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Integrating Art Psychotherapy and Cognitive Analytic Therapy (CAT)

Rose Hughes, 2013. Integrating Art Psychotherapy and Cognitive Analytic Therapy (CAT). Reformulation, Summer, p.44,45,46,47,48,49.

A case example: Joan

Keywords: non-directive, trauma, transference and counter-transference, elaborations, grief process, embodiment, symbolic, witness, Jung, Freud, Edwards

This case study was presented as slides at the ACAT annual conference at the British Library in 2005. It was, at that time, intended to show the therapeutic beneï¬t of using images in the therapy process and to outline some central concepts of art psychotherapy. For this reason, and because of the passage of time and my move from the service where I worked with Joan, the CAT tools that accompany this case are sketchy. However, these included the observance of a time-limited treatment, in which time Joan received a reformulation letter and an SDR and we exchanged goodbye letters.

In the years since Joan’s therapy I have integrated CAT and Art Psychotherapy with many clients in the NHS settings in which I have worked, including an Adult Psychotherapy Service, a Psychology Service and as Head of Art Psychotherapy within a Community Mental Health Centre. In each context and within each case, the balance between the use of each ‘tool’ has varied in response to the client’s inclination in discussions with me about what the art making and the verbal and CAT diagrams seem to be adding to the focus of the therapeutic work. The descriptions I share here were co-authored in the sessions, ï¬nding meanings that made sense for Joan.

For Joan there were two processes which held and integrated the therapeutic aims of her treatment. There was her history of sexual abuse, which had remained a family secret, and the current impetus now in her mid thirties and beginning married life, to hope for a happier family life than she had experienced herself. She wished to work through and move forward with an improved sense of herself in the world. In this aspect Joan spontaneously and dynamically felt able to express through art making that which had felt so unspeakable and remained unheard since her abuse by the husband of a close family member throughout her adolescence. Her intuitive aim was to work through this trauma.

The second process utilised CAT to make sense of her current frustrations and distress with her parents and family and the denial and concealment they insisted upon, not only to the outside world, but also within the family. It was as if her parents had taken a rubber and erased this trauma from the family narrative, from Joan’s reality and as such gave her the implied message that she and she alone should carry this burden. In the past Joan recounted how she had taken on this role magnanimously, but very dangerously, by offering herself as a ‘victim’ as she had internally authored her explanation for abuse in part at the time of her abuse. This was in a bid to protect her younger siblings. Later, as part of this pressure to turn her abuse on her self, as her family and the abuser had done, she described how she would sit in lonely isolated settings to offer herself as a victim to any rapist or paedophile who may be passing and hoping that she would be a sacriï¬ce to quench their perversion and so protect others. She had begun to see something transcendent for herself, perhaps as a way of processing her deep sense of vulnerability and as a form of social rescue as substitute for the absence of appropriate rescue and care from her family.

Another CAT ‘snag’ attempt at healing had been to marry a close relative of her abuser, as if again to create healing for herself and others in a symbolic dialogical way that was not successful, as it implied healing within the family and with her abuser without redress for her. Later, she attempted prosecution of her abuser through the legal system of the country where the abuse took place. At the time I met her, this case had been in due process for a number of years and offered some prospect of acknowledgement for her, taking the seriousness of her abuse through legal channels and ending the wall of denial, concealment and betrayal which existed at a number of interpersonal and psychological levels.

In our work together we teased out reciprocal roles in her relationship with her parents and the message that she should be silent and protect the family and not distress others with the truth of her entrapment and rape. Recognising how these roles persisted and played out in the more current interaction with her middle class professional family helped her to recognise where the potential lay for healthily relating with her second husband and within herself and within her work and social circles. Our work supported her to think about how to respond to family dictates and her deep pain of being overlooked and martyred; roles she now sought to process in ways which took care of her and did not offer her up as a scapegoat to avoid the unpalatable deceptions of sexual abuse .

The images in this article will, I hope, communicate to you the struggle for emergence and expression of buried feelings that Joan brought to her therapy sessions. The descriptions of the art process and the images are the result of the shared process of making meaning that is the three way dialogical process of art psychotherapy: client, therapist, object. Joan defended against painful feelings through a buoyant ‘in control’ persona, the persona esteemed within her aspirational middle class family. To compensate for the neglect and disregard she experienced since her life narrative presented her and the family with the ‘victim’ role, leading Joan to some sanctuary through her identiï¬cation and vitality in defending the weak and vulnerable.

However, this defence allowed no place for her own wounded inner child to exist. The silence demanded by her abuser and then by her family was internalised and blocked ‘working through’.

In art psychotherapy we have, as professionals, many prior years of practical and theoretical study of the art making process, for example the symbolism of style, material, image and process along with the dyadic process particular to a therapy where the therapist can sit alongside and witness the transferential material in the art object as well as understand and speak through and to the transference held in the art object/image. A cornerstone of art psychotherapy of the British Association is the non-directive approach. Freud deï¬ ned this in 1909 and noted the importance of the therapist’s role to:

receive impressions
suspend judgement
evenly suspend attention

This analytic practice supports the art maker’s free expression, rather than the therapist’s directed work. Freud (1909) wrote that it was not our business to understand a case all at once; this is only possible when we have received enough impressions of it. The image, the client and the therapist work together to inform and ï¬‚esh out these impressions through discussion, feelings and enactments in the transference. In CAT we do something very similar and ï¬nd that art psychotherapy provides a language where words cannot be found, where words may limit or restrict or may be curtailed by defences, where the unconscious can speak through images, by passing intellectual ï¬ltering.

To help describe Joan’s therapy process to you I have grouped a small selection of her many images as they link to the well recognised phases of grief. The grief process seems to me to parallel in a broad sense the ‘working through’ of traumatic experiences which as either shocking or depriving life scripts include the following phases of grief.

shock and denial
suffering
disorganisation
aftershock
reorganisation
hope

Joan’s art works produced in therapy were in pastels, paint and clay. In her art making and the therapeutic process and therapeutic relationship Joan began to reach into and connect with the authentic feeling responses of her hidden experience. This was an integration she felt ready to inhabit. In the room the art making was sometimes accompanied by our joint silence and sometimes by discussion of disparate themes and concerns and at other times, usually when a piece was ï¬nished, a space for Joan to describe the process, how she felt, what thoughts came to mind and sometimes I would note an aspect I had witnessed in the process.

Works in Clay

In Joan’s works in clay (ï¬ gs 1 and 2), the manipulation of these almost life size pieces of clay seemed to physically empower and catalyse as Joan’s physical power controlled the medium where she had been powerless under the physical dominance of her abuser and emotionally in the restricting and avoidant gaze of her family. The clay sculpting required manipulation, control and effort thereby serving as an embodied and symbolic redress to abuse and silence. At an expressive narrative dimension they were also revealing and containing.

The horror and yet seemingly paradoxical silence of this scream with the ears and eyes so prominent, but the mouth and neck caught somewhere between horror and muted passivity, reveal the tension between suffering and shock at the heart of Joan’s psychic predicament. This traumatised response, not entirely dissociated, but trapped and powerless in relation to her abuser, and reinforced by the absence of a ‘caring other’ in her actual and internal world, no other to acknowledge her anguish. My role as therapist provided the potential space for a new role, to bear witness with compassion and a containing space for feelings and thoughts to be processed.

These hands appear to be tearing at the face and seemed to reï¬‚ ect aspects of Joan’s visceral response on a number of levels around her attack and the attacker. The hands appear to belong to another and to be destroying her clay face. In this image there is both the abuser and the abused enmeshed in the conjoined clay and in the invasion depicted. Carl Jung described how depicting trauma in art can help to take away its traumatic impact and this is something central to the emotional processing that art psychotherapy can support. Jung said:

“… you can get a patient’s mind at a sufï¬ciently safe distance from the unconscious, for instance by introducing him to draw or paint a picture of his psychic situation”

“In this way the apparently incomprehensible chaos and unmanageable chaos of his total situation is visualised and objectiï¬ed"

“It can be observed at a distance by his conscious mind, analysed and interpreted”

“The effect of this method is evidently due to the fact that the original chaotic or frightening impression is replaced by the picture which, as it were, covers it up … made harmless and familiar”.

Art psychotherapy and the CAT tools seemed to combine to contain and support Joan’s increasing sense of herself and others and increased her sense of self as observer, participant and agent for her future.

In summary, the picture interposes itself between the painful experience and the individual and keeps terror at bay.

Works in Paint and Pastel

Here again, like the clay pieces, Joan portrays a scream; her scream. This time, there is more sense of her presence, rather than the psychic retreat of the previous image. The proximity of the face to the viewer mirrors its closeness to her face as she drew it, its intentionality towards her rapist, now with teeth! and for myself and others in her internal world of characters, to see, to witness, to not avoid. The tongue sat at the back of the mouth and the lower interior revealed is the moment at which the scream is expelled, its intensity and her gaze is direct, only here the frame of the page restricts. Her feeling is bigger than the container, yet contained by this representation.

In the following image, ï¬ g 4 we can see that Joan is representing a physical action. The painting was made by brush and by hand as if smearing and all the physicality that this associates to. In this contained and safe therapeutic context Joan was able to draw out, to depict and place the horror outside of herself, revealing the awfulness of being physically and psychologically trapped inside the abuser’s mess. The hand may also appear to reach for a helpful other, to be caught in the moment of anticipation and hope. The helpful other did not appear and Joan was not rescued. As we have seen, Joan tried many ways to process her vulnerability, through risk taking martyrdom, caring roles and various interpersonal relational strategies to heal and restore equilibrium. It is as if the artwork gave opportunity to reï¬‚ect and rework with the more benign presence of the therapist.

The following ï¬ ve images, ï¬ gs 5 to 9, are taken from an extensive phase in Joan’s therapy. They appear to show aspects of turmoil, distress and disorganisation. These images encapsulate the suffering and vulnerability as they exist alongside the internalised representations of the abuser’s violence and Joan’s resistance and powerlessness. This internalised dynamic we recognise in CAT as the abusing to abused reciprocal roles procedure.

In this image (ï¬ g 5) the browny-red forms seem to try to invade the central black shape, which in turn seems resistant and closed.

In this image (ï¬ g 6) and many similar ones later in the therapy, the shattering violence was linked to her experience and reclaimed afresh in terms of her own vitality and dynamism as if the controlling other was overthrown, this dynamism existing both in the narrative and in the art making process, now on large sheets of paper with ample use of paint.

In a later phase (ï¬ g 7) we can see expression of vulnerability and a sense that the therapeutic alliance had come to a safe containing space for Joan to feel vulnerable and importantly; contained, not bury or take risks to manage her human vulnerability, which had been so cruelly exploited by her abuser.

In this clay piece (ï¬ g 8), the foetus-like form is emerging out of the clay and in the next slide (ï¬ g 9) the form is growing in size, literally on the page. The light area in the head can perhaps be seen as the development of a new self, a new sense of identity and integrity, importantly the invader is less actively present. It was during this phase of therapy that Joan and her husband conceived their ï¬rst child. This foetal- type imagery illustrates clearly how multi-layered meanings can exist in the art image and how elaboration in discussion and expression can hold many themes all in a piece. Joan was delighted to be pregnant and as a strong woman physically, her dominated and exploited self was enabled to be shed as she protected and waited for her baby to arrive with conï¬dence and joy.

Alongside the continuing and cyclical work of processing shock and terror there began a more active and intentional phase of transforming disorganisation into reorganisation. Art in psychotherapy can facilitate the expression of dissociated feelings and can lead to their conscious and subconscious reintegration and acceptance. Art can support the reintegration of disavowed and polarised aspects of one’s life and personality. In Joan’s case feelings and events which were overpowering and make vulnerable could be reclaimed and reworked creatively.

Joan linked this image (ï¬ g 10) to her feelings of loss and anxiety, but with a new element, where the once alienated forms, now move from both sides of the page, more equal in size, form and power. The forms join in the centre of the image. For Joan this image held her feelings of loving union, like passion and placenta.

This image (ï¬ g 11) was explored in both clay and painting. In this painting we can see the integrating and containing relationship of these interconnected forms. This connectivity, given Joan’s new pregnancy, seemed to contain within it layer upon layer of expression and meanings, including nurturing, supported and supporting roles and the more ‘safely’ vulnerable woman she sought to be. The three smaller forms perhaps projecting forward the further additions desired for her family in the future and reï¬‚ ecting her protective role with her siblings.

Towards the end of therapy Joan produced the following two paintings.

In ï¬ g 12 Joan shows herself emerging out of the dark and into the light – a potent collective motif. As a swimmer Joan shows the levity and the power of her movement as it ascends through the yellow sunlight and there is a communication that this is her powerful side at each stroke lifting the other side out of the potentially dangerous waters. A representation, therefore, of rescuing herself and moving on.

Fig 13: in this image we see the conventional schema of left to right (as in our taught writing schema). The emergence out of darkness through an orangey red into yellow again held for her emergence, but also the entire journey, the trauma and the long process of resolution, an integrated view of herself and her experience of life. The previous image of the ï¬ gure in the water and the thread running through this image readily associates with birth, the umbilical relationship and the processes of life, and survival. These images carry hope.

Like the phoenix emerging from the ashes in Fig 14 Joan depicts a strong female form ascending, a rebirth!

This ï¬ nal image (ï¬ g 15) produced in therapy was drawn in our last session together. The end of therapy can bring renewal and independence, but also challenge as the therapist’s role recedes, except in memory, and the client, in this case Joan, moves forward in life with less distress and more consolidated independence and interpersonally rewarding relationships, alongside an increased sense of being valued and heard and of capacity to bear, in a non-self destructive way, the failures of care from the past.

This self portrait shares her sadness as a tear falls to the bottom right of the page. Alongside her sadness there is the clear-sighted ‘observing eye’, aware of being seen as she looks from out of the darkness seen by her therapist. Thereby something of the dissociative split between her abused self and the silent trauma is healed in the room with the therapist bearing witness and providing therapeutic containment. Here is a new observer-self, one whose sadness and vulnerability is better understood and acknowledged, where formerly it existed only in the dark or to be martyred.

The process of working through brings together the split between unacknowledged distress and her adapted and coping self in a way that supports elaboration and increased depth of understanding to these two realities.

Working through the process

Development of an observer self
Awareness and experience of the therapist’s bearing witness
Integrating dissociative split between non-verbal and the verbalisation
Expression through art and the therapy relationship
Creativity supporting enhanced observer and participant roles and observations the internal and interpersonal themes
Bringing together of unacknowledged feelings and reintegrating a modiï¬ed coping self.

This therapy seemed to come at just the right moment for Joan, a moment of transition and gave support to the journey of processing trauma.

alongside cognitive role awareness and that facilitates the transformation of self-destructive martyrdom into healthily working on her own behalf and for her new family.

It is with consent that I have shared Joan’s story and it is her hope that others may be helped by this. Joan is not her real name.

Art and Working Through

Anxiety is often a fear of chaos. The same can be true of the empty stage, the unplayed instrument. The arts can thus remind us of frightening aspects of our personal relations to chaos. However they can also moderate this experience by providing a suitable image on which to project our fantasies.

Full Reference

Rose Hughes, 2013. Integrating Art Psychotherapy and Cognitive Analytic Therapy (CAT). Reformulation, Summer, p.44,45,46,47,48,49.

Search the Bibliography

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Plugging in and Letting Go: the Use of Art in CAT
Hughes, R., 2008. Plugging in and Letting Go: the Use of Art in CAT. Reformulation, Summer, pp.9-10.

Comment on James Turnerâ€™s article on Verbal and Pictorial Metaphor in CAT
Hughes, R., 2011. Comment on James Turnerâ€™s article on Verbal and Pictorial Metaphor in CAT. Reformulation, Winter, pp.24-25.

Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship â€“ A Case Example
Bristow, J. and Reason, A., 2010. Therapeutic Change that is Dialogically Structured, Mediated by Signs, and Enabled by a Relationship â€“ A Case Example. Reformulation, Summer, pp.31-33.

Do We Allow CAT To Have A Heart - And If We Do, Does This Make It Soft And Wet?
McCormick, E., 1995. Do We Allow CAT To Have A Heart - And If We Do, Does This Make It Soft And Wet?. Reformulation, ACAT News Summer, p.x.

CAT, Metaphor and Pictures
Turner, J., 2011. CAT, Metaphor and Pictures. Reformulation, Winter, pp.39-43.

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