The Art Psychotherapy Median Group

Introduction

For several years I supervised a colleague who facilitated a weekly 90 minute art psychotherapy median group for acute psychiatric inpatients and outpatients (most of whom had spent time as inpatients). The group was originally a drop in open art psychotherapy group set up in response to the belief that patients considered to have a severe mental illness would struggle to commit to a more formal group.

As with the open/studio group and my experience of ward groups in particular, and also some outpatient groups—with this patient group, high turnover and irregular attendance, including staff—are the accepted norms. The individual patient becomes the predominant focus and concern, rather than the group as a whole.

By reversing this thinking we saw a median group blossom with members attending regularly.

A service review threatened the group with closure and we had to justify its existence: on what grounds was such a large membership—generally 15 to 18 people—indicated? Researching the theoretical basis and clinical precedents for our group we found de Maré et al. (1991), on median groups, and Jones and Skaife (2009), on large groups, valuable in addressing the political challenges we faced through our specialism being called into question in terms of a lack of quantitative evidence.

The Median Group

At the time of the review the Allied Health Professions lead for New Ways of Working (Department of Health, 2003) asked for examples of good art psychotherapy practice. Our group was included, with particular reference to its capacity for holding those making the transition from in- to outpatient, and continuing to hold people when readmission was necessary. I wanted to emphasize ‘think group’ since by maintaining this apparently obvious attitude (although not to all professionals within the NHS) we had witnessed, over time, that the group held a securely boundaried identity.

The large group is a key, valued and challenging component of the art psychotherapy training at Goldsmiths College (Jones and Skaife, 2009). Our model had similarities to this group especially the aspect of members making images. In these groups, to make art without necessarily needing to speak becomes an act that demands attention. Allowing this in the presence of so many who are rich in large group journeys seems to me to be a potentially powerful political and emotional act. The images people make can be of great interest and are often seductive in their power to draw the therapist in. It is not that this should be discouraged, but all group members should be encouraged to show an interest if desired by the individual. Thus each finds a place and a way to share or relate as they wish to and it becomes acknowledged that each is important.

Many members knew each other from their various times in hospital or other patient led groups. They were aware of the hospital as a larger group. Service or staff changes on the wards, leavers and joiners etc. were frequently announced and there was a sense of ‘in and out’, of connexions and a growing awareness of the group’s existence within other groups, both within and outside the hospital. This reduced any feeling of us—the staff—and them—the patients. Rather we all existed as parts of larger groups, some of which overlapped.

Thus what we achieved was a balance of sociotherapy (Rapoport, 1960) and psychotherapy. Like Whiteley and Gordon (1979) we were concerned that too much attention to the individual could be obstructive and distracting from the member’s own and others’ considerations. Whiteley and Gordon’s concern regarding larger groups was that over emphasis on individual psychotherapeutic interventions led to an annulment of the group in that other members would feel incapable of competing or engaging with another individual (patient) and the expert (staff) speaking to him or her. Then ‘the expert becomes even more powerful in the eyes of the group and it is difficult not to take on this power in a prima donna way’ (Whiteley and Gordon, 1979: 139).

Frequently patients referred to art psychotherapy groups have little hope of change, mirroring the views of the many professionals they have already seen that any improvement is highly improbable. In open/drop in groups the staff can find themselves taking up the role of the expert as if to compensate for the patients (particularly those with a long psychiatric history) who, in my experience, have often long forgotten their own expertise and authority.

We realized in the median group that it was important to resist our expert position, otherwise, as Whiteley and Gordon observed, ‘the patient simply waits dependently for the next wise statement and group progress is halted. The patient assumes a passive role waiting to be cured. The psychotherapy has become obstructive’ (Whiteley and Gordon, 1979: 139).

The actual person (who happens to be a patient) is often lost, or at least neglected, under the weight of the psychiatric diagnosis.

Referrals

Despite wanting art psychotherapists to avoid deferring to diagnosis (Dudley, 2004), this becomes more difficult as NHS funding is increasingly dependent upon NICE recommendations. To survive, services need to be explicit as to what they provide within NICE guidelines. For instance, NICE recommends arts therapies for those diagnosed with Schizophrenia. While accepting these facts it is important that we remain confident that what we are offering is of value to a person seeking therapy regardless of diagnosis.

When conceptualizing the median group as a formal therapy I had the confidence not to think in terms of diagnosis but rather what sort of group would be appropriate if group analytic (McNeilly, 1984) or individual art psychotherapy was not indicated. (These were the choices available to consider at the patients art psychotherapy assessment). What would be most helpful to the individual irrespective of the given diagnosis?

I came to realize, also, that referrals were often made to certain groups on the bases of class and prejudicial grouping attitudes. Those considered to be middle class and educated were more likely to be referred to the analytic group; on the other hand, those considered working class, less articulate or less educated were more likely to be referred to the art psychotherapy median group. Once I began not to take on board such assumptions then educational, professional and class divisions became much less evident across the groups’ memberships.

Each person is a subject, not an object. ‘Non-diagnostic approaches demand a very different set of assumptions which in turn demand a different set of social and therapeutic responses (Boyle, 1999: 88).’ It is important to hold in mind the possibilities and potential of transferential enactments. Getting to know someone’s history well (often not the case, particularly within ward based groups and given that many cannot give in depth histories due to a lack of verbal expression and confidence) helps us to think about what is likely or might be enacted, and such ongoing awareness enabled many to remain in the group.

Many (both staff and patients) have in mind a hierarchy of verbal therapies over arts therapies. The value, or not, of art becomes worth thinking about and voicing together.

The relationship between the art and verbal language or between perceptual and the cognitive is historically hierarchical and mirrors divisions in race, class, and gender which is reflected in the low status given to perceptual and imaginative treatments for psychiatric conditions. (Skaife, 2008, cited in Jones and Skaife, 2009: 207)

Irregular Membership

As predicted with our patient group, there was a fairly high turnover of people at first. However, encouraging the group as such be held in mind created a core of identity and responsibility. Once this was established the membership settled somewhat and became a median group. This may seem obvious to those of us facilitating analytic groups. However, sticking to such thinking was not easy in the face of high levels of disturbance, many members having very low self-esteem, and some rarely speaking at the beginning. For the median group to survive and hold its membership it was necessary to think over and again, in the group and in supervision, ‘group’—that is, the actual group and the internalized group experiences. Thus the group started to live and exist as such.

A person’s identity within larger groups (e.g. community and race) becomes consciously established. Everyone, including the therapist, is considered to be part of the community / large group of the institution. The images made (often the most consistent and dominant expression over words) reinforce each member’s sense of membership. Their permanence affirms a person’s participation, importance, influence and responsibility within the group; but also affirms that the group continues in an individual’s absence and is still there when they return. The space in which the group physically manifests is there to be moved within and related to. When the therapist talks to the group as a whole everyone is included. In my experience this is explicitly and vitally different to many hospital groups, which tend predominantly to consider in turn what each individual brings on the day.

At the point of first meeting a patient, even if only briefly (as was often the case with inpatients unable to come to a longer assessment meeting), we would stress the value of the group and the importance of that person’s contribution. The idea of the group as a whole (Foulkes, 1975) introduced the patient to a space— literal and psychic—that could offer both individual freedom and interconnection, if desired, with another. All were held within the arms of the group. Everyone, patient and therapist, contributed to these metaphorical arms, ensuring that they held firmly, that their hold was welcome, helpful and valuable. Many had experience of the complete opposite: frequently their experience was one of hostile and ambivalent ‘holding’ with no good reason to trust the ‘authority’ including, sadly, ‘the authority’ within the psychiatric services.

Such simple, possibly obvious, actions were intended to make it clear from the start that the work / therapy / group begins once ‘you’ are within the space, and that the group will work because of what you bring and contribute. Many found that coming to believe this was a huge step in raising self-esteem.

Sarra facilitates art psychotherapy groups in an acute minimum secure ward and observes that: thinking in a ‘longitudinal time frame’ (Sarra, 1998: 82) allows the inclusion of ‘once only’ attendees. If, from the outset, one thinks of the group continuing for a long time then, as in all groups in society, some people will remain for a long time, or throughout, while others may come and go, possibly returning, but all this may be accommodated within the overall concept of the group.

Some members were able to come for only a very short time, sometimes as little as five minutes, or were unable to get to the group until half way through a session. Where, within an analytic group, we might consider such boundary challenges, here the therapist would quietly and gently observe the person’s arrival or departure just enough to acknowledge the importance of the member’s presence and / or absence. It was an important progression for members to be able to stay for the whole session and most eventually achieved this.

Specific dynamic observations were not made in the group, though they formed a key part of supervision and pre and after group discussions.

However, I agree with Main (1974, cited in Goering and Littman, 1981: 54) to an extent in thinking such discussions to be too formalized; all anxieties tend to be taken from the group to these smaller forums with the result that the patients are used for new and continued projections. Even so, these discussions are vital, particularly in settings and institutions, which deny, disable or disrupt the notion of ‘group’. But I would keep Main’s concerns in mind as it is easy to slip into talking about ‘them’ rather than ‘us’. I have found this to be particularly the case with those considered to have a serious mental illness.

The Room

The room where art making can take place is key for art psychotherapy. It is ideally large and with a wide range of art materials.

Within the room all sorts can happen at the same time: talking, writing, making, painting, emotional expression, physical expression and so on. There is an ambience of energy, action, aliveness, movement, and potential through multiple opportunities for relating and experiencing.

It was important that the new patient be shown the room and where the art work would be stored. Also, we would always contact each new member just prior to their coming into the group to ensure that there was a familiar face waiting for them when they entered. When first seen, the large room might evoke negative feelings, arising, for instance, from bad memories of school, care home or prison. But as the group and the space became intertwined the individual could adjust to the space being one that each could influence and create within; what was created would be kept safely.

The larger physical space necessary for the Art Therapy Large Group poses the room as an interactive stage, and the art materials and peoples’ bodies, as performers or spectators, become art works. The relationships between the student (patient) and their art work, the art and the group all become mixed, inviting new ways to consider the art in art therapy. If we understand all activity in the group as interrelated performances and apply this to the small group, it helps confront the issues of art and the perceptual being thought of only as a bridge to more important verbal interaction. (Jones and Skaife, 2009: 207)

The Members

The sense of space, of body space and of potential—almost to hide away—was vital. Some patients led very isolated lives, in some cases never speaking to anyone. Some were extremely paranoid, feeling that they might be attacked or hurt in some way; or they led lives limited by such trauma as sexual abuse, domestic violence, or serious emotional deprivation.

Many observed that they were always looking outwards, wishing for more. Some spoke of not being able to imagine that anyone would want to be in a room with them; some, through anger and relating patterns of rejection, regularly pushed others away while wishing they would not. Many were preoccupied within a world of hearing unexplained voices or seeing things they were told were not there. Some founds themselves in an alien culture and race, having been displaced through war or for other political reasons, sometimes having experienced torture, and they were struggling to find ways of belonging; with limited English they needed to find ways of communicating effectively with others. Thus the group developed the potential to think globally. Most agreed that they wished to communicate. The thwarting of this was a familiar and often stirring experience, but was also a uniting resonance which seemed to provide a strengthening force in the group matrix, containing member’s wide ranging differences of class, race, background, psychological presentation and so on.

The art making seemed to be a uniting force which, irrespective of origins, all could undertake as and when they wished within the frame of the group. Talking was also valued, but some members had spent a long time in the psychiatric services where words were the most required and valued form of expression. They came to realize that it was not always so; words might even, perhaps, be of less value than the silence many brought as their usual mode of being.

Words are not always what is needed. Sometimes it is better to live the experience as if in a country where you cannot speak the language. It can be as much about simply being present with others, sensing their bodily presence.

[By] attention being drawn to our bodiliness in our attitude to materials, by attention to visual and tactile experience, then a real interaction between the physical material of the world and the client’s body is brought into focus, with the result that the client comes to inhabit their body more, through finding it in the interaction. The result of this is to begin to feel alive and connected to the world again. (Skaife, 2001: 48)

Protecting the Group

The service administrator was key in protecting the walls of the group. She was the first point of contact with the members and many needed her support and kindness just to get to the department at all. Some would take weeks before they got to the initial meeting or to the group. She would greet them and acknowledge if they were late or finding it hard to get through the group door, or if they left after only a short time. She always spoke to them on the phone if they could not or did not attend. Increasingly such phone calls became rare. These apparently inconsequential acts were actually very important in reinforcing the realization in members’ minds that they were part of the group and their membership was important for the group to work.

A key dilemma for art psychotherapists is whether they too should make art within groups they are facilitating. I am not sure that we need to spell out our belief in art or to role model how to use the materials as this seems to me to fall into the trap of art equalling production and action. I think that to work alongside can serve to deny one’s position of power as a staff member—and so any opportunities to think about status and power may be lost.

Thus I viewed the therapist as a leader keeping a watchful eye on the group as a whole and ready to respond as openly and honestly as possible.

Working in a therapeutic community I learnt that for a group to believe in itself it needs to know the therapist is genuine in his or her views and opinions, is fallible, adaptable and can take something on and take action as necessary. In art psychotherapy open groups, as well as doing art, or doing art with a patient on one piece of work, it is common practice for the therapist to move around the room from member to member. I prefer that the therapist remain still as much as possible. Moving around the group can reinforce the sense of ‘I the therapist’ have all the knowledge and the privileged position to bestow the word of support, encouragement and so on. But this may be felt negatively by the person being visited.

Artist art psychotherapists often have profound memories of critiques by their college tutors. One describes ambivalence towards the tutor coming up to inspect the work and the terror of what they might say or do. ‘Suddenly they are behind you, or beside you and you think “what will happen now?” The intrusion evokes terrible anxiety.’ The balance between being so careful and caring that the group members are disempowered, and then expecting so much from the members that it has the same effect, is not an easy one. When words are few, the therapist intuition and watchfulness needs to be highly tuned.

Hinshelwood observes that the experience of good and bad in the group is an important clue to its dynamics. Yet so often the therapist will seek simply to have a good experience with his or her group members and to minimize the bad ones.

This is a way of surviving but makes for a group where nothing happens, where there is superficial harmony which may be beneficial for some, but others will feel some issues cannot be raised and some feelings cannot be expressed such as anger. These will be driven underground and so the purposes of the group, to facilitate expression and openness of communication, will be defeated. (Hinshelwood, 1987: 28)

Group Themes

Themes arising within the group frequently demonstrated synchronicity or, one can say resonance. (Remember that many in the group were mostly silent, only gradually over time finding words and so sharing with others.) For example: The inclusion of a co-therapist trainee each year would spontaneously evoke a theme related to the trainee’s background, such as their previous profession, without any information being disclosed. Such evocations indicated the existence of a group unity or mind and a sense of belonging. A life experience that had previously seemed profoundly lacking was something that could be discovered within the group, and perhaps emerges from a place that was pre-conscious or hidden. In this apparently non-connecting group membership there were, in fact, profound connections.

Over the group’s lifetime re-admissions reduced, people found work, made friends, joined adult education courses but many continued to make art. This is usual within analytic art psychotherapy groups although not necessarily the case in open groups. The images stayed in the room throughout each member’s time within the group. The group’s shelf and cupboard established itself as something like a shrine: a central point of ritual to which all would go at one time or another, to place something in it, to revisit, to remove and replace and so on. It was a symbolic representation as to why we were all there.

Through ‘making a mark’ and ‘finding a voice’ students (group members) in the Art Therapy Large Group struggle with feelings of alienation and fragmentation and with how to find a place for themselves in the group. Their actions in art or talk, recognised by the others in the group, allow them a sense of belonging in the community. The boundary of the arena, which creates a space like an empty page, allows for a response to an action or visual statement to be observed, noted and reflected upon. (Jones and Skaife, 2009: 206)

Looking over their art at the time of leaving the group and taking it with them as a record of the work they had done became an important ritual for the group in which all could share in saying good bye.

Group Closure

In spite of excellent feedback the group was closed and the therapist was made redundant.

Defeated for a time, I drew on the knowledge that the group and experience of the space stays with you and carries you on to the next space to be discovered. Dialogue continues in some shape or form in some place or other.

As the group matured and a group culture passed from one generation of members to another there developed a responsibility for the group; e.g. concerns as to how the cuts would affect ‘us’. When the group was to close members decided, without any therapist input, to protest its closure, and this protest continued over several months. This indicated that the aim had been achieved: a voice found within the group had translated to a voice outside the group.

What we did worked. However, NICE does not recommend art psychotherapy—other than for those given the diagnosis of schizophrenia. Our membership included these patients and also those diagnosed with Borderline Personality Disorder, Severe Depression and Bi Polar Disorder.

Even though NICE is clear that it only advises and does not dictate to local services, and the fact that the group was felt to be useful, our views and beliefs were seriously challenged. The therapist and I looked to such as Mentalization (Fonagy and Bateman, 2006), much used now within the NHS psychotherapies services, and to the Department of Health’s Arts in Health Agenda (encouraging art activities), and it was suggested by some we should rebrand the group in the name of either or both of these. In the end events took over but I like to think that our belief in the group and the theories which underpinned it had validity, and to have renamed it would have felt like a betrayal of what the group had achieved over many years.

Also at this time the Social Inclusion Agenda (2006) was being given much attention. We discussed that we could say our group was attempting to enable members to be included.

The nature of the larger group is that it also seeks to challenge the status quo. Within the group strong feelings—through images or words—are often expressed related to being socially excluded.

The therapist and I considered it was perhaps better to look outwards to the social and political context and not necessarily to be integrated into current initiatives, and to allow and trust action/expression via intervention, word or image. In other words to trust the members as knowing what they wanted and what they were finding helpful, and in time for those voices to be heard more widely and to have influence on the services. Social inclusion after all rather assumes that some are not included and these should be aided by those who are.

Perhaps the question to be explored is what constitutes this society (and I mean this to include the psychiatric services), which we are supposed to aspire to, and perhaps try to change it rather than attempt to fit in and belong.

The ‘clinical large group runs counter to the forces and pressures in society, that for so long has regarded the mentally disturbed patient both as irresponsible and lacking in the normal skills required for socialization’ (Pines, 1974 cited in Kreeger, 1974: 302). The use of the large group subverts society in that the well staff and sick patient are not clearly defined and it

… threatens the fundamental process of the wider society which has resulted in the creation of the hospital as a system for isolating and containing mental illness. Both staff and patients in their ‘social unconscious’ contain and are to some extent controlled by the powerful unconscious image of the proper relationship of patient and staff. (ibid)

In the future perhaps voices from the group will be strong enough to be heard. The collective memory, after all, remains. This is better than allowing a process of colonization whereby we automatically accept the voice of scientific and government rhetoric which tells us how we should be treated and what we need to be well. Must we concede that the psychotherapy professions will only survive within the NHS if they take this rhetoric to heart and allow ‘science’ to override the views, experience and knowledge accumulated by art/psychotherapists/analysts concerned with the unconscious and relationships?

Conclusion

There is a desire for service users to be integrated into our society by pushing them through such initiatives as the arts in health, recovery or social inclusion agendas. My concern is that this further separates / defines ‘us and them’ instead of discovering opportunities for unity within the group itself. There is expertise and wisdom to be found in every group member. By separating staff and users as somehow different to each other the assumption emerges that expertise and wisdom lie only with the managerial and professional leads. Together we can think and act on the many societal, psychological, emotional, global and political issues which concern us all. For me, due to this potential awareness of larger contexts, it is the median group, more than any other group size that can remind us as to who the person behind the diagnosis is. The median group enables individuals to find means of negotiating their ways through other groups, larger and smaller, in society; and the median art psychotherapy group is especially valuable in its wider approach to the possibilities and potentials for interaction and growth.