‘The Application of Social Constructionism and Discourse Analysis to the Examination of Art Therapy with People with Learning Difficulties’
Author: Jamie Lofts
This study explores the application of social constructionism and discourse analysis to the examination of Art Therapy with people with learning difficulties. In particular there is a concern with the way in which psychotherapy has increased it’s influence within practice over the past twenty years.
The central question is "What factors enabled this development?"
Emerging narratives include that of emotions, normalisation, institutional and community issues, and finally professional development. Cultural factors are considered but prove to be problematic to study given the design of the study - which consists of an examination of published literature and an interview and questionnaire with an Art Therapist.
What emerges is that practice is a response, and a resistance, to theoretical, institutional and political pressures. It is suggested that awareness of such forces forms a part of good practice.
Professional and Theoretical Development.
Involvement in the provision of services to those people who happen to have a learning difficulty has drawn my attention to the changes that have occurred in the approach to therapeutic work with this client group. Of particular interest was the shift that seemed to occur through the 1980's into the 1990's; a shift that might be summed up as the move towards psychotherapy being seen as a viable intervention when deemed necessary, rather than training and recreation being viewed as the only option open to people.
Art therapy, it appears, embraced this movement, in keeping with its general move towards adopting a psychotherapeutic stance. This shift in emphasis took place against the background of structural change within the National Health Service that saw the gradual closure of large institutions in favour of smaller community based units.
My aim is to examine this particular period of history in relation to this client group, from the perspective of Art therapy. However, as well as the excavation of historical leads from published literature and personal testimony, I also hope to uncover something of the cultural and political values and assumptions that underpin and accompany that history.
This then is a qualitative study, draws upon the research traditions of social constructionism and discourse analysis. I would expect, therefore, that the question, methods of data gathering, and analysis thereof to be problematic and culturally framed. Thus reflexivity must play a key role within the study.
An expansion of the rationale and philosophy behind the research question and choice of research method will be presented, before going onto describe what data is to be considered.
Implications for current art therapy practice, should any arise from this endeavour, will be considered towards the end.
Rationale & Method
'The ways in which we theorise a problem will effect the ways we examine it, and the ways we explore a problem will effect the explanation we give.' (Parker, 1994, p.13)
Writing about reflexivity in research, Ian Parker argues that any piece of research, quantitative or qualitative, which is undertaken by subjective individuals who bring their own biases to their work. Acknowledging this subjectivity requires a justification of what it is that has lead me to investigate this subject and select a particular research path.
The main research proposition can be summarised thus: "That the relationship between Art Therapy and learning difficulties, in the U.K. became influenced by psychotherapy; a process that began in the early 1980's and has continued to the present day." This is a relatively unproblematic proposal - a review of published literature around the area of art therapy and learning difficulties confirms this. What is problematic is the asking of the question "Why did this happen?”
Why is it important to engage in this inquiry? I need here to make clear my bias. Having spent some time in the early part of the 1990's working in a psychiatric hospital, in contact with people working in mental handicap hospitals, I observed what can best be described as harsh. I am not talking here about well-funded acute wards attached to general medical hospitals, but long-stay and residential wards in old psychiatric hospitals. Containment was the prime concern it seemed. There was little in the way of activity off the ward and not much more on it. In short I felt a deep sense of injustice, an inner sense that this was wrong.
It was a relief to find that in many ways the quality of life for people caught up in such a system had improved when I later started to work with similar clients. Although in a different setting (voluntary day services, different health authority) it was clear that much had changed in the provision of services for those with a learning difficulty. As part of this voluntary work, the seeking out of relevant theoretical literature formed a strong component. It was this search for literature that drew my attention to two things:
. In comparison to other client groups, learning difficulties is poorly represented in Art Therapy literature.
. What does exist points to a gradual increase in the use of psychodynamic principles in therapists approach to working with people with learning difficulties.
Due to the paucity of relevant art therapy material I turned to other disciplines, mainly psychology and psychotherapy. It was from this extended search that the foundations were laid for this piece of research. I wanted to respond in some way to what Valerie Sinason referred to as 'reinventing the wheel' (1992, p.4) in which she describes the phenomena of each generation of therapists having to rediscover that psychotherapy can be of use to the client group. I wanted to find out if such a pattern occurred within Art Therapy.
What I also became curious about was the wider picture. What were the social and political influences upon art therapies changing approach to people with learning difficulties? What was influencing individual therapists to question current practice? Were there cultural factors involved?
This widening of vision into the sphere of social knowledge beyond the area of therapy, medicine and the hospital was encouraged by an increasing interest in the work of sociologists and psychologists, who can be described as social-constructionists. As this forms my main philosophical approach to the study, an explanation of my reading of it is appropriate.
Parker & Burman, writing about discourse analysis and psychology, state that:
'Social Constructionism encompasses a range of approaches in psychology which share the view that our knowledge about ourselves is culturally bounded and that different cultural (and subcultural) systems entail different psychologies' (1993, p.160)
The point is made that knowledge changes over time and from culture to culture, and importantly that it knowledge that is shaped by culture, as opposed to the reverse. If this is the case, bodies of knowledge can no longer claim to be value free or scientifically neutral. It is further argued that we should be sceptical about 'teleological progression' (Foucault, 1980, p.49) as the notion of progress is itself a social narrative - a product of culture. Knowledge and truth become separated.
One of the key concepts within the social constructionist system is the notion of discourse. Discourse, within this context, comes to mean both micro-level conversations, including communications between individuals, and macro-level communication between whole bodies and systems of knowledge within society (Yardley, 1997.) Acknowledging that 'truth is considered to be a situated, changeable concept' (Yardley, 1997, p.33) leads to an examination of a given subject, that takes a multiple perspective approach, more concerned with generating new narratives than the discovery of hidden truths. Within this approach is a concern to include many forms of social discourse: from the verbal, interpersonal interview, to the interplay between zones of knowledge within a professional journal article. Attempts are made to draw out (or rather allow the emergence of) potential ideologies (values, beliefs, opinions) and to note how they interact with each other, within the text and between participants - it is this that I will attempt to do.
Intertwined with this process of deconstruction is the notion of power. Within the context of social construction and discourse analysis Foucault’s conception of power 'as a productive network which runs through the whole social body, much more than as a negative instance whose function is repression.' (1980, p.119) helps to understand how competing bodies of knowledge can operate upon each other, and how individuals are able to resist and counteract dominating ideologies. It is the interaction - the relationship that exists between individuals and institutions and between bodies of professional or social knowledge- that forms discourse. Within a given dialogue competing ideologies and bodies of knowledge can be observed to be operating.
Problems do exist with social constructionism and discourse analysis. Those that seem particularly pertinent include: the danger of premature foreclosure of reading - of stifling the life of the text (Parker & Burman, 1993); the danger of not acknowledging the power of the researcher to impose their own values and judgements - particularly relevant to interviews (Burman, 1994) and the problem of relativism, whereby all views are held to be equally valid (Kenwood, 1999). I have already stated that the question I have asked is problematic. The method I have chosen to use in an attempt to answer it is equally problematic. Again it is necessary to return to reflexivity: the 'attempt to make explicit the process by which the material and analysis are produced.' (Tindall, 1994:p149). I believe I have utilised 'personal' and 'functional' reflexivity (1994, pp.150-1) by acknowledging what this research means to me individually and by taking a critical and sceptical approach to the method and its results.
As suggested already more than one source of data was utilised in this study - published literature and interviews. This is in part to satisfy considerations of evaluation through triangulation (Tindall, 1994). This includes triangulation of data and method - use is made of published literature, relating both to art therapy and verbal psychotherapy over a period running from the beginning of the 1980's up to the middle of the 1990's. In addition use was made of interview data gained from one interview, and a questionnaire, with an art therapist who worked with people with learning difficulties during the 1980's and 90's. Theoretical triangulation is at work in the influence of both psychological and sociological disciplines upon my readings and interpretations of texts.
Focusing upon the interview for a moment - this was conducted face-to-face, was broad ranging in its scope, relying upon a semi-structured approach (Burman, 1994) and occurred before I had fully formed the focus of this study. However it did help to formulate ideas about the historical perspectives of Art Therapy with this client group. The questionnaire took the form of an open question centred on the therapist’s perceived influence of social, cultural and intellectual factors upon their practice during the time frame in question. This questionnaire was sent out some six months after the interview, at which point I had a clearer idea about what it was I was studying.
Taking account of the opinion that 'research sets up, and is conducted within, power relationships.' (Burman, 1994, p.51) and challenging the 'presumption that participants within research share the research goals.' (1994, p.53) requires that I acknowledge differences between the interviewee/respondent and myself in terms of gender, and possibly also in terms of cultural background and theoretical alignment. In the presentation of my analysis and interpretation of literature, interview and questionnaire, I attempt to make transparent my reasoning behind the questions asked and themes highlighted.
Furthermore, the weaving together of primary, secondary and subjective narratives creates a new narrative.
From applying the use of discourse analysis to the chosen texts, several key narratives emerged. Examination of these ensues, each in turn, before looking at how these connect and relate to each other.
1. Narrative of emotions
Included is all references to psychoanalytic, psychodynamic and developmental approaches to psychology and treatment, including references to the emotions felt by the client group.
This is first and most obvious narrative to emerge, given the focus upon attempting to discover why Art Therapy moved towards a psychodynamic approach with people with learning disabilities. A key indicator of change is the use of clinical labels. Where Neville Symington uses 'subnormal' (1981, p.187) later authors use 'mental handicap'. Later still this becomes 'learning difficulty' and 'learning disability'.
What seems to emerge is that there was a growing belief, that those people who do have some form of intellectual disability, are as prone to emotional disturbance and mental ill-health, as the general population - if not more so (O'Hara & Sperlinger, 1997). However this appears to have been far more prevalent, and happening sooner, within verbal psychotherapy than Art Therapy. For example Symington in 1981, writing about individual therapy with a 33 year old man referred to him due to challenging behaviour, states that he 'thought it would be worth while to try to reach the anxiety that underlay it (constant questioning) and perhaps with luck alleviate it.' (Symington, 1981. p.188) and further on: '...he was beating the air with frustration, trying to induce someone to listen to him.' (1981, p.188)
The benefits of adopting a psychodynamic and psychoanalytic approach is continued by Pantlin (1985) who describes a pilot study of group-analytic psychotherapy within a residential hospital. And recognition of emotional difficulties being as prevalent within the person diagnosed as having a mental handicap, as it is within those without such a diagnosis, is taken further by Valerie Sinason’s paper (1986) in which she introduces the notion of secondary handicap. And, as well as a concern for the historical development of societies attitudes to intellectual, behavioural and emotional difference, Sinason makes the case that to have a mental handicap is not necessarily due to organic or genetic factors and is thus open to psychodynamic intervention.
This compares with Males, writing in 1983 and one year later with Stott (Stott & Males, 1984)- who, whilst acknowledging Art Therapies basis in psychotherapy and the fact that those with a mental handicap do suffer from emotional difficulties, places more emphasis upon achieving independence and promoting social-skills training.
Developmental psychology appears particularly important; stating that: 'one guide we have found very useful is the concept of stages of development in comparison with children.' (Males & Stott, 1984, p.118) and greater emphasise is given to ideas of 'normalisation' (expanded below) than to ideas about transference and insight, such as found in Symington's paper.
Robin Tipple (1992) critiques this developmental approach adopted by Art Therapists, suggesting that a purely developmental approach 'can result in some communications being overlooked or ignored' (1992, p.108). The emphasise though is still upon the individual, and their seems to be some discord between the acceptance of the developmental approach and a desire to work in a less deterministic fashion.
A slightly different approach emerges when reading Kuczaj (1990). Again there is the recognition that the emotional needs of the client group had been, for a long time, neglected - provoked by the 'prevalent assumption that a more limited cognitive capacity indicates a more limited emotional capacity.' (1990, p.117) and awareness that emotional problems, which may be a reaction, exacerbate the original learning difficulty. However, as well as looking at challenging behaviour and emotional disturbance, Kuczaj notes that the development of relationships - or lack of - with others within the institution (in this case a residential hospital) is an important factor to consider. Specifically he is concerned with that relationship that develops between client and therapist.
This focus upon current social relationships as being important to emotional well being appears more pronounced when considering those therapists working with groups. This is especially true of Sue Strand's (1990) description of her use of Art Therapy with people with mild to severe learning difficulties in a residential hospital. She writes that 'group art therapy is able to address the issues of individuals through their relationship with others in the group.' (1990, p.258) and that 'it counteracts many of the detrimental effects of the institution by working on a principal of empowering group members.' (1990, p.258). Thus there is a subtle shift from a predominantly developmental and individualistic vision of the person, to one in which they are seen as being in relationship to others, and not just with the professional therapist.
Group-analytic psychotherapy with the client group, has been described by Hollins and Evered (1990), Hollins (1992) and, more recently, by Art Therapists Lomas and Hallas (1998). What these authors share in common is a belief that groups allow members to share something of the pain involved in accepting difference, loss and dependency. Emphasis is being placed upon the value of relationships, as much as it is upon individuation and development.
The interview/questionnaire respondent states that her own practice was informed by a belief that the client group "be free to make choices for themselves" and that "people with leaning difficulties are no different from the rest of us, when it comes to feelings and emotional experience." She goes on to say that she was very influenced by the work of Sinason, the experience of working with a community based project that involved Drama and Music therapists and a feeling that it was "common sense to me to apply psychodynamic principles to people with learning difficulties."
Their aim seemed very much to do with encouraging interaction between the group members, that that in self could be beneficial, very much it seems in the manner of Group-Interactive Art Therapy (Waller, 1993). Saying that:"I also thought it was very important to get some validation and recognition for what they had done [imaging], and to help build up social confidence and interaction and communication from having time . . . if they chose . . . to talk"
What is repeated on a number of occasions is that the desire to encourage the sharing of feelings in a group, and the building of relationships was, as well as a theoretical stance, a direct reaction to the effects of institutionalisation and behavioural psychology (both of which are examined below) that she felt "dehumanised" and "objectified" people. There is a sense that they were in part motivated by anger at the system they found themselves in; that it
"was a reflection of my frustration and despair about how human beings can be treated, just because they don't have a voice for themselves"
This powerful statement is an important admission because of its uniqueness. Perhaps also those therapists looked at, whom also developed an approach that recognised feelings and emotions, did so because of such subjective feelings, but due perhaps to the constraints of academic writing, make no mention of this.
Within the discourse of emotions then, two sub-narratives seem to emerge: the person as a developmental being, with independence as a key aim: and the person as a being in relationship to others. Both views recognise and acknowledge the value of emotions and feelings, and importantly for this study, that the person with a learning difficulty is as capable of feeling the full range of human emotions as anyone else. But there is a very subtle difference between them in their emphasis upon the role of independence and relationships.
The traditional conception of psychoanalytic theory has been described as deterministic and patriarchal in construction (Burt, 1997), and just as it has been criticised for rendering women impassive and emotionally juvenile (Joyce, 1997) we might consider that it has done the same to those with a learning difficulty. Further it has been presented as purely an extension of 'old moralism' (Richer, 1992, p.117) that has been updated to the twentieth century, in which introspection and reliance upon the wisdom and authority of the therapist help to infantilise the person.
However such concerns must be read in connection with those other narratives I have chosen to highlight. They make greater sense when considering the narrative of institutional, political and social issues. The next narrative I look at: that of 'normalisation', is especially important, as it helps to frame the development and existence of this narrative.
2. Narrative of normalisation
This includes references made to social skills training, normalisation programs and behavioural psychology. These approaches seem to have been in place before a psychodynamic approach was explored.
Bruce Males is quite clear that Art Therapy be seen to be: 'specifically linked to treatment programmes, with the aim of bringing about behavioural change.' (Males, 1983, p.28.) He also states that Art therapy 'provides opportunity for the development of social skills and appropriate behaviour away from the institutional model.' (1983, p.27) and as being part of the 'philosophy of normalisation which is prevalent today.' (1983, p.29).
In a later publication (Stott & Males, 1984) whilst discussing the value of 'normalisation', Art Therapy is described as having 'an important role in creating and supporting such a philosophy.' (1984,p.114). This philosophy is described as being based around the belief that there are basic human rights, to which all persons ought to have access to. Emphasis upon aiming towards 'normal' socially appropriate behaviour is framed by Stott and Males within the movement from large residential hospitals to community based facilities; and they conclude that:
'we feel that the emphasis now placed on individual development and the greater integration of mentally handicapped people matches the philosophy of art therapist in such a way as to ensure a long and interesting relationship.' (1984, p.125)
Where Art Therapy is earlier described as espousing personal freedoms and self-expression.
However this easy partnership between developmental psychotherapy, the concept of 'normalisation' and Art Therapy, that appears above is shown to be problematic by later writers. Expanding upon the earlier reference Pantlin made about group psychotherapy with the mentally handicapped as encouraging democracy, he writes that it complements the educational and self-help work occurring in the hospital, but this that in turn causes conflicts within the institution.
'there is often a conflict in the psychiatric hospital between its role of 'care', for the benefit of patients, and 'control' for the benefit of society.' (Pantlin, 1985, p.49)
Whether 'normalisation' and education is care, cure or control, is openly questioned by Brandon (1989). Acknowledging that the movement towards training was in response to the realisation that care alone leads to dependency, he believes that there is still the danger that an 'unequal power relationship' (1989, p.9) will develop between those giving and those receiving instruction. These sentiments seem to highlight the uneasy balance being experienced at that time within institutions and the community, between the different therapeutic philosophies that in turn advocate freedom and individual choice whilst attempting to achieve appropriate social behaviour. Powers existing with those whom define 'appropriate'.
Art Therapists also began to question the ethos of 'normalisation'. Kuczaj firstly points out the institutional preoccupation with the production of objects within training work, that he sees as stemming directly from the initial philosophy that inspired the founding of such institutions. That being: vocation as a means to salvation, and 'in order to save society from a 'dangerous' degeneracy.' (Kuczaj, 1990, p.116) He links social skills training to this philosophy also, noting that it also helps 'to bring a sense of direction to what often seems an area of work full of unknowns and uncertainties.' (1990, p.116); implying that the use of training was used as much to aid staff in their negotiation of institutional pressure as it was for the benefit of clients. Kuczaj goes on to explain that attempting to work within this philosophy of care, and at the same time take account of the emotional needs of the people he was working with as an Art Therapist was problematic; essentially because such philosophies, he felt, do not recognise emotional needs.
A similar problem existed, Kuczaj found, when attempting to introduce psychotherapy (via Art Therapy) into a system that also employed behaviourism as a treatment method. He writes that 'the introduction of a psychotherapeutic medium alongside this approach has had to be a slow and careful one.' (1990, p.127). Although not specific as to why such a cautious approach is adopted, it appears as if this is as much to do with a concern for multidisciplinary harmony as it is for client safety. Whilst acknowledging the tendency for behaviourism to be a rather blunt instrument, he indicates that Art Therapists often found that people with challenging behaviour were referred to them.
Sue Strand continues the uneasy alliance that seems to have existed between Art Therapists adopting a psychotherapeutic model and the prevailing use of training and ‘normalisation’. She notes that it 'became acknowledged that people with learning difficulties have educational needs that do not just stop at eighteen years.' (Strand, 1990, p.255) and applauds the value of promoting independence. However she repeats the claim that there is the danger of reinforcing childlike dependency if it is always the staff giving instructions and clients receiving them; that it can add to the overprotection leading to a 'childish and sexless state' (1990, p.256) that enhances the person’s already acute and isolating sense of being different. The claim that power is unbalanced in such a regime is reiterated, and given a new twist, by her assertion that 'The behavioural approach establishes a sense of hierarchy or conflict between staff and residents which actually encourages individuals to rebel as a healthy act of self-assertion.' (1990, p.256)
Such a view would appear to fit with a conception of individuals resisting and asserting power that 'can be analysed as coming from the bottom up' (Sawicki (1991) quoted in McGowan, 1994, p.95).
Strand goes on to state her belief that just to mirror the 'world of work and leisure' (Strand, 1990, p.257) is not enough, that it is important to confront the issue of institutionalisation and the accompanying effects upon the self. Her approach to this is to use group Art Therapy as a means of building relationships and combating isolation that in the process might contain some elements of social skills teaching.
That behaviourism and social-skills training was often the treatment of choice within institutions - as opposed to psychotherapy - is lamented by Gravestock and McGauley (1994), who point to the statistics that indicated that many therapists did not consider people with leaning difficulties to be suitable for psychotherapy. Thus, there appears to have been a situation in which therapists trained in the use of psychotherapy, were working within institutions that operated treatment philosophies that jarred with their own.
This theme is reflected in the interviewee’s response.
"The prevailing approach we encountered through day centres and social services was "normalisation" - which stressed the need for people with disabilities to be treated like everybody else (i.e. as normally as possible) but which was often used in a more socially controlling and conforming way."
They go on to say how this conflicted with the Feminist principles of the organisation they were working with, when 'normalisation' was applied to such things as encouraging women clients to wear feminine clothes.
Sinason, who advocated an awareness of emotional needs in all cases of disability, is referred to as being especially important, given the environment that they found themselves: "because the dominant "therapeutic" treatment used in the hospital was behavioural, which focused on behaviour and almost objectified people, so that staff seemed to rarely empathise with clients. I found this very dehumanising"
In talking about the use of Art Therapy within an institution that had been using Behaviour Therapy and Industrial Therapy they said the following:
"for someone to come along and start implying that there are big psychological issues going on . . . I think they view us as being in our ivory towers" and "It's [Behaviour Therapy] seen as the method of working with people with learning difficulties. And so again talking about feelings, things like that, is a bit irrational. Not subjective, not clinical enough. So there's part of that in terms of how we are probably viewed by other professionals."
Art Therapists operating within institutions seem to have worked with a prevailing treatment philosophy, but at the same time were inspired to challenge and resist it. References to Behaviourism, social-skills training and 'normalisation' make no appearances in later publications (Rees (1998) for example).
Either Art Therapists have come to a happy compromise with such treatment philosophies, or perhaps such treatments have been supplanted by psychotherapy and other treatment philosophies. It might also be that Art Therapy in general has moved sufficiently in the direction of psychotherapy (Waller, 1992) to no longer feel it has to compete openly with- or define its self in relation to - those other approaches.
That Art Therapists had to work within wider institutional and social environments with philosophies that may have been in variance to their own leads into the next narrative.
3. Narrative of Institutional, Political & Social issues
Includes references to the institutional structure, and the role that community care and social integration policies have played in the shaping of practice. Looking also for issues of gender, race, class and other power relationships that are directly or indirectly written or spoken of.
The concerted shift of emphasise from care within the institution to care in the community, in relation to people with learning difficulties, is well documented and described (Office of Health Economics, 1986; Symonds & Kelly, 1998). Although this movement was well under way from the early 1980's onwards, much of the writing I have looked at seems to suggest that many therapists still worked predominantly within large institutions. And as well as making references to the institution some were also willing to take into account wider social attitudes and practices.
Symington (1981), as well as taking account of the effects of psychotherapeutic practice upon staff, discusses social attitudes towards mental handicap, stating the following 'It is an interesting fact that, even in our so-called enlightened age, mental illness is surrounded by a powerful mythology.' (1981, p.198) going on to explain how he feels the person who presents as having a mental handicap, is very often reflecting an internalised sense of deficiency that is projected onto them by their family and society.
He also makes the assertion that the lack of interest in employing psychotherapy with this client group was in part to do with the fact that as carers 'we are retarded in some areas of our mental functioning . . . It is only too understandable that we prefer not be so reminded.' (1981, p.199)
This drawing together of psychotherapeutic principles and an awareness of social attitudes was taken up and expanded later by Sinason (1986, 1992). As well as an account of the social history of the words and labels attached to those who behave differently, she makes reference to Bicknell's observation that the ‘whole network around the handicapped is often equally involved in fighting insight to keep the handicapped individual in his secondary "sick" role.' (Sinason, 1986, p.133) indicating that the denial and projection of social and institutional disability plays a role in maintaining handicap (within clients and careers.) She also indicates the role of poverty and deprivation, suggesting that 'in many cases the handicap is environmentally caused.' (1992, p.10) as opposed to an organic or genetic origin. Further she repeats a view that it is not nature but politics that is at the root of much disability and handicap.
Brandon (1989) is overt in his criticism of institutional and community care models, pointing out the detrimental effects of 'negative and casual images' (1989, p.5) and the history of people with learning difficulties being seen as deviant. The process of segregation that he sees occurring within institutions (schools and hospitals) are just as likely to occur within smaller community based environments; something Tomlinson (1991) refers to as 'Transinstitutionalisation' - the process of the transfer of practices from one institution to another (albeit smaller) one.
The effects of the philosophy of community care, and of institutional structures upon clients and professionals also appear in the work of Art Therapists. In 1983 Bruce Males states that 'Most Art Therapists in mental handicap presently function from hospital bases - the move to Community Care, however, need not be a threat to Art Therapy, any more than any other professional group in Mental Handicap.' (Males, 1983, p.30)
This statement would seem to suggest that there was concern about the future professional role of Art Therapy within the community at that time.
In the work of Kuczaj (1990) he describes his experience of the hospitals focus upon production and employment. He also says that the lack of recognition that people with learning difficulties show any real emotions 'may be due to the institutions characteristics of rigidity and conformity which leave little room for personal expression of feelings.' (1990, p.116), giving the example of bereavement being dealt with through denial and neglect by both clients and staff. He further links emotional disturbance to institutional structures, stating that 'an institution or caring situation can disguise many problems.' (1990, p.122)
Whereas some Art Therapist writing about their work may only briefly allude to the environmental impact upon their clients and their development of practice, others certainly have. One such therapist is Sue Strand. Her 1990 paper 'Counteracting Isolation' is based around her belief that it is the institution of the residential hospital that is the prime cause for 'isolation, dependency, passivity and lack of any feeling of individuality.' (1990, p.255). I have included already her comments upon Behaviourism and social skills training. What she also asserts is that the institutional focus upon behaviour makes the acknowledgement of feelings difficult. She notes that one way this occurs is in the staff not having an adequate vocabulary to describe the emotions and feelings they observed clients exhibiting.
The importance of the institution upon Strands practice is made clear when she states that 'People with learning difficulties may have no memory of an outside life, no status, influence or even, literally, a voice with which to protest if conditions are bad.' (1990,p.257). Going on to say that 'the important issue to confront is the institutionalisation and the adjoining sense of personal and emotional repression.' (1990, p.257). It is in response to the powerlessness and deprivation that she sees as being an inescapable product of the institution that she introduces group Art Therapy based around the principles of group-interactive psychotherapy, in which she feels clients are able to gradually assert control, explore their emotional reactions to their handicap and environment and build relationships, that would otherwise be impossible. She concludes with the following: 'The group attempted to counteract the destructive effects of institutionalisation and the isolation that this vulnerable group of people experience in a society which has yet to empathise fully with or understand the experiences of being a person with a learning difficulty.' (1990, p.263)
Of importance here is the very clear and direct link between the therapists personal reaction to an institution and their development of their practice.
The answers provided by the interviewee/respondent reveals a willingness to react to institutional and social structures. First is their belief that working as part of a community based art project, with therapists from other creative paths had a big impact upon them.
"An important factor in our work was about integrating groups for people with and without disabilities, and involving people with disabilities in arts activities which helped them to socialise with and contribute to the wider community"
They go on to say that the 'People First' movement was a strong political influence upon the groups work, as was Feminism. This is contrasted with their experience of institutions, that were experienced as being "very stuck with the dependency of their service users" and of reinforcing institutionalisation through their use of behavioural approaches to treatment.
Reactions expressed include the following:
"one of the most desperately depressing things about the institution was that people lived together but had no . . . they didn't even know each others names"
"they [staff] don't like to see that people are struggling, they don't like to see pain; they want to see success."
"I found it quite difficult at times to get people to take what I was doing seriously"
"it was very dehumanising"
It appears that this particular therapist went into the institution already prepared to utilise a psychotherapeutic approach to Art Therapy, but met with institutional resistance and misunderstanding. They talk about a Psychiatrist not being used to presentations of clients work; staff impinging upon therapeutic boundaries, and a general denigration of expressive endeavours (something that they attribute to the wider society also: "our attitude as a whole society toward art is product orientated"). In spite of this it seems they did manage to stick to their beliefs in the value of psychotherapeutically orientated Art Therapy and in some way to counteract the institutionalisation they saw around them.
That it can be difficult to pin down political and cultural influences is evidenced by the following comments:
"I became aware of Valerie Sinason's work in the context of a level of political awareness which is hard to define, because these things are usually 'in the ether'."
"The political activities of the 70's and 80's which challenged notions of labelling and seeing the disability not ability must have played a large part in the thinking of many of us working with clients in the 1980's and 90's. I haven't thought about it before but I am sure this is true of me."
A picture emerges then of many therapists being aware of both institutional and social attitudes and structures that exacerbated, or even lay at the roots of, the problems that their clients presented with. The main issue that materialises is that the working environment of the therapist does seem to have played an important part in the shaping of their practice. Some attempted to integrate with the predominant ethos, which seems to have been mostly behavioural in approach; others reacted against and resisted, what they perceived as a disabling environment through the introduction of psychotherapeutic models of therapy; whilst others anticipated the move into the community as an opportunity to expand their services.
This narrative holds particular interest for me, simply because of my own felt reaction to working within institutions, and being aware of social attitudes seems to match some of the anger and dismay that is alluded to in the above. I specifically asked the interviewee/respondent about their thoughts on institutional, social and political influences. In fact it may be the case that I chose to approach them because of what I had previously read about their work, feeling a certain political affinity with them. Interestingly they said the following "art therapists are far more likely to be critical of the structure of the place" - how true this is of other therapists I do not know, but it resonates with my own political consciousness.
A critical approach to the issues of institutions and the community is certainly not without precedent. It was an area of inquiry that received much attention from Foucault in his studies of asylums (1961) and prisons (1991)- the appearance of both being linked to the liberal notions of personal discipline and social control. Peter Barham has written about institutional and community attitudes to mental illness (1992; 1993) noting that the philosophy that underpinned the asylum (moral control) has been transferred to the community via more subtle means than incarceration (e.g. drug therapy). Elsewhere Mays (1991) points to the differing and sometimes conflicting views about what community care is amongst providers and users. The subject of institutional and community care then, is vast and far from simple and the evidence I have presented in this narrative does seem to indicate the problems facing any therapist in trying to negotiate it.
4. Narrative of Professional development
The final major narrative that I have identified is concerned with ways in which texts are used to argue for the place of a particular therapeutic stance to be recognised within the institution and the National Health Service. In many ways the above narratives are all concerned with this, but here I am highlighting specific points where authors put forward a case for professional development. Also of note is the appearance of the case that art therapy can offer something unique to those people with a learning difficulty; that there may be something intrinsic within Art Therapy.
In her desire to put forward a strong case for psychotherapeutic practice Sinason is careful to not denigrate 'the value of the increasing good treatment practices that have developed in other disciplines over the last decade.' (1992, p.13), at the same time she laments the lack of the widespread use of psychotherapeutic ideas within work with the mentally handicapped (although acknowledging that the situation had improved since the 1970's.)
One of Sinason's most interesting statements is the following: noting the tendency for Psychotherapists, who make the discovery that people with a mental handicap can benefit from psychotherapy, to move on into other fields, she states her belief that 'ten years later another psychotherapist is reinventing the wheel.' (1992,p.4). She supports this view with reference to a number of authors who, over the years, have indicated the value of applying psychoanalytic ideas to work with mental handicap; these include Ferenczi (1929), Chidester and Menninger (1936) and Bourne (1955). Her point being that despite individual cases of realisation there has been little continuity or sustained research. Those narratives that I have illustrated above do seem to point to psychotherapy being the exception rather than the rule, more so at the beginning of the 1980's. Of note is Sinason’s assertion that an important realisation is that good verbal communication skills are not necessary for participation in psychotherapy - thus pointing to the use of Art Therapy.
This is a view that is held by Males who states that 'Art Therapy provides an alternative means of communication for a group of people with profound communication problems.' (Males, 1983) However Males emphasis is more upon normalisation and social skills training than it is upon purely psychotherapeutic aims, even though he acknowledges Art Therapies roots in psychotherapy. In a later article (Stott & Males, 1984) 'directive' and 'non-directive' approaches are presented as two ways that Art Therapy can be used with the client group, being a topic that seems to have played an important role in the shaping of Art Therapy in general (Waller & Dalley, 1992).
Kuczaj (1990) describes his development from an art instructor to an Art Therapists, and the development of a handicrafts department to an Art Therapy department with the emphasis now towards psychotherapy rather than recreation. He presents the view that whereas art is generally considered to be important to the growth of the client, 'Art Therapy aims to be more specific in terms of its role when dealing with someone's emotional state or behaviour.' (1990, p.118). What appears important is a desire to understand what is the best way of using Art Therapy with the client group. Is it something within the nature of creativity and expression, or is it about the interaction with a therapist that is of value?
This question is continued by Robin Tipple (1992) who highlights the fact that Art Therapists have always worked with people with learning difficulties and that much of that has been 'studio-based' (1992, p.106) and non-directive in which it is the intrinsic properties of creativity that is valued, although Tipple is keen to promote the use of a more psychodynamic and psychotherapeutic approach.
Those working with verbal psychotherapy seem also to be keen to promote their profession with the client group. Gravestock & McGauley (1994) report upon the value of group psychotherapy with the client group, whilst saying 'that more resources and research are required to establish the effectiveness of various psychotherapies for people with LD.' (1994, p.165) - something that Pantlin (1985) had asked for ten years previously.
As already mentioned the interviewee/respondent stated that being able to work with other therapist from different paths was of use in her own professional development, as was the fact that within the institution she was not the only Art Therapist. She holds a similar view to those Art Therapists above when they say that "Obviously art therapy provides a different way of expressing and 'articulating' feelings that can offer an opportunity to communicate with others." also saying creativity is able to help raise self-esteem.
An interesting historical insight is given when they state that at the time of their training they did not come across literature concerning Art Therapy and learning difficulties, nor did they receive training concerning the use of groups - that came later when working with Drama Therapists.
In talking about the value of group Art Therapy, they present the following:
"there's that group aspect and the process of Art Therapy, by putting things down on paper you externalise, you let feelings out and you put it into clay or paper or whatever."
Added to this is the value of having that externalisation recognised by the members of the group.
They are also keen to point out the difference between the recreational use of art and the therapeutic work that is carried out in Art Therapy and the importance, they see, of keeping the two things separate to avoid value judgements about art products adversely effecting the client. Pointing out the belief that Art Therapy works at a deeper, more "profound" level, something that the recreational use of art is unable to do.
Again they state the importance of Valerie Sinason’s work, and that of the Tavistock Clinic, to their own development - saying that in the late 1980's they came across very little psychotherapy employed with the client group, and no history of working with groups at the institution they worked at; but ten years on they felt the situation has changed - that psychotherapy is more prevalent and literature more widespread.
This seems like a far harder narrative to get a grasp of than the others examined. There seems less direct reference to professional development, but as already stated, the arguments all the authors have put forward about their particular practice can be read as them stating a claim for their way of working to be noticed and taken seriously.
It is necessary to now draw upon all four narratives in order to expand the points raised, and to gain a fuller picture of those forces upon Art Therapy that allowed it to develop in the way it did.
Having presented the four key narratives, an attempt needs to be made to draw them together and to put forward my interpretation.
Several themes emerge.
What strikes first, are the strong links that seem to exist between all four narratives. What appeared, during a first or second reading to be quite distinct, in the process of analysing, becomes far more interrelated. For example the presence of the behavioural model, is not just perceived by therapists as an abstract theory and set of ideas, but is present within the structure of the institution itself. Thus any attempts to offer a service that has a different ethos (i.e. one that is far more concerned with feelings, or one that is inspired by individual freedom) must come into contact with that very real space of the institution - it's rules, it's professional hierarchy etc.
Some things changed drastically during the time frame looked at. For example: labels, the provision of care in the community and integration policies. But other things, the philosophical values, have remained largely intact: the dilemma between valuing differences and attempts to achieve 'normal' goals (for example, independence may be seen as representing another form of applying social norms and values). One area that seems to have changed a great deal is the recognition that those people who do have a learning difficulty, can live happy and fulfilled lives, and equally are as prone to emotional pain and trauma as anyone else - it must be accepted that this realisation is a result of the philosophy of 'normalisation' and the insights provided by psychotherapy. Both of these value systems have informed Art Therapy practice with the client group over the past two decades.
That Art Therapy does have its roots in psychotherapy is confirmed by studies carried out by Dianne Waller (1991; 1992). And all of those therapists taken into account acknowledge its importance (even when they do propose ways of working that do not always seem compatible with it). But she also demonstrates how Art Therapy has a history that includes art education and Occupational Therapy, and that these are associations that have had to be resisted in the development and recognition of Art Therapy as a unique entity. It might be that the earlier ways of working with the client group were very much more to do with recreation or education, and that this interfaced easily with a system of care based around behavioural and social-skills training. As Art Therapy has become increasingly recognised as a profession and at the same time aligning itself more and more with the profession of psychotherapy (Hogan, 1997) so it is that therapists have been far more willing and able to provide a unique service within institutions.
Of interest is Waller's (1991) reference to the work of Bucher and Strauss's 'process' model of professional development.
'In this model, a profession is seen in terms of segments, missions, and evolution, and in relationship to the political and economic fluctuations of a given society.' (Waller, 1991, p.xiv)
It is the stresses and conflicts within the profession that enables new developments to occur. Such a model can easily be seen to be appropriate to that of Art Therapy in the field of working with learning difficulties, as evidenced by the different treatment philosophies Art Therapist were willing to embrace.
What is of particular interest is the point made above about the influence of politics upon change. Looking for political and cultural factors that might explain the development of Art Therapy with the client group had formed part of my original intentions, but this proved harder than anticipated, especially in relation to published literature. Far greater success with this particular aim was gained from the interview and questionnaire - this is in part due to me specifically asking them questions about what role cultural and political values had upon their practice, partly perhaps because they were more politically motivated, and maybe partly because of the freedom of anonymity. But, even though they were able to say something of the impact of social values, and political action upon their development, they also say how difficult it is to pin this down. What they were able to identify as influencing factors were: Feminism, advocacy movements and the general challenge to medical labelling. Also each of the therapists, in their own way, to varying degrees, have commented upon the political and social system, even if that is 'just' about the politics and culture of the hospital.
From looking at such opinions it seems that a major political impact was that of the slow closure of residential hospitals and the move towards community care - a process that Tomlinson (1991) sees as a product of a 'dissatisfaction with the cost-ineffectiveness and under-achievement of centralised social planning.' (1991, p.1) and of the need to contain welfare spending. Essentially then it has been the philosophy of 'rolling back the state' that has had one of the biggest impacts upon work with this client group. It is significant that an essential component of that political credo is the encouragement of individual responsibility - a concept that is central to medicine (Radley, 1994) and social discourse (Foucault, 1980). Such an emphasis may be seen as being responsible not only for the policy of community care, but also for the philosophy of 'normalisation' and of encouraging individual therapists (and emerging therapies) to make a bid for theoretical and economic attention in the medical and welfare market place.
Other cultural and political factors are certainly less forthcoming, such as ethnicity, class and gender. Few of those therapists looked at, make a mention of cultural factors within their assessment of their clients or practice, fewer still make a reference to their own culture as being of importance. This is perhaps understandable, given that the value and importance of such issues upon therapeutic theory and practice is a relatively new phenomenon. This might seen to be especially true given that 'it is not always recognised that people with learning difficulties face issues other than those connected with their disability.' (Fennell & Jones, 1998, p.194) One piece of work specifically focuses upon gender issues in learning difficulties, contains the following statement: '. the dominance of our services by implicit male views elevates independent functioning as the most important goal and emphasises the individual as the focus for change via technical input. The significance of relationships and feelings in this enterprise are notable by their absence.' (Clements et al, 1995, p.429)
Such criticism sounds remarkably similar to that levelled against behavioural regimes by therapists advocating a more psychotherapeutic approach. Whether it is appropriate to apply such a reading, as that presented above, to those therapists whom I have mentioned seems unclear - simply not enough information exists in this study to draw a firm conclusion - but it is a possibility.
If a central conclusion is sought, it is that Art Therapy with people who have learning difficulties is framed and constructed by the social and political context it operates within. The adoption of a psychotherapeutic model was more than just a theoretical development, but was the product of co-operating and resisting institutional systems; of attempts to achieve a greater degree of professional autonomy; and the product of a political consciousness.
As to discovering a pattern of discovery and forgetfulness - that Sinason (1992) suggests exists in this field - this study is unable to respond. If in ten years time a continuum of approach can be seen to exist with Art Therapy in relation to learning difficulties between then, now and ten years ago then perhaps it will be possible to say that such a pattern has been overcome.
Finally, what then can be learnt from this study that is applicable to current practice? Is it the case that a highly critical and sceptical stance to current practice need be taken? I believe that the emerging narratives - and the focus upon the negotiation between therapists, treatment philosophies and institutions - highlight the importance of attempting to uncover the underlying philosophical, social and political currents that have led to Art Therapy operating the way it does today; the value of becoming aware of the ways in which therapy is a product of institutional systems; and of acknowledging the role of personal politics upon therapy.
Good supervision is based upon taking a critical stance of ones personal impact upon the therapeutic encounter (Casement, 1985); I would argue that such a stance should encompass political and social, as well as purely psychological, agendas.
Given the way this study was designed and conducted, with a heavy reliance upon published literature and less use of asking questions directly of therapists, it is unsurprising that some issues that I had hoped would have been more amenable to examination, have remained hidden. I am thinking in particular about person specific cultural values (ethnicity, class, gender etc.) A future study that did rely far more heavily upon focused questions via interview or questionnaire, would I feel be more productive in this area.
However I do feel that the application of social constructionism, discourse analysis and an awareness of the operation of power within systems of knowledge and institutions, has been an appropriate means of study given the focus upon uncovering historical strands.
That Art Therapy can offer something of value to those people with learning difficulties whom are in need of emotional support and understanding and the suitability of such clients for psychotherapy is now generally accepted.
What is required is a continual questioning of the way in which therapeutic practice is constructed and framed, especially given the historical vulnerability of this client group to forces outside of its influence.
Given the increasing professionalisation of Art Therapy and the current trend towards the decentralised provision of care, it would seem important to continue examining ways in which therapeutic practice can be both responsive, and critical, of the different theoretical and structural environments it operates within.
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