Art psychotherapy with patients presenting

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International Journal of Art Therapy
Formerly Inscape
ISSN: 1745-4832 (Print) 1745-4840 (Online) Journal homepage: https://www.tandfonline.com/loi/rart20
Lost in translation: Art psychotherapy with
patients presenting suicidal states
Kate Rothwell
To cite this article: Kate Rothwell (2008) Lost in translation: Art psychotherapy with
patients presenting suicidal states, International Journal of Art Therapy, 13:1, 2-12, DOI:
10.1080/17454830802102314
To link to this article: https://doi.org/10.1080/17454830802102314
Published online: 03 Jun 2008.
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ORIGINAL ARTICLE
Lost in translation: Art psychotherapy with patients presenting
suicidal states
KATE ROTHWELL
Abstract
This paper proposes that art therapy enables individuals to explore their destructive and murderous impulses through the use of art
materials, in order to develop a better understanding of their internal disturbance. The phenomenon of suicide is discussed in relation
to the psychoanalytic understanding of aggression and the psychodynamic practice of art therapy. The apparent lack of literature
pertaining broadly to the theme of art therapy and suicide in the UK may indicate that clients do not take their own lives in treatment.
Many suicide attempts go undetected as paradoxical states of mind may not be fully understood. Clinical practice with a patient
diagnosed with anti-social personality disorder, who presented with suicidal ideations whilst detained in a medium secure setting and
succeeded in committing suicide, is discussed in relation to the importance of the art therapy process, therapeutic relationship, role of
the image and importance of supervision in recognising and identifying the presentation of pre-suicidal states.
Keywords: Suicide, personality disorder, paradox, image, acting out, aggression
Introduction
This paper is an exploration of the phenomenon of
suicide traced through a case study and theoretical
perspectives that have helped shape my thinking
about the many contradictions and paradoxes experienced when working with people in art therapy
who are thought to be suicidal.
I am reminded of an Arctic Monkeys video to the
track ‘Leave before the lights come on’ (‘then you
don’t have to see what you’ve done’, 2006, Domino).
It tells a vivid story of a man walking along a street.
He picks up a shoe that has just fallen behind him.
Looking up he sees a young woman standing on the
edge of a building. He talks the woman out of jumping
only to become the object of her enacted anger when
he rejects her advances and she once more resumes
her position, dropping her shoe off the edge of the
building.
Watching the story unfold I observed a familiar
scenario reminiscent of my own clinical experience
with people who metaphorically stand on the edge
looking over as if ‘about’ to jump. These are patients
who survive by keeping a sadistic loop in their
relationships, as if ‘trapping’ the unsuspecting in the
hope of being rescued but ever vigilant that any
mistake, however minor, could set off a suicidal
reaction.
I have come to learn that my task as a therapist is
not to rescue but to sit on the edge with the patient
and think about what it feels like to be there. This may
be easier said than done as the function of thinking
can be unbearable for them, but through art making,
the patient I shall discuss discovered a way of
communicating without words, keeping the art psychotherapist transferentially in touch with his suicidal
ideation. In reference to the title of this paper I hope it
reflects how I was drawn into suppressing my
awareness, causing a painful failure of communication
with the patient.
Art therapy can play an important role in the
course of treatment of severely disturbed people
whose destructive external behaviour can disguise
deeply unconscious emotions that seek evacuation or
protection through highly primitive defence mechanisms. I am seeking to better understand these
mechanisms and drives that promote this behaviour
and to put forward an argument that art therapy is
uniquely placed to work with these very complex
cases.
I will refer to clinical material with an adult male
patient in a medium secure personality disorder unit,
who committed suicide having completed two years of
treatment in art therapy, and how his image making
enabled him to depict his contradictory thoughts and
co-existing aims. I am informed by the work of Hale
Correspondence: Kate Rothwell, 77 Hilltop, Redbourn, Herts, AL3 7NX, UK. Tel: 01582 626375. E-mail: [email protected]
International Journal of Art Therapy, June 2008; 13(1): 212
1745-4832 (print)/1745-4840 (online) # 2008 British Association of Art Therapists
DOI: 10.1080/17454830802102314
(1991, 2005) and Campbell (1991, 1999), Bateman
(2004), Fonagy (1999, 2004) and Target (1999), and
Schachter (1999) who describe suicidal fantasies and
the complexities involved in these processes. Theories
established by Freud, Steckel, Bion, Segal and Glasser’s concept of core complexes further underpin my
thinking in this paper.
National statistics
Deliberate self-harm is the second most common
cause of death in men under 35 years (Hawton et al.,
1998). In 2000 the Department of Health National
Study of Prison Suicides statistics showed that in two
years 172 suicides were committed (Shaw, Appleby, &
Baker, 2000). More recently, The Sainsbury Centre
for Mental Health published a report (number 32.
2007) stating that in 2006 there was a total of 67
prison suicides and a total of 22,324 self-harm
incidents recorded during 200506 (Prison Reform
Trust, 2007). Attempted suicide over a 12-month
period ranged from 7% (in male sentenced prisoners)
to 27% (in female remand prisoners) (Brooker,
Rapper, Beverley, Feriter, & Brewer, 2002). Young
people in prison are 18 times more likely to commit
suicide in prison than in the community (Prison
Reform Trust, 2007).
Working with disturbance
My work is informed by several theories on treating
this client group. Asch (1980), quoted by Hale (2005),
identified psychological constellations of suicidal states
of mind which he divides into three groups: the first
are high achievers, unpredictable, isolated, arrogant,
who encounter sudden humiliation and who struggle
to cope with failure. Second are people with low selfesteem and depression who are not acting out but
attempt suicide when experiencing acute mental
states. The third constellation of suicide refers to a
group who present a high level of acting out, have a
history of delinquency, and who exist by constantly
putting their life on the balance. The latter is relevant
in the treatment of personality disorder where selfharm can be understood as a coping mechanism
employed to protect against intolerable emotions to
gain relief and control. Self-injurious behaviour does
not increase the risk of suicide but, for a patient who
self-harms, to stop may increase distress if other
coping mechanisms are not available.
Bateman and Fonagy (2004) explain that the
therapist, to be of any help to the patient, needs to
hold a non-interpretative stance, not look for complex
unconscious reasons, drop the ‘blank analytic screen’,
resist premature use of interpretation in terms of
personal history that may alienate the client, and use
common sense (Bateman & Fonagy, 2004, p. 41). I
employ intuitive understanding by using my gut
reaction, informed by the content of artwork and how
the person is making use of the art materials,
relationship and space to try and get to know the
client and how they respond to the world around
them.
Bateman and Fonagy (2004) believe the ability to
use metaphor and verbalise feelings depends on
having a stable self-structure and ability to form
symbolic representations, therefore personality disordered patients cannot be assumed to be able to work
with conflict in the absence of these attributes. If the
patient is unable to hold in mind different representations and their accompanying affects at any one
time, the therapist must accept the balance between
these opposing perspectives and work with both even
though they appear contradictory.
Through the practice of mentalisation-based treatment, suicidal acting out behaviour is viewed as no
more than a protective action, to defend against a
perceived overwhelming threat of disintegration as a
last resort to save the self (Bateman & Fonagy, 2004).
In their paper ‘The image, mentalisation and group
art psychotherapy’ Franks and Whitaker (2007) have
recently contributed to the understanding of a mentalisation-based approach in the treatment of personality disorder. Through research they came to realise
how the image in art psychotherapy group work
becomes central to the mentalisation process, by
enabling their clients to ‘observe their sense of self
emerge as others in the group came to perceive them as
thinking and feeling’ (Franks & Whitaker, 2007, p. 4).
Suicide and aggression
Freud took up the notion of suicide as aggression
turned against the self in his 1917 paper ‘Mourning
and melancholia’. He wrote:
The analysis of melancholia (now) shows that the ego can kill
itself if … it can treat itself as an object if it is able to direct
against itself the hostility which relates to an object and which
represents the ego’s original reaction to objects in the external
world. (Freud, 1917, p. 252)
Bion (1957, 1967) takes the stance on suicidal states
of mind that there is an internal conflict between
the psychotic and non-psychotic parts.
While the non-psychotic parts are capable of reflection, the
psychotic part, fuelled by envy and hatred of psychotic reality,
operates by evacuating troublesome feelings, thereby creating
hallucinations and delusions. The psychotic part then covers up
its murderous activity by appearing calm and reasonable.
(Lucas, 2003, p. 36)
Glasser understood suicide to be an extreme
expression of a ‘body state’ where ‘internalised
Lost in translation 3
aggression is sufficiently intense it may run
amok … and be directed in a crude, gross way at
the ego’s basic functions’ (Glasser, 1979, p. 286). He
proposed the idea of sadism and aggression in the
core complexes when love and hate become
merged and confused. Two differing states of mind
become one and the same.
Describing the core complexes as ‘interrelated
feelings, ideas and attitudes’ set in very early developmental stages, Glasser states:
A major component is a deep seated and pervasive longing for an
intense and most intimate closeness to another person, amounting
to a ‘merging’, a ‘state of oneness’, a ‘blissful union’. To envisage
closeness and intimacy as annihilating, or separateness and
independence as desolate isolation, indicates the persistence of a
primitive level of functioning. (Glasser, 1979, p. 285)
Translating the mind of someone thinking about
killing themselves
According to Hale the notion of suicide causes an odd
contradiction of being taken seriously, yet not. He
states that the first suicide attempt is a defining
moment in deciding to take one’s life and can be a
sign of crisis meaning ‘a crossroads or a possibility for
change either to move into something new or to
continue repeating familiar patterns’ (Hale, 2005).
To define suicide may be to say that ‘at the time of
the act the intention is to kill the body, it is a murder’
(Hale, 2005). This idea suggests there is a surviving
self, as if a part of the person lives on in a changed
new form: the concept being that something survives
the suicide, thereby holding the notion that the self ’s
body is killed to attain psychic survival.
Freud defines suicide as a repetition compulsion, a
form of acting out. Suicide is the settling of old scores
held in the memory with no understanding. This
extreme form of acting out Freud describes as a
substitute to remembering early traumatic experiences
as a child when he/she suffered passively (Freud,
1964). The intention is threefold: to remember, to
repeat and to reverse early childhood events. However, the person finds they ‘do’ something but do not
know why, thereby acting out in the here and now
what is driven from the past.
Quoting Steckel (1910 [1967]), who first linked
murder and suicide, Keval states ‘No one kills himself
who has never wanted to kill another or at least
wished the death of another’ (Keval, 2003, p. 36). This
predicament is seen as the solution to an impossible
dilemma in which the self is freed by destroying the
internalised other (Fonagy & Target, 1999). A sadistic
act, it involves two people and has ambivalence at the
very core of a suicide attempt. It may be a cry for help
or could be a manipulative or rational solitary act of
desperation.
Attempted and actual suicides have different aetiologies but the overlapping similarities are so great it
is a difficult distinction to make. According to
Campbell and Hale (1991) and Campbell (2005) selfharm has the intention to torture and keep alive to
triumph over death. In suicide the intention is to
murder in order to punish the ‘lost-loved and hated
person’ (Hale, 2005), therefore the body becomes
identified as a separate object, the other person.
The role of art therapy
Despite an absence of published art therapy literature
in the UK referring specifically to suicide, I found the
following literature has been helpful to my understanding of the subject of the role of art therapy and
the image with patients presenting disturbed mental
states.
Franks and Whitaker argue that they observed
through their research how the artwork made in the
art psychotherapy group acted as a ‘communication
interface, as mentalising images, between intra- and
interpersonal relationships that crucially enable the
internalisation of this capacity to mentalise’ (Franks &
Whitaker, 2007, p. 9). Their findings are significant in
reference to the role of the image for suicidal patients
when discussing their observations on how their
clients created an unspoken visual language between
themselves and others in the group, thereby serving as
a visual dialogue as a ‘means of being known’(p. 14).
Levens, discussing the effectiveness of dynamically
orientated art therapy in relation to defence mechanisms, states:
The client may use art to test out his dangerous thoughts and
ungratified wishes in a safer way than directly in relation to the
therapist. In this way his art can act as a mirror in which to see
himself more clearly, or as in intermediary between self and nonself, inner and outer worlds. (Levens, 1989, p. 144)
Levens explains that for people who experience
thoughts and feelings as concrete reality, having
murderous thoughts can be terrifying, but by
externalising through art making, denied or repressed aspects of the self can be first met safely
through an image.
In the paper ‘The ideation in the art work of
suicidal patients’ Honig (1975) looks at the quality of
images made by suicidal adolescents and finds that
emergent themes included manifestations of death
(gravesites), death obsessions (slashed wrists and self
hangings), and violence (house robberies), feelings of
failure (a jail cell), isolation (a person huddled in a
corner), hopelessness and helplessness.
4 K. Rothwell
Harden, Rosales, and Greenfield (2004) identify a
dearth of literature on art therapy and suicide in the
USA but conclude that their study indicates the value
of art therapy with suicidal adolescents specifically.
The authors state that art therapy should be considered as a ‘viable treatment option’ as it presents a
powerful tool to overcome the emotional constraints
inherent in a therapeutic process with such a
population
Case study
John
John, a 44-year-old single, Caucasian man, was
diagnosed with an anti-social personality disorder
whilst serving a life sentence of imprisonment following a conviction of murder. He was referred to art
therapy for individual psychodynamic treatment with
the aim of supporting his move to a low secure unit.
He was not engaged in any other form of therapy and
had sabotaged many previous treatment initiatives,
using intimidation to act out his omnipotence. He was
also vulnerable to intimidation, which promoted his
murderous feelings expressed through anger and selfinjurious behaviour. John was highly narcissistic and
swung between idealisation and denigration. He grew
up in a culture of belittling, humiliation, control and
domination and could use these traits to powerful
effect. He also held profoundly negative feelings
towards all figures of authority.
The process in art therapy for John was largely nonverbal. He described the therapy space as somewhere
cut off from the rest of the hospital ‘like a foreign land
where the therapist translates the lingo’. This meant
in my role as therapist, I was also split off in his mind
from the rest of the team and experienced as an
extension of himself rather than a separate person.
During his early period in art therapy John
explored narcissistically idealised parts of his self in his
artwork whilst I was left to sit and look on, as if in a
vacuum, excluded from his relationship to the image
but able to provide a regular consistent safe space and
art materials. I felt he kept these roles in order to feel
safe in his unintegrated state by remaining solely
contained in his artwork.
The interim stages were a period of greater
uncertainty in the work. John brought more disturbing material to the process but continued acting out
his aggressive and destructive impulses by threatening
suicide, behaving in a challenging and provocative
manner towards staff and fellow patients and bringing
drugs into the unit.
The content of his artwork focused on anger, selfsacrifice, self-hatred, isolation and desolation. I identified this as his attempt to risk more attachment to the
therapy by testing what boundaries, security and nonjudgemental regard I could offer. Throughout this
period, although John’s suicidal, self-harming
and sadistic behaviour increased, he kept the art
psychotherapist in touch with his suicidal ideation
through transferential material in his artwork. This
meant I could monitor the level of risk he presented
through my counter transference and use this to feed
back to staff what external measures they should
consider instigating to support him, for instance
whether to increase or decrease the intensity of
nursing observation.
In the latter stages of treatment John became totally
dependant on the therapy and consciously exposed his
emotions and vulnerability in session. Unconscious
material became so deeply placed that on three
occasions I felt as if I had been anaesthetised and
fought to stay awake; at other times my response was
to disassociate from the work he made. This I came to
understand as my way of surviving John’s most
disturbing material until it could be processed through
supervision.
Whilst showing greater intimacy, sensitivity and
trust in the therapeutic relationship, the content of his
artwork became extremely violent, disturbing, shocking and upsetting. His depression was more apparent
and his acting out behaviour decreased as he developed resources to cope with his disturbances and a
more sophisticated symbolic language of expression.
Assessment
‘Art attack’
His first piece (Figure 1), made in clay, was a hand
holding an eye; it was like a small grave ornament
set in stone, with a dice and thin slivers of clay with
the words ‘art attack’, ‘reject’ and ‘rejected’ imprinted with the sharp end of a pencil and a dice.
He described it as his hand holding his father’s eye
and on completion stated that the ‘hand destroys
what it creates’. I wondered what this meant and
asked him to tell me more about it. He said he did
not know and showed little interest in satisfying my
curiosity.
My initial feelings were of anxiety and fear. At one
point he dropped the eye and we both jumped as if it
had a life of its own. He responded saying ‘the hand is
quicker than the eye’. This gave me a sense that John
would keep much hidden from me and I would have
to be quick to identify anything meaningful.
Discussion
His first piece of the unseeing eye controlled by his
hand seemed to embody something not seen or notto-be seen, as if disconnected parts that could not be
Lost in translation 5
connected. The value of art therapy for John was in its
non-verbal function. Through art making John was
able to portray his most terrifying, violent, desolate
and fearful images hidden in his unconscious and he
found a way of expressing his most abhorrent fantasies
and desires revealed to him in visual form. The
concrete nature of art making and materials appeared
to naturally enable John to remain in control of his
own process. John experienced words as intrusive and
although he gave the impression he could understand
metaphorical language, he easily confused metaphor
with literal meaning, which muddled his understanding of my words. The artwork most essentially became
our common language.
Treatment
‘Don’t get lost’
John went on to make several images by scraping
coloured chalk pastel with a pair of scissors onto A2
sheets of black card (not illustrated). He described
them as looking like a vast cosmos of distant stars
and planets and added the words on a tiny sign post
‘you are here don’t get lost’. As he worked with the
materials he expressed some frustration at the chalk
falling off. He attempted to stick it on with lots of
fixative and, eventually, Gloy glue.
Discussion
John’s images of the vast cosmos helped me to
understand his lack of early maternal holding and the
spatial quality of this piece seemed to show him as tiny
disintegrated flecks needing to be held together. This
function he eventually discovered was provided by
Gloy glue, giving him the ‘skin protection’ he needed.
Whilst he gazed with narcissistic pleasure at his own
creations, I was in touch, counter transferentially, with
feelings of sadistic cruelty that I should put him
through the torture of expressing such feelings of
shame, pain and hopelessness that he was beginning
to expose. Any attempt I made to connect with him or
his artwork was met with resistance and dismissal,
confirming my inadequacy, but John’s capacity to
express his emotions, through art making, became
more accessible and enabled him to visually articulate
deeply rooted feelings in an aesthetically sensual style.
Making one image per session he consistently chose to
use chalk pastels on black card that he blended with a
specific tool like a cross between an eraser and pencil.
His was a laborious, considered and deliberate
process, rather than a free flowing style.
During this period staff reported John’s behaviour
as remaining challenging and threatening. Sympathy
and tolerance towards him in the staff team had
diminished and his diagnosis was subsequently changed to severe psychopathic personality disorder.
20th session
‘False alarm’
John described feelings of fear, helplessness and
anxiety in response to his change in diagnosis,
stating ‘it’s like starting a life sentence all over
again’. He felt hopeless that he’d ever be released
and more venomous hatred towards the authorities
that he saw as deliberately impeding his progress.
Using a range of colours in his artwork, John
worked spontaneously and commented that his use of
the medium and art therapy helped him express his
emotions (Figure 2). On finishing the image he
carefully flicked red paint over it. Just before the end
of the session the fire alarm went off. It was a false
alarm but effectively disrupted our flow. John spoke of
not understanding his image so I confirmed we could
Figure 1. ‘Art attack’.
6 K. Rothwell
think about it together next time but I was left with
uncomfortable and disturbing feelings.
21st session
‘Self portrait’
This session was a planned review of his artwork.
Laying out his pieces he became overtly disturbed
by the previous week’s image he called a ‘self
portrait’ (Figure 2). He associated a feeling of terror
from his stomach that emanated, he said, from the
mouth part of the picture. He suddenly exclaimed
that he wanted to run away and held his hand over
his mouth as if stifling a scream. This self-portrait
depicted what looked like a fleshy face squashed
between two rigid, hard, inflexible structures as if
being squeezed out.
Concerned I would not be able to contain him if he
resorted to violence, I suggested he use the materials
to express how he was feeling. This he did, using a
single hue of blue; he began with a central circle then
dragged the chalk to the edge of the paper. On
completion he pushed the piece towards me and sat
back. The image looked like a controlled explosion
(Figure 3).
Stating curtly that he had done what I had asked
him to do, he asked to be returned to the ward. I
made an attempt to link his feelings to the image but
he became very upset and demanded me to stop. With
tears in his eyes he then described his fear of asking for
help and said a door had opened in his head and he
wanted to be a whole person, not in parts. He went on
to say that from past experience, when he asked for
help he was treated cruelly and abandoned, and he
had come to fear rejection.
Discussion
Through John’s art making process a metaphorical
door had opened to expose unconscious emotions that
were previously inaccessible to him and I felt I had
witnessed something extremely undeveloped and
Figure 2. ‘Self portrait’.
Figure 3. ‘Controlled explosion’.
Lost in translation 7
fragile embodied in his ‘self portrait’ image. John’s
description of a door opening in his head vividly
described a feeling of a lid being lifted to release
unfamiliar feelings for him and stimulated his disclosure of his fear of rejection. Paradoxically, I had a
sense of us looking voyeuristically at an embryonic
form needing to be treated with the utmost sensitivity,
and yet suggesting a deep trust had been reached.
However, despite what appeared to be a poignant
moment in John’s progress he went on to treat his
work like a quiz, for instance one piece (Figure 4)
depicted equations and conundrums, with the words
‘do you understand’ added on the bottom of the A2
black sheet of card, as if formulating equations neither
he nor I could comprehend. I felt like a pawn in a
sado-masochistic game as John dismissed any attempt
I made to understand, and I was concerned by the
absence of explicit aggression in his work and
wondered where he had put those more destructive
feelings.
46th session
‘Door mat’
John attended following a rescheduled session and a
disappointing assessment from a drug and alcohol
dependency unit. He commented, ironically, on
wishing he had an addiction so he would be
accepted there, and then drew an image. It was a
door mat with the carefully woven words like
footprints ‘why do people keep walking all over me’
and a pair of crying eyes (Figure 5). I decided to
associate the image with my having rescheduled his
session and said that I wondered if he was angry.
Speaking in a cold way he replied: ‘Well, you’ll just
have to remain wondering’. Looking at the time he
said ‘Oh, good, I can get out of here now’. Whilst
escorting him back to the ward John stated with
incredulity and shock that I had commented that
his image had been related to the session. I was left
shaken by the impact of John’s intense anger and
disappointment, as if I had tripped over his door
mat and fallen flat on my face.
Discussion
Following this session staff reported John’s behaviour
to be more cooperative, considerate and less volatile
and demanding. He settled into a period of engagement in art therapy, bringing increasingly disturbing,
aggressive and violent material to the process (for
example, ‘Fuck you’, Figure 6). Becoming less prone
to idealisation and reassured that I had survived his
most murderous fantasies, John brought issues he was
dealing with linked more to his own impact on
relationships. Emergent feelings showed in John’s
remorse and guilt as his depression surfaced. Staff
interpreted this as a sign of progression.
Processing in supervision
Supervision was vital for any of the material to be
safely processed. Whilst John’s psychic world was held
in the images, the verbal thinking elements of the
work were held in supervision. Up to this stage our
thinking focused on how John’s images indicated no
sense of an internal object. Through his depictions it
was possible to see that beneath his grandiosity were
just fragmented powdery parts and we felt that if he
came to realise this, his mental state could become an
increased cause for concern.
Also observed in his imagery was a sense of his
anxiety shifting between fragmentation and compartmentalisation. Not unlike infant observational techniques, this work was about mindful holding,
observing and thinking about what he was feeling in
order to help him make some connections.
In the process it felt like John was trying to make
sense of himself, events in his life, different emotions
and his change in diagnosis and it could be observed
through his images that he would explore his poorly
understood feelings. This was evident in images that
could be regarded as pre-suicidal where feelings were
only apparent in my counter transference. With his
lack of internal constants I hoped he would reach
deeper fragmented parts to begin to help him find a
way of forming an attachment in the therapy when
the art psychotherapist would become associated with
his primary objects. This I knew would be a
frightening time for him; whilst aware that although
he tried to make attachments and needed relationships, he did not really know what they were.
During the mid phases of treatment John’s grandiosity decreased as he found consistent holding through
art making and repetition, created in session by my
instigating a space for reflection when it felt it would
Figure 4. ‘Do you understand’. be manageable for him. At this time John was still
8 K. Rothwell
splitting the therapist off in his mind to defend against
linking, yet his attacks were contradicted by his need
for linking and being held in the therapist’s mind. On
occasion John would demand for me to stop talking
and I understood this as his attempt to quell his terror.
My response was to acknowledge and reassure him
that it was very difficult and painful work but we
needed to keep going the idea being that we needed
to move beyond his perverse ways of coping to keep
him alive.
By his 22nd Christmas in confinement, a year into
his art therapy work, John appeared to be shutting
down. His experience of loss would cause him to
disengage; this was compounded by the break in
therapy and by now John’s images were full of
contradictions. He wanted freedom but was terrified
of an outside world beyond his imagination.
John’s art making from the onset of therapy quickly
developed into a style that he mastered with artistic
competence. He stated that the work was not symbolic
of him but actually was him, and he seemed to use the
images to create a ‘body’ of work that eventually gave
him form. This puts me in mind of Segal’s theory of
symbolic equation (1957) where, in relation to her
schizophrenic patient’s difficulty in symbolising, the
patient made no distinction between symbols and the
objects they symbolised.
Translating suicide in an image
Over the following year in therapy John’s persecutory
and fearful feelings increased as his depression
surfaced. In the latter stages of treatment John’s
capacity to use the process deepened with excruciating sensitivity of feeling. He was desperate, isolated,
and felt harshly punished and we both struggled to
find a means of communicating the incommunicable
now John focused his art making on suicidal depictions. The art therapy space was even more vital as a
containing place, split off in his mind from the rest of
the hospital: a safe haven he could occupy internally
and externally. As the work progressed and my
Figure 5. ‘Door mat’.
Figure 6. ‘Fuck you’.
Lost in translation 9
capacity to survive and remain consistent endured, so
John’s sadistic attacks lessened. I found myself connected to unconscious aggressive material linked to his
suicidal ideation, which I felt John wanted me to
witness in silence.
‘Forgive me’
Coming up to his 23rd Christmas in confinement, two
years into his art therapy work, John worked in silence
in his third-to-last session then stated his image was
unfinished and he would continue the next week. It
was a mysterious image depicting a tall pyramidal
shape and an unembodied eye (‘Forgive Me’,
Figure 7). And I could only guess at the meaning. The
following week he continued working on the same
piece whilst stating that 22 years locked up in prison
was a very long time. We discussed, as much as he
would tolerate, his having left an image incomplete for
the first time. I said I thought he had taken a great risk
in entrusting me to hold onto his unfinished image.
John said this was his best piece, leaving me with a
feeling that this work held a conviction, depth and
resonance that came from a real place. This moment
was short lived. I voiced the possible significance that
his risk taking might be signalling a link to suicide, a
comment he then rejected. I accepted this rejection
thinking his response indicated more hope.
The unconscious suicidal feeling was yet to be
known to both of us, and whilst making his final image
in the last session (untitled, Figure 8), I heard him state
positively he wanted to make the most of this his 23rd
Christmas inside. I believed him and for once I left for
a break feeling he was not at immediate risk to
himself.
During the break my manager phoned to inform
me that John had committed suicide.
At this time John had seven staff members working
with him. His attack was probably meant to hurt and
punish those who cared for him and perhaps we were
all being made to pay for the grievances he held. The
attack was made even more painful for me by the
depth of unconscious material I was left with, feelings
from which others escaped, and perhaps having
evacuated these feelings enabled him to commit
suicide.
Hindsight is a wonderful thing and when looking
back I saw possible references to suicide in coded
messages in his last images spelling out ‘forgive me’
and an all-seeing eye (Figure 7), ladders reaching
upwards, a key and locked door, a stick figure
reminiscent of the game ‘Hang-man’ (Figure 8).
John’s images reflected the disassociated part I was
holding and I thought about how he had severed my
empathy connected to his suicidal part, having
possibly already made the decision to die. The latter
images appeared to draw in aspects of earlier pieces as
if pulling the threads of his life together. I noticed in
his final image (Untitled, Figure 8) the faraway
proximity of the tiny building in the distance. He
hanged himself away from the hospital in the grounds.
The psychoanalyst Donald Campbell describes a
feeling I recognise well when discussing his patient’s
depression lifting as he planned his suicide, whilst his
sociability and optimism deceived others:
At this critical point in the analysis I saw myself, in retrospect,
as a guard going to sleep at his post. The decisive factor in
precipitating the suicide attempt was the relaxation of my
vigilance regarding the suicide risk, a lessening of my empathetic
contact with the patient. (Campbell, 1999, p. 84)
Discussion
For patients like John who are highly dependant on
the therapy and feel a break means going away
forever, in their belief system this would give them
reason enough to kill themselves. The flip side is that
powerful patients want to keep the power and the last
Figure 7. ‘Forgive me’.
10 K. Rothwell
thing they do is inform the therapist of their ideation.
Hale (2005) describes gaps, or breaks, in therapy as
‘the killers’ for the suicidal patient who will experience
them as a rejection.
What cannot be underestimated is the necessity of
having the space to share complex material, particularly for lone working art therapists working with
intense levels of disturbance. The dilemma is how to
convey what material therapists hold when it is
essentially held in images rather than words. Like
MacLagan (2005) I looked for a descriptive language
to describe the image making in the hope that
meaning would not get lost and the ‘lingo’ could be
translated.
Therefore, the images in art therapy are important
for many reasons, not least because they are a record
of a person’s thoughts and feelings as evidence of a life
in artwork. They also provide a link with the patient’s
suicidal ideation, perhaps as a defence but to also keep
alive. In John’s case perhaps the realisation that he
was being faced with his wish to live his life with more
freedom could be explored in his art making process
but was too anxiety provoking, so great was his
dependency on others, to be realised in practice.
Nonetheless, John used the therapy to think about
death in a less nihilistic way, but as his defences
became eroded, so the apparent futility of his life
emerged. John couldn’t really get angry with anyone
so his ultimate attack or act of aggression was suicide.
Conclusion
In processing my feelings related to John’s death in
supervision I discussed my need to mourn at his
funeral alongside other team members, his family and
friends. I also participated in staff debriefings and an
internal inquiry where my process notes and patient
notes, along with staff reports referring to the days
leading up to Johns death, were analysed and, in this
instance, no blame was apportioned but lessons were
learnt and put into practice as hospital directives.
To further my understanding of the role of art
therapy for suicidal patients I have looked at how art
therapy uses a non-verbal visual dialogue that enables
the articulation of concretised belief systems and
provides a neutral space where suicidal fantasies and
desires can be explored through art making. The role
of the image may also be to provide staff teams with a
more developed awareness of the feelings and mechanisms active in suicidal patients.
For the patient I have discussed there were many
warning signs that indicated a propensity to suicide.
These included a family history of suicide and
previous attempts, withdrawal into the body, emotional blackmail, loss of concern and powerful and
consistent counter transferential material held within
our therapeutic relationship and his art making
process.
I have spoken of the fantasy imbued in suicide
being essentially psychotic in that the individual
believes that the attack on their body will not end in
death, as a part of the self will survive. Following
Campbell and Hale’s ideas (1991) the link to violence
and aggression through core complex anxieties attributes to the fear of merging and separation. The
patient I discussed became more alive in the therapy
as the development of early attunement enabled more
clarity of interpretation and thought. His integration,
however, was his downfall. As with the guard going to
sleep at his post this could be a sign, ironically, of
improvement in the patient’s mental state. However,
there is a fine line in patients who live precariously
balanced between wishing to live and die.
Returning to the Arctic Monkeys video where the
man was hoodwinked into thinking the woman was
suicidal, I similarly felt embroiled by the patient’s
contradictions and found my empathetic contact with
the patient stretched to its limits. I wondered if he
used his artwork to keep a safe distance or as a process
Figure 8. ‘Untitled’.
Lost in translation 11
to form an identity through art, regardless of which I
often felt completely in the dark. However, the
discovery of experiences that are beyond words and
feelings, aroused in art therapy through counter
transferential material, may help practitioners develop
a better understanding of the long-term effects of past
trauma, acted out through suicidal and aggressive
states, to provide more consistent and far reaching
treatment initiatives in clinical practice.
To summarise, ‘whatever else is said about suicide,
its function as a solution is born of despair and
desperation’ (Campbell, 1999. p. 76). Never was this
more apparent than in my work with John.
Please note the patient gave signed consent for
his work to be used for the purposes of
publishing and research.
Acknowledgement
My indebted thanks to Clive Rothwell, husband and
fellow Art Psychotherapist, without whose substantial
contribution of knowledge, experience, support and patience this paper would not have been written.
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Biographical details
Kate Rothwell, a State Registered Art Psychotherapist,
supervisor and private practitioner, has extensive experience in special needs, education and mental health
settings with children and adults. She currently practises
at Kneesworth House Hospital Medium Secure Unit
and lectures on the MA Art Therapy programme at the
University of Hertfordshire. Kate is a member of the
Forensic Arts Therapies Advisory Group.
12 K. Rothwell

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