
Struggle ceaselessly to uphold the image of the
other’s true being which once you saw.
This struggle is loyalty.
In the effort to be loyal in this sense – man shall
be close to his fellow-man,
with the strength of a Guardian Angel.
How can we work together?

The next encounter is the spoken exchange. ‘What would you like to
tell me about yourself ? What brings you here? What is it you want
to achieve or explore in this space, now?’
Physical practicalities
Given the range of debilitating physical symptoms with MND,
resulting in my patients’ loss of coordination and use of their limbs,
my next question would be: ‘How can I enable this person to do art
therapy?’
Practicalities and health and safety issues became the focus of

initial sessions. Experimentation and creativity entered a new realm.
Is the table at the right height? Does it need to be on blocks to
accommodate the wheelchair? If I move the table, is the light source
suitable to work in? Would this person be more comfortable staying
in their wheelchair or transferring to an ordinary seat? How do we
manage a safe transfer? Do we need grab-rails in the room? If so,
where and at what height? Is there a nurse available to bring the
patient to and from the session? Can she stay to assist the patient
into a comfortable seated position? Do we need a desk, easel or
blocks to raise the painting board? At what angle must this be to
enable the person’s hand and wrist to work to maximum capacity?
I relied heavily on the involvement and knowledge of one patient,
Christopher, who is my co-author.
Mirroring processes
When recently I asked Christopher how his mind came to terms
with the damage to his body he told me, ‘Initially it was hard. I
have developed a combination of acceptance and resourcefulness:
my focus isn’t on what I can’t do, but how can I do X?’
Although we had never discussed it, I realised this response
mirrored my own process. In the countertransference I felt vulnerable
and became anxious about dependency issues when I needed to
ask colleagues for help. Sometimes I would feel frustrated and
unsupported whilst awaiting assistance. I wondered how often my
patients felt like this. I realised there was a sense of forbearance in
each of them which I too needed to acquire; relinquishing some
degree of my own sense of control and freedom. Whilst waiting, e.g.
for grab-rails to be fitted, I learned to become more innovative and
develop a new depth of patience and tolerance.
Mobility and medium

Having established these practical arrangements, the next priority
was: What medium and which tools will we need to enable the
patient to work? One patient could not use her limbs and so we
decided that she would paint with a brush in her mouth. We tried
different weights of brushes and sponges on sticks to make sure that

she could control the implement. We opted for the brush because a
sponge did not give enough resistance. The length of the brush was
important. How long should it be to create enough distance for the
patient to actually see the work? If it was not long enough the work
was out of focus; if it was too long she had no control.
Another patient, formerly an accomplished football player, had
lost the power in his hands and wrists. We explored foot painting
and working with sand which I warmed in the Aga to make it a
more pleasurable experience. I introduced him to lemniscates,2 (a
rhythmic movement) to try to re-establish the memory of movement
in his feet. These activities were to some extent enjoyable, and could
be beneficial in the longer term if continued at home. However, they
proved clumsy and did not produce anything artistically meaningful,
which he wanted to do. We tried mouth painting, but this was
arduous for him.
The most satisfying activity was blowing paint through straws,
developing and exploring patterns from the marks and shapes. He
was delighted by this. He told me he could imagine doing it with
his very young children, which could compensate for not being able
to engage in physical activities. He regarded this playful discovery
as a real achievement.
Asking a patient what their physical limitations are is delicate;
asking if they would like to try mouth or foot painting when there
are few other options is even more sensitive. How does one maintain
another’s dignity and enable him/her to rise to a challenge? I have
found that being completely pragmatic normalises the situation.
Christopher
Christopher was my patient at the clinic for four years. I have continued
to visit him for occasional painting days since the clinic closed. He is
an anthroposophist and familiar with the approach and terminology.
Christopher’s first symptoms occurred in 1997. He is still (as of
2012) able to walk a few metres with the aid of a Zimmer frame. He
2 A lemniscate is a plane curve with a characteristic shape, consisting of two

loops that meet at a central point.
tends to slump when sitting and needs to stand and stretch occasionally.
He is not in pain; his current symptoms are stiffness and barely audible
speech. His grip and hand control have weakened a little during the
seven years we have worked together. Stress stiffens and weakens him
and makes it hard for him to stand up and walk.
The ongoing emotional consequences of the illness arise from
a deep frustration about communication difficulties. Christopher
has developed a particular sense of humour, which has become an
important coping strategy (Day 2007).
When I first met Christopher, his speech was already severely
affected. If he could not make himself understood, he wrote what he
wanted to say. He rarely ventures to speak now, so setting up for him
includes making sure that a pen and paper are at hand for him to
communicate his comments and needs. He visited the clinic for respite
and recuperation for two weeks twice a year. At that time Christopher
walked slowly with two walking sticks and was brought to the studio
in a wheelchair. He was accompanied by a nurse when moving about
the clinic. He is right-handed and I noticed that his grip was loose. It
has grown weaker in the past three years, but he can still write and
work with a brush or cloth. He cannot stretch his arms very far and
materials are laid out accordingly.
During previous admissions Christopher had painted watercolours,
wet on wet, with my colleagues. I was familiar with his work. He had
wanted to be an artist as a young man, but as he is red/green colour-
blind he had studied sculpture and architecture, though his first love
was painting. Christopher is an architect. His particular contribution
to architecture is to produce buildings that are in harmony with the
landscape and also consensus design, which engages communities
in deciding what they need and how they can achieve it, together.
Sensing that he would enjoy a new challenge and the vibrancy of oil
paints, I asked Christopher if he would like to try oil painting with
cloth. I suggested using cloth because using the hands in this way
produces some resistance with the materials and does not necessarily
require precision. The senses of sight and touch are engaged. Touch
is the principle sense which gives an experience of one’s own body.
Christopher was very positive about this suggestion. This has become
his preferred medium, although he needs more assistance with oil
paints than he does with watercolours, as he cannot perform the fine
motor activities required for watercolour painting, such as opening
tubes of paint.
Themes: nature and the senses

Christopher always asks me if I have suggestions for painting. Many
of his works reflect the Welsh landscape, whether or not the theme
is directly related. He enjoys painting series, ‘because series always
bring development, have a relationship to the etheric (life forces) and
soul development and allow me to feel into the work a bit deeper
each time.’
We have worked with themes such as times of the day, the
seasons, the Creation story, fairytales. These themes encompass the
four elements and the rhythms of life, which are fundamental to
our cosmology. They relate to the essential principles and creative
substance of all life. I began to grasp Christopher’s need to recreate
the natural world more fully when I read the following words from
one of his books:
In the search for inner renewal from the deep well-springs
of nature, some people seek solace in (relatively) wild
environments [which] are essential for the de-stressing, re-
rooting and life-renewing which all too rarely can be found
in most people’s daily surroundings… These are places which
give us strength and renewal… These sort of places are food
for our spirit.
(Day 1999, pp.182–183)
This desire to paint nature themes, and for them to resemble the
Welsh landscape, became all the more poignant when I realised that
as a very young child Christopher was sent away from home in Wales
to boarding school in England. Being in nature is an entirely sensory
experience. The world is revealed to us via our senses. In painting
nature Christopher can live into the sights, the sounds, fragrances,
temperature, movement of wind on flesh and the abundant variety of
colours in the landscape, and thereby experience renewal.
Looking at a view from a car isn’t the same as breathing it, which is
multisensory and touches the heart. I can never walk there now but
as I live into a painting a regional memory arises into my present.
I am connected with the sustenance of nature through painting;
my senses are stimulated and reawaken the heart’s memory. I
concentrate on the soul of the painting. Painting is predominantly a
feeling activity, but when something isn’t right, I may need to think.
Figure 13.1 Creation story, second day (see colour plate).
Figure 13.2 Eden (see colour plate).

On colour
Notwithstanding that Christopher is red/green colour-blind, many
of his works use dramatic, bold colours. It is interesting that each
of my MND patients used very bold, bright, pure colours, and each
worked with a determination as if their lives depended upon it. Is this
a reflection of an optimism necessary to live with this illness, or is it an
expression of the soul’s longing to be made visible?
Writing about motor sensory nerves, Thomas Cowan MD argues
that the health of the nervous system lies primarily in what it is
exposed to, stating that ‘the therapy of neurological problems… must
include surrounding oneself with that which is beautiful and true’
(Cowan 2004–2009).
Perhaps by bathing in the experience of making colour come alive,
the sufferer of MND is satisfying a desire for soul nourishment? The
use of bold colour may be a combination of many things.
Christopher’s experience
It is not a conscious desire to paint colours very boldly. Being red/
green colour blind, I am not sensitive to that. I normally see a
difference between red and green, but can only see poppies in a
green field when shown where they are.
When I work with colour I love and live into the beauty of it.
Its beauty brings a special kind of calm. Peace. I’m calm anyway,
but not like this. I use a lot of yellow and violet in my paintings.
I am not sure why, maybe they sing together, maybe because
they are dawn colours. I love dawn; it brings hope in every
new day.
After painting for many years Christopher wrote me a note
one day. It read, ‘I just discovered magenta.’ I asked him if
he could describe how that felt. This colour appears a lot in
his work.
Magenta feeling: wow! That’s beautiful – it raises the spirit. Not
too hot or fierce like some other reds, and technically it’s easier to
control its strength than crimson lake, also beautiful, but sometimes
too warm. Is it a ‘spiritual colour’?
(Magenta is the first visible colour at daybreak, it heralds the dawn,
ending the darkness of the night. It is the colour of the hypocotyl, the
point of a shoot as it emerges from the earth into the light, especially
noticeable in bulbs; it is the colour of blood, the life force of warm
mammals. It is visible in the rainbow, mankind’s symbol of hope. It
appears alongside viridian green when black and white are observed
through a prism.)
Art therapy and process

Christopher is a very private person, so reluctant to focus on personal
issues that I rarely dared to suggest these when he asked me what to
paint. His inner life was revealed in the colour and movement of his
work, but never directly spoken about. However, recently, I suggested
he consider painting a series honouring the phases of his life. Knowing
that Christopher would probably want to paint Wales, I added that he
might paint it as a series of landscapes. He liked this idea and it opened
up a completely new phase of work for him, a phase in which he
began digesting and revisiting episodes in his life, some of which were
unpleasant and required entering unresolved territories. He suggested
we use some of that work for this chapter.
It will be seen from the paintings that Christopher has skills and
technique which have not been affected by MND. Sometimes when I
describe his work to him, he seems surprised by what it reveals.
Figure 13.3 Age 7 – leaving home.

In Figure 13.3, for example, the sky has a lot of movement, as if a storm
may be on its way. Christopher’s comments about the painting reveal
his churned-up feelings at the time.
Figure 13.4 Granny with angry spots.

In Figure 13.4 Granny is depicted in rectangular form, without arms,
darkness is behind her and she has ‘angry spots’ on her face and neck.
It was Granny’s rigid attitudes that led to Christopher being sent to
boarding school and left a lasting impression on him.
In many of the paintings we see polarities – lightness and heavy
weight, ethereal and dense colours, turbulence and calm – side by
side. Sometimes these polarised regions blend together to create a
balance (see Figure 13.1 and Figure 13.2). At other times the worlds
are separate (see Figure 13.5), creating a sense of drama, tension and
disconnection between two experiences.
Figure 13.5 42–49 years. My horizons opened, but painfully.
Portrait format = a growing up period.’

I’ve always enjoyed painting. Drawing is as natural to me as writing
(and often easier), but it only shows the character of things. Painting
evokes the soul of things. Until I was 29, I approached painting more
or less as coloured drawings. In various anthroposophical settings I
learnt wet-painting, veil-painting and lazure techniques3 and came
to understand that colour is about touching the soul. Painting does
this for me; coloured drawings don’t. I paint landscapes – but never
actual ones – soul landscapes, remembered, imagined or craved-to-
be-in.
I approached art therapy in this light. I didn’t know what to
expect of it, except that it would involve painting. Most exercises
seemed to be about particular states of soul, but for me all started
out from colour-as-soul. And such colours sing. Sometimes, however,
3 Both techniques involve subtly building up colour by painting thin layers,

or veils, of water based paint. This creates a sense of movement, dimension,
permeability and light.
primary colours feel too ‘pure’, so need to be grounded by working

in a little earth colour: ochres and umbers. The ‘inner’ life of my
paintings, as with all life, exists in the realm where darkness and
light interact – so I frequently blend, wet-mix or over-veil colours
on the paper. Once I had been shown how to oil-paint with folded
rags, I discovered that dark hues, even black, emphasise the song of
lighter-toned primary-colours.
At home, painting is increasingly hard to arrange: I can’t carry
things, reach everything I need or re-screw tops on paint tubes. So I
do it less often.This makes art therapy especially important for me.
And art therapy’s effect?
I discovered historical emotional wounds, and consequent underlying
attitudes, that I never (even at the time) realised I had. I discovered
soul-balm, spirit-nutrition, at a depth I had never previously
experienced.These included the bleakness of the formed but lifeless
earth in its early stage of creation, the timeless tranquillity of love
in the Garden of Eden, the hidden menace of Red Riding Hood’s
forest and wolf, and my Grandmother’s hidden, hurt-full – and hurt
– motives.
I think all this – discovered joy and uncovered hurt, soul-
nourishment and spirit-transformation – strengthened my positive
motivation, so contributed to my changing attitude to life. All
this slowed symptomatic deterioration, but didn’t cure anything.
Much more importantly, however, it triggered (or coalesced and
accelerated) a process of inner healing. So I’m certainly not cured,
but almost completely healed. Art therapy was part, probably a large
part, of this.
Commentary
When you talked about the first painting (Figure 13.3), I almost
cried, I had suppressed the memory (of leaving home to go to
boarding school) for 63 years.
It was a good feeling! Healing! Making it visible is good. It helps
heal wounds. My actual feelings of that school are good. Most
teachers really cared about us, we could play in the woods and boat
pond, all good. Leaving my mum at seven was cruel. Soul assaults
eventually emerge as illness, which gives a chance to deal with them
in another way. Therapy is dealing with old or new issues, i.e. the
same issues, but in a new form.
The trees represent firstly the wood at school, but also a gateway.
Secondly, the two sides of the boarding school experience; one of fun
being with other boys, and the other, separation from family… I
don’t really want to go back there again. That feeling has emerged
from doing the painting.
After a pause Christopher added, ‘Can I go out to play now? Please?’
The power of painting

Christopher enters a silent retreat when creating. He paints with a
devotion to the task as if it is the only thing that matters at that
moment. His work often expresses an exuberant joy that seems
unrelated to his reality, until he writes me a note that makes first him,
then me, dissolve into laughter. That is when I sense that Christopher
has his finger on the pulse of the hilarity of existence; that these deep,
rich, sometimes exaggerated but vital tones and hues are an expression
of that joy; the joy and diversity of life itself. Just as colours emerge
from the interplay of dark and light and are sung into existence, form
arises from the tones in his paintings and he becomes the creator of
a microcosm, the god of his space. The buried and painful emotions
of the past sometimes emerge to be experienced and acknowledged,
but his physical limitations and consequent dependency are no
longer apparent.
Of our work together Christopher has commented that he always
feels stretched, ‘firstly via the exercises and secondly the observations.
I stop when time runs out, I never want to stop. Painting is fulfilling, it
gives me energy, it doesn’t sap it.’
Summary
In working with patients with MND I have found that initially
practicalities take priority. How can one enable the patient to access
the therapy, given the limitations of the body? Enthusiasm for art-
making has been a hallmark of these patients, possibly because
many other pursuits are closed to them and the possibility of
communicating, producing and being in control is exciting. Use of
colour has been intense, at times uncomfortable for me to witness.
Perhaps this reflects the power of the assault on the body and
a desire to be perceived beyond the illness via the use of bright
colours, which patients do not experience as especially bright. It also
expresses a passion for that which creates life. Colour raises the spirit
and gives rise to form, which the body is defying; the spirit is acting
as a counterbalance to this catabolic (breaking down) force.
The medium of art therapy has stimulated Christopher’s process
of emotional digestion of his life’s experience. As he has said, ‘Soul
assaults eventually emerge as illness, which gives a chance to deal
with them in another way.’
Such mirroring processes between body and soul, and the
comparative benefits to patients when the four bodies are treated
separately, or as an interconnected whole, merit further research.
The therapeutic aims for Christopher were, first, to enhance
vitality and to provide soul nourishment through the medium of
colour and the senses. Second, to enable undigested processes to
surface and be acknowledged; and ultimately to enable him to
integrate those experiences. Thus the ‘song’ arising from the interplay
of light and darkness in his biography, becomes a symphony in
which the dissonance of polarised events, as seen in his work, brings
emotional insight and contributes towards comprehending his life’s
destiny. This is what I believe McNiff describes as ‘the soul’s process
of ministering to itself ’ (McNiff 1994, p.26).
The sustenance of nature and colour has given meaning to
Christopher’s life. They are the legacy he wishes to pass on to
future generations, in architecture and through his art. The life
forces in nature nourish the senses and through them the life forces
of the human body and soul. To this extent they are essential for
continued survival.
Margarethe Hauschka wrote, ‘Whoever becomes absorbed in
the cycle of the seasons causes his entire being to breathe (and) a
continual transformation is accomplished’ (Hauschka-Stavenhagen
1997, p.93). Through his journey with Hauschka’s approach to
art therapy Christopher has indeed entered a process of continual
transformation.
Addendum
Twelve months after we began the series, I asked Christopher if he
wanted to work on the time when he received his diagnosis. With
only a vague idea of what he was going to do, he began working. The
paintings that emerged are reproduced below.
Christopher wrote that the rock in the first image (Figure 13.6)
was ‘threatening, bleak, ominous, frightening and depressing. It felt like
pressure squeezing.’ Although he could still breathe, he could not see
beyond it. He described it like a ‘night fear, not specific, not known, not
understood, something I somehow had to find a way past. It was like
carrying a heavy weight which involved fear, a sense of terror.’
The diagnosis was very sudden and the prognosis brutal. The way
of getting past that moment (in the session) was to do another
painting, but the second painting only partly helped, so I had to do
a third to fully recover and then a fourth to consolidate the recovery.
It was too overwhelming, I hadn’t anticipated that when I initially
started painting. The intent emerged; it was only a vague idea at
the outset.
In image two I meant to break up the obstacle, but in fact it’s
the dawn sky that puts the mountain (rock) in context i.e. it’s not
so bad. Sky represents beauty, hope, spirit, life, to me. Image three
[Figure 13.7] is about peace and hope; image four, a new resolution,
the rock serves the sky. There is a residual cloud, but it’s retreating.
The obstruction has metamorphosed. Now it is ground that shows
up the light-filled sky, by contrast.
Christopher realised that he had not allowed himself to feel the
horror of the moment of his diagnosis until he worked on this first
painting, 15 years later. During the following three months Christopher
organised his carer to assist him to paint 28 ‘veil’ paintings, many larger
than he had tackled for a long time. The transformation in his work
was astonishing. Christopher is swimming through the colours into
extraordinary depth, balance and light, and he has changed. Significantly,
he wrote: ‘I found a light – touch and technique.’
Figure 13.6 The diagnosis.
Figure 13.7 Peace and hope (see colour plate).

References
Cowan, T. (2004–2009) ‘Motor or Sensory Nerves.’ AnthroMedLibrary. Accessed on
14 June 2012 at www.anthromed.org.
Day, C. (1999) Places of the Soul: Architecture and Environmental Design as a Healing Art.
London: Thorsons. (Originally published in 1990.)
Day, C. (2007) (My) Dying is Fun: A Comedy of Disabled Misadventures. Oxford: Trafford.
McNiff, S. (1994) Art as Medicine Creating a Therapy of the Imagination. London: Piatkus.
Mees, L. F. C. (1990) Blessed by Illness. Great Barrington, MA: Anthroposophic Press.
(Originally published in 1983).
McLeod, J. E. and Clarke, D. M. (2007), ‘A review of psychosocial aspects of motor
neurone disease.’ Journal of the Neurological Sciences 258, 1, 4–10. Accessed on 15
November 2012 at www.ahasc.org.uk/health/anthroposophic-healthcare.
Steiner, R. ‘Loyalty verse.’ In a personal letter to Christoph Boy. The Life Science
Trust Centre for Goethean Science and Art, Pishwanton. Available at www.
pishwanton.org, accessed on 27 February 2015.
van der Bie, G. and Huber, M. (eds) (2003) Foundations of Anthroposophical Medicine. A
Training Manual. Edinburgh: Floris Books.
Further reading
Brown, J. and Addington-Hall J. (2008) ‘How people with motor neurone disease talk
about living with their illness: A narrative study.’ Journal of Advanced Nursing 62,
2, 200–208.
Davis, J. (2004, updated May 2008) ‘Psychological benefits of nature experiences:
Research and theory with special reference to transpersonal psychology and
spirituality.’ Naropa University and School of Lost Borders. Available online at
www.soulcraft.co/essays/psychological_benefits_of_nature_experiences.pdf,
accessed March 31 2015.
Children
CHAPTER 14
Art Therapy and Encephalitis

Mark Wheeler
The patient is identified under his chosen nom de plume, ‘Werner

Krauss’, the actor who played Dr Caligari in Robert Weine’s 1920
silent movie Das Kabinet des Dr Caligari. ‘Werner’ is having ‘The Last
Laugh’ (the title of a 1925 Expressionist movie by Murnau). The
film Das Kabinet des Dr Caligari concerns a somnambulist, and the
narrative is presented almost entirely in flashback. The movie’s story
within a story is analogous to the process of writing this chapter,
which took place within the therapeutic encounter. The movie
script’s narrative also mirrors the patient’s episodic experience of
time following brain injury.
Although much of the process of art psychotherapy for this young
man, 14 years old at the start of art therapy, has been nonverbal,
the words of this chapter represent a significant art piece in the
art therapy process. Our using these words and agreeing on them
together, means that the chapter has become a significant tool in
the process of enabling the unconscious to become conscious. The
chapter is presented as a film script, and so the words should conjure
an image in the reader: a two-dimensional image on a big screen
ahead of the reader.
Recent neuroscience suggests that the brain is often just as much
stimulated by imagining an image as it is by an image itself. Indeed,
relational neuroscience has been researched entirely by using
images of loved ones, not the loved ones themselves. Such neural
connectivity is a core driver of the recovery model of rehabilitation
to which art psychotherapists aver in multi-disciplinary teams.
279
The cinema excludes distractions; it enables a willing suspension

of disbelief and it carries the viewer along a narrative without the
viewer having to perform their own editing – unlike the minute-
to-minute editing demanded by daily life. Brain injury often results
in an inability to prioritise sensory data. There are similarities to
autism in this respect, as brain injury can render a person unable
to discriminate between the important and the trivial, and those
who have acquired brain injury (ABI) may struggle to give minimal
attention to the sensory stimulus of the weight of their shirt on their
shoulders, and to the distant sounds of a passing car and birdsong
near the window, and maximum attention to the sound of their
mum trying to explain what has to be done today. Prefrontal and
right parietal lobe damage can particularly affect this ability to tease
out the significant from the background. Art psychotherapy has a
special relationship with the significance of signs and signifiers, so
has unique capacities to address this.
Other similarities with autism were experienced by Werner. He
no longer enjoyed social occasions, becoming hermit-like and no
longer wishing to play with his old friends on his road. After his
illness, Werner no longer identified humour easily and believed
everyone was constantly making fun of him. This affected his mood,
which could be labile or volatile, fluctuating rapidly.
About 18 months into art therapy, following discussions in
external clinical supervision (from an art psychotherapist), Werner’s
sessions were increased from fortnightly to weekly. The continuity
of weekly sessions was found to produce benefit disproportionately
to the mere doubling of hours. In work with patients with significant
neurological damage, interruptions to the regular repetition
that helps build and maintain memory have a disproportionately
negative impact.
Following assessments by paediatric medicine and education, and
psychological assessments by Child and Adolescent Mental Health
Services (CAMHS), a programme of interventions was devised for
Werner, primarily educationally based, including physical activity.
Psychological therapy has been solely art psychotherapy provided by
CAMHS. After two years of art psychotherapy Werner’s functioning
is now transformed, emotionally and intellectually. In particular
Werner can make intellectual connections to his emotional states;
Art Therapy and Encephalitis 281
he has become able to think about how he feels. In sessions he

now jokes and initiates banter, cautiously teasing the therapist and
enjoying the ripostes.
This style of emotional interaction is both masculine and age-
appropriate. For the first 12 to 18 months of life, much of our brain
development is right-hemisphere and relational. Our capacity to
organise thought and linear intellect depends heavily on this early
relational development. In recovery from ABI, art psychotherapy
is uniquely positioned to replicate this developmental process
from the imaginal and implicitly relational, to the rational and
explicitly relational.
Shortly after this progress was observed, a significant family
trauma occurred. Werner responded to the trauma with unexpected
warmth. He displayed empathy for other family members, becoming
aware that they were all experiencing events differently. Werner’s
emotional functioning was now much more sophisticated and age-
appropriate than it had been at the start of art therapy. A family
trauma with significant psychological impact might be expected to
impede recovery, but Werner’s response contributed to his emotional
growth. Recognition of this progress by Werner’s family provided
an external witness to Werner, reinforcing his internal narrative of
his own recovery.
This external (to the therapeutic relationship) event strengthened
the process and the progress of Werner’s recovery as an individual.
This can be attributed to the effect of the therapeutic relationship on
Werner, being offered in the context of Werner’s loving family. For
the family, their experience of Werner’s response to this family crisis
has been to extend or reinforce their narrative of Werner’s capacity
for recovery, at a time when they were understandably anxious about
his future. The family are carrying many stories between them,
about Werner’s life, his illness, his recovery and his future, and this
experience demonstrates previously rarely observed qualities.
The sudden onset of severe encephalitis in a previously healthy
boy of six, which left him globally impaired, caused family life to
alter to adapt to his illness. This account emphasises that change, by
referring to other family members only in terms of their relationship
to the patient. On his discharge from hospital, doctors had reassured
the family that Werner would probably make a complete recovery
and return to his pre-illness range of activities and relationships.

However, in letters to fellow professionals and in Werner’s notes
they appear more doubtful, with comments describing ‘a rather odd
encephalopathy’, inviting repeated future MRI scans, and expressing
the desire to hear how Werner progresses.
Subsequent reports also describe the ‘extreme fatigue’
characteristic of brain injury, cognitive problems, sudden weight
gain, and a need for constant monitoring of personal appearance
and personal hygiene. Werner reported many headaches, which were
both uncomfortable in the themselves and also reminded him of the
onset of his illness.
Werner loves movies. Movies demand attention to the details that
the director and cameraman have deemed worthy of the viewer’s
attention, removing the need for the viewer’s constant, priority
filtering of stimuli. Werner particularly enjoys the genre of German
Expressionism, which is characterised by stark lighting, prevalence
of detail-less shadows, curious camera angles, underlit nocturnal mise
en scène, and above all geometrically eccentric sets, with walls and
floors not quite perpendicular to one another. A common theme is a
nightmare from which the protagonist is unable to awaken.
The context of German Expressionist cinema differs greatly
from that of today’s viewer. This movie art form emerged during
the Weimar Republic in Germany and all its problems. The contexts
in which Werner and the therapist had viewed these films differed
as greatly from each other as from the filmmakers’. The enigmatic
power of a character like Caligari, explored in the context of a
therapy conversation, is potently imaginal; these filmmakers were
transferring the real fears of society into fictional horrors, just as
a patient’s bewildering journey from health to illness and towards
recovery might be transferred into the imagery of art therapy sessions.
Saint Augustine stated, in 398 CE, in Confessions, Book X
(Hustvedt 2011) that without names for objects and ideas, we
cannot speak about them. Art therapy enables wordless images to
be created that may then become objects, about which we can then
speak. The writing of this chapter was part of the art psychotherapy
process. It was an intensive form of review for patient and therapist,
and a co-construction of shared meaning. This is another dimension
of making the unconscious conscious, through the process of
putting things that have previously been assumed, seen or felt, into
shared words.
Working Title: ‘With Art Therapy You Don’t Get

Awkward Silences, You Get to Watch Paint Dry’
Scene 1
Werner (aged 15) and the therapist, Mark, are outside the
fire escape of the art therapy room in the small grassed area
between the clinic and a metal fence. They are carrying a table
outside and the therapist says, ‘There should be enough light
out here to take the pictures.’
Werner asks: ‘Did you manage to get one of those medical
cameras?’
Mark responds: ‘’Fraid not. Apparently nowadays they’re
attached to a big machine, not a camera body.’
Mark asks Werner which part should be photographed first, and
Werner replies that it doesn’t matter. Mark, as though thinking out
loud, adds, ‘of course, the scene order gets done at the editing stage’.
They both squat by the table, peering into the ends of the T-shaped
balsa wood object on the table, commenting about the size of each
other’s eye at the opposite end of the ‘T’ cross (see Figure 14.5 on
page 296). Mark describes out loud what is happening, as it happens, as
though to confirm that it really is happening. Werner directs Mark to
photograph the leg of the T; Mark asks for direction about using the
fisheye lens attachment. Werner and Mark both need both hands to
coordinate holding the camera, the balsa wood object and the fisheye
lens attachment, while both peer alternately at the tiny screen of the
camera. ‘I can hardly see anything,’ comments Werner.
‘Yes, we’ll only really know if they’ve worked when we put them on
the laptop,’ continues Mark, peering into one end of the object directly
through the fisheye accessory. He exclaims, ‘Wow, it really is like a little
world in there.’
Werner, handed the fisheye adaptor as he brings his eye to another
opening in the object, comments, before using the fisheye, ‘Imagine
how confusing it would be in there…’
Figure 14.1 Expressionist entry.
Scene 2
A boy of six, Werner, is lying on the settee at home in his dressing
gown. His two older brothers (aged eight and ten) are sitting, in school
uniforms, in chairs on either side of him. Suddenly Werner freezes.
His hand begins shaking. His brothers try to speak to him, eventually
shouting his name at him. He remains almost motionless. He appears
to be losing consciousness. The shaking increases. The older brother
jumps up and the camera follows him to the sitting room door as he
shouts, ‘Mum…MUM!!’
[The script deviates from facts here to summarise several days of the
family trying to get medical intervention for what began as an intense
earache, for which antibiotics were prescribed, and progressed to
grand mal tonic-clonic seizures, causing breathing to stop. The family
felt they were not taken seriously at first, then they felt excluded by
the incomprehensible medical jargon used. This is an important lesson
to any professional working with brain injury.]
Scene 3
A white-coated figure in front of a blackboard shows chalked diagrams
of the brain, like those scenes set in lecture theatres in horror films for
explicatory plot devices. The figure addresses the camera as though it

is a room full of medical students.
‘In a tonic-clonic seizure, before anything can be seen externally
in the patient, they often have a profound sense of dread,
of foreboding. This “aura” phase can even include physical,
auditory or visual hallucinations. Towards the end of the aura
phase the patient may begin to make repetitive movements,
which gradually increase until the “tonic” phase is reached.’
Scene 4
Another white-coated doctor in a clinic room, surrounded by trappings
of medicine (stethoscope, blood pressure sphygmomanometer, box
of latex gloves, papers, etc.), is addressing the camera; the camera
tracks back to show him framed between the shoulders of Werner’s
parents’ backs.
‘Werner was transferred here on 31 March with a three-day
history of headaches and earache. This was associated with
seizures. It is typical of encephalopathy. His previous history
was unremarkable…’
Werner’s Dad interrupts to say, ‘It’s all very well you saying
“unremarkable”, but he was a very capable boy…’
[As the doctor continues, the parents’ heads drop lower.]
‘On admission the patient’s OFC was 51.7cm. He was not
speaking but did obey commands to some extent. He was able
to sit unsupported. Plantars were upgoing and reflexes easily
elicited. His electroencephalogram (EEG) showed generalised
slow wave activity, as can be found in any encephalopathy. His
CT scan suggested mastoid pathology and an MRI confirmed
this on the right side. However, there were two right parietal
and one bilateral frontal lobe focus of white matter, high T2
with some signal enhancement. It was unclear what these were
due to, but they do suggest vasculitis or perisivular infiltration.’
Werner’s mum asks: ‘What does that mean? What does that
mean to Werner and to us?’
The doctor continues: ‘Although Werner had four further
seizures in the 48 hours after admission, he had no seizures
over the next 24, he became more alert and oriented with only
minor ataxia, residual motor abnormalities and slowed speech.’
‘So when can we take him home?’ asks Werner’s mother.
Scene 5
A children’s ward glistening with cleanliness. Werner is screaming at
his mother, ‘You’re crawling with spiders, you’re crawling with spiders,
you’re crawling with spiders…’
[Fade to black.]
Scene 6
Outside a typical NHS hospital main entrance, eight weeks later.
Werner’s mother is holding a bag in one hand and Werner with the
other. His hair is much longer (to indicate passage of time and a change
in his self-awareness). She says:
‘The doctor’s given us all these medicines that you’ll have to
keep taking…’
At this point a car draws up in front of them, driven by Dad, whom we
see through his open window.
[It transpires after pressure from the family that rather than being put
on additional drugs, Werner is taken off medication and his condition
improves.]
Scene 7
At school in the headteacher’s office. Werner’s mother is sitting in a
tiny chair next to Werner, who is sitting in a similar chair in front of
a large desk, behind which sit two teachers, one young and the other
older.
Werner’s mum: ‘I’ve brought you all this information about
encephalitis and its effects.The doctors said that Werner should
be able to return to mainstream education eventually, but the
Encephalitis Support Group suggests that recovery tends to be
slow and that the brain cannot cope with the sudden demands
of full-time mainstream education.’
The older teacher speaks: ‘It is our experience that all children
should be back in school full-time as soon as possible, for their
own wellbeing.’
Mum: ‘We have done some research into home education,
alternative education and gradual return to school…’
[There is a knock at the door.]
‘Ah,’ says the older teacher, ‘This will be the educational
psychologist. COME IN!’
[Another adult walks into the room and stands behind and between
the two teachers who remain seated behind the desk, like an
omnipotent trinity.]
The older teacher continues: ‘We were just saying how it is
usually best for pupils who have been ill to return to school as
soon as possible.’
Werner’s mum says: ‘I was just saying that the Encephalitis
Support Group recommend that due to the nature of the
illness and its long-term effects on the brain, the return to
school should be taken slowly, perhaps after a period of home
tuition.’
The Educational Psychologist speaks: ‘Yes, headteacher, that
is probably for the best. There’s not much we can offer
immediately for home tuition, so it would be better to see
how he gets on in school.’
Scene 8
A classroom – camera at child height. There are pupils all standing
around the edge, there is a teacher facing down to camera, and a boy
facing Werner, leaning towards him, prodding his chest, while arguing
in front of the teacher. There are chairs and desks knocked over and a
crooked picture on the wall. Many of the other children are shouting
or screaming.
‘Fuck off!’ screams Werner.
‘Stop that now,’ shouts the teacher.
Werner runs round the teacher toward the door, knocking over chairs
as he goes.
Scene 9
Mother in the garden breaks down sobbing, her head in her hands. A
neighbour peers over the fence and asks what is wrong. She tells him
how unsupported the family feel and how they have heard nothing
from the education department about home education, and they have
had no contact from the school either.
The man says, ‘As it happens, I’m your local councillor and
I have responsibility for education round these parts. Can I
come round and get the details and I’ll look into it for you?’
Scene 10
Inside the family home hallway. A knock at the door. The councillor is
on the doorstep.
‘Hello, I’ve looked into Werner’s situation. Unfortunately, his
school had never informed anyone of Werner’s illness and
difficulties. Werner will now be assessed for home education
and we will see if there is a suitable school that might offer him
some facilities.’
Scene 11
A different classroom with a clock high on the wall showing 3.30pm.
There are fewer pupils in this classroom. The teacher has a gentle
voice. Werner seems overwhelmingly tired and is struggling even to
hold a pencil. The teacher is saying, ‘Just try one more time.’
Scene 12
At the front door of the house, the care worker, who has been coming
for two weeks is talking into the dark hallway from outside.
Carer: ‘You went to the special school yesterday. Why not go
today?’
Werner replies in a tight lipped monotone, ‘It’s all the same,
schools are the same. It’ll soon be just like the last one.’
Scene 13
Outside the house. Mum’s voice can be heard: ‘Werner! It’s way past
lunchtime. It doesn’t do you any good being stuck in your room. Your
brothers will be home soon. You need to get up and out sometimes,
we all do.’
Scene 14
View over Mum’s shoulder at computer screen, where the logo of the
Encephalitis Society can be seen.
Scene 15
CAMHS Child and Family Therapy clinic. Close-up on clinical
psychologist’s face, tracking back to show back view of Werner (now
aged eight) sitting facing her across a table. There are papers set
out on the table, and building blocks and A4 pictures as part of an
assessment kit.
Werner’s mother walks round into shot and the psychologist holds up
the papers in her hand and says:
‘I did a WISC (Wechsler Intelligence Scale for Children) and
Werner’s performance is so different on the subscales that
little conclusion can be drawn regarding his overall IQ. Even
within subtests like verbal functioning, Werner’s results show
dramatic strengths and weaknesses, although overall they
indicate that he struggles with his language skills…’
‘That is our daily experience,’ responds Werner’s mum.
‘Werner’s nonverbal performances also vary and sometimes
he is distracted or responds impulsively. Werner achieved
unusually varied scores in tests that investigate his perceptual
organisation, verbal comprehension and processing speed. His
freedom from distractibility index, including working memory,
was the only area of consistency. He scored on the eighteenth
centile, which puts him in the bottom fifth of people his age.’
Turning to Werner’s mother, the psychologist adds, ‘You’ve told
me about Werner’s lapses in concentration and memory at
home and in lessons. In my tests Werner was only able to
remember a small amount of information from verbally
presented stories. The large variation of his test results make
confident interpretation of his cognitive assessment problematic.
These problems are common following encephalitis.’
Scene 16
Child and Family Therapy, a CAMHS review. Mark, the art
psychotherapist, is sitting next to Werner (now aged 14), speaking and
regularly looking at Werner to see if he is listening and understanding.
‘Art therapy sessions will be offered fortnightly. What we hope
to achieve with art therapy for Werner is the “kindling” of
new ‘neural pathways’. Think of these as the routes round our
minds; like any other route, if there is an obstruction, we hope
to find a way around it. Verbal language has quite a complicated
route round the brain. It goes from thought, memory or feeling,
to reach the bit that makes lungs, mouth and vocal chords
coordinate enough to get words out. Art therapy can often
connect more directly to the feely parts of our brains, even
when the thinky bits aren’t engaged yet.’
Scene 17
The art therapy room. Werner, immediately after greeting, walks to
the materials area and chooses his materials. Werner and Mark play
their own variation of the Squiggle game, Werner choosing a new rule
change this time.
Scene 18
The art therapy room. Werner makes an image of ‘before’ and ‘after’
pictures (like a movie storyboard) of shooting and death. The dead
people still have thoughts and speak. A second image is started, of
a superhero foiling a getaway, sharing features with the first image.
Mark offers interpretations, beginning, ‘I wonder if…’ but Werner
ignores them.
Scene 19
The art therapy room.
Werner says that he is bored in sessions, bored by the art-
making and bored talking, adding, ‘I can only make stick men.’
He continues quickly, ‘They only had one Hubba Bubba there
at the shop even though they had two trays.’
Mark responds: ‘You’ll have to explain that. For a start I don’t
know what a Hubba Bubba bear is…’
Werner: ‘Eh?’
Mark responds: ‘I said I don’t even know what a Hubba Bubba
bear is?’
Werner: ‘I don’t know what you’re talking about.’
Mark explains: ‘You said they only had one Hubba Bubba bear
at the shop and I said I don’t even know what that is, you’ll have
to explain “Hubba Bubba bears” to me.’
Werner: ‘NO, not BEAR – I said they only had one kind of
Hubba Bubba THERE!’
As Werner patiently explains what Hubba Bubba is, the
therapist’s imagined bear seems to take on a life of its own,
and they decide they have invented the Hubba Bubba Bear.
Eventually Mark asks, as Werner begins painting a cardboard
packaging inner from the materials stash, ‘What would the
Hubba Bubba bear say about that?’
Werner says, ‘It’s a shat on castle.’
Scene 20
The art therapy room. Werner brings his Nintendo DSi (a handheld
games console with inbuilt cameras).Werner and Mark make tableaux,
which Werner photographs and manipulates with the built-in software.
At the end of the session it is clear how well Werner now understands
the therapeutic process, because he deletes all the images from his DSi
without being asked, announcing, ‘I’m just deleting all these pictures
before I go.’
Scene 21
The art therapy room. The light outside is dappled with spring bright
greens. Werner is sharing images of his magazine collection, on his
DSi, with Mark. Werner offers to hand his DSi to Mark; Mark asks
permission to handle it. (It is appropriate to ask permission to hold
the object whenever a patient offers a personal photograph, a mobile
phone, handheld games console, iPad or similar picture holding device.)
Werner then takes a picture of himself. He asks permission to
make a picture of the therapist. Boundaries are negotiated and Werner
uses software to make himself morph into Mark and back again. Mark
offers interpretation possibilities that Werner chooses to ignore.
Werner deletes the images from his DSi without prompting (close-
up of hands deleting files). Throughout the process Werner explains
the technology carefully to Mark, and teaches him how to take pictures
with the DSi.
Scene 22
The art therapy room. The leaves outside the window are turning
brown. Shot close-up from below head height.
Mark offers: ‘Whenever emotions and feelings enter the
conversation you seem to divert to something else.’
Werner says: ‘I get bored then.’
Mark continues: ‘But, whenever we have talked about brains
and how they work, and how they can be damaged or repaired,
you do seem interested.’
Werner responds: ‘Yes, and I never know what the time is or
how hot or cold it is or when things happen.’
Mark: ‘Do you think your internal clock and your internal
thermostat were broken by the encephalitis?’
Werner: ‘Yes. Like in films where there are too many flashbacks
or the story jumps about.’
Werner adds: ‘I’ve got an old Joe 90 annual. Do you remember
Joe 90?’
Mark responds: ‘Yes. I do remember Joe 90. He was a boy
whose dad had a machine that would make Joe’s mind know
all the skills and knowledge of some expert, so that he could
undertake secret missions no one would expect a boy to do.
Do you think that a machine like that would be a good thing?’
Werner replies: ‘Yes. You should see my Joe 90 annual. Mum’s
making me have a haircut today’.
Scene 23
The art therapy room, after an interval of six weeks without fortnightly
sessions. Werner brings a 1969 ‘Joe 90’ annual into the room.
Mark says, ‘Wow! You remembered we talked about this.’
The conversation covers the ‘Mind Transfer’ technique in the book and
its implications for people if such technology existed.The conversation
evolves to the semiotics of the Gerry Anderson ‘Supermarionation’
oeuvre, Thunderbird puppets and all.
Scenes 24–28
The art therapy room, shot identically from above the table. These
scenes are cut rapidly with fast dissolves. Mark and Werner are in
different positions sometimes, and each short scene is characterised
by a burst of laughter.
Scene 29
Clinical supervision in the art therapy room. The fortnightly sessions,
plus inevitable interruptions of breaks, some quite lengthy, are impeding
the engagement. The sessions are increased to weekly intervals.
Figure 14.2 Corridor and outside world.
Figure 14.3 Distant Hulk (see colour plate).

Figure 14.4 Big Hulk.
Scene 30
The art therapy room. There is a conversation about Expressionist
films, without Mark revealing any prior knowledge. Mark asks Werner
what each film mentioned means to him, their ‘silent’ nature and the
way they look. Mark eventually has to admit his own knowledge of
the genre in order to continue the conversation more naturally. Mark
asks Werner about the distorted sets and featureless shadow areas
and how this might relate to Werner’s changed sensory perception
since his encephalitis. Werner recognises the connection and decides
it would be a good idea to build an expressionist film set with balsa
wood. At first Werner is inhibited by lack of confidence in his practical
skills, but is soon absorbed and sawing balsa wood.
Scenes 31–39
The art therapy room. Close-ups of evolving mini Expressionist film
set components made from balsa wood.
Scene 40
The art therapy room. Close up of parts being laid out to dry, following
painting. Camera pulls back for long shot, then close up on Werner,
who says, ‘Unlike other therapy, with art therapy, instead of awkward
silences, you get to watch paint dry.’
Mark is speechless and convulsing with laughter at this.
Werner adds: ‘My friend doesn’t get it. He thinks you just paint
to feel better.’
There follows a thoughtful conversation about memory, brain damage
and psychological mindedness.
Scene 41
The art therapy room. The receptionist enters to tell Mark that
Werner will be unable to attend this week.
Scene 42
The art therapy room. Werner spontaneously discusses a serious
family situation. The situation is the reason for the previous week’s
cancellation. The situation is profoundly exercising all members of
the family emotionally. Werner discusses this emotional crisis with
empathy for other family members. He is able to guess how others are
feeling and to feel it with them, in addition to his own feelings. Werner
also recognises that they do not all have the same feelings about the
situation, and is thoughtful and tactful about everyone’s feelings and
how he has responded.
Scene 43
The art therapy room. Werner is tired and sleepy on arrival and says
he is going swimming after the art therapy session. He says he used
merely to sit in the jacuzzi the whole time, but last time he swam
15 lengths. Throughout this session Werner takes the lead; he makes
decisions confidently and is spontaneous. Mark reflects to him that
only six months ago he had struggled to make decisions between two
options, ‘either this, or that’ but that now he doesn’t even need the
options to be offered. Werner is now deciding for himself what the
options are and which he prefers.
Scene 44
The art therapy room. Werner is wondering what to build next,
whether to extend this model or build something new. He talks about
photographing his film set model last week (as seen in Scene 1), giving
the viewer a taste of how time becomes episodic for those with ABI.
Werner would like to make a movie in the set, using a miniature
camera. He says the camera would show more explicitly how the ‘hulk’
figure seems large in one place and small in the other. Mark wonders
whether wandering inside the set might be like wandering round
neural pathways in our brains and encountering dead ends, strange
side doors and things that are at once big and frightening, but at other
times, the same thing is small and safe. Werner suggests that console
games are like that too, especially when there are workarounds to get
around a task or battle, reminding Mark of the early sessions.
Figure 14.5 Outside view of set and lens.
Conclusion
Constructing an art object – an Expressionist stage set – enabled
a concrete image to serve as a metaphor for the bewildering
experience of recovery from brain injury. Through the set and the
idea of the film, conversations became possible that were embedded
in metaphor. More neurological activity is stimulated, in more areas
of the brain, by metaphor than by other thought processes. Art
psychotherapy can replicate infant brain developmental stimuli and
enable the implicit right-hemisphere development to organise the
explicit left-brain activity. This enables connections to be made from
the unconscious and emotional to the rational and thoughtful.
Art psychotherapy was the only treatment that Werner was
receiving. The example in this case study suggests that for
best potential recovery from brain injuries like encephalitis, art
psychotherapy must be within the range of treatment modalities
offered.
References
Hustvedt, S. (2011) ‘Three emotional stories: Reflections on memory, the imagination,
narrative and the self.’ Neuropsychoanalysis 13, 2, 187–196.
CHAPTER 15
Art Therapy with a Boy Living

with a Life-threatening Illness
Judith Ducker
Introduction
In this chapter I will focus on work that took place with Alex from
the age of seven to eleven, a boy suffering from a brain tumour
(astrocytoma on optic nerve). First, I will describe the setting for
therapy, and his history and background, including his presentation
at referral. Then I will give a short synopsis of his art therapy
journey. In the main body of the chapter I will concentrate on six
different phases during the art therapy process, which show how he
came to terms with his illness and prognosis whilst also adjusting
to a future he imagined he never had. In doing this, I will link
it to recurring themes that emerged throughout the work, such as
constant uncertainties, loss, a need for control, inner and outer space,
change and ordinary life. I will also refer to other authors to explore
the states of mind that Alex communicated.
The setting
I work within a charity-funded centre for children affected by life-
threatening illness and bereavement. It offers free therapeutic support
to children and their families. The approach of the centre is to
work holistically and, as well as art therapy, it offers psychotherapy,
homeopathy, counselling, massage, music and play therapy. Emotional,
psychological, physical and spiritual needs of each family member
are taken into account in the work of the centre. The centre is self-
referring and children are brought by their carers.
298
Art Therapy with a Boy with a Life-threatening Illness 299
Art therapy takes place in a well-equipped art room located in the

centre, a Victorian house close to the city centre. Once a home, it has
a warm and friendly atmosphere which adds to its accessibility. The
art room is light and has a large central table and four chairs, and a
smaller table for younger children. It is equipped with a range of dry
and wet art materials, paper and card of varying colours, a sand tray
and a dolls’ house.
History
Alex was 19 months old at the time of his diagnosis, following which
he spent the next four to five years in and out of hospital. (He was
unconscious for some of the first year.) During this whole period, he
received three treatments of chemotherapy to try and keep the tumour
stable, had a shunt fitted (to drain off excess fluid), and eventually had
surgery, which consisted of two ten-hour operations, both within the
same week. He then started radiotherapy and, following his recovery
from treatment, he was put on a ‘wait and watch’ programme and
received scans every three months. Eight months later, now aged
seven, he was referred to art therapy.
Prior to his diagnosis, Alex was living in America with his sister,
who was six years older, and his parents. There were difficulties in the
marriage, and the parents separated, with his mother leaving his father
to move to England with both of the children. There has been little
contact with the father ever since, despite Alex’s mother trying to
improve his relationship with their children, by returning to America
for a visit when Alex was about four years old. A year later Alex’s
mother met Josh, her current partner. At the time of referral, they
were living separately.
The referral/presentation
Alex is a good-looking boy with dark hair and big, dark eyes, and small
for his age. He was put in touch with the centre by statutory services
and was assessed initially by the centre manager. He was described
as ‘angry and insecure’, sometimes shouting, hitting and kicking his
mother, and at other times holding on to her for security. When I
met with him and his mother, four-and-a-half months later, for an art
therapy assessment, it was not difficult to see how his illness had
affected him neurologically, physically and psychologically. His tumour
had left him visually impaired, which, coupled with his chemotherapy,
had resulted in his growth being stunted. He had muscle weakness
and poor coordination and suffered from headaches. As I grew to
know him, I recognised other symptoms such as poor concentration,
tiredness and susceptibility to coughs and colds, although some of

these improved over time. Also, it became apparent that he struggled
socially because of being limited physically, and often had to rely on
others for mobility.
At school Alex carried a white stick, which helped to give him
some independence. Since his brain tumour had affected his sight and
mobility, causing secondary behavioural difficulties (frustration), he had
been granted a Statement of Special Educational Needs (now called
Education, Health and Care plan). Such a statement is available for
children in need of extra physical and psychological support. In Alex’s
case, this enabled him to access the support of a Braille teacher, as well
as a teaching assistant and a Special Education Needs Coordinator
(SENCO). Outside school he had further support, including a clinical
psychologist, social worker, paediatrician, consultant paediatric
oncologist, consultant paediatric endocrinologist and physiotherapist.
He attended a mainstream school and was of normal intelligence, but
due to the amount of school he had missed, he had not reached normal
milestones. His self-esteem and confidence had also been affected.
Overall, what stood out for me most during the assessment was
Alex’s description of himself as being ‘a nuisance to others’ and I
was struck at how often he apologised. He told me that he wished
he could be like other children and that his limitations had left him
feeling sad. Most of all, he told me, he wanted to be ‘understood’. His
mother’s goal was for him to be helped with his frustration and his
lack of self-esteem.
In addition to his mother’s goals, I found myself thinking about
whether there was anything else she might want Alex to have from
art therapy. I thought about how parents of children with a terminal
illness may find it intolerable to bear the physical and emotional pain
they witness in their suffering children, particularly if it touches on
similar feelings within themselves. It helped me to understand the
frequent use of defence mechanisms employed by parents during
such circumstances, especially in the early stages of a child’s illness.
Researchers (Brown 2007; Brown and Arens 2005; Judd 1995; Kübler-
Ross 1983) have shown how terminally ill children can be intensely
aware of the anxiety generated in their parents by their illness, so
may also employ defence mechanisms and deny themselves their
grief in order to protect the parents. Judd (1995) argues that even if
children have not been told about their prognosis, or may not have
reached a conceptual understanding of death, they are usually aware of
something that is wrong with their body. But perhaps more important,
as Black (2002) suggests, it is the way their primary carers cope with
the child’s illness, and how open the family is to the expression of grief,
that enables a child to adjust to their situation. It seemed all the more
important, therefore, that there was an emotional space such as art
therapy available to the child, where he could continue to exist and
express his needs, fears and concerns, should this not be possible at
home. It brought all the more into sharp focus the need for the art
therapist to connect with, contain and think about that which seemed
unthinkable or ‘intolerable’, so that over time it could become possible
for the child (and parents) to tolerate and make sense of his reality
and bring about some emotional relief. Finally, I realised how important
it is for the art therapist to maintain a sense of hope, not only for the
individual child but also for those who love and care for them.
The next four years: Alex’s art therapy journey

Right from the start, with an unclear prognosis, the journey began with
uncertainty. As with most beginnings, and as part of settling, like other
children in therapy, Alex pushed the boundaries, testing for his safety.
He found it hard to trust me, and often tried to extend the sessions or
ask to take his artwork home. For reasons of safety and containment,
it is usual for an art therapist to hold onto a client’s artwork until
the end of an art therapy contract, when the client can choose to
take it home. When I didn’t grant Alex his wishes, he pushed further
by becoming angry, threatening to leave therapy altogether. Then,
four months later, there was a breakthrough as he made a postbox, a
symbol of communication (Figure 15.1), and began to tell me about his
hospital experiences: his anger about his tumour and how it made him
different, setting him apart from his friends (he couldn’t play football or
ride a bike and have the freedom that they could with such activities), a
time when a friend also suffering from a tumour had died, and how at
other times he wished that he could be born again, without a tumour.
During the second and third years external changes such as Josh
(his mother’s new partner) moving into the family home, a new baby
on the horizon, a house move, a school move and fears that art therapy
would end as a consequence, affected Alex internally. He painfully
questioned whether such changes might have occurred because of the
impact of his illness on his family. As he did so, core fears of rejection
and betrayal, of ‘not feeling good enough’ and ‘taking up too much
room’ also came to the fore.At times Alex just expressed the ‘mess’ he
felt inside by pouring onto the floor tubs of sequins and matchsticks,
leaving me to clear up. In his fourth and final year of art therapy, having
explored these doubts and conflicts, he began to find resolution and
a hope for the future as he realised that his tumour seemed to be
stabilising. The phases that follow show his journey in more detail.
Figure 15.1 Postbox (see colour plate).
Scaffolding sculptures
During the early stages of Alex’s art therapy, he began to make a series
of buildings constructed from boxes held precariously together with
tape and pipe cleaners, which he called ‘scaffolding’ (see Figure 15.2).
As a general rule he preferred to work three-dimensionally, using his
hands, as the tactile process suited him where his sight was limited.
He often invited me to help him stick various parts together when it
became practically too difficult for him, preferring to use sellotape, as
it was transparent and interfered less with the overall appearance of
the sculpture.
The buildings were metaphors for himself. In her book The Dying
Patient in Psychotherapy, Joy Schaverien (2002) says that, in addition
to acting as a metaphor for the psyche, a house can also become a
metaphor for the body. She goes on to say how this can be particularly
so when someone is seriously ill, explaining that when a story is told
about a house, anxieties about the body and its deterioration are bound
to be present. She discovered that when working with her patient, ‘the
concrete reality of the physical world would become a metaphor for
the psychological, and the psychological for the physical’(Schaverien
2002, p.38). This seemed to be true for Alex too, and was reflected in
his scaffolding sculptures, which also expressed the fragile state of his
body. In addition being supported by scaffolding, Alex’s buildings were
also often ‘boarded up’, a theme he picked up on from derelict houses

he had seen while travelling to school, and, as with the scaffolding,
the boards were used to help hold the buildings together. He told
me that without (and despite) such supports, the buildings would be
too dangerous for people to enter. However, on occasion, and feeling
supported like the houses, he allowed me to ‘enter’ his inside world,
where he could tell me more about his illness. On one occasion as
he was doing this, the tape he was using became badly tangled and
prompted him to say ‘Cut it off…get rid of the yucky stuff.’ I likened
this to his tumour, at which he said, ‘Yes, I wish I could get rid of it
… Why can’t I get rid of all of it… It’s not fair.’ Eventually he threw
the tangled tape onto the floor, expressing his frustration and despair
about not being the same as his peers.
Figure 15.2 Scaffolding.

On other occasions, in spite of using boards and scaffolding to make
buildings safe to enter, Alex expressed a desire for others not to enter
the buildings (his internal world). When using boards and scaffolding
in this different way, he erected more scaffolding to existing buildings,
adding further boards and tape in order to completely ‘close them

down’. ‘No one can get in now…the shop is shut,’ he explained,
repeatedly saying ‘Keep out’ and making signs to stick on the buildings
saying the same. He likened these feelings to being in hospital and how
he wished that he could stop the doctors from operating on him.‘Keep
them all out,’ he would say, adding, on one occasion, how he had been
fed up because he had just been prescribed an additional medication,
a fourth on top of the three he already had to take at breakfast time.
Reassuringly, as his buildings developed, they became ‘only in need of
repair and temporarily out of use’. Significantly, one of the last buildings
he made in this series was constructed without scaffolding (see Figure
15.3). The inside was more visible and its contents were spilling out.
In an attempt to contain what was inside, Alex built a wall of card
around the building’s circumference, but the wall did not fully conceal
the contents.While there seemed to be a desire for containment, I felt
that Alex was inviting me again to witness his internal state, one that
was overwhelming and uncontained for him. With deepening trust in
me, he disclosed anxieties connected to news of his mother’s partner
moving into the home, and how he feared that his many needs as a
result of living with his tumour might get completely pushed out. This
led to a further series of work, some models of double beds. They
reflected his mother and her partner coming together and explored
consequent new anxieties.
Figure 15.3 House without scaffolding.

Models of beds
During this period where Alex struggled to accept Josh moving into
the family home, he also became curious about me, and my life outside
the session, particularly in relation to ‘the other children’ I saw at the
centre. For example, at the beginning of each session he always fetched
the biggest and best of the objects in the modelling box, including
anything that was new, in order to prevent other children from using
them. On one occasion, walking past the play therapy room after his
session, he knocked on the door to deliberately ‘spoil’ another child’s
therapy. His desire to have me, the art therapy room, its contents and
other consulting rooms in the centre all to himself seemed to express
his difficulty in sharing his mother with Josh and tolerating their union.
It was during this time that his sculptures significantly increased in
size.They challenged the storage space in the art room and seemed to
be a further attempt to ‘push out’ the other children, as there was little
room left on the shelves for them to store their work. I wondered if
the large size of his sculptures also begged the question about whether
he could be seen by others in his life, since, if he couldn’t see, he might
well ask whether they could see him.
At this point he began making models of beds (see Figure 15.4).
This model of a bed more painfully reflected the sexual union of his
mother and her new partner. In this piece, Alex chose several ‘pairs’ of
objects and placed them securely on the bed with sellotape. As was
often routine in building a model, because of his limited sight, he turned
to me for help with dispensing strips of sellotape and then asked me to
hold a particular item in place ready for him to stick down.
Figure 15.4 Bed.

Hedgehog and Rabbit

A difficult period followed after Josh moved into the family. Not only
did it change the family constellation, but his presence brought the
absence of Alex’s father to the forefront of his mind. Core feelings of
abandonment were re-stimulated as he asked himself if he could trust
Josh, unlike his father, to stick around. Parallel processes also took
place in the workplace with me, as he asked himself whether he could
trust me to ‘stick around’.
It was during one such testing session that the characters
‘Hedgehog’ and ‘Rabbit’ emerged. Angrily, Alex tried to leave the
room following a disagreement between us, in which I had asked him
not to cut some coloured ribbons that held together rolls of card. He
claimed, as he said ‘leave me alone’, that he’d once again had enough of
therapy and wanted to go. As he approached the door, I reached for
two puppets and began to retell the story of what had just happened.
One step removed, Alex was able to tolerate the feelings around the
conflict. He gradually relaxed and changed his mind about leaving.
From this point on the characters became important vehicles for Alex
to continue exploring his circumstances metaphorically. They suffered
negative and positive projections, with Hedgehog playing the role of
the bad, the prickly and rejected, while Rabbit stood for the good, the
soft and accepted. There were many instances where Alex’s process
was helped by speaking through these characters. I have chosen to
focus on just a few.
During the period where Alex was still finding it hard to accept
Josh, he often played the role of Rabbit within a narrative where he
struggled to live alongside Hedgehog. On one occasion, he claimed
that because Hedgehog had been so horrid to Rabbit, he would not
share his hutch with him. As a punishment, Hedgehog was persecuted
by being stamped on and used as a floor cloth and then thrown in the
bin. Minutes later he was retrieved, but the story did not end there.
He was gagged and bound with masking tape, then buried in the sand
tray. When I attempted to link life between the two animal characters
with his home life, Alex looked relieved and told me about the conflict
between himself and Josh, and the difficulties he encountered sharing a
space with him, including trying to find his new place within the family
as a result. ‘We keep falling out,’ he said, ‘and I feel unloved.’ During
further play of this nature, he described Hedgehog as ‘dead, buried
and gone forever’, expressing again his desire to get rid of his tumour.
Hedgehog was therefore multifaceted, standing for many parts of
Alex and others: sometimes all of himself, sometimes his tumour, or
his baby sister, Josh, his mother, and at times myself.
Some months later, Alex recognised that there were benefits to

having two adults looking after him at home. More settled, he began
to accept Josh (he called him ‘dad’ by mistake). His increased security
enabled him to explore his anxieties about his tumour more explicitly,
including fears of his own mortality. During one session I was asked to
be Rabbit, who was kind, loving and gentle.Alex opted to be Hedgehog,
who by contrast was prickly and defensive. He told me that Hedgehog
had to have an operation on his eyes and, feeling angry, he wanted to bite.
The eyes needed to be ‘poked about’, he told me, a job that ‘had to be
done’. So Alex wrapped Hedgehog in paper secured with sellotape and
buried him in the sand tray. Rabbit remained as an onlooker. Hedgehog
was then briefly unburied and brought back to life before the whole
story was re-enacted. He needed another operation, at which Alex
announced ‘Surgery time!’ He was wrapped up again securely in paper,
but this time he was placed in a box with a lid fixed firmly on top. Alex
carried the box to the sand tray and buried it. He then turned to me,
playing the role of ‘doctor’ and explained again that Hedgehog was
having an operation. Rabbit voiced his concern and told the doctor
that he hoped that Hedgehog would be all right. The doctor explained
that if the operation was successful, Hedgehog could go home, but if, in
his own words, ‘he was not all right, or needed more time to recover,
or if he dies, then he wouldn’t be going home’.With these instructions,
Rabbit was left, waiting anxiously for the result. When the operation
was complete, Hedgehog was unwrapped and brought back to Rabbit
in the box. On this occasion the result was favourable, indicated by
Alex saying, ‘Take off your white thing.’ Then Alex told him gently, ‘You
can go home’ (see Figure 15.5).
It takes little imagination to see that in Alex’s play, he was
processing his hospital experiences during the time of his operations.
The uncertainty he felt about his survival was also expressed, as were
anxieties about being separated from his mother, and handing over his
trust to others where his life was in their hands. Judd (1995) highlights
in her book Give Sorrow Words: Working with a Dying Child that even in
reunion with parents, anxiety in a child increases with each admission.
Although Alex was probably aware that he was suffering from no
ordinary illness, it is likely that at the time of his admissions, being so
young, he might not have fully understood what was happening to his
body, which would only have created further anxieties. Some years on,
with distance and greater maturity, the art therapy was giving him an
opportunity to make sense of his illness. In the last example, Hedgehog
survived. However, with his prognosis still uncertain, there were many
other examples where he didn’t survive, and where Alex explored

persecutory phantasies about why his illness had happened specifically
to him. (Indeed, he once asked me, ‘If I were born again, would it still
happen to me?’) He continued, therefore, to use Hedgehog to explore
his uncertain prognosis and feelings of annihilation, questioning
whether his illness had occurred because of a persecutory belief that
he was bad (Klein 1946).
Figure 15.5 Hedgehog and Rabbit.

With little confidence, and low self-esteem as a result, he explored
such doubts by routinely throwing Hedgehog into the bin at the
beginning of each session. With tubs of sharp pencils and scissors
representing surgeon’s tools, syringes and cannulas were then slung
on top, often followed by sand and soggy tissues representing sick
and poo. Following such abuse, Hedgehog was then forgotten about
and left in the bin while Alex turned his back on him and worked on
something else.
At the end of each session Alex expressed his ambivalence about
Hedgehog’s outcome by either retrieving him from the bin with
warmth and compassion, or leaving him there to face his fate. If the
latter occurred, I retrieved him after the session and returned him to
the shelf. On one occasion I too forgot to retrieve him, and, unbeknown
to both of us, Hedgehog got transferred from the art room’s bin to
the outside dustbins ready for collection. The following week, when
Alex asked where Hedgehog was, he was horrified to discover what
had happened and asked me to conduct a search for him after the
session. I agreed, and rummaging through several bin bags, I eventually
found Hedgehog, damp and dishevelled. When Alex attended his next
session, he was relieved, smiled and said, ‘Life wouldn’t be the same
without him!’
Regardless of whether Hedgehog was retrieved or not, Alex’s play
generally represented getting rid of something in his life. With the
above example, where Hedgehog was not immediately retrieved, being
expelled to the outside bins, I felt that Alex was questioning whether
or not he deserved to be ‘rubbished’ and therefore believed that, like
Hedgehog, he should be discarded. Undoubtedly, being thrown into
the outside bins would have intensified Alex’s feelings of expulsion.
However, it seemed that such intensity, ironically, helped him realise
that perhaps his phantasies of annihilation could be challenged, as
was shown when Hedgehog was found and Alex was able to express
relief. He became hopeful after all. On other occasions, often when
Hedgehog was retrieved prior to the end of the session, it seemed
that Alex was merely trying to get rid of his tumour, the ‘bad’ part
of him. Hedgehog, then, also represented the tumour. Getting rid of
Hedgehog when he symbolised just the tumour suggested that Alex
wanted to preserve his ‘good’ or viable part and opt for life.
Possibly, Hedgehog also stood for Alex’s rival new baby sister,
before and just after she was born. I say this because his preoccupation
with Hedgehog spanned a period of about a year, coinciding with his
mother’s pregnancy. More poignant, the above incident of Hedgehog
being lost, found and then re-integrated into the art therapy room,
took place between the time when his mother was preparing to go
into hospital to have the baby (following a Caesarean delivery), and
her return home. Alex expressed many anxieties about the baby’s
arrival, including feelings of being pushed out (got rid of), and therefore
often retaliated by attempting to push others out. So Hedgehog also
stood for these parts of himself and his baby sister, and no doubt also
Josh, as the baby’s arrival reactivated feelings that Alex had recently
experienced in relation to Josh’s arrival.
Not long after the incident of Hedgehog being retrieved from the
outside bins, and following the birth of his sister, Alex’s preoccupation
with Hedgehog subsided. At the same time, it was becoming apparent
that although his prognosis was still uncertain, he had reached some
stability in his illness. This had surprised us all. It meant that his focus
turned toward adopting a future rather than feeling limited by time,
and marked a turning point in the emphasis of his art therapy.
The final year

Alex was now ten-and-a-half years old, and we had worked together for
three years.The last year was spent revisiting past events, consolidating
much of what he had learnt and preparing for a future – a concept that
still seemed quite new to him.
During an art therapy session at the beginning of this final year,Alex
proposed making a new art folder, as if, in part, to reflect a new future.
He fetched two large pieces of card and stapled them together. It felt
as if the two pieces represented the two of us, and were symbolic
of Alex’s wish to be close together with me, a containing presence,
during a time when he understandably doubted his ability to stand on
his own two feet.
Following this, perhaps questioning whether he could manage
without art therapy, he went on to make a couple of pieces which he
insisted needed to be ‘freestanding’. The first, a large collage on card
with his name boldly inscribed on it (so that it was clearly visible to
him), would not stand up on its own, despite his efforts. The second,
an elaborate sculpture of a ‘fire station’ was more successful (see
Figure 15.6). It included a ‘handrail’ that almost replicated the centre’s
stair rail, which Alex depended on to help him reach the art room
safely and independently. Both works seemed to pose the question
about whether he could stand independently, as well as highlighting
his continual dependence on others or aids. The first piece, toppling
over, seemed to reflect a struggle to accept this, whereas the second,
with the inclusion of the handrail and the fact that it did stand alone,
suggested acceptance of some dependence. Indeed, on completing
this model and talking again about ending therapy, Alex said with
confidence, ‘You’ve got to try it and move on, it’s part of life!’
Figure 15.6 Fire station with handrail.

During the next three months Alex experimented with sticking two
clip frames together, then separating them. He did this several times.
It seemed to me that he was exploring the process of separating from
me, trying out how it felt to leave therapy. He covered it in layers of
purple and black plastic and paper, colours I saw as funereal – and he
agreed. They also reminded me of layers of skin, which Bick (1967)
refers to as being our first line of defence. Alex then developed this
into a three-dimensional cube with a lid and a base, which seemed to
be a metaphor for himself again. Finally he added a vertical cylinder and
four feet to the base to give it more height. ‘I want to give it a boost.’
The box could almost have been a rocket with a booster, ready to be
launched into the future.
Conclusion
It is remarkable to think that when I first met Alex, he could only
concentrate on one activity for just a few minutes at a time and often
referred to himself as a ‘nuisance to others’. He was understandably
anxious, with little confidence, and he had poor self-esteem. The
material discussed shows how at first he spent time coming to terms
with his illness and how it impacted upon him. It also helped him
to explore his own mortality, something few children have to do.
The secondary losses he encountered as a result of his tumour also
helped him connect with other losses in his life. Later, the material
shows how he adjusted to his new life situations, namely the
coming together of his mother and her new partner, the birth of
their daughter, the family moving house, preparing for a change in
school and, most significantly, how he realised he had a future, and
adjusted to having a life for himself.
The process of art therapy helped Alex develop an emotional
understanding of himself, something he asked for when I first met
him. He learnt how to manage feelings of frustration and how to
negotiate conflict, both in the making of art and in his relationship
with me. He also learnt how to ask for assistance when he needed
it, as well as finding the confidence to attempt tasks independently.
Despite having limited vision, he found a way to use the art materials
consistently throughout the process, which had important meaning
for him symbolically. The artwork discussed also shows how the art
continued to be an integral part of his process, giving him a source of
control, a chance to manipulate the materials and to find expression
in a nonverbal way. The whole process equipped him with many
new skills and a new-found confidence not only in himself, but in
his future. Added to this was a renewed containing capacity in his
mother, who became able to think about her son again, which in
turn enabled me to confidently hand back the thinking role (Bion
1962) and the space for him to express and be himself.
References
Bick, E. (1967) ‘The Experience of the Skin in Early Object Relations.’ In M.
Harris Williams (ed.) Collected Papers of Martha Harris and Ester Bick. Strath Tay,
Perthshire: Clinic.
Bion, W. R. (1962) Learning from Experience. London: Heinemann. (Reprinted in
paperback: Maresfield Reprints (1984) London: Karnac Books.)
Black, D. (2002) ‘Bereavement.’ In A. Goldman (ed.) Care of the Dying Child. Oxford:
Brown, E. and Arens, G. (2005) Siblings Project: Listening to Brothers and Sisters.
Birmingham: Acorns Children’s Hospice Trust.
Brown, E. with Warr, B. (2007) Supporting the Child and Family in Paediatric Palliative
Care. London: Jessica Kingsley Publishers.
Judd, D. (1995) Give Sorrow Words: Working with a Dying Child. London: Haworth Press.
Kübler-Ross, E. (1983). On Children and Death. London: Macmillan.
Klein, M. (1946) ‘Notes on Some Schizoid Mechanisms.’ In M. Klein (ed.) (1975) Envy
and Gratitude. London: Hogarth.
Schaverien, J. (2002) The Dying Patient in Psychotherapy: Desire, Dreams and Individuation.
Basingstoke: Palgrave Macmillan.
Ehrenzweig, A. (1967, [2002]) The Hidden Order of Art. London: Phoenix Press.
Gage, F. R. and Muotri, H. R. (2012) ‘Your Brain is Special.’ Scientific American, March,
22–25.
Gould, E. and Gross, G. (2002). ‘Neurogenesis in adult mammals: Some progress and
problems.’ Journal of Neuroscience 22, 3, 619–623.
Headway, The Brain Injury Association: www.headway.org.uk.
Schofield, N. (2004) Personal correspondence.
Personal
Reflections
CHAPTER 16
Art Therapist, Heal Thyself !

Mark Wheeler
Context
About a dozen patients in one cohort went through the rehabilitation
programme of the King’s Lodge Brain Injury Unit, Derby, over a
decade ago. Many are still in touch with each other, forming an
informal group, ‘The Headaches’, who still meet together most weeks.
Of this group, who came from different pre-injury backgrounds,
there are four men of similar ages and with a shared sense of
humour. Of the whole group, only two are regularly working and
evolving their lifestyles and regularly embracing new activities. I,
Mark, (henceforth writing in the third person for clarity) am the
oldest of these, and attribute my higher rate of recovery to combined
therapeutic arts activities with long-term weekly psychotherapy, as
part of a multi-modal therapeutic approach. Andy, the other more
recovered person, has undergone weekly psychotherapy and arts
activities and he is now training to be a counsellor. This therapy,
funded from personal injury claims by both men, was additional to
treatments offered locally to patients with brain injury.
In this cohort two other men of similar age, intelligence and
pre-injury skills and education have not accessed art or weekly
psychodynamic psychotherapy. Every other aspect of their post-
injury activities have been almost identical, including regular gym,
walking and cycling, but they now live with their primary identity
as ‘men with head injuries’ and are not gainfully employed. All four
met professionals whose mantras have been dominated by ‘patients
with head injuries should not do that’. These four treatment journeys
317
began with spectacular traffic crashes, eventual admission to the

same brain injury inpatient unit, and equal participation in the same
outpatient groups.
The story of this outpatient cohort, while not a normalised or
controlled cohort study, let alone a randomised controlled trial,
exemplifies some important lessons for professionals to learn from
patients. These are elaborated as the story unfolds in roughly
chronological order.
For the arts therapies and psychological therapies in general, the
critical message (in every sense of that adjective) is that a multi-
modal approach to brain injury reaps benefits in excess of the sum
of the parts. For every acquired brain injury (ABI) patient a multi-
disciplinary team (MDT) that includes an art psychotherapist will be
better than any MDT that does not.
Art psychotherapy combines physical, emotional and psycho
logical activity intricately, intimately and simultaneously intertwined.
These activities mirror those complex patterns developed in infancy
in the brain itself. The neurobiology of making relationships and
learning in childhood offers us a model of recovery. Our language
emphasises the primacy of the visual to the verbal; we see and feel
and make patterns long before we can speak, because such skills
are essential prerequisites to learning language. Art psychotherapy
contributes to physical and psychological recovery.
Nigel Schofield (2004) notes:
Anybody who has worked in brain injury rehabilitation…is
well aware of how difficult it is to separate these two factors, as
the neurological and psychological factors in any brain-injured
individual interact with each other in a circular and mutually
reinforcing fashion and are thus often difficult to tease apart,
even with psychometric assessment.
The multi-modal treatment package

benefitting the author
This included the following:
• systematic neuro-rehabilitation
• bilateral motor stimulation
Art Therapist, Heal Thyself! 319
• bilateral aerobic exercise

• cognitive function stimulation
• clinical hypnotherapy
• long-term weekly psychodynamic psychotherapy
• therapeutic art-making
• therapeutic music making
• smart phone reminders
• good diet and supplements.
Treatments beyond those patchily offered within existing NHS
resources can be made available through personal disability budgets,
social services, direct payments schemes, personal injury claims,
charities and third sector providers like Headway, the brain injury
charity. The long-term cost of patients who never become able to care
for themselves, who are never able to make significant contributions
to family and community life, and who are never able to take up
employment, far exceeds the short-term cost of proper treatment,
which needs to include art psychotherapy.
Since returning to employment, the author has contributed much
more in taxes than it would have cost to provide art psychotherapy
to all the members of the four outpatient treatment groups attended.
The author no longer receives Incapacity Benefit and uses Disability
Living Allowance to provide the support necessary to attend
work and care for his children. Increased recovery enables greater
participation in society, which further reinforces recovery and
protects against mental and physical health problems.
The only other person from this cohort to have consistently
worked in that period also received personal psychotherapy by his
own arrangement and is active in the arts. Andy is currently seeking
art psychotherapy to take his recovery to the next level and it is
clear that more comprehensive multi-modal treatment plans over
extended periods are cost-effective in purely cash terms as well as
health and social benefits.
Figure 16.1 Ghost in the gallery.
Case study
Fourteen years ago, while riding home from work, Mark’s motorbike
was struck by a car that had crossed a red traffic light and turned right
from an ‘ahead only’ lane. Mark’s ‘dopey driver radar’, the motorcyclist’s
survival instinct developed by years of road riding, had failed to protect
him. A 13-year-old girl at the scene tried to keep Mark conscious
by talking to him until an ambulance arrived from nearby King’s Mill
Hospital, Mansfield. She, and some of the other witnesses, described
him as incoherent and rambling. Having been catapulted 10m through
the air to head-butt an iron railing, Mark was assessed on admission
for head injury, using the Glasgow Coma Scale (GCS). Part of the
assessment is ‘retrograde memory’. Mark reported a ‘memory’ of 20
minutes earlier of an event that had happened weeks before, suggesting
that the first lesson to learn from the brain injury patient is:
Lesson 1: Never assume that the brain-injured patient reports accurately.
They have had a brain injury.
As the internal bleeding continued, the retrograde amnesia grew. Mark

has no recollection of any of the time spent in three hospitals, nor of
the year before and several months afterwards. Coherent narratives
are observed in those who are most able to recover from trauma.
Through friends’ narratives and photographs Mark later constructed a
coherent version of those periods.
During the time in the Intensive Care Unit (ICU), early CT scans
showed multiple small intra-cerebral haemorrhages in the right
temporal and parietal lobes. The GCS was 8/15, and Mark required
ventilation and intubation. Mark had a cardiac arrest the day after
the collision, and reports also suggest a period of up to 35 minutes
hypoxaemia during that afternoon. Throughout the unconscious
period there was extreme turning inward of the left foot and lower
leg in constant tension, a hint of which has been manifested ever
since. Flexor and extensor posturing are commonly seen in coma
after structural brain lesions and are indicative of severe brain injury.
Mark continued to need 40 per cent oxygen, and five days after injury
another arrest call was put out.
While the unconscious brain-injured patient remains unaware
of all this excitement, it affects their hospital carers and profoundly
affects their loved ones. Mark’s young children witnessed their father
unconscious, intubated and extubated; his wife and parents stayed,
knowing his wishes regarding life support if ever he succumbed to
persistent vegetative state (PVS), and that a further drop in the GCS
would lead to difficult dilemmas, conversations and decisions. Mark
remained unconscious for five days.
A day or two later Mark was transferred to an orthopaedic ward,
where he woke up. Instead of asking, ‘Where am I?’, he tried to stand
up and promptly fell out of bed, sustaining a cut over the left eyebrow.
This was the only visible external injury, but the first of many caused
by lack of motor skills. At this point it also became obvious that Mark
could not walk.
Initially Mark displayed full tetraparesis (loss of movement in all
four limbs), which improved to partial hemiparesis (right side). With
daily intervention from physiotherapy, occupational therapy and
speech and language therapy, Mark learnt to walk short distances with
support and to improve speech. Mark’s reflexes were exaggerated.
Once mobile, paraesthesia of the lower leg and synaesthesia (cross-
over of the senses) became obvious.
Mark was visited daily by family, friends and colleagues.They report
that although his speech seemed superficially coherent, it was obvious
he was repeating old narratives and was not aware of his present
surroundings and circumstances, nor of time passing.
Barse, Mark’s best biking buddy, spontaneously undertook the first
phototherapy exercise. He assembled an album of images of the 12
months missing from Mark’s memory. Barse and other friends then
told stories from the missing year while going through the album
with Mark. Long-term memory works by remembering remembering,
setting up internal repetitions. Those stories were reinforced by
images, however tenuously related, so Mark’s manufactured memories
of that missing year, 14 years later, are probably as good as anyone’s.
Figure 16.2 Mark’s biking year book.

On that first head injury unit, physiotherapists and occupational
therapists continued to manage Mark’s recovery of walking ability and
balance and assisted him to regain some stamina. The intermittent
synaesthesia experiences were dismissed by professionals as
psychosomatic, insisting this could not be brain-injury related, although
it is reported in the literature. Art therapists are able to work with
such experiences as they are presented, without prejudice, the art
therapy model being more inclined to the importance of a person’s

experience of recovery, rather than needing causal explanation.
Lesson 2: Loads of medical and social stuff might have happened to your
patient as a result of their injuries, their treatment and people’s responses to
their new disability, before you meet them for art psychotherapy.
Mark was later transferred to a brain injury unit nearer to his home,
where he received treatment as an inpatient for ‘significant balance
[and] psychomotor problems [and] deficits in information processing’,
but there were ‘no signs of mood or affect disorder’.
Five weeks later, Mark was transferred to the outpatient team.
At discharge the family were told that most recovery would take
place in the first six months. Mark was under the care of a consultant
clinical neuropsychologist who had knowledge and experience of
psychodynamic psychotherapy. Mark undertook cycles of the specialist
‘Stamina and Co-ordination Group for people with head injuries’ and
the ‘Cognitive Group for people with head injuries’, spread over a
period of more than 12 months.
Following ABI, the brain regions that have been damaged tend
to dictate any functional deficits, which are typically manifested in
activities involving actions and information processing.Thus, scar tissue
in the motor cortex might cause autonomic deficits like paralysis,
abnormal movements, balance or mobility problems. Initially, recovery
tends to be accelerated soon after tissue damage and new neural
pathways are kindled through neighbouring regions, which bypass
the damaged areas and attempt to maintain functions. Conventional
mythology is that recovery slows considerably after the initial six
months, and all possible recovery is completed during two years post-
injury; these figures are repeated often to patients and carers.
The ability of the brain to recover by adaptation is called ‘functional
plasticity’ and some brain areas are reported to be more plastic
than others. The central corpus callosum regions are thought to be
less plastic than the hippocampus, where plasticity is determined by
stress hormones as much as by stimulus. Hence, art therapy works
in two dimensions to restore hippocampus function, both reducing
stress and kindling pathways. As this tiny central brain region is key to
memory, coordination, affect regulation and attachment, improvement
in hippocampal function will be key to recovery. Because of the
location of the vulnerable hippocampus, any major blow to the head
that is sufficient to produce a closed brain injury, may also damage
the hippocampus.
The hippocampus also responds to adrenal hormones, which are

likely to be raised following trauma by both the physical injury and
by the event that caused it. The hippocampus also modulates changes
in synapse formation and dendritic structure. Repeated stresses,
including post-traumatic stress disorder (PTSD) episodes, can cause
atrophy of dendrites. Hence, recovery of hippocampus function is
valuable to other neural recovery. Much of what has been written
about the neuroscience of psychotherapy, especially the use of image
and metaphor, emphasises the effects of image and metaphor on the
hippocampus and other limbic system functions.
Mark’s difficulties in walking required conscious step-by-step self-
instruction:‘Left foot forward, now right foot forward, now left foot…’
This implies damage to the corpus callosum, hippocampus or motor
cortex, or all three. Mark’s gait remained noticeably abnormal for
over two years, with the whole left leg swinging sideways. A useful
exercise, suggested by occupational therapists, was trying to walk
carrying a drink, so being able to walk with two drinks became a major
personal triumph.
As Mark researched this chapter, progress was hampered by case
notes and letters full of inaccuracies and contradictions, even basic
facts of admission and transfer dates.
Lesson 3: The patient may have been moved from ward to ward, or hospital
to hospital, and the notes and GP letters might not be accurate.
Assembling a coherent life narrative is really important. The ability
to report coherent life narratives has been connected to maintaining
healthy attachment and to lower likelihood of impairment by PTSD
symptoms. Keeping a diary becomes very important to people with
ABI, and Mark’s diaries were used to write this chapter.
Hilariously for others, Mark suddenly began talking in a strong
Wolverhampton accent for a period of six weeks. Mark restarted
smoking, as if forgetting that he had not smoked for over five years.
The rekindling of new neural pathways might cross old ones and follow
them for a while. Stimulant drinks (caffeine and taurine) can increase
performance in everyday functioning and in psychological tests.
Extreme fatiguability is characteristic of brain damage, and stimulants
can be very useful in prolonging functional periods, but when the effect
wears off there is a sudden rebound.
Mark’s spatial awareness would be better described as spatial
unawareness.This is expected with right parietal lobe damage, but also
with hippocampus damage, and treatment by regular motor practice is
recommended in either instance.The stamina and coordination groups
provided weekly core activities designed to boost these abilities, to

which Mark added his own basic daily coordination exercises. These
included using the non-dominant hand for simple activities of daily
living like washing, shaving and brushing teeth, no matter how awkward
and clumsy.
The difficulty synchronising left and right functions while walking
and performing other motor functions demonstrates impaired
connection between hemispheres. A psychologist friend who looked
through the notes while visiting the hospital, described scans showing
numerous right temporo-parietal haemorrhage shadows and a
small shadow in the mid-corpus callosum. Unfortunately the scans
were unavailable for inspection for this chapter. The front portion
of the corpus callosum has been reported to be significantly larger in
musicians than non-musicians. Spending some of his enforced inactivity
time learning a musical instrument seemed like a good plan for Mark.
Having co-presented a paper in 1997 on the benefits of combining
music therapy and art therapy, Mark knew that the potential benefits
of both combined exceed either, and he began to learn bass guitar,
practicing three or four times a week.
Principally because of the ‘most recovery occurs in the first
few weeks to six months’ mantra, Mark’s marriage ended. The ‘six
months mantra’ sets up false expectations of rapid recovery and
return to ‘normal’, but relatives experience their loved one body-
snatched, to be replaced by a poorly functioning shell. The six-month
myth is contradicted by evidence that new neurons are formed in
adults. What is more, these neurons display more robust long-term
potentation (LTP) than those in infants and remain in a structurally
plastic condition for at least two years in the human dentate gyrus
(Gould and Gross 2002).
However, such cell production is inhibited by stress hormones, as
is the activation of those cells newly created. Conversely, the new cells
also may help regulate stress. Hence, brain injury recovery is aided
by reduced stress, and recovery may improve stress regulation. Mark
and his then wife agreed on how to share care of their two children
equally. Personal care was then arranged, using money borrowed
against the personal injury claim. The reduced stress enabled a step
change improvement in Mark’s recovery.
Unfortunately, it is a common experience among brain-injured
patients that at times when the brain is not functioning well, it is also
not creating memory. Hence, the patient knows little of the less lucid
moments and consistently under-reports difficulties. If those around
them do not want to see those difficulties either, for fear perhaps of
prompting grief, the professional team is unlikely to know the degree
of impairment being experienced.
For the brain-injured patient there are often moments of dreadful
insight. After watching the movie Memento (dir. Nolan 2000) together,
a group of friends asked Mark, ‘How did you cope with the way time
jumped about? Scenes switching between forward and backwards
time?’ ‘What?’ Mark replied, incredulously, ‘No it can’t have, I didn’t
notice anything.’
The most spectacular moment of insight came from watching many
hours of surveillance film made by private detectives acting on behalf
of the other driver’s insurance company. Mark had been warned this
would happen, so the appearance of a large pile of VHS tapes on the
lawyer’s desk came as no surprise. The contents were a revelation,
though. For the first time, even though the private investigators had
been employed to show minimal impairment, Mark actually saw how
badly he functioned. The distant camera viewpoint prevented much
sound pick-up, so the tapes had the quality of early silent slapstick
comedies. (Lesson 2 again: Things ‘happened’ to your patient as a
result of their injuries, their treatment and people’s responses to their
new disability.’)
Meanwhile, Mark continued the daily physical exercise that
promotes neurogenesis.Through daily art activities and music practice,
however, cacophonous, he hoped to kindle neural pathways around
the obstacle scars, and knew the exercise made this more effective,
although not knowing why at the time.
Lesson 4: Brain damage – a life-threatening experience
Mark passed a disabled drivers’ assessment, but rarely drove. However,
the following spring he began to ride his other motorcycle in the
company of friends. He experienced post-traumatic symptoms when
riding. However, when he followed another motorcyclist the effects
were rare and slight. With the other motorcycle in front, Mark would
imagine accidents caused by bad driving of other vehicles on the road.
Mark’s biker friends noted that this occurred at the same moment
as their own ‘dopey driver radar’ was activated by another driver, so
together they hypothesised the effect to be a dramatic exaggeration
of the so-called sixth sense that all living motorcyclists have to develop
to remain alive.
Identifying the nature of these symptoms accurately led to Mark’s
choice of effective treatment. Using self-directed desensitisation by
graded exposure, Mark used scaling to evaluate exposure nearly every
day and was able to increase journey duration and traffic levels. Finally,
the overlearning, flooding exercise consisted of riding back and forth
over the junction where the collision had taken place, on the first
anniversary of the crash.This systematic desensitisation to motorcycle
riding, reinforced by a flooding experience, eventually resulted in
extinction and complete recovery from the PTSD symptoms. Such
behavioural or cognitive approaches should also be valued by art
therapists, and should not necessarily be contra-indicated while art
therapy is being undertaken.
Mark privately undertook six sessions of clinical hypnotherapy,
concentrating on restoring memory. These were funded with borrowed
money to be repaid from the personal injury claim. The effectiveness
of the hypnotherapy was such that recall of existing memory became
better than ever. This improved recall indicated that anterograde
amnesia, the creation of new memory since injury, was such a severe
problem that new memory was only being made when deliberately
and explicitly actioned, similar to the ‘left foot forward, right foot
forward’ walking instructions. This again emphasises the vulnerability
of one of the key components in memory creation, the hippocampus.
Art psychotherapy might be anticipated to be more effective than
other therapy interventions in restoring memory function, as it has
the potential to stimulate simultaneously numerous neural pathways
in both hemispheres, and thus encourage hippocampal traffic.
Mark had moved house to a village during the year of which he
had no memories, so most days he went for walks, making sketches,
taking photographs and making notes. With no sense of direction and
having lost all map-reading ability, these walks became adventures,
often accompanied by visiting work colleagues or local friends. Digital
photography would now make this easier, cheaper and more effective,
thanks to its immediacy. The constant repetition of making images and
looking at them began to form an internal narrative of local journeys.
Lesson 5: Use phone cameras as visual diaries that might act as catalysts
for image-making in art therapy, which in turn might consolidate memory.
Eight months after injury Mark began seeing a Jungian analyst, following
discussion with the neuropsychologist. Mark would have chosen
art psychotherapy, but prior professional relationships meant that
there was no appropriate art psychotherapist within the region. This
weekly psychotherapy was funded by loans taken against the
compensation claim.
Images were not brought explicitly into the therapy room as
objects, but the images were implicitly present. Between sessions Mark
was constantly making images, which helped consolidate the content

and process of the previous week’s session, or prompted content in
the next. These were small sketches, photographs on film, sometimes
scanned and incorporated into mixed media pieces. Some of these
sketches were part of an aide mémoire process, together with
writing (with both hands) names, words or numbers that had to be
remembered. It is impossible to tease out the benefits of seven years
of weekly psychotherapy sessions, from those of clumsy music practice
and clunky image-making. It is the combination that has contributed
to the rebuild.
Mark began a new relationship that continues to this day. The
contribution of loving and being loved to neurological rehabilitation
cannot be overstated. Ironically, four months into this relationship, a
lorry ploughed into a queue of cars, causing Mark’s partner to suffer
a brain injury which resulted in a horrible hospital experience in New
York, which exemplified the superiority of the NHS. Their jointly
produced artwork ‘Brain Damage in the Big Apple Box’ encapsulated
this experience (Figure 16.3).
Figure 16.3 Brain damage in the Big Apple Box.

Mark began a phased return to work three years after injury. This
would not be possible for someone wholly dependent on welfare
benefits, as the trial return to work cancelled most of Mark’s welfare
benefits whilst providing no income, as he was on a voluntary contract.
Mark’s employers would have been entitled to terminate employment,
but good managers insisted that Mark take whatever time was
needed. Active participation in work protects against depression and
other mental health problems, but, sadly, few ABI patients have this
opportunity.
Six years after injury, Mark continued to enjoy four to five
functional hours a day, when his estimated functioning was about 80
per cent compared to pre-injury. Another hour or more could be
had from stimulant soft drinks, but the next day he would be what
the diaries describe as a ‘gibbering wreck’. Fellow ‘Headache’, Andy,
uses the term ‘meltdown’ to describe this experience. During these
times Mark repeated the same phrase or part sentence over and over
before completing it, unaware sometimes that this was happening or
how many times a phrase was repeated before resolution. During low-
functioning hours speech would be limited, with much stammering or
stuttering.
Mark’s neuropsychologist advised that fatigue is the major issue
needing care, to ensure that ‘neither [Mark’s] children nor his
psychotherapy clients suffer the consequences of a failure to pace
himself very carefully’.
Brain injury, PTSD or mid-life crisis?

Some of the Headway and NHS professionals’ descriptions of
reaction to ABI, offered to families living with someone with ABI,
could equally be used for post-traumatic symptoms following any
life-threatening event. Brain injury symptoms may be difficult
to distinguish from post-traumatic symptoms. This might be
important if the indicated treatments differ, but art psychotherapy
addresses both.
Lesson 6: The patient is not just a bang on the head carried about by a
soul-less body.
All the patients in this ABI cohort had also experienced life-threatening
events. An occupational therapist’s dismissive comment, ‘Oh that’s
typical after brain injury; it’s a common personality change,’ is wrong
in two respects; first, the outdated concept of immutable personality

types, and second, the assumption that there are typical sets of ‘before’
and ‘after’ behaviours that must be accepted. Long-term potentiation
(LTP) is the plasticity that enables memory to be formed, and equally
enables psychotherapy to have an impact, particularly in the core
relational areas of the limbic system.
Repetitive drawing of a planned rebuild for the damaged motorcycle
began rehabilitation of an object and a lifestyle with which Mark had
been closely identified for 20 years. The trauma of seeing their close
friend so injured and changed by an event over which he had no control
also affected the circle of biking friends. One evening they gathered
together in Barse’s garage and systematically salvaged the parts from
the wreckage. They then created mock-ups of a reconstituted bike – a
phoenix from the ashes, formed of steel and cardboard.
The damaged parts of the bike remained discarded in a heap. A
week later Mark and friends were gathered again in Barse’s garage.
They contemplated the pile of smashed pieces and, with few words
between them, began to construct a ‘Techno-Organic’ sculpture.
Quietly a creature emerged, looking as if trying to crawl from the
wreckage of discarded broken components. The process of making this
art object had the hallmarks of closed group therapy. The relationships
between these men formed a powerful group matrix that functioned
as the facilitating therapist in the room. That the room was a familiar
garage, with familiar tools, machinery and motorcycle pictures on the
walls, enabled it to serve as the containing capacity of an art therapy
studio. Exhibiting the sculpture in Nottingham’s West End Gallery
completed this therapeutic process (Figure 16.4).
A life enriched by novel stimulation and aerobic exercise will
generate much larger numbers of new neurons than was previously
accepted (Gould and Gross 2002), especially in the hippocampus. The
triangular process of art psychotherapy is uniquely able to stimulate
interconnection between these neurons and integrate them into
existing neural pathways.
It does not matter to the patient whether the art psychotherapy
is addressing the direct tissue damage or addressing the emotional
damage of the consequences of injury. Post-traumatic symptoms
closely resemble many symptoms attributed exclusively to brain injury.
To demand monocausal explanations of ABI sequelae will inevitably
result in failure to offer the patient the complexity of treatment
required to address their condition.
Figure 16.4 Barse in the West End Gallery.

Retrotransposons (jumping genes present throughout life, particularly
in human brain cells) are particularly active in the hippocampus in
progenitor cells. These give rise to hippocampal neurons (Gage and
Muotri 2012) and may be implicated in neural plasticity. Or it may
be that with 100 billion neurons making 100 trillion interconnections,
the opportunities for alternative connections merely have to be
exploited by the art therapy relationship and its emulation of early
attachment relationships. As our knowledge grows regarding this
primary mechanism, more effective targeted art therapy interventions
may be developed, strengthening the case for treating people with ABI
with art therapy as a treatment of choice.
Conclusion
Motor accidents may tear us apart, but love will heal. To be able to
give and accept love is widely reported as a key indicator of good
recovery from trauma and from all mental health symptoms, even
when ‘love’ is clumsily and prudishly diminished to the description
‘healthy attachment’. If the art therapist’s sole outcome for the brain-
injured patient is to enable them to respond better to attachment and
love with their loved ones, this must be a successful outcome.
It was tempting to write the case study with random changes of
tense to demonstrate how time is experienced by many brain-injured
patients. This is very similar to the way that the art image allows
the simultaneous presence of different moments. The art-making
process enables both scattered attention, during bursts of creativity,
and linear thought when aesthetic considerations come into play,
especially during the final resolution of the artwork. Art-making
makes demands on both hemispheres of the cerebral cortex – the
capacity of a created object to encapsulate this in a single piece of
art has a potentially profound effect on the capacity to create new
memory (Ehrenzweig 1967 [2002]).
The problem with the controlled experiments of scientism is that
they are based in myths of monocausality. The trinity of art therapy
– art, words and relationship – begins with an advantage which
is denied by reductionism. art therapy can reach the parts talking
therapies might not reach, especially where the neurological routes
are damaged.
Like Mark’s old motorcycle, there has been no attempt to restore
him to a previous condition. The Wheeler rebuild has made the
most of the bits that still work to create a machine whose wiring is
now reasonably functional and works reasonably well most of the
time. ‘Good enough’, that’s good enough.
Thanks everyone.
References
Ehrenzweig, A. (1967, [2002]) The Hidden Order of Art. London: Phoenix Press.
Gage, F. R. and Muotri, H. R. (2012) ‘Your Brain is Special.’ Scientific American 306,
3, 22–25.
Gould, E. and Gross, G. (2002). ‘Neurogenesis in adult mammals: Some progress and
problems.’ Journal of Neuroscience 22, 3, 619–623.
Headway, The Brain Injury Association: www.headway.org.uk/caring.aspx
Schofield, N. (2004) Personal correspondence.
Glossary
Acquired brain injury. An injury to the brain that has occurred since
birth, which can be caused by a traumatic or non-traumatic event. Common
traumatic causes include road incidents and traffic accidents, assaults and
falls. Secondary injury may be caused by bleeding or increased pressure
within the skull. Non-traumatic causes of acquired brain injury include
stroke, haemorrhage, aneurism, asphyxiation, the effect of toxic substances
and tumours.
Agnosia. Failure to recognize or know the meaning or significance of
familiar objects.
Amygdala. Two almond-shaped, limbic system structures that initiate the
sympathetic nervous system’s stress response – especially fear, rage and
emotion-linked memory.
Amnesia. Loss of ability to remember things that have been experienced.
(See also post-traumatic amnesia and retrograde amnesia.)
Aneurism. A deformity in the wall of a blood vessel which may burst,
causing haemorrhage.
Anthroposophic medicine. A holistic approach to illness extending
beyond the illness to the person as a whole. It is an extension of conventional
medicine developed from the work of Rudolf Steiner and Dr Ita Wegman.
Both medicines and therapies are used to stimulate the natural healing
processes and bring body, mind and spirit into balance.
Apperception. The ability to relate new information from the senses to
past experience. Winnicott used the term ‘creative apperception’ to describe
an infant’s experience of their first caregiver, leading to a sense of self and
engagement with the environment.
Aphasia. Disturbance of comprehension and/or expression of language
caused by brain dysfunction. Also called dysphasia.
334
GLOSSARY 335
Ataxia. Unsteadiness of movement; muscular incoordination when

voluntary movements are attempted.
Attachment. The propensity of mammals and humans to seek their
caregivers in establishing a safe, secure base for exploration. Patterns of
attachment influence future relationships.
Attunement. A developmental or attachment theory term. It indicates
a person’s emotional capacity to identify with another’s state of being.
Attunement happens before having actually interacted with the other
person, as well as during any subsequent interactions.
Alzheimer’s disease. A progressive neurodegenerative disorder. It is the
most common form of dementia. Alzheimer’s is a progressive disease, and
over time more parts of the brain are damaged and the symptoms become
more severe.
Autobiographical memory. Episodic memory (see below) that connects a
person’s sense of self to their past, present and future.
Brain stem. Governs basic involuntary body functions like heart and
breathing functions. It connects the spinal cord with subcortical brain
regions. The brain stem and thalamus co-regulate sensory information
moving upward from the body, as well as motor information moving
downward towards the body.
Cerebellum. Part of the brain situated behind the brain stem. Regulates
movement.
Clinico-anatomical method. A process that allows brain function to
be inferred by studying the correspondence between clinical signs and
symptoms and the location of damage (lesions) to the brain.
Cognitive abilities. Mental skills such as thinking, memory, planning,
understanding concentration, using language.
Confabulation. A memory disturbance resulting in fabricated, distorted
or misinterpreted memories about oneself or the world without any
intention to deceive.
Consolidation. The process of stabilising internalised representations and
short-term memories with pre-existing long-term memories.
Craniotomy. A surgical operation in which a bone flap is temporarily
removed from the skull in order to access the brain.
Dementia. Generic term for different types of disease involving progressive

degeneration of the structure and chemistry of the brain affecting memory,
perception and communication. The most common forms of dementia are
Alzheimer’s disease, vascular dementia and dementia with Lewy bodies.
Denial. In the context of brain injury: denial of deficits or difficulties can
have cognitive (see cognitive abilities above) or emotional causes.
Disinhibition. Difficulty in controlling urges to speak, act, or show
emotion. Can include sexual disinhibition.
Dysphasia. Co-terminous with aphasia (see above).
Dysarthria. Difficulty with articulation due to weakness or incoordination
of muscle tone.
Epilepsy. A group of long-term neurological disorders characterised by
epileptic seizures.
Epileptic seizure. A sudden burst of intense electrical activity in the brain.
This causes a temporary disruption resulting in the brain’s messages getting
mixed up. This can range in severity from an ‘absence’ − momentary loss of
awareness, to ‘tonic-clonic’, aka ‘grand mal’ seizures involving uncontrolled
jerking body movements and loss of consciousness.
Episodic memory. Long-term mental maps of personally experienced
past events that contain specific time and context – what, when, how
and where. Episodic memories can be explicit/conscious or implicit/
unconscious. (See also implicit and explicit memory.)
Explicit memory. Conscious, intentional recall of previously learnt
information from past experiences and/or facts for conscious exposition
and task performance.
Frontal lobes. Vulnerable to injury, as they are located at the front of the
brain. Damage causes a wide variety of symptoms. These include ‘executive
functions’, i.e. divergent thinking, problem solving, attention and memory.
There can also be difficulty in inhibiting responses, with initiation, impulse
control, and social and sexual behaviour.
Hippocampus. A stress-sensitive, seahorse-shaped, limbic structure in the
central brain region. It is responsible for spatial navigation, learning, and
initiating and consolidating explicit memory processes.
Hypoxia (also known as Cerebral hypoxia). Decrease of oxygen in the
brain. Prolonged lack of oxygen causes brain cell death.
GLOSSARY 337
Implicit memory. Memory used during tasks not requiring conscious

recall, like walking or talking. Sometimes referred to as automatic, non-
declarative or procedural memory, implicit memories are free of time or place
of origin references.
Individuation. A Jungian term: the process by which a person becomes a
psychological individual – that is, a separate, individual unit. Individuation
does not shut one out from the world, but gathers the world to oneself. ‘To
find and be the real you.’
Intrapsychic. Material occurring within the mind.
Intersubjectivity. Material occurring between two or more people.
Janus. The Roman god who faces both ways and deals with present events.
Presides over doors and beginnings, hence the month of January.
Korsakoff ’s syndrome. Neurological disorder caused by a lack of
thiamine in the brain. Linked to severe malnutrition or chronic alcohol
use, or both.
Left hemisphere. The brain hemisphere associated with cognitive and
language functions, sequential processing, explicit awareness and conscious
functions.
Limbic system. A group of cortical structures including the amagdala and
hippocampus that regulate, evaluate and integrate emotions into survival
responses, memories and basic drives, including sex drives.
Long-term memory. A type of memory that holds needed information
for periods from 30 seconds to decades. By comparison, short-term memory
holds limited information from 20 to 30 seconds, unless the information is
retained for longer by being mentally rehearsed.
Long-term neurological condition. The National Service Framework for
Long-term Conditions (DoH 2005 p.9) describes a ‘long-term neurological
condition’ as resulting ‘from disease of, injury or damage to the body’s
nervous system (i.e. the brain, spinal cord and/or their peripheral nerve
connections) which will affect the individual and their family in one way
or another for the rest of their life’. This includes sudden onset conditions
followed by a partial recovery, intermittent and unpredictable conditions
and progressive conditions.
Meninges. The membranes that envelope and protect the central nervous
system. In mammals they are structured in three layers: the dura, arachnoid
and pia.
Motor neurone disease. A progressive disease of the motor system

attacking the motor neurons or nerves in the brain and spinal cord. This
disrupts signals to all voluntary muscles, leading to severe muscle weakness
and wasting.
Multiple sclerosis. A progressive, auto-immune disorder. It destroys
the myelin sheath that insulates the neurons in the brain and spinal cord,
making it harder for the brain to communicate with other parts of the
body. It is characterised by successive relapses and remissions, leading to
increasing tremor, ataxia and speech disorder.
Myelination. A white sheath that develops over neuronal axons as they
mature. Myelin enables faster, more efficient communication.
Neurodegeneration. Umbrella term for the progressive loss of the
structure, and function and/or death of neurons in the brain. Diseases
such as Alzheimer’s, Parkinson’s and Huntingdon’s occur as a result of
neurodegenerative processes.
Neuron/neurone. The basic functional unit in the nervous system. It
receives information through specialised receptor sites and conveys
information to other neurons and cells, using electrical impulses and
chemical messengers (see Neurotransmitters).
Neuroplasticity. A neuron’s ability to increase, decrease or shift synaptic
connections. Can change and to some extent ‘rewire’ neural pathways.
Refers to the ability of non-injured brain cells to take over functions of
damaged cells. Caused by changes in behaviour, environment and neural
processes.
Neurotransmitters. The chemicals that communicate information
throughout our brain and body, by relaying signals between nerve cells or
neurons. There are two kinds of neurotransmitters: inhibitory transmitters
calm the brain and help create balance; excitatory neurotransmitters
stimulate the brain.
Parietal lobe. The part of the cerebral hemisphere concerned with the
perception and interpretation of sensation and movement.
Parkinson’s disease. A progressive disease of the motor system associated
with a tremor that is more pronounced in resting limbs. Parkinson’s
is caused by the slow deterioration of the nerve cells in the brain that
create the chemical dopamine. Dopamine helps control muscle movement
throughout the body.
GLOSSARY 339
Perseveration. Involuntary, prolonged repetition of words or actions.

Post-traumatic amnesia. A state of confusion immediately following
a traumatic brain injury in which the person is a lower than the fully
conscious score on the Glasgow coma scale. PTA is considered resolved
when continuous memory returns. Also known as post-confusional state.
Proprioception. The sense of the relative position of parts of our body
and of the degree of effort employed in movements.
Psychoimmunology. Interdisciplinary study of the interactions between
psychological processes and the nervous, immune and endocrine systems
of the body.
Rehabilitation. An active process by which an injured or disabled person
realises optimal physical, mental and social potential.
Retrograde amnesia. Loss of memory of events that occurred, or
information learnt during a period of time before the brain injury.
Right hemisphere. The brain hemisphere associated with global,
nonverbal and affective processing; preconscious and visual spatial
awareness; feelings and intuitions; and how more immediate stress and
emotions impact bodily change.
Semantic memory. The part of long-term memory that deals with
meanings concepts and knowledge about the external world shared with
others. This is independent of personal experience and contrasts with
episodic memory which is made up of personal facts and experience.
Spinal cord injury. Caused by trauma or disease (e.g. polio, spina bifida).
Injuries can vary from having no lasting effect to loss of function including
paralysis or incontinence.
Stroke. A stroke or ‘brain attack’ happens when the blood supply to part
of the brain is cut off and brain cells are damaged or die. Strokes affect
people in different ways, and recovery depends on the part of the brain that
is affected, how widespread the damage is, and how healthy the person
was before the stroke.
Subarachnoid haemorrhage. A bleed in the brain in the space between
two of the three layers of the meninges (see above): the arachnoid layer and
the pia layer.
Subdural haemorrhage. A bleed in the space between the dura and
arachnoid layers of the meninges, and the brain.
Tracheotomy. An operation to open the windpipe and insert a plastic

tube to facilitate the passage of air and evacuation of secretions.
Trepanation. The surgical practice of making a hole in the skull in order
to relieve pressure beneath the surface.
Vestibular system. Located in the middle ear; perception of the body in
relation to balance movement, and spatial orientation.
Wernicke’s area. An area in the left temporal lobe area of the brain
associated with understanding language and syntax.
Working memory. Temporary memory storage of information that
supports the performance of current tasks only.
The Contributors
Elizabeth Ashby has worked with older people for 16 years and also
works with people with learning disabilities. She is employed by the NHS,
and is doing a PhD at Goldsmiths College, London University.
Simon Nicholas Bell PhD qualified as an art therapist in 1986 and
worked with a variety of client groups before specialising in palliative
care in a hospice. He has been a lecturer for the Art Therapy Northern
Programme in Sheffield. He was Network Patient Information Manager
for North Trent Cancer Network, and now works independently.
Quentin Bruckland practises as a senior art therapist in the rehabilitation
department, and the UCLH Sir William Gower’s Inpatient Assessment Unit,
at the Epilepsy Society. He set up and developed the art therapy service at
the Society after graduating from the University of Hertfordshire in 2003
with an MA in art therapy.
Carole Connelly has worked in the NHS for over 20 years as an art
therapist with adults with physical disabilities, and privately with children
and families. She has been the art therapist at Northern Ireland’s Regional
Acquired Brain Injury Unit since 2008.
Judith Ducker has worked as an art therapist for 26 years in the NHS,
as well as privately and for charitable organizations, with children and
adults. This has included fields such as learning disabilities, hearing and
sight impairment, and mental health. Currently she works with children
who are bereaved and with adults with mental health needs.
Melody (Crocker) Golebiowski has been involved with the arts –
specifically music and the visual arts – throughout her life. Melody has
worked as an art therapist with people of all ages and in different clinical
contexts, including residential care; community and NHS hospitals;
schools and – increasingly – clients’ homes.
Marion Green has a background in social work and teaching horticulture.
Anthroposophically trained, she has practised art therapy in a private
341
residential clinic, the prison service, and with sex workers; in the NHS
adult acute and intensive care psychiatric wards; as a supervisor; and as a
trainer in intensive trauma therapy, specialising in secondary trauma.
Andrea Gregg is an art psychotherapist working for an epilepsy specialist
provider in the private sector. She is self-employed and set up practice in
2004. She is also a guest lecturer on the Art Psychotherapy Foundation
Course at Goldsmiths University of London, where she lectures in epilepsy
and art therapy.
Anna Knight practises as a registered art psychotherapist at a Headway
Rehabilitation Centre for adults with acquired brain injury from a wide
largely rural community. She set up the art therapy service in 2002 and
currently runs group and individual art therapy sessions. She works with
a multidisciplinary team covering all aspects of ABI. Anna’s work as an
artist and her familiarity with farming and country life enhances her work.
Marian Liebmann PhD has worked in art therapy with offenders,
women’s groups, and for 19 years in a community mental health team;
also with Penny Brohn Cancer Care. She runs art therapy workshops at
centres and universities in the UK, Europe and Africa. She is the author or
editor of ten books, most recently Art Therapy and Anger.
Debbie Michaels practices independently as an HCPC registered
art therapist and clinical supervisor in different settings across public,
private and voluntary sectors. She has taught on the art therapy Northern
Programme for a number of years, and finds personal expression through
art-making, exhibiting, singing and performing.
Iris von Sass Hyde worked as an art therapist in Lincoln in a newly-
created post for neuro-rehabilitation patients for 15 years. This work was
both on the unit and in the community. She trained at Sheffield and her
work has a Jungian perspective.
Sally Weston was a community worker in London and Yorkshire before
training as an art therapist in 1991. She has worked as an art therapist in
the NHS in adult mental health in Bradford, and for the past 17 years in
neurological rehabilitation. She is also an art therapy educator.
Mark Wheeler is an art psychotherapist and clinical supervisor working
in NHS Child and Adult Mental Health Services and in private practice.
He also teaches PhotoTherapy techniques to counsellors, art therapy
students and mental health professionals. He has published widely and
The Contributors 343
been interviewed by magazines and BBC radio. In 2004 Mark was made
a Fellow of the Royal Photographic Society.
Jenny Wood qualified in 1997 from the University of Hertfordshire and
has worked in mental health and learning disabilities in community and
secure hospitals; in palliative care; with children in a special needs school;
and in private practice. She has undertaken additional training in clinical
hypnosis, cognitive behavioural therapy and systemic skills.
Subject Index
Page numbers in italics refer art therapy, identity and amnesia 77, 243, 320–1,
to figures and captions. adjustment after 327
99–114 aneurysm see ‘Fran’ case
acquired brain injury (ABI) art therapy service study; ‘Luke’ case study
art therapy at a day centre 100–1 anger 20, 80, 105, 110,
115–34 ‘Martin’ case study 117, 123, 144–5, 147,
‘Ben’ case study 124– 103–4, 105–12, 228–9, 301
6, 124–5 106–7, 109, 110, anodiasphoria 48
benefits of art therapy 112 anosognosia 48
120–2 ‘Pop Art Portrait’ anthroposophical art therapy
client testimonials project 102–3 see under motor neurone
131–2 portraiture 101–2 disease
contribution of art service context 100 aphasia 41, 121, 225
therapy at the and inability to prioritise see also ‘Ben’ case study
centre 119–20 280 Apocalypse Now (film) 181
how therapies and ‘Mark’s’ story 317–33 archetypes 81
activities can case study 320–9, 320, Aristotle 40
overcome the 322, 328 Armagan, Esref 122
effects of ABI context 317–8 art-making, function of
118–9 multi-modal treatment 21–4
‘Invisible Lines’ poem package 318–9 art psychotherapy see art
132 post-traumatic therapy
knitting life back symptoms 329– art therapy
together 118 31, 331 in America 51–2
long-term agnosia 225 benefits of 54–5, 113,
rehabilitation alcohol misuse see ‘Frank’s’ 120–2, 155–7, 176,
116–7, 116 story 209, 270
physical, cognitive and ‘Alex’s’ story 298–313 in Britain 51–2
psychological the art therapy journey hints for practitioners
effects of ABI 301–11, 302–5, 24–5
117–8 308, 311 artists, art therapists as 25–6
spirituality 122–3, 123 history 299 Artists in Residence 101
therapy assessments referral/presentation assaults, trauma of 77
129–30 299–301 see also ‘Brian’ case history
therapy tools 130–1 setting 298–9 assessments, for therapy
ways of working in art Alzheimer’s disease 48, 129–30
therapy with ABI 51–2, 54, 206, 221, assumptions 20–1, 148, 155,
126–7 251 182, 330
ways of working with see also dementia astral body 258
clients with ABI Alzheimer’s Society 218, astrology 40–1
127–9 221 attachment 17, 79–81, 95,
124, 235, 324, 331–2
344
Subject Index 345
Augustine, Saint 282 theoretical frame Catholic Church 223–4, 231

autism 280 136–8, 137 chakras 111
see also ‘Clive’ case study coming to terms with Charcot, Jean-Martin 41–2
awareness and insight, after 76–96 Child and Adolescent
brain injuries see under art therapy service 78 Mental Health Services
brain injuries ‘Brian’ case history (CAMHS) 280, 288–9
89–95, 90–4 Chirico, Giorgio de 102
babies see infants case material 88 ‘Christopher’ case study
‘Bananagrams’ 125 pace and timing of 262–71, 265, 267–9,
Bauby, Jean-Dominique therapy 96 272–3, 274
63, 103 research themes and clay, working with 125, 147,
Beauty and the Beast (film) stages 81–8, 164–6, 165–6, 224
194–5 82–4, 86–8 clinico-anatomical method
bed sculptures 305, 305 therapeutic journey 41, 42
‘Ben’ case study 124–6, 79–80 ‘Clive’ case study 197–200,
124–5 timescales 78–9 198
bereavement 213 work of the unit 77–8 Clock Face assessments 130
biographies 24–5, 231, 272 impact 117, 142, 153, cloth, painting with 263,
bodily fluids (humours) 299–300 270
40–1 see also acquired brain collages 125, 131, 310
body images 130 injury colour wheels 111
brain injuries brain, the colours, use of particular
art therapy and insight anatomy and physiology 109, 111, 162–3, 258,
and awareness after 44–6, 44, 46 266–7, 269–70
152–69 communication, coma 63, 122, 321
first sessions 157–60, connectivity and confabulation 159, 243, 253
158 plasticity 47–9, 47 coping strategies 119, 146,
‘Fran’ case study 159– impact of damage or 174–6, 263
60, 160–3 disease 48–9 craniotomy 40
further sessions 160–6 hemispheres 41–3, 45, 46, CT scans 321, 325
literature review 154–7 156, 209, 281, 325 cultural issues 221–4
‘Luke’ case study 157– hippocampi 42, 323–4,
8, 160–1, 163–6, 330–1 ‘Dan’ case study 176–84,
164–6 lobes 41, 46, 46, 124, 179, 180–2
brain injury and stroke 280, 285 Das Kabinet des Dr Caligari
services 135–51 brain tumours, art therapy (film) 279, 282
art therapy in a stroke with a boy living with Data Protection Act 226
rehabilitation a life-threatening day-to-day issues 85, 118,
centre 139–43, illness (’Alex’) 298–313 128, 174–5, 190, 196,
139, 141 the art therapy journey 199
discussion 145–8, 147 301–11, 302–5, de Kooning, Willem 251,
‘Henry’ and ‘James’ 308, 311 253
case study 143–5 history 299 death
‘Karen’s’ experience as referral/presentation anthroposophical view
a music therapist 299–301 257–8
143–5 setting 298–9 facing 21
music therapy in a ‘Brian’ case history 89–95, reactions to 92, 92, 213
hospital inpatient 90–4 see also ‘Frank’s’ story
setting 143–5 British Association of Art dementia
‘Norma’ case study Therapists (BAAT) 22, an art therapy group for
140–2 135, 226 people with 203–19
subjective experience British School of artwork by group
138 Psychoanalysis 136 members 206,
Broca, Paul 42 211, 214–6
dementia cont. epilepsy clinical manifestations

dementia 206–8 ancient theories on 40 and impact of
the group 204–6 art therapy after Korsakoff’s
support levels in the acquiring seizures in syndrome 242–3
group 210–2 adulthood 173–86 creating ego foundations
themes emerging in coping and adaptation 249
sessions 212–7 174–6 directing change 247
therapy processes ‘Dan’ case study evaluating the portraits
208–10 176–84, 179, 180, 250, 250
benefits of art therapy 54 181–2 first session 243–4
definition 221 refractory epilepsy 174 ‘Frank’s’ story unfolds
‘Frank’s’ story 242, 246 art therapy with young 245–7, 247
with Lewy bodies 221 adults with epilepsy managing grief 249–50
minority ethnic people and learning referral 242
experiencing EOD disabilities 187–200 self-portraits 247–8, 248
living at home ‘Clive’ case study theoretical understanding
220–38 197–200, 198 251–2
cultural influence epilepsy 188–9 free association exercise 130
221–4 ‘George’ case study Freud, Sigmund 41–2, 50–1
developing an 190–3, 192,
approach 224–6 199–200 Gage, Phineas 41–2, 49
developing empathy learning disabilities Galen 40
229–30 189–90 ‘George’ case study 190–3,
ending 232–3 ‘Nadia’ case study 192, 199–200
evaluation 236–7 193–7, 194–6, Gestalt 50
evidence base 226–7 199–200 Glasgow Coma Scale (GCS)
forming the group setting 188 320
227–9 benefits of art therapy 55 God 123
reminiscence recording impact 48, 174 Goethean Observation 259
231–2 relaxation techniques 122 Goldstein, Kurt 50
summary 234–5 Epilepsy Society 26 Grease (film) 194–5
Dementia UK 218 Equality Act 2010 222 Greece, ancient 40, 50
depression 77 ethnic minorities see under grief
see also ‘Frank’s’ story dementia managing 249–50
Descartes, René 40 everyday life see day-to-day stages of 105, 107
desensitisation 326–7 issues see also ‘Frank’s’ story
despair 93, 140, 142–3, 145, executive functions 23, guilt 138, 228–9, 259
147, 147, 303 53–4, 124
diary-keeping 324 exhibitions 128, 330 Harry Potter films 194–5
difference, respecting 223 Expressionism, German 279, Hauschka, Margarethe 256,
Disney films 194 282, 294, 296–7 258, 272
dogs 124, 192–3, 192 eyes, drawing with the eyes Hawking, Stephen 63
drug abuse 89–91, 95 shut 121 head injuries see brain
dysphasia 77 injuries
family issues see ‘Alex’s’ story Headway 26, 319, 329
early onset dementia (EOD) fantasy worlds see ‘Nadia’ Health and Care Professions
204, 207 case study Council (HCPC) 222,
see also under dementia film noir 20, 25, 279–97 226
Egypt, ancient 40, 101 fire station sculpture 310, heart, the, ancient theories
electrotherapy 41 311 on 40
encephalitis, ‘Werner’s’ foot painting 262 ‘Hedgehog’ and ‘Rabbit’
script 279–97, 284, ‘Fran’ case study 159–63 puppets 306–10, 308
293–4 ‘Frank’s’ story 241–55 hemispatial neglect 117, 121
end of life 52, 64 ‘Henry’ and ‘James’ case
study 143–5
Subject Index 347
hints for art therapy clinical manifestations metaphor 24, 56, 132, 187,
practitioners 24–6 and impact of KS 296–7, 302, 306, 311
Hippocrates 40 242–3 mild cognitive impairment
‘HM’ case 42 creating ego foundations (MCI) 207
holistic approach 17, 24, 50, 249 mind maps 129, 129
62–3, 65, 298 directing change 247 mindfulness 123
see also anthroposophical evaluating the portraits mirror pictures 93, 93
art therapy under 250, 250 mirroring 53, 96, 122, 130,
motor neurone first session 243–4 166, 192, 261, 272,
disease ‘Frank’s’ story unfolds 279, 318
horses 84, 84, 126, 228–30 245–7, 247 Moore, Henry 223
house-tree-person (HTP) managing grief 249–50 motivation
assessments 130 referral 242 importance of 50–1
humours (bodily fluids) self-portraits 247–8, 248 lack of 48, 153, 154
40, 41 theoretical understanding motor neurone disease
hypnotherapy 241, 245, 251–2 (MND)
249, 319, 327 anthroposophical art
language therapy 68, 321 therapy and 256–75
illness representation 21, learning disabilities 189–90 ‘Christopher’ case
175 see also under epilepsy study 262–71,
individuation 80 lemniscates 262 265, 267–9,
infants 23, 45, 136, 147, The Life Science Trust 259 272–3, 274
229, 252, 325 limbic system 45, 104, 330 context 256–7
insight and awareness, after Lincoln Hospital 76–95 first impressions 259
brain injuries see under locked-in syndrome 103 ‘Loyalty verse’ 260
brain injuries ‘Loyalty verse’ (Steiner) 260 medical approach
intersubjectivity see ‘Luke’ case study 157–8, 257–8
phenomenological 160–1, 163–6, 164–6 motor neurone disease
ideas Luria, Aleksandr 50 258–9
intrapsychic learning 17 summary 271–2
‘Invisible Lines’ (poem) 132 magic 40 working together
iPads 11, 125, 131 magnetic resonance imaging 260–2
(MRI) 106, 122, 126 benefits of music therapy
Jackson, Michael 197 mandalas 111 55
‘James’ and ‘Henry’ case ‘Mark’s’ story 317–33 Charcot and 41
study 143–5 case study 320–9, 320, impact 48, 78, 259
‘Janus response’ 19, 76–7, 322, 328 ‘Peter’s’ story 65–6
79, 80, 95–6 context 317–8 motor skills 54, 121
Joe 90 (TV series) 292 multi-modal treatment mouth painting 65–6,
joint images 69, 71–2, 71 package 318–9 261–2
Jung, Carl 51, 80–1, 155–6 post-traumatic symptoms MRI scans 106, 122, 126,
Jungian analysis 327 329–31, 331 282
Marley, Bob 197 multi-infarct dementia 207
Kahlo, Frida 101–2 meditation 123 multidisciplinary approaches
Kandinsky, Wassily 158 Memento (film) 326 18, 51–2, 100, 139,
‘Karen’s’ experience as a memory 152, 257, 318–9
music therapist 143–5 benefits of art therapy on multiple sclerosis (MS)
King’s Lodge Brain Injury 22–3, 121 benefits of art therapy 55
Unit, Derby 317 retention issues 19, 22, case material 82–3, 85,
Klee, Paul 102 119, 243, 247, 86–7
Korsakoff’s syndrome (KS), 320–1, 325–7 Charcot and 41
restructuring self- Meningitis Now 26 impact 48, 78–9
identity with a man Mental Capacity Act 226 pace and timing of
with (’Frank’) 241–55 Mental Health Act 153, 226 therapy 96
Merleau-Ponty, Maurice 156
Multiple Sclerosis Society 26 organisational dynamics Prigatano, George 51

Murnau, F.W. 279 17–19, 135–51 PTSD see post-traumatic
music, listening to 50, 131 stress disorder
music therapy 52–5, 63–4, pain, addressing 119 puppets 306–10, 308
143–5, 325 painting, power of 271
palliative care 64–5 Race Relations Act 1976
‘Nadia’ case study 193–7, paper conversations 131 222
194–6, 199–200 Paralympic Movement 74 Ramachandran, V.S. 104
narcotics 40 paralysis 41, 63, 89, 119, reflective spaces 143–6
National Dementia Strategy 121, 321 refractory epilepsy 174
210, 221, 226 parenting issues 95 Regional Acquired Brain
National Health Service Park Attwood Clinic, Injury Unit (RABIU),
(NHS) 26 Worcestershire 256 Belfast 100
National Stroke Strategy 55 Parkinson’s disease 41, 48, relaxation techniques 122
near-death experiences 122 55, 122, 221 reminiscence recording 220,
nervous system 43–4, 47, perseveration 157, 159, 161 231–2, 236
161, 242, 266 person-centred approaches representational systems 245
neural pathways 47–8 117, 126, 221, 225–6 Riding for the Disables 126
creating new 12, 23, 43, ‘Peter’s’ story 65–6 risk assessments 226–7
53, 157, 209, 324, phenomenological ideas 17, road traffic accidents (RTAs)
326 23, 156, 225, 234 77, 83–5, 83–4
neuro-imaging 17–8, 22, 43 philosophical issues 21 see also ‘Mark’s’ story
Neuro-psychological Art phone cameras 327
Therapy (NAT) model photographs / photography safety issues 90, 153, 199,
127 11, 92, 102, 131, 231, 261
neuro-rehabilitation 51–5 322, 327 sand play 125
evidence base 54–5 phrenology 42 scaffolding sculptures
influence of neuroscience physical limitations, people 302–4, 303
52–4 with severe 62–75 Schiele, Egon 102
use of music therapy holistic approach and seizures see epilepsy
63–4 interiority 62–3 self-criticism 121, 127
see also individual case use of art therapy 64–74 self-portraits 101–3, 247–8,
studies ‘Peter’s’ story 65–6 248, 250, 250
neuroaesthetics 126 ‘Tony’s’ story 67–74, senses, the 23, 119, 122,
neurological understanding, 70–3 157, 160, 264
development of 39–44 use of music therapy see also individual senses
neurons 41, 47, 47, 325, 330 63–4 sexual abuse 89, 95
neuroplasticity 17–8, 42–3, physiotherapy 93, 164, shamans 188
48, 120, 323, 330–1 321–2 shame 20, 174–5, 224
neuropsychoanalysis 154 Picasso, Pablo 102, 223 shapes, symbolism of 111
neuroscientific developments plasticity see neuroplasticity Sheffield University 76
17 poetic imagination, Sherrington, Charles 42
neurotransmitters 42–3, 47 accessing the 23–4 sight, loss of 122
NHS see National Health poetry 131, 132, 260 sign language 124
Service ‘Pop Art Portrait’ project Silver drawing tests (SDT)
Nietzsche, Friedrich 122 102–3 130
Nintendo 291 portraiture 101–3, 247–8, social exclusion 20–1
Nolan, Christopher 326 248, 250, 250 spatial awareness 324–5
nonverbal communication post-traumatic stress Special Educational Needs
52–3, 56, 66, 68–9, disorder (PTSD) 324, 300
71, 144 326–7, 329 speech therapy 41, 68, 121,
‘Norma’ case study 140–2 postcards 131 321
posterior cortical atrophy Sperry, Robert 43
occupational therapy 93, 221 spinal cord 44, 48, 77
321–2, 324
Subject Index 349
spirituality 21, 122–3, 123, VIRbal© (Verbal Image

223, 264 Reminiscence
‘Christopher’ case study Recording) 220,
266, 269–70, 272 231–2, 236
‘split-brain’ research 43 visual intelligence 112
Steiner, Rudolf 256, 259–60 vulnerable adults, protection
stigma 20–1, 175, 222, 224 of 226
stimulant drinks 324
Storr, Anthony 126 Wechsler Intelligence Scale
straws, blowing paint for Children (WISC)
through 262 289
stroke 48, 55, 122 Weine, Robert 279
‘Martin’ case study 103– ‘Werner’s’ script 279–97,
4, 105–12, 106–7, 284, 293–4
109, 110, 112 Wernicke, Carl 42
‘Norma’ case study 140–2 wet-paper technique 121
‘Tony’s’ story 67–74, white boards 131
70–3 witch doctors 188
see also under brain injuries witchcraft 40
Stroke Association 26 ‘With Art Therapy You
Stroke Toolkit 55 Don’t Get Awkward
substance abuse 89 Silences, You Get to
Sucsy, Michael 99 Watch Paint Dry’ (film
suffering, reactions to 138, script, ’Werner’) 283–
145, 147, 300 97, 284, 293, 294
symbolic conversations 130 The Wizard of Oz (film)
synaesthesia 321–2 194–5
work, returning to 329
Tavistock Institute of
Human Relations, younger onset dementia see
London 136 early onset dementia
team work 18–9, 24
terminal illness 62, 64, Zeki, Semir 126
300–1, 302
testimonials 131–2
The Vow (film) 99
therapies and activities,
types of 118, 257
thiamine (vitamin B1)
deficiency 242
‘Tony’s’ story 67–74, 70–3
tools, for art therapy 130–1
touch 161, 263
traumatic brain injury (TBI)
63–4
‘Brian’ case history 89–
95, 90–4
trees, symbolism of 110
trepanation 40
truth, fabricating 190–2
vascular dementia 207, 221

veil-painting 269, 270, 273
Author Index
Abram, J. 156 Cregeen, S. 52, 189 Gilroy, A. 54

Aitken, K.J. 225 Cummings, J.L. 53 Girvan, L. 48, 51, 142, 146
Aldridge, D. 54, 63, 64 Glozman, J. 50
Aldridge, J. 249 Damasio, A. 43, 45 Goldstein, L.H. 175, 176
Alzheimer’s Society 222 Dartington, T. 136, 147 Golebiowski, M.M.G. 227
Anderson, E. 175–6 Day, C. 263, 264 Gordon, R.M. 142–3
Anthony, E.J. 225 de Oliveria, G.N.M. 174 Gould, E. 325
Antonak, R.F. 174–5 Del Giacco, M. 155 Gray, A. 78
Arens, G. 300 Department of Health (DoH) Greene Stewart, E. 252
Armstrong, D. 137–8 48, 55, 189, 210, Gross, G. 325
Axline, V. 109 221–2, 226, 236 Guekht, A.B. 176
Dissanayake, E. 246, 251,
Bagan, B. 22, 209 253 Haddad, M. 176
Baker, G.A. 174 Doidge, N. 43 Halton, W. 137, 142, 146
Barnes, C. 65 Dubowski, J.K. 163 Harlow, J.M. 42
Battino, R. 245 Dzilnar-Šilova, I. 53–54 Harman, E. 174
Bauby, J.-D. 63, 103 Harrison, R. 101
Becker, S. 249 Edwards, B. 121 Hass-Cohen, N. 16, 48, 53,
Belkofer, C. 44, 53 Edwards, D. 50 209, 252
Bell, S. 62, 64 Ehrenzweig, A. 332 Hatfield, L. 147
Bick, E. 311 Ehresman, C. 53, 55 Hauschka-Stavenhagen,
Bion, W.R. 136, 312 Elkis-Abuhoff, D.L. 55 M. 272
Black, D. 300 Ellenberger, H.F. 50 Havlena, J. 54, 55
Bogner, J. 154 Espinel, C.H. 251 Hawking, J. 63
Bogousslavsky, J. 102 Evans, J. 48, 146, 154 Health and Care Professions
Bond, N.W. 242 Council 222
Bowlby, J. 80, 95 Feeney Mahoney, D. 222 Hinshelwood, R.D. 135–6,
Brown, C. 138 Ferenczi, S. 188 138, 143, 146
Brown, E. 300 Ferguson, K. 63 Hjulmand, K. 156
Buddy, T. 251 Fieldhouse, J. 249 Hodgson, D. 251
Butters, N. 251 Finger, S. 40–3 Hoffman, D.D. 112
Buzan, T. 129 Foulkes, S.H. 225 Homewood, J. 242
Byers, A. 156, 226 Frankl, V. 122 Huang, M. 126
Freud, S. 188 Huber, M. 257
Cantopher, T. 244 Huet, V. 146
Carr, R. 16, 44, 48, 53, 203, Gage, F.R. 331 Huffington, C. 136
209, 252 Galbraith, A. 54, 210 Hustvedt, S. 282
Cermak, L.S. 251 Garner, R.L. 18, 22, 52, 118, Hyland Moon, C. 155
Clarke, D.M. 257, 259 127, 155
Coopersmith, S. 247 Gaser, C. 43 International Network of
Cowan, T. 266 Gerhardt, S. 45 Neuroaesthetics 120
Gibertson, S. 63, 64
350
Author Index 351
Jacoby, A. 174 Meyerowitz-Katz, J. 138 Schacter, D.L. 154

Jaffe, A. 156 Michaels, D.A. 52, 135, Schaverien, J. 132, 138, 222,
Jervis, S. 138 137–8, 142 302
Johnson, C.M. 55 Miller, L. 49–50, 175–6 Schmid, W. 55
Johnson, S.C. 52 Mirnics, Z. 176 Schnur, K.J. 52–3, 156
Judd, D. 50–1, 300, 307 Mittan, R.J. 175 Schofield, N. 318
Jung, C.J. 80, 104, 156 Moessner, A.M. 48, 154 Schore, A.N. 23, 43, 225,
Mondanaro, J.F. 55 229, 234, 236
Kaplan, F.F. 16, 53, 104, Moniz-Cook, E. 236 Sempik, J. 249
112, 241, 246, 253 Morley, S. 175–6 Shakespeare, T. 65
Kaplan-Solms, K. 43, 154 Muotri, H.R. 331 Shelley, M.W. 41
Kemp, S. 175, 176 Murrey, G.J. 48–50 Sheppard, L. 16, 54, 218,
Kitwood, T. 221, 224 226, 233–4
Klein, M. 136, 145, 308 Nahum, I. 176 Siegel, D.J. 43, 45, 47, 53
Knight, A. 48, 51, 142, 146 Naitove, C.E. 189 Silver, R. 52, 130
Koffka, K. 50 NHS London 55 Simon, R. 24, 110
Kopelman, M.D. 242, 251 NICE 55, 135, 148, 221–2, Sinason, V. 156
Kottlow, M. 157 236 Skaife, S. 156
Krezinski, A.J. 54, 55 Skogstad, W. 135, 136, 138,
Kübler Ross, E. 105, 300 Obholzer, A. 136 142, 145–7
O’Gorman, M.P. 52, 145, Small, L. 176
Lahav, A. 53 154 Snape, D. 174
Lakey, L. 221 Osborn, C. 104–5, 111 Soderfeldt, B.A. 174
Langer, K.G. 146, 154 Oscar-Berman, M. 251 Solms, M. 43, 154
Larsson, B.M.W. 174 Osler, I. 156 South, T. 245
Lawrence, G. 52, 54 Ostermann, T. 55 Stafstrom, C.E. 54, 55
LeDoux, J.E. 43 Stapley, L.F. 115
Levine-Madori, L. 53–4 Page, M. 249 Steiner, R. 260
Lezak, M.D. 245 Panksepp, J. 43, 53 Stern, D. 225, 232, 234–5
Liebmann, M. 130 Pascual-Leone, A. 122 Sterz, C. 55
Livneh, H. 174–5 Patel, N. 222 Stevenson, R.L. 42
Lott, S.M. 174–5 Peisah, C. 52, 54 Stewart, E.G. 53
Loya, N. 209 Philips, J. 101 Strand, S. 50, 52, 55
Lusebrink, V.B. 53–4 Pratt, M. 62 Subrin, R. 210
Preminger, S. 157 Sullivan-Marx, E.M. 55
McCann, J.P. 51 Press, D.Z. 55 Suzuki, T. 174
McFarlane, A.C. 43 Prigatano, G.P. 48, 51–2,
McGraw, M. 155 146, 154 Thornhill, A. 129
McGuinness, M.M. 52–3, Travis, J. 174
156 Raglio, A. 54 Trevarthen, C. 225
Mackinnon, H. 55 Räty, L. 174–6 Turnbull, O. 43, 154
Maclagan, D. 74, 155 Restak, R. 43
McLeod, J.E. 257, 259 Reutens, S. 52, 54 van der Bie, G. 257
Macmillan, M. 49 Reynolds, F. 55 van der Kolk, B.A. 43
McNiff, S. 272 Rogers, D. 15 Vance, R. 251, 253
Magee, W.L. 52 Ross, D. 54, 210 Velissaris, S.L. 176
Malchiodi, C.A. 16, 53 Rubin, J.A. 126 von Sass Hyde, I. 52
Malec, J.F. 48, 154 Rusted, J. 16, 54, 226, 233
Markowitsch, H.J. 251 Ryan, R. 174 Wahlin, K. 251, 253
Martinsone, K. 53–4 Ryde, J. 138 Wald, J. 52, 155
Maxwell, D.A. 138 Wallace, C.A. 154
May, A. 43 Sabrina, S. 54 Waller, D. 16, 50, 52, 54–5,
Mees, L.F.C. 257 Sacks, O. 43, 49, 56, 154, 142, 145, 147, 218,
Menzies-Lyth, I. 136, 138 162 226, 233–4
Mercer, G. 65 Safar, L.T. 55 Weisaeth, L. 43
Weston, S. 48, 51–2, 142,

145–7
Westwood, M. 101
Wilkinson, M. 42–3
Williams, S. 99
Wilson, B. 126
Wilson, S. 50–1
Winnicott, D. 126, 138
Wisdom, C. 52, 155
Wood, C. 74
Wood, M. 52, 62
Zagier-Roberts, V. 136, 145

Zaidel, D.W. 44,

Art Therapy With Neurological Conditions (PDFDrive)

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‘If anyone needs confirmation that art therapy is the approach to

use in the treatment and recovery of neurological conditions this

‘Art Therapy with Neurological Conditions is an interesting book,

‘This book should be read by everyone who is interested in the

Art Therapy with Physical Conditions

Art Therapy and Anger

Art Therapy and Clinical Neuroscience

Assessment and Outcomes in the Arts Therapies

Neuroscience for Counsellors

Edited by Sally Weston and

Jessica Kingsley Publishers

Foreword by Jackie Ashley 11

Part II Acquired Brain Injury

Part V Other Neurological Conditions

When my husband, the broadcaster Andrew Marr, suffered a serious

when people are enjoying art. It is undoubtedly helpful in making

This book is a companion volume to Art Therapy with Physical

of what is useful with particular conditions, and whether there is a

This book draws together the experience of art therapists across

Reading the contributions in this book, this is still the core of

Theories and ideas

1. Neuroscience to provide evidence and explanation for the

Neurology: brain, body and mind

‘lighting up’ as human beings respond to relationships with others,

Settings and team work

processes that can operate in organisations when staff are dealing

enabled him to come to an important resolution, linking his feelings

Identity and self-esteem

Stigma, assumptions and exclusion

tells how low expectations of professionals can affect outcomes and

Philosophical/spiritual issues and mortality

The function of art-making

and Chapter 15 illustrates effective ways to work with a client with

Memory and cognition

The role of the senses

Access to the poetic imagination,

There are many examples of how clients use artistic expression to

Hints for practitioners of art therapy with

describes clients for whom art-making stimulated memories of

and the impact of damage or disease. The chapter goes on to outline

2. Simon Bell: ‘Beyond Limits: Art Therapy with

3. Iris von Sass Hyde: ‘The Janus Response:

4. Carole Connelly: ‘Who Am I Now? Art Therapy,

5. Anna Knight: A‘ rt Therapy at a

8. Quentin Bruckland: A‘ rt Therapy after

9. Andrea Gregg: ‘“This is my Dream

10. Elizabeth Ashby: ‘Reframing and Reconnecting:

needed to achieve these. Themes emerging during sessions include

11. Melody Golebiowski: ‘“My Coat or Yours?”

12. Jenny Wood: ‘“Have We Met Before?” Images

The chapter includes a description of Korsakoff’s syndrome and

13. Marion Green with Christopher Day: ‘What has

14. Mark Wheeler: A

problems decreased, as his concentration, empathy and sense of

15. Judith Ducker: A‘ rt Therapy with a Boy

16. Mark Wheeler: A

Setting the Scene

Neurology and Art Therapy

The development of neurological understanding

were identified in the mid-seventeenth century with the naming of

balance between his intellectual faculties and animal propensities,

Key twentieth century discoveries