Art is created and viewed for pleasure, for distraction, to tell stories, to evoke emotions, for documentation purposes, as an educational tool, to channel creative energies, for processing of personal experience and for healing (Dalley, 1984). The essence of art therapy lies in creating something, and this process and its product are of central importance and the art process facilitates the emergence of inner experience and feelings, which might be expressed in a chaotic raw form (Schnetz, 2005).

Significance of the mark and place where it is made, the therapy room, and how it is received, the therapist’s response, all of this sets up the essential parameters of the art therapeutic process. Various components of this are considered here in detail. One of the most important aspects of images is that they can hold many meanings at different levels; reflecting the culture, within which they were made, and within which they are viewed. In a therapy relationship, an artist/patient transfers his/her own meaning into the image from his/her own 'culture' into the 'culture' of the therapy room where it is viewed with the subsequent impact and resonance on both patient and the therapist. The importance of remaining open to these many levels of communication in a picture, and being aware of them, is central to the practice of art therapy.

 Pictures, even when apparently finished, evoke movement and relationship, but cannot be read. Maps can be read; on maps, the figures and marks do not necessarily signify something beyond themselves. No picture can be fully explained in words; if it could, there would be no need to make it.

 It is the presence of the art form, which creates the complexity and essentially the uniqueness of art therapy, and the intensity of this relationship is fundamental to the art therapy process. Art therapists who use a psychoanalytic approach encourage the process of pictorial expression of inner experience, and in this sense the art is recognized as a process of spontaneous imagery released from the unconscious. This is similar to processes of free association developed by Freud as the fundamental rule of psychoanalysis. At the session of free association, the patient says everything that comes to his mind, however trivial or unpleasant. This gives an access to unconscious chains of associations, to the unconscious determinants of communication. In interpreting a dream, although symbolism may be important, an access to its meanings is through the patient's free associations. A dream involves gathering together or 'pooling' of unconscious events in the patient's mind and the associations to it are externalized in words. Painting provides another way to externalize these feelings and events, but as parts of dreams might be committed to memory, the concrete nature of images means that they take on a life of their own. Paintings or images of patients in the art therapy can be understood and approached in the same way in terms of the patient's associations - images that are produced may be one-off sketches, doodles, accidental marks, and can be destroyed or significantly changed (Betensky, 1973). They might be accomplished paintings that have been worked on for over a number of weeks, but it is not always a finished and considered piece of work that the art therapist and the patient will be reflecting on at the end of a session.

 This clarifies the position that making art in a therapy session has a different purpose from that of, for example, painting with a view to public exhibition where the painting is likely to be looked at in terms of its aesthetic value. It is not just an art product but also the process that is important. The art process in a therapeutic situation will be affected by many considerations, which include the setting, the client and most prominently, the therapist.

Art and Psychoanalysis

 When art activity is understood in terms of spontaneous expression giving some access to unconscious material, the links with psychoanalytic practice become clearer. There is an exploration and introduction to some of the literature and background of ideas on art and psychoanalysis that have influenced and formed present thinking about art and therapy. It is intended to be more of an introduction for prospective art therapists in order to encourage them to make their own forays into the subject, rather than a critical review, but inevitably the authors' bias will be apparent at times. Emphasis is placed on those writers who have made significant contributions to the debate, tracing the re-evaluation of primary process thinking and its implications.

Melanie Klein was a pioneer of child analysis, discovering that all child's play had symbolic significance. This led to the development of her own play technique where the main task is to understand and to interpret the child's phantasies, feelings, anxieties and experiences expressed by the play, or, if play activities are inhibited, the causes of the inhibition.

Objects can be external, where the subject recognizes the object as being outside oneself, or internal. An internal object has acquired the significance of an external object, but it is a phantom (Rycroft, 1977 ) - an image occurring in a phantasy, which is perceived as real. They are images, derived from the external reality through introjection and conceived to be located in the internal reality. Kleinian theory is an object theory, not an instinct theory, because it attaches central importance to resolution of ambivalence towards the Mother and Breast. It does, however, attach little importance to the infant's experience of actual mothering, which later object-relations theorists were to do (Fairbairn, 1939; Winnicott, 1988. Kleinian analysis, therefore, follows Freud in having a dual instinct theory, but it prefigures later an object-relations theory in attaching great importance to the first year of life.

 The difficulty for the infant is to cope with the overbearing instinctual drive in relation to the Mother and the Breast. Love and desire for it when it is satisfied; hate and destructiveness for it as it is frustrated. Envy at weaning that the 'giving' breast does not belong to it, is not under its control and fear of its loss. The infant has phantasies about the Mother and the Breast. Phantasies are seen to be a mental representation, a psychic representative of instinct. Phantasies color the infant's experience of real objects, and the impact of reality constantly modifies the fantasy life. Phantasy life expresses itself in symbolic ways: 'All art is symbolic by its very nature, and it is a symbolic expression of the artist's fantasy life'.

 In Kleinian terms, the ego is innate, not formed by the reality principle as we saw earlier in Freud. The growth of the ego is a product of a continual process of projection and introjection. Through these mechanisms a whole world of internal objects is formed with their own fantasized relationships: 'lt is this internal world, with its complex relationships, that is the raw material, on which the artist draws to create a new world in his art' (Segal, 1975, p. 800).

In her discussion of Art and the Inner World, Segal refers to Melanie Klein's work on rebuilding of the inner world in mourning. Every time we experience loss, we are taken back to the depressive position, and our original loss is relived. In mourning, we have to build our inner world as well as our external world of relationships. She feels that the artist is working through again the infantile depressive position every time as a new piece of work is embarked upon: 'The artist's aim is always, even if he is not quite aware of it himself, to create a new reality. It is this capacity to create and impose on us the conviction of a new reality that is, to me, the essence of art'.

 Like the history of avant-garde art, the history of modern industry and business is characterized by constant innovation and competition between rival groups. Experimentation and invention by scientists and engineers has resulted into new media technologies such as photography, cinematography, videotape recording, computers, etc., which in turn have given the rise to huge new manufacturing and entertainment industries, mass employment, and products enjoyed by billions. At first, the rarity and high cost of new media technologies meant that they were confined to wealthy organizations and specialist, professional producers. After a while, however, such devices as cameras, camcorders and computers appeared on the mass market (Fordham, 1966). These developments enabled millions of people with average incomes to make and enjoy their own images, to become part-time cultural producers. The popular hobby of amateur photography is one such example.

Photography

 Visual culture produced by amateurs tends to be highly restricted in terms of its content, form, and social functions. Most amateur photography, for example, is concerned with the positive moments of private, domestic, family life; it is strongly associated with leisure activities and tourism. Amateur photography is less than truthful in its avoidance of the unhappy and tragic incidents of family life. Beginners and amateurs rarely question the medium they adopt. Normally they imitate the pictorial conventions of the mass media with which they are already familiar. Few of those who own cameras or camcorders think of using them as critical tools, as political weapons. For the most part, popular pastimes are used to fill or kill time rather than to use it in the ways that contribute to the understanding and solution of urgent social and ecological problems.

 Some radical initiatives have occurred in the twentieth century: during the 1920’s and 1930’s, for example, worker photography and film movements developed in Germany, Holland, Britain, and the United States. Prompted by the left-wing parties, associations and pictorial magazines such as A-I-Z, these movements were intended to provide an alternative popular culture to that supplied by the mainstream media. Their aim was to dispel the 'policeman in the head' syndrome and to encourage participants to become 'the eyes of the working class'. This objective was to be achieved by documenting the social reality, by operating collectively in teams to produce systematic accounts of events, and by supplying the left-wing press with images taken from a working-class viewpoint.

 Community photography -- a phenomenon of the 1970’s -- was similar in certain respects. Local groups and workshops were established to provide facilities, teach skills and encourage citizens in deprived neighborhoods to use photography as a critical tool. A slide-tape show documenting the poor state of council housing, for instance, could serve as an effective audio-visual aid when presenting a case for repairs to local officials. In the East End of London, the organization called ' Camerawork' has exerted some crucial influence on the non-commercial promotion of photography. It has encouraged the production of images and mounted circulating exhibitions. Camerawork also has a permanent exhibition gallery and for a number of years it published a magazine, which fulfilled a vital educational function.

 Jo Spence (1934-1992) helped to establish Camerawork, moreover, she was one of the most energetic and courageous British photographers of recent decades to emerge on a working-class background.  Her early experience of working in high-street commercial photographic studios eventually resulted in disillusionment in the aesthetic and social functions the medium performed (for example, the popular genres of portraiture and wedding photographs). However, through involvement with socialist and feminist groups during the 1960’s and 1970’s, she developed highly original ways of using the medium to address such themes as children's and women's rights, women's working conditions, the representation of men, health services, her personal history and identity.

 In 1980, feeling she lacked an understanding of the theory of photography, Spence undertook a polytechnic media course where she studied the semiotic analysis of imagery. Besides taking photographs, Spence taught and lectured; she organized exhibitions and wrote articles and books about the medium and her own practice. With Terry Dennett, she established the Photography Workshop, and together they edited the first volume of an alternative photography annual entitled Photography/Politics (Kaplan, 2007).

 Spence took some memorable photos of her naked, middle-aged body that were startling in their honesty and intimacy. In 1982, Spence learnt she had breast cancer. Characteristically, instead of abandoning photography, she took her camera into hospital. Later, in collaboration with Rosy Martin, she used the medium of photography as an aid to healing and serf-understanding. They devised the terms 'photo-therapy' and 'psychicrealism'. Camera sessions were employed in order to act out scenes from the past and to explore the various images of the self, from which their social identities were constructed. Photo-therapy was intended as a radical alternative to conventional portraiture and medicine.

 For several decades Spence employed the method of 'staged photography' to challenge the assumptions and practices of professional, commercial, documentary, amateur and fine art photography. The fact that her iconoclastic work is so difficult to place is a tribute to its refusal of existing photographic genres and conventions of good taste and beauty.

Music

Music plays an important part in most people's lives.  Most of us will be able to recall a favorite tune, sing it or tap out its rhythm. People can remember the shapes and patterns of music. Singing in church or a 'sing-song' in the pub, nowadays more likely to be singing to a pre-recorded backing track, are examples of a more public musical expression. This pattern increases a division between people who listen to music, passive receivers, and those who take an active part, the musical players.

We are all exposed to the surrounding musical culture with its wide range of musical styles. To some extent we all share this musical tradition. If we take the musical element of melody, for example, we observe that there are similar adult and childhood profiles. On one level, we all know people who have problems pitching notes; on another level, there are people who can keep to a melodic shape within a given tonality, but who make an occasional slip with the size of a musical interval.

The Influence of Musical Training

 Adults referred for either individual or group music therapy will have very different personal musical histories. The range of musical tastes will vary; some people would have had music lessons as children; some people would be able to read music, others not (Gilroy & Lee, 1994). There are degrees to which people feel comfortable singing and playing musical instruments. At the start of a music therapy group or a staff workshop, we are often met with comments such as: 'I'm not musical'; 'I was never good at music at school'; or 'I can't sing.' People who have had some degree of musical training are often encouraged by other members of the group to perform or 'show us how it's done' (Gilroy & Lee, 1994).

 Very often though, it is the people with the musical training who find it difficult to improvise and free themselves from the constraints of the musical strait-jacketing that pervades some of more formal and exam-ridden traditional musical teaching. Later in life, as adults, we often have to search long and hard to rediscover a child's more open spontaneity, to free ourselves from the fears, doubts and competitive attitudes that beset us while singing or making music -  and this can happen at all levels of music-making.

 The relationship of musical training and personal history to free musical exploration presents a challenge to music therapists in supporting people as they discover or re-discover their potential for making music. It also has implications for the kinds of music presented to adults, one example being the debate amongst music therapists of the balance of improvised and pre-composed music - especially old-time songs - when working with the elderly.

The Use of Improvisation in Adult Music Therapy

 A group of music therapists began to explore their feelings that emerged when taking part in an improvisation workshop as part of a two-day conference held in Bristol in 1986. Most of the therapists had experience facilitating groups, specifically in the adult mental health field (Gilroy & Lee, 1994).

There is a great deal of discussion among music therapists concerning the central position of improvisation in both individual and group work and for both children and adults alike. Is improvisation a means of helping people contact some of their deepest feelings? Is the expression an authentic reflection of the self? Is it possible to hide behind the music, to use music as a defense or even be untruthful in music? The forms of music have been invested for centuries with some of our deepest feelings and impulses. In music therapy, people talk of music helping them to release a feeling, to articulate in a musical gesture a feeling for which they find words inadequate. At the end of such musical experiences it is as if we were temporarily suspended in a different time framework when the problems associated with finding meaningful connections in words are often insurmountable, a kind of transcendental experience. People can articulate in a musical form some feelings and impulses that in other forms could be quite alarming, destructive or even harmful. In musical improvisations people can find release of a wide range of emotions and often some resolution of what is hurting and painful.

Sometimes the end-result of an improvisation may be more akin to simple 'sound forms', where the emphasis is on the process rather than the final artistic musical product. Music therapists are trained to work at the highest musical levels yet can adapt to a vast range of sound and musical forms that make up the improvisations created by clients of all ages. The general goals of improvisational music therapy are the following:

            - awareness of self, physically, emotionally, intellectually and socially

            - awareness of physical environment

            - awareness of others, including significant persons in the family, peers and groups

            - perception and discrimination in sensorimotor areas

            - insight about self, others and the environment

            - self-expression

            - interpersonal communication

            - integration of self (sensorimotor experiences, levels of consciousness, parts of self, time, roles etc.)

Music therapy has been used throughout the history as a general diversion in alleviating mental strain and distress and that only recently has its full potential as a therapy for adult health begun to be recognized and studied. Within the psychiatric services in this country music therapy departments began to be set up within the large institutions for adults with mental health problems. Music therapists have developed services across the whole range of ages and problems: long-stay work with chronically ill people; short-stay acute work; specific work with young people or the elderly (Henley, 2002). In line with the present resettlement plans, music therapists are also beginning to develop services in small day hospitals, community-based centers and hostels.

 A tradition of a very musically active approach has evolved in the UK, with clients being encouraged to create or listen to live music. A wide range of musical styles is employed, with an emphasis on music being improvised with the clients. Pre-composed music has its place and again the range is wide: folk music, classical, jazz, traditional songs and current popular music. Interaction through the music, both between members of the group and with the therapist, is stressed. This emphasis on a wide musical base has led to the British pattern of therapists requiring a strong musical background before training. The dependence on live over recorded music and the development of interactions with the therapist are highlighted in Helen Odell's review of her music therapy approach in mental health work. In the UK, there tends to be a predominance of group work, although individual referrals do come through consultants and other members of the clinical teams, the balance being dependent on the approach of the particular unit or hospital and the therapist's orientation.

Although at present there is no clear psychodynamic meaning of music, still some music therapists do relate their work to the processes in psychoanalytical theory. The most widely known and internationally respected British therapist in this field is Mary Priestley. In her specialized form of Exploratory Music Therapy (originally called Analytical Music Therapy), the client is encouraged to talk through the issues being brought to the session, as in a normal analytical session, before exploring the issues within the musical improvisation. Very often the therapist and the client will adopt a particular musical stance (Withrow, 2004). If, for example, the client presented difficulties in expressing anger, during the first section of the improvisation, the client may choose to play out some angry feelings with the therapist representing the more controlling side of the client's personality; in the second section, the roles might be reversed. In order for the two split parts to be heard and integrated, Mary Priestley plays back a tape-recording of the improvisation. The client hears all the sections of the music and is helped to recognize all the component parts of the whole improvisation. The final discussion is then an opportunity for some of these musical insights to be processed verbally. We read in Priestley's descriptions of her work that much of what takes place in the musical interaction can be regarded as a reflection or an analogue of various internal processes.  Helen Odell also refers to a psychodynamic approach in her work, distinguishing between this approach, which includes all relationship issues - self, family, friends - and an organic, more physiologically based approach: 'the music therapy group focuses on what is happening within and between the members of the group, and this can be heard in the music, and worked with in a dynamic way to help clients understand more about themselves'.

 There is no typical session, but in general a group session may begin with a warm-up period in the form of some listening, exploration of the instruments or rhythmic work. Out of this opening period, a musical idea, issue or a theme may emerge that can be explored in an improvisation. Emotional reactions to the improvised music may help to focus on an individual's problem and lead to further improvisation. Some common themes may emerge that resonate with many members of the group, and such themes often develop into longer improvisations. The improvisations may spark off some verbal discussion on the feelings created by making or listening to the music. Sometimes the music is recorded and played back to the group. The group members may gain further insights about their responses, their behaviour in the group, their relationships with each other and the therapist, either it is an individual's problem or an aspect of the life of the group.

Music Therapy as a Resource for the Community

 The way in which music and music therapy can build links is very important. A great deal of the early work of professional music therapists began within large institutions for mentally handicapped and mentally ill people, to use the terminology of the day. It is only forty years later that we are currently witnessing major changes in the way in which society is adapting to people with such problems. The terminology is shifting, with the current terms 'learning difficulties' and 'mental health problems' replacing the older ones. A further radical change is closing-down of these large institutions and their replacement by more community-based day centers, small units and hostels. We are currently going through difficult implementation stages, with the concomitant implications of additional human and financial resources. The start of the 1990’s has also seen an increase in unemployment, homelessness and further strain on our probation and prison service. What is the music therapist's response to all these changes? The members of this profession are working hard to develop an effective service outside the security of a hospital department. We are only a small profession, and today's market is stressing a supply-and-demand, purchaser-and-provider model. We shall need to organize our small resources to meet the enormous demand and challenges in a fashion that will gain the support of the funding bodies. Otherwise, there is the real danger of the profession losing some of the momentum it has gained over the last few decades as it struggles again to find a new identity, indicate its efficacy and hold its own in the open market-place.

 As technology increases our ability to travel and contact each other in all corners of the globe, we are learning more about different cultures and discovering more common links than differences between people from many backgrounds. We are hearing more music from different cultures and meeting more musicians fluent in non-Western traditions. It is now possible to attend musical events such as the WOMAD festival and to hear and see performers from all over the world (Fuller, 1980). Such opportunities were only available to intrepid musical explorers until a very few years ago. Pioneering spirits such as Peter Gabriel are bringing musicians from many traditions together to play music and to learn from each other. The advanced technology of the Western recording studio can then be used to record some of these new mixes. How will music therapy adapt to this growing culture mix when we are realizing with increasing clarity that music of all kinds is a key link to what it is to be human? The essence of our humanity is in our music, making it possible to unite people of many backgrounds, experiences and ranges of ability in music.

Music can help people at all levels of cognitive ability, namely music therapy is helpful for adults with learning difficulties (formerly called mental handicapped). For these clients music therapy can provide a needed support in the move out from the traditional hospital setting.

 Historically music therapy has developed expertise in meeting the needs of adults with some of the gravest cognitive and physical impairments. Departments of music therapy have been set up in many of the formerly large institutions where people with such severe problems lived, often for many years. In such settings a music therapy culture is able to develop, and staff becomes used to referring Johnny and Sarah for music therapy not 'because they like music', but for other reasons over and above music's aesthetic, pleasurable and recreational aspects. Connections with the cognitive, emotional, physical and spiritual areas of a person's life become increasingly the area of the therapeutic focus. We begin to see that whatever the degree of impairment is, a music therapist can contact the person beyond the problem and make an emotional connection through the musical transaction. Therapeutic objectives can then be discussed to help develop physical mobility or some aspect of learning, social or emotional behaviour, even in the areas of so-called 'challenging behaviour'. The range of problems presented is vast, from the very withdrawn and passive to the hyperactive and self-stimulating. All of this range can be said to present a challenge to the music therapist. Isolation seems to link many of these difficulties, and the situation of an adult with a profound learning problem is often further complicated by overlapping problems such as visual or hearing impairments, physical disabilities or mental health problems such as acute depression. The history of the profession indicates that music therapy can offer a great deal to an adult with such difficulties. A music therapist can make links with the essential personal qualities that lie beneath some of the presented problems. In what way do the problems interfere with or frustrate the process of communication through music? Stephanie Zallik reminds us that developmental or physical delay does not prevent a person from feeling with the full range of intensity of somebody whose mental and physical faculties are more developed. As a music therapist, she is willing to understand and work through these outer layers so as to reach for the innermost layer where she feels the real needs of the person are met.

 For instance, Sally, a 27-year-old with profound learning difficulties, would sit curled up in a foetal position in her chair. She appeared to be completely withdrawn into herself. She was referred to music therapy to see if any communication system could be established. I had very mixed feelings about inviting her for the first session. How could I intrude in a world she had created for herself, possibly as a means of protection from the aural invasions of ward noises, including both the television and the radio? I sat beside her and began to play some long and quiet sounds on a small pipe. I sang her name gently and slowly. Over the weeks she began to express some curiosity about these sounds. She began to uncurl herself and turn sideways towards the source of the sounds. A few weeks later she began to reach out and touch some of the instruments. This led to her facing me as I began to sit opposite her. All this took place within an extremely slow time framework; any sudden or loud intrusion would set her back into herself. She eventually began to vocalize and make long sounds and sighs. We improvised such long sounds together. After a period of nine months of weekly sessions she would come into the small room off the main ward, sit in a chair facing me, sing and reach out for the instruments. Towards the final stages of our work together she would get out of her chair as soon as I entered the ward and lead me to the room, singing en route. The speech therapist observed and notated a wide range of sounds that she produced in her singing, sounds that could perhaps be the basis for some kind of communication system. She began to attend speech therapy.

Research is nevertheless indicating that music therapy can be effective with people who have the profoundest of difficulties and can make specific contributions above and beyond those expected from a period of such sustained attention. Amelia Oldfield, for example, investigated the efficacy of music therapy in accomplishing a set of individualized objectives when working with adults with profound learning difficulties.

 Tony Wigram has recently reported an example of such a sustained period of work. He charted the development of a group of five highly disturbed and at times aggressive young adults. Weekly sessions over a period of two years helped this group to increase in tolerance towards each other. The group became less resistant both to being involved in the music and to physical contact. The music therapists adapted the musical approaches as the behaviour of the group members developed, with noticeable changes in social behaviour. There was a deeper level of contact between all of the people involved in the music-making.

 Clearly stated objectives, observations and reporting can help the profession to gain more external validity and acceptance with other professionals. We can indicate that music therapy is a viable medium for working with this population, both inside and outside the hospital setting. This kind of descriptive work relates to an early stage in the history of the profession and it is understandable that researchers such as Oldfield have chosen to focus initially on observable behaviour, behaviour that can translate more readily into strong, time-based measures. In adopting this perspective, we are all aware that we are choosing to overlook some very central issues. To date, it has been difficult to set up some research projects that examine, for example, those fleeting feelings and emotional responses that pass between the therapist and the client in any musical transaction. We need to develop finer research tools to explore some of these central issues.


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