A Relational approach to art therapy

Journal Pre-proof A Relational Approach to Art Therapy Yael Gerlitz, Dafna Regev, Sharon Snir

PII:

S0197-4556(20)30017-4

DOI:

https://doi.org/10.1016/j.aip.2020.101644

Reference:

AIP 101644

To appear in:

The Arts in Psychotherapy

Received Date:

16 October 2019

Revised Date:

18 January 2020

Accepted Date:

15 February 2020

Please cite this article as: Gerlitz Y, Regev D, Snir S, A Relational Approach to Art Therapy, The Arts in Psychotherapy (2020), doi: https://doi.org/10.1016/j.aip.2020.101644

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Running head: A RELATIONAL APPROACH TO ART THERAPY

A Relational Approach to Art Therapy

Yael Gerlitz and Dafna Regev Graduate School of Creative Arts Therapies University of Haifa, Israel

Sharon Snir

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Art Therapy MA Program Tel Hai College, Israel

Author Note

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Correspondence concerning this article should be addressed to Yael Gerlitz, Graduate School of

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Creative Arts Therapies, University of Haifa, Israel, E-mail: [email protected]

Highlights

Four art therapists were asked how they implement Relational psychoanalytic theory.

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Each therapist was interviewed once a month for five months.

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Data was analyzed using interpretative phenomenological analysis.

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This study suggests the relational approach as a new theoretical framework to art

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therapy.

Abstract In psychotherapy of any kind, theory is an important basis for clinical practice but also evolves from it. Art therapists and other psychotherapists who use art materials need a 1

Running head: A RELATIONAL APPROACH TO ART THERAPY

theoretical framework to help them understand and conceptualize what happens in therapy. The Relational approach has never been presented as a theoretical framework for art therapy. Here, interviews were conducted with four art therapists who use this approach. Interpretative phenomenological analysis revealed how Relational principles manifest in art therapy and the challenges that arise when implementing this approach. Practical implications and the relationship between the therapist's personality and his or her theoretical affiliation are

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discussed.

Keywords: Relational approach, Art therapy, Theoretical framework, Two-person

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psychology, Qualitative research.

The use of active art-making alongside the application of psychological theories in the

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therapeutic relationship can enrich the client, support therapeutic goals and promote personal

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growth and change (American Art Therapy Association, 2017; Regev & Cohen-Yatziv, 2018; Slyton, D'Archer, & Kaplan, 2010). Gerber (2016a) argued that art therapy has a dialectic intersubjective aesthetic worldview in which inner and outer realities meet in the room and

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generate aesthetic knowledge. She claimed that through the dialectical dialogue of creation, exploration and identification between therapist and client, new intersubjective realities,

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meanings, insights and change can emerge. Art therapists' therapeutic presence involves not

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only attentiveness, but also suggesting art materials, helping organize the workspace or making the artwork, and sometimes even participating as art makers, though the latter can generate complexities and is less common (Knill, Levine & Levine, 2005; Moon, 2002; Schwarz, Snir, & Regev, 2018). The two-person psychology model adopted in Relational psychoanalytic theory perceives therapy as an interactive process of continuing dialogue, which both the therapist

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and client add to and shape. Its premise is that the mind is a product of relational constructions and develops through relationships; i.e., mutual emotional engagement. Therefore, the therapist's emotional engagement is seen as necessary, enactments as inevitable, and self-disclosure as having a therapeutic potential, as long as it is done cautiously and the client's needs and experience are the focus of attention. Relational psychoanalytic theory takes a dialectical worldview in which the internal conflict is also considered as interpersonal and as an integral part of relationships including the therapeutic

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one. Even intersubjectivity is perceived in a dialectical manner as the way in which reality is constructed from its beginning and as a developmental achievement of the continuing

interactive processes of mutual recognition and mutual negation (Aron, 1996; Beebe, 2004;

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Beebe, Knoblauch, Rustin & Sorter, 2003; Beebe, Rustin, Sorter & Knoblauch, 2003;

Benjamin,1990; Berman, 1997; Lyons-Ruth, 1999; Mitchell, 1993, 2000; Ringstorm, 2010a,

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b). This similarity between both worldviews suggests that the Relational approach should be

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highly suitable for art therapy.

Although art therapy is a relatively young profession that was only defined as a mental health care discipline in the 1940s (Borowsky Junge, 2016), there are a number of

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books presenting different theoretical frameworks for clinical practice (e.g., Gussak & Rosal, 2016; Huss, 2015; Malchiodi, 2003, 2012; Rubin, 1987, 2001). However, none have

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presented Relational psychoanalytic theory as a theoretical framework for art therapy, and

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authors who use Relational terms and concepts have not explicitly referred to it (Bat Or & Zilcha-Mano, 2019; Bragge & Fenner, 2009; Gerber, 2016a,b; Skaife, 2001; Springham & Huet, 2018). One exception is Schur (2015), whose art-based evaluation model is based explicitly on Relational psychoanalytic theory. This study explored how art therapists interpret Relational psychoanalytic theory and how they use it as a theoretical framework in clinical practice.

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Method The emphasis on processes and construction of meaning in the Relational approach as in art therapy, and the exploratory nature of this study led us to implement phenomenological qualitative research methodology (Creswell, 1988; King & Horrocks, 2011; Moustakas, 1994) and apply Interpretative Phenomenological Analysis (IPA) (King & Horrocks, 2011; Smith, 2017). Participants

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The sample was composed of four experienced art therapists - three females and one male. We applied purposeful sampling (Shkedi, 2003); namely by looking for participants

who use the Relational approach and thus could shed light on it. The sample was small and

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homogeneous as is customary in IPA research (King & Horrocks, 2011; Smith 2017; VanScoy & Evenstad 2015). The participants were not graduates of a Relational

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Psychotherapy training program, and to the best of our knowledge, there are no such art

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therapists in Israel. Inclusion criteria were: (1) Self-definition as an art therapist who works in the Relational approach, and (2) rich clinical experience. Participants were 44 to 63 years old (M=52.5, S.D.=7.5), and had 10-31 years of art therapy experience (M=17.3, S.D.=8.2). All

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participants had master's degrees and worked with adults and children, three of them also supervise other therapists, and two taught in psychotherapy and art therapy training programs

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(Table 1). All participants gave their written informed consent to participate. Participation

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was voluntary and participants were free to drop out of the study at any time. The study was approved by the Faculty of Social Welfare and Health Sciences Ethics Committee of the University of Haifa. During the interviews, it emerged that two considered the Relational approach to be their theoretical framework, one considered it as a growing component in her eclectic approach, and one was ambivalent. Procedure

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In order to find art therapists who met the criteria, we conducted an extensive search online. In addition we contacted senior professors and various training institutions and forums (e.g. the School of Creative Arts Therapies in the University of Haifa, Israel Ministry of Education art therapists forum, the Relational psychotherapy program at Tel-Aviv University, the Israeli forum for Relational psychoanalysis and psychotherapy, the psychotherapy program for art therapists in the Israel Winnicott Center) to ask them to disseminate a call to participate through their mailing lists. Four art therapists who stated they

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worked with the Relational approach were found, and were contacted by phone. We described the nature of the study and how it would be carried out; namely, a 60-90 minute

interview once a month for five months, and all four agreed to participate. A month before

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each interview we sent them an email with an interview guide (see procedure below). All the interviews were recorded and later transcribed. At the end of the data analysis, we sent the

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findings to the therapists for feedback to enhance trustworthiness (Larkin & Thompson, 2012;

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King & Horrocks, 2011; Lincoln & Guba, 1986). Furthermore, to ensure the quality of the research and allow the readers to examine it, we did our best to present sufficient evidence in

Data collection

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the Results section in the form of the participants' verbatim (Osborn & Smith, 1998).

We conducted in-depth, semi-structured interviews, in which both sides contribute

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and are influenced by the conversation (Shkedi, 2003), since this format is compatible with

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the Relational worldview and is customary in IPA research, which explores idiographic subjective experiences (Biggerstaff & Thompson, 2008; Smith, 2017; VanScoy & Evenstad, 2015; Windle, Hickling, Jayacodi & Carr, 2020). Relational psychoanalytic theory is not a unified school of thought (Aron, 1996; Aron & Harris, 2005; Berman, 1997). However, the following concepts recurring in its literature, and in our opinion, can be referred to as Relational principles: two-person psychology; relational conflict; affect, process and

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enactment; self-disclosure; confrontation and negotiation (e.g. Aron, 1996; Berman, 1997; Mitchell, 1993, 2000; Mitchell & Aron, 1999; Ringstorm, 2010a, b). Since this was a preliminary study, we addressed each of these concepts and examined whether and how they were manifested in art therapy. We decided to conduct five interviews with each participant. Each interview focused on one principle (two-person psychology, relational conflict, selfdisclosure) or several related principles (affect, process and enactment, confrontation and negotiation). This was done to obtain as rich and in-depth data as possible. We used an

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interview guide composed of a collection of short passages describing them taken from Meeting of Minds: Mutuality in Psychoanalysis (Aron, 1996). About a month before each

interview, we sent the participants an email with the interview guide so that they could reflect

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on the meaning of the passages and find examples from their clinical practice. The interview guide was the starting point for the conversation and we tried not to limit the interviewee's

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freedom of expression (Biggerstaff & Thompson, 2008). Our aim was to examine each

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participant's personal clinical experience and interpretation of the Relational approach rather than impose any pre-existing ideas or hypotheses of our own (Smith, 2017; Windle et al., 2020). In the first interview, the therapists also filled out a short demographic-professional

Data analysis

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questionnaire to collect background information.

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The first researcher applied interpretative phenomenological analysis as follows: (1)

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Familiarization with the data – reading the transcript several times and writing down everything that came to mind to identify and consider preconceptions; (2) Identifying themes – identifying experiential claims and concerns of the participant in a line-by-line annotation of the transcript; (3) Clustering themes – grouping themes that described core elements in the participant's experience into clusters of superordinate themes, and organizing them in a table with examples from the transcript; (4) Constructing a summary table that involved integrating

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the superordinate themes and organizing them in a master table. The latter was done twice: for each participant and then across participants while looking for similarities and differences (King & Horrocks, 2011; Larkin & Thompson, 2012; Windle et al., 2020). Our goal was to describe "both convergence and divergence within the study sample" (Smith, 2017, p.303), and to give voice to each participant's personal experience. For this reason, we included the superordinate themes of single participants in the findings. Results

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The results are presented thematically according to specific Relational principles. All names were replaced with pseudonyms. Two-person psychology

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We are two in here. The participants referred to themselves as being a subject in the therapeutic relationship, and described its various manifestations in the room and in the

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creative process. They stated they were active partners in the art-making in terms of the

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selection of the materials, the creative process and the construction of meaning. Even when a client creates alone, they argued, the artwork explicitly or implicitly is co-constructed as a product of a meeting of two. Dana described her participation in a client's creative process:

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"She works entirely alone but it is still a product of our togetherness here in the room. [...] Although technically she creates it by herself, it is entirely the result of negotiation and co-

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construction, whether in terms of materials [...] or in terms of meaning." According to the

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participants, they bring their personal, cultural and professional worlds into the room, which they perceive as an expression of subjectivity and authenticity. Ziv said that displaying clients' artworks in the room is an expression of his professional world: "I'm not trying to hide other clients' artworks because, for me, if we talk about the position of the therapist, then the therapist brings himself, he brings his world. My professional world is in this room and as such, people are exposed to other people." The participants described how sometimes they

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were co-creators in joint or parallel art-making, and they perceived this as an explicit expression of their subjectivity. They argued that they typically engage in art-making in a reactive and gentle manner, but they also described cases in which they made a more blatant artistic gesture. Adi discussed a client who had asked her to copy his paintings for a long time, and the moment she decided to express her own subjectivity in the paintings: "I started to resist and not to obey. And it felt good. It was time. [...] On the one hand, there was a lot of intimacy in this togetherness but on the other hand, it was like saying, 'I want to be me too.

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[...] I'm not here as your draftsman.'" Active therapist. Being active partners: asking questions, sharing thoughts and

feelings, assisting in the selection of materials, demonstrating artistic techniques, being

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involved in the art-making or participating as an art maker were mentioned by all as a way to help clients to express themselves, and was especially emphasized by Adi and Ziv. In their

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view, being active; that is, being involved in the art-making or even creating is often

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essential, and is part of being in a relationship, being together, and part of their therapeutic presence and empathy. Adi described working with clients suffering from dissociative identity disorder and said: "I would go under the table, sit down on the floor […] put some

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paper between us and communicate with her on it, to be there with her so she wouldn't feel alone. If she couldn't talk.." Ziv stressed the importance of assistance; i.e., enabling the client

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to experience success, even when it means intervening in the creative process or engaging in

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joint artwork: "Art therapists should consider the possibility of being active partners in the art-making together with the client. [...] failing is something the client knows all too well. Our job is to help him succeed." Using joint painting as a therapeutic tool. All the participants described using joint painting as a way to bond, to deal with uncooperative clients, or to foster the client's selfexpression. Ziv considered it a core element in his practice and developed it into an

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evaluation model as well. He was the only one to report proactive and systematic use of joint paintings for evaluation, overcoming inhibitions, and as a way to be together: "I do it with almost every new client [...] I've been doing it for a very long time and not just in the beginning, but also as part of working together in therapy to break through barriers, [...] to be closer to the client's artwork, [...] to be able to say 'we' about things." An aspiration for equality alongside inequality. All the participants described their reservations about being an authority figure and their aim to promote equality in the

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therapeutic relationship. This is manifested, in their view, for example, when they do not know which artistic technique to use or how to draw an image or what material is the most

suitable. According to Gabi, not knowing an artistic technique can enhance the clients' self-

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worth: "I often join them [...] and I think it shows something like 'I don't know, and I also have a need, and I want [to learn] from you because I think that you can contribute

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[something to] me.'" According to Ziv, his aim to promote equality appears in his 'joint

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painting' model by sharing the paper and art materials in addition to not knowing what will happen on the paper: "My goal to be on an equal footing with the client as much as possible hasn't changed. He and I get dirty in the same way, have the same set of artistic options, use

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the same paper, [...] and neither of us knows what will happen there." Alongside their aspiration for equality, they all described inequality in the therapeutic situation as well, since

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the client is seeking help and must be considered center stage whereas they are trained and

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experienced and are there to help. Ziv said: "I'm more skilled and I also know [because] I'm trained. That means that my starting point in a painting is not the same as the client, first because he was the one who came to therapy. I'm there because he came to me for help and not vice versa [...]. Moreover, my control of the art instruments and materials allows me manipulate them in a way that he usually can't."

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The relationship is in the center. According to all the participants, the 'here and now' is the focus of the investigation and the relationship is what promotes change. Dana said: "being able to get lost or being in a place of not knowing, whereas the focus is the relationship, the mutuality, what's going on between us". They argued that the shared experience in the creative process as in therapy in general is the main thing. Gabi described participating in art-making while working with a group of adolescents, and how her artwork was also explored by the group: "they talked about it and said what they felt about it, and

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what they thought about it." Mutual influence. All the participants expressed the feeling that the client affects the therapist just as the therapist affects the client. This mutual influence is especially prominent,

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they said, in joint or parallel art-making. According to Adi, to provide mirroring and a

therapeutic presence, she shows clients their influence on her in parallel art-making: "I show

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her that I'm doing the same [...] and that gives some validity to the fact that I'm with her there,

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[...] that she affects me, that I see her". However, they stressed that mutual influence also exists when the client creates alone. Dana described the clients' influence on her experience when they choose an art material that she does not like: "The basic recoil I have, it changes

the material."

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with the client. I am often filled with admiration for what happened or what was created with

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The personal and the professional are connected. All four therapists stated that the

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personal influences the professional and vice versa. Ziv explained that his personal creative experiences are the foundation for his understanding and ability to enable creative processes in the room: "I'm not afraid that he will work and destroy because I trust myself that I'll know how to accompany him in that process, since I've also experienced it." The participants described how their personal lives enter the room via their clothing, their presence, the way they respond to color, voice, texture and words, or more explicitly when working at home.

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Ziv explained: "I try to keep things uncovered and open, and that's why I have no problem working right next to where I live. And when my children were young and they either needed something or they quarreled and their yelling was heard loud and clear, o.k. ... that's part of life." Adequacy and adequately. All the participants repeatedly emphasized that the client and his needs are always center stage, and their interventions and personal verbal and artistic expressions take this into account. Adi described her cautious participation in a joint painting:

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"Usually I tend to minimize myself in joint artworks. I'm very careful." Dana talked about cautiously sharing associations to the client about the artwork: "There is an internal debate: does it belong, is it relevant, how it will be accepted, is it the right time now, [...] which

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association will be appropriate to say." Regarding the use of self-disclosure, Gabi noted that sometimes she would simply ask for permission: "sometimes it's appropriate, sometimes it

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isn't. [...] sometimes I ask 'is it o.k. for you that I share so that I can show you that I'm also.."

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Relational conflict

There's always a conflict. Conflict in relations with others and between various voices of the self are seen in the artwork and in the client's relations to it, according to the

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participants. They described the client as having an internal conflict that is also interpersonal. Gabi described a client's internal conflict – the desire to share and open up pitted against the

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desire to keep to herself and hide, which is also interpersonal; i.e., a conflict in their

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relationship: "She's creative, she… in here not so much, o.k.? She provides something very impoverished in terms of the art-making." She said that the same conflict also manifests in the client's relation to her artwork: "She sees the bear she made and she's totally terrified of it. [...] I ask her, 'maybe you want to continue?' [...] 'Maybe next time', that happens a lot, this 'maybe next time.'"

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The participants described expressions of conflict both in the client's artworks and in joint/parallel art-making. In personal artworks, they described images of a struggle between good and evil, between forms and/or contrasting colors, as well as more implicit contrasts, such as using soft materials to express a difficult experience. In joint/parallel art-making, they described contrasting images in content and in modes of creation, and also a struggle over space on the paper or next to it. In his 'joint painting' model, Ziv gives the client the choice of erasing or changing the painting with white paint. He stated that an internal conflict which is

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also interpersonal comes best to the fore at this time: "I've been in situations where the paper was completely covered. [...] And it is difficult both ways, it's the client who got erased but also whoever painted with him."

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Therapist internal conflict. All the participants described conflicts within

themselves when dealing with clients, art materials, creative processes or artworks.

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According to Ziv, his inner conflict in response to a client's artwork indicates something to

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investigate: "It can be a certain color combination, it can be the way the paint was applied, it can be the type of pressure on the art material. There are no rules but it's this understanding that 'you have to be here now, you mustn't go', because you want to go." All the participants

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reported some conflict between personal behaviors or needs and the therapeutic position. Adi talked about her internal conflicts about being unable to unveil her artistic skills: "and I feel

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this conflict with highly talented clients as well. I suddenly say to myself 'wait a minute, and

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where is my creative side? And where is my talented side?'" Affect, process, and enactment Emotional involvement and intimacy in the therapeutic relationship and the art-

making. The participants described themselves as emotionally involved in the therapeutic relationship and the art-making. Gabi described how a client made her feel hurt and angry, and said: "I'm not a totally 'blank screen'. I can also show my less pleasant feelings, [though]

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not in a raw way.." Most of them claimed that intimacy is essential to the therapeutic relationship, and according to Ziv, even love: "I believe that all in all, meaningful therapy occurs when there is love between therapist and client. [...] I say for certain that where there are deep feelings, the therapy leads to much more meaningful places and is overall more meaningful." The participants described the intimacy generated by disclosing and revealing artworks, and stressed that an emotional response is an integral part of being in a meaningful relationship. Adi described an intimate moment and her emotional response when looking at

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a client's artwork: "We both just sat there and cried [...] I think it allowed her to cry, and it allowed me to cry about different losses, and it was all through that artwork." The

participants stated that an emotional response endows witnessing and validity to the client's

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experience and artwork. Adi explained: "These women I work with, who have been sexually abused, need a witness to what they created. I mean, the girl who drew that belly or drew

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thighs with cuts [...] she needed to have it turn my stomach inside out too."

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Emotional involvement evokes difficulties. The participants described themselves as walking on a tightrope between emotional involvement and providing regulation, holding, and containment. According to Adi, it is not easy to keep that balance during the creative

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process: "On the one hand I felt like I was participating in this with him and I'm there in it with him, and on the other hand, I had to protect him and it was very hard for me." The

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participants noted that their emotional involvement also challenged the client. Ziv described a

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client who had difficulty coping with his emotional response: "And I think that he recognized some disappointment in my face. The next meeting, as though it has nothing to do with that, he announced that it would be our last meeting." Processiveness. The participants took a developmental perspective that views therapy as an emotional process of soul-searching and getting closer to one's self and the other, and as a process of creating a meaningful relationship, constructing meaning, personal growth and

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change, and referred to its manifestation in the creative process. Ziv described a process of giving meaning to artwork that constructs the creative process in the therapy: "As far as I'm concerned, interpretation in art therapy means to talk with the client about the creative process and try to open the door to his next artwork." Adi stated that she told a client about the process of getting closer to her: "I said to her, 'slowly slowly, some sort of process took place between us and I started to like you, so that today you are very important to me'". Enactment is both positive and negative. The participants described enactment as

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contributing but also as an obstacle. They said their activeness and emotional involvement in therapy and especially in art-making contribute to authenticity, to creating a meaningful

relationship, mutual learning and the ability to provide a corrective experience. When Dana

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described how she stopped a client's creative process to plan how to use the materials to

execute his ideas, she said: "I think it's terribly important in therapy too, to teach [clients] to

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think while working." On the other hand, everyone noted that their involvement might also

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inhibit or narrow the client's space, freedom of action and creativity, and in some cases even block the therapeutic process or cause ruptures. Dana added: "I stopped him. I told him, 'Wait a minute, put the [utility] knife aside, first, we must plan', [...] it's an active intervention. I

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could let him waste time and... destroy, and sometimes it happens. I have a problem. A problem?! It's me. I can't stand to see them destroy."

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Self-disclosure

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Using self-disclosure to foster the therapeutic relationship and therapy. The participants described using verbal and artistic self-disclosure to foster the therapeutic relationship and therapy. Dana said that she rarely creates with her clients and as artistic selfdisclosure reported only sharing associations to the clients about their artworks. The others, however, also described their images in joint/parallel art-making as self-disclosures. Adi described artistic self-disclosure when making a mosaic with a group of victims of sexual

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assault: "I remember looking several times, specifically when they talked about something, looking for red because I had to put red components right then to show the wound, to show what I felt." She said it was a way to connect the clients to their emotional experience: "I felt that I had to use myself to explain to them what it was like to feel this aggression, to feel the... feel being raped." The participants also described using self-disclosure as a way to cope with uncooperative clients. Gabi described using artistic self-disclosure with a child who was afraid to enter the room: "She stood there in the corner like those cats, you know, that are

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really scared or hurt by something and they stand there hiding. [...] Because I have this board here, so I started painting." The participants suggested that their self-disclosure could reassure and create trust and thus foster therapy. Ziv said: "Sometimes I answer and then ask, 'why do

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you want to know?' Often I find that a direct answer is somewhat reassuring and enables you to get to what is behind this question more quickly." He also said that self-disclosure is

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inevitable: "I don't see any value in hiding, especially since it's impossible. It is simply

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impossible to hide." He emphasized that in today's internet and social media era, the therapist is constantly exposed, whether consciously or not.

Hiding and the wish to hide. Alongside the use of self-disclosure, all the therapists

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also described a desire to "keep to oneself" that manifests in the art-making as well. Ziv, for example, said that in joint artworks he not only discloses but also hides: "For better or worse,

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I am more skilled at not showing something I don't want to show."

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Self-disclosure evokes difficulties and ambivalence. The participants noted that it is not easy to disclose, and most of them explicitly expressed concerns and ambivalence. They argued that the challenge is twofold: the difficulty disclosing and the difficulties it can evoke in the client. They stated that clients sometimes have trouble making constructive use of the therapist's self-disclosure. Gabi shared a concern that her self-disclosure would be used against her and described getting hurt by a client's criticism of her artwork: "When I

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authentically expressed myself, she devalued me, [...] and sometimes I was really hurt by it." In her view, artistic self-disclosure causes more concern: "I think that when I draw, I have less control than when I choose to say something. The artistic endeavor intimidates me more." She recounted how she quickly erased her image in a joint painting because she feared it disclosed negative emotions: "It was like a quick reaction to something I thought I had done and that I felt it was… yes, that I couldn't contain it." Sometimes the participants presented reservations and sometimes a willingness accompanied by concerns about exploring their

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artistic self-disclosure with the client. Adi said: "Usually I draw less attention to my artwork and minimize it when looking at it. [...] I try to hide it. [...] there, I'm suddenly not a Relationalist."

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Confrontation and negotiation

Negotiation and confrontation to foster therapeutic relationship and therapy. All

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the participants noted that negotiating with clients and confronting them have a therapeutic

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potential, such as fostering separation and mutual recognition or enhancing authenticity, and added that it is often accompanied by the therapist's self-disclosure. They stated that they confront clients when there is a theoretical rationale to do so. Dana, for example, described

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how she insisted on gluing a client's broken artwork together again because of the impact of the symbolic corrective experience even though it annoyed the client: "The fragments were

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scattered inside her and there was no one to connect them. I think it was really a symbolic act

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of someone connecting the broken pieces for her." The participants noted that sometimes they confront their clients with difficult feelings or even criticism primarily as part of their aim to provide an authentic presence, but also to help clients recognize external reality, their influence on it, and its influence on them. In their view, this kind of confrontation in a relationship leads to recognizing the other as a separate individual, and they stressed its importance to mental health. Adi described negotiation in a joint painting with a client

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suffering from anorexia, which ended up by confronting her with criticism: "In the painting, I tried to portray things related to growth. I drew a watering can and a sun [...] she didn't want to take them. It was such a small plant. In the end, I drew this big plant because I wanted to say to her, 'You can't stay this small.'" Co-construction of meaning through dialogue is also a form of negotiation, according to all. In addition, the therapists noted that the greater part of negotiation and/or confrontation in therapy is about the setting. Everyone, for example, referred to negotiations on what is traditionally done in art therapy; namely, leaving the

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artworks with the therapist. Dana said: "Usually I let them take it but not before we talk about it and talking about it is a kind of negotiation."

Confrontation and negotiation evoke difficulties. One of the difficulties that all the

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participants described was clients' aggression during negotiation and confrontation.

According to Dana, negotiation about the setting and art-making takes place from the

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beginning and challenges her as much as confrontation: "I need to have lots and lots of

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persistence and faith in my perspective." The participants were not blind to their clients' difficulties in conflict and negotiation. Adi argued that female clients in particular have trouble being able to confront others: "Most of my clients are women, so relatively speaking,

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women tend not to confront and not to argue about material... or anything. [...] There's also guilt in saying 'I don't want to. You're telling me to [use] plaster bandages? I don't want

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plaster bandages.'" All the participants described relinquishment, which is part of

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confrontation and negotiation, as challenging. Parallel to negotiation or confrontation with the client, they explained that they experienced internal negotiation and conflict about whether to withdraw or to insist. Dana said: "And also to myself I said 'no, I have to confront her', and that's also a kind of negotiation." Red lines. The participants stressed the need to be flexible; however, most of them noted that not everything is open to negotiation, especially their therapeutic approach or

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Running head: A RELATIONAL APPROACH TO ART THERAPY

professional and personal freedom. They said that negotiations in therapy are conducted in accordance with the asymmetry that characterizes the therapeutic relationship, and sometimes they will set boundaries based on professional considerations. For example, the therapists noted that they do so when using liquid art materials to prevent clients from having a dismantling experience. Since they perceive themselves as a subject in the room, they maintain their personal and professional freedom. Ziv stressed that his activeness was nonnegotiable: "I won't let anyone tell me how much to be involved. I ask myself what's right for

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me and what's right for the client. I think I'm right. If I'm not, then we'll have to deal with it." Adi, Ziv and Gabi stated they would insist on their Relational approach. Adi said: "I told him, 'I'm not that. I'm not like that. You're right, I bring myself. And sometimes I also bring my

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doubts and questions and I won't give you tips and tell you what to do. That's not me.'" The therapists' experience enables them to confront and negotiate. The

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participants considered that their professional experience contributes to their ability to

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negotiate and confront clients. However, Adi was the only one who described it as essential and referred to the therapist's personal experience: "Nowadays I'm absolutely not afraid of having others direct their anger towards me and even evoke it [...] I think it has to do with

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some confidence that's not always there at the beginning. In my view, it has to do with experience, maturity, and also to... you know, to the experience of coping with aggression in

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one's childhood."

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Discussion

This study examined how art therapists interpret and apply Relational psychoanalytic

theory in art therapy. This section discusses the practical implications of the findings, including the challenges associated with adopting a Relational approach. The relationship between the therapist's personality and his or her theoretical affiliation is also discussed. A Relational approach to art therapy – practical implications

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Running head: A RELATIONAL APPROACH TO ART THERAPY

Two-person psychology. The art therapists interviewed here stated that they consciously and intentionally take their subjectivity into the room, and are active partners in the selection of materials, the creative process and the construction of meaning. In order to foster their clients' expression, they offer personal cultural contents, display clients' artworks in the room or even actively participate in the art-making. Their personal creative experiences are the basis of their understanding and the way they enable creative processes to unfold in therapy. Their aspiration for mutuality and their recognition of mutual influence allow them

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to be open to learning artistic techniques from their clients. When creating with clients, they authentically and openly express the clients' influence on them, as well as unconsciously, and in their view, the shared experience and art-making are the focus of investigation. Maclntosh

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(2017) noted, like the therapists in this study, that she could literally see the mutual influence in parallel art-making during therapy in that her drawings and those of her client often

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displayed similar sensations or atmospheres and sometimes even similar images. She claimed

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that parallel art-making made some part of her accessible to her client that could not be expressed in words, and enabled mutual healing of traumatic and detached experiences for them both. Aron (1997) pointed out that the aspiration toward mutuality and intimacy and the

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recognition of mutual influence does not cancel out "the important asymmetries, the important differences in our knowledge, power, authority, and responsibilities" (p.885). Like

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him, the therapists in this study also claimed to be the "responsible adult" in the room, and

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emphasized that they provide adequate participation in the art-making and in therapy in general.

Relational conflict. The therapists in this study argued that expressions of conflict

that are both internal and interpersonal are manifested in their clients' personal artwork and in joint artwork. They stated that contrasts and collisions between colors and forms describe the struggle between the desire to be in relationship and the desire to avoid one. They chart the

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Running head: A RELATIONAL APPROACH TO ART THERAPY

conflict that the material, artwork or creative process evoke within the clients and in themselves. According to Darroch-Lozowski (2004), when using art-making as a healing technique, we take a risk: will it evoke more difficulties or will it help cure us? She argued that once people take the risk, there is typically an urge to continue when recognizing that "what is being formed on the paper is something we have never seen before and, yet, is something with which our body-psyche is intimate" (Ibid, p.11). Levine (2005) claimed that

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an experience of chaos is essential to art-making, and in order to find a new form, one has to surrender to it and relinquish the omnipotent subject position. The fear of losing control, he

wrote, always evokes resistance and "a paradoxical will-to-not-will is thus necessary in order

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to overcome the initial resistance" (Ibid, p.25). He argued that in creative arts therapies only giving up control while engaging in the creative process can lead clients to greater sense of

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competence and control. To use Benjamin's (1990) terms, art creation (process and product)

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contains a constant internal tension between the wish for omnipotence and the desire to be in relationship with a not-me. An artistic product is an expression of relational conflict but can

internal tension.

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also evoke it, and in the end, may be the resolution as well since it embodies both sides of the

Affect, process and enactment. The therapists viewed the client's art-making in each

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session and throughout therapy as a creative process that evolved from moment to moment

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and from session to session. They considered its meaning to be structured together and as being a creative process in and of itself. In their actions in the room, whether they were engaged in art-making or not, the therapists responded emotionally and as a function of their personality to the use of the art materials, the creative process and the artwork. They did so relatively freely and authentically, although they often needed to overcome fears or the recoil that closeness and emotional involvement can evoke. Along with emotional involvement and

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Running head: A RELATIONAL APPROACH TO ART THERAPY

closeness (which in joint art-making is also physical), they needed to protect the client and provide regulation, holding and containment. They stressed the constant need to maintain a delicate balance between proximity and distance, between expressiveness and restraint (Mitchell, 2000). According to Stern (2013b, 2015), in the Relational perspective, enactment – the conscious and unconscious mutual involvement in the therapeutic relationship – is mutual, inevitable and essential, and is driven by desire. Art, which is driven by emotions and desire,

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is a discipline of the senses that perceives impressions and often stirs people unconsciously and/or uncontrollably. Thus, mutual involvement in joint/parallel art-making as well as in the relationship of maker and viewer inherent to art, is conscious and unconscious, inevitable and

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even essential. The Relational concept of enactment seems particularly appropriate for art

therapy, and Ziv presented this view explicitly. Levine (2005) argued that artwork cannot be

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predicted during the process, and can only be understood retrospectively; the artwork

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illuminates what was previously vague, and actually "arrives to re-organize the field that preceded it" (p.25). Stern (2013b) argued that enactment resolution increases relational freedom and thus the freedom to experience new and unbidden experiences in the therapeutic

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relationship. This suggests that in art therapy the dialogue about the art-making and its meaning has a similar effect.

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Stern (2013b, 2015) noted, as did the therapists in this study, that there are two

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difficulties associated with enactment: the difficulty involved in recognizing it since recognition is always retrospective, and the difficulty of choosing the specific emotional response from the spectrum of responses available to the therapist that will promote change; i.e., expand the relational patterns of both sides. Authentic emotional involvement is not a therapeutic technique that can be applied, but is personal, unplanned and occurs in real time; thus, awareness and control are limited. This is even more true in art-making since the

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Running head: A RELATIONAL APPROACH TO ART THERAPY

artwork exposes and evokes conscious and unconscious parts of the mind; thus, art therapists cannot really know what they are doing. Stern (2013b), like the therapists in this study, noted that the therapist's professional experience and training help him or her find the authentic emotional response needed at a specific moment. Self-disclosure. The therapists in this study expressed their emotional response to the clients and their art-making directly, freely and authentically in words or via artistic gestures. They did so to provide emotional resonance, connect the clients to their emotions and

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experiences, create an atmosphere of closeness and mutuality, and foster authenticity. They also used self-disclosure as a way to cope with uncooperative clients. However, they were

fully aware that alongside the conscious or the inevitable unconscious self-exposure in their

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art-making and gestures, something always remains hidden, intentionally or not. Like any

individual, they also want to hide sometimes (Aron, 1996). They noted that the obligation to

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maintain a delicate balance between free and authentic expression and restraint and to ensure

challenges and raises doubts.

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that the client and his or her needs and art-making remain center stage presents them with

In the art therapy literature, it is difficult to find references to free and authentic

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expression of the therapist as a creator; i.e., to the use of therapist self-disclosure. In a rare reference to the subject, McNiff (2009) specified the difficulties along with the benefits of

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using therapist self-disclosure mentioned above: fear of exposing vulnerability; namely,

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feeling insecure about one's artistic abilities or a sense of inferiority compared to the client's creative expression, and uncertainty about the client's response to the therapist artwork. Confrontation and negotiation. The therapists in this study sometimes found it

necessary to confront their clients with their negative feelings or even criticism of their artwork, and did so via artistic gestures or verbally. They negotiated with the client and sometimes disagreed about different aspects of the art-making such as whether and how to

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Running head: A RELATIONAL APPROACH TO ART THERAPY

use an art material or engage in art-making, how to create a joint painting, etc. Although it is customary in art therapy that artworks are kept by the therapist during the whole therapy process, negotiations are relatively common, and are part of the ongoing negotiations over the setting and boundaries. Another ongoing process of negotiation that the therapists mentioned was the dialogue about the meaning of the artworks, which is a creative process in itself. The two-person perspective and its emphasis on mutual influence and dialogue has led Relational authors to conceptualize internal and interpersonal processes, including the

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therapeutic process, as negotiations (Aron, 1996; Mitchell, 1993; Pizer, 1992, 2015; Slavin & Kriegman, 1998). Pizer (1992) used the term intersubjective negotiation to define the conscious and unconscious emotional mutual influence that occurs all the time in

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relationships. In his view, this negotiation, verbal or not, is over construction of meaning, and can provide an affirmation of the client's implicit experience. He termed this intersubjective

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affirmation, and argued that confronting clients with negative feelings towards them can also

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provide this affirmation, in the sense of not leaving them alone and unaware of what is going on between them and the other, or between them and themselves (Pizer, 2015). The therapists in the study had similar views and argued that intersubjective negotiation and affirmation can

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clearly be seen in joint art-making. However, they noted that it also exists when clients create alone, since they are present in the room and sometimes even actively involved in the

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selection of materials, etc. Maclntosh (2017) described an intersubjective affirmation

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experience in parallel art-making in therapy: "For Hannah and me it was not just about her making art and me consuming, reflecting, even interpreting the art that was transformative, it was the experience of art-making in parallel that was pivotal for creating a space for expression. It was just as important to Hannah that I witness her creations as it was for her to witness me, witnessing her, through my creations" (p.450). According to the therapists, intrapsychic negotiation – internal regulation between different self-states, and interpersonal

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Running head: A RELATIONAL APPROACH TO ART THERAPY

negotiation – the overt arrangements in relationships, to use Pizer's (1992) conceptualization, are expressed in joint art-making as well as in personal art-making. In fact, clients' personal artworks also provide intersubjective affirmation, since art is an intermediate space of experience (Winnicot, 1951); i.e., it belongs to both internal and external reality. Negotiation and confrontation challenged the therapists and the therapeutic relationship, but their experience helped them muster their courage, determination and belief that these will support and promote therapy. However, their experience also allowed them to

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keep an 'open mind', and relinquishment. Since neither are easy to do, they experienced parallel internal negotiation/confrontation over the benefits, cost and rationales. In line with

their personality and experience, they created a balance between conforming to their client's

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demands and relinquishment, and between insisting and setting boundaries. Aron (1996) stated to his clients that "a good deal of what goes on between us is negotiable, not

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they draw red lines when necessary.

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everything, but much is" (p.144), and so did the therapists in this study, who stressed that

Conclusion

In 1987, Robbins queried "Essentially, the problem comes down to a very basic

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question: how can we translate the language of psychology into a language of art?" (p. 212). In order to do so, this study explored how four experienced art therapists interpret Relational

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psychoanalytic theory and use it as a theoretical framework in clinical practice. It appears that

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adopting a two-person psychology model directed them towards an active position, and parallel art-making and joint paintings were not strangers to their clinical practice. Since they saw themselves as active partners in the room, the shared experience and art-making were the focus of investigation. Adopting a dialectical worldview made them sensitive to visual conflicts and conflicted relations to artworks and art-making, which were perceived as internal and interpersonal as well. By adhering to the notion of mutual influence in therapy

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Running head: A RELATIONAL APPROACH TO ART THERAPY

and being emotionally involve in the art-making, they considered their emotional responsiveness to artworks and art-making as necessary. However, despite their recognition of mutual influence, conscious and unconscious mutual involvement in the art-making and artworks raised self-doubts and sometimes even guilt. In what can be perceived as a dialectical act in itself, regardless of the extent to which involvement was inconvenient, they used self-disclosure authentically though cautiously disclosed feelings and thoughts. Perceiving therapy as a continuing dialogue, aspiring for equality and a tendency toward

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activeness made them open to negotiations on the art-making, the artworks and their meanings. However, they did not avoid confrontation with clients and set boundaries when needed.

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The relationship between the therapist's personality and his or her theoretical affiliation The findings suggest that implementing a Relational approach challenges the therapist

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and can lead to numerous difficulties. Although adopting a Relational approach does not

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seem to be easy, the therapists whose worldview and personality were in line with Relational principles seemed to feel that it was a natural choice. Relational psychoanalytic theory draws on object-relations theory, self psychology,

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interpersonal psychoanalysis, and even contemporary Freudian thinking (Aron, 1996; Berman, 1997; Kuchuck & Sopher, 2017), and therefore is eclectic in nature, which may

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attract people who are by nature ambivalent. In this study, the therapists whose personality

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seemed to include this type of trait stated they used a Relational approach with little reservation or clarified that it was only one part of an eclectic approach. Limitations and contributions This study has a number of limitations. This was a preliminary study with a small sample since, to the best of our knowledge, there are almost no Israeli art therapists who use the Relational approach. As Emanuel Berman noted (Choder-Goldman, 2014), Israeli society

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Running head: A RELATIONAL APPROACH TO ART THERAPY

is relatively small and clients often know someone from the therapist's social circle or family. Therefore, regardless of their theoretical affiliation, Israeli therapists may be less inclined toward the classical position of anonymity, neutrality, and abstinence (Adler, 2010; Lane & Hull 1990). In future research, a larger sample should be contacted and include therapists from different countries. In addition, our decision to conduct a qualitative phenomenological research and apply interpretative phenomenological analysis clearly reflects our belief that other interpretations can always be made. Future research carried out by other researchers

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with the same or different samples using the same or another approach is likely to uncover other and/or additional insights.

Despite these limitations, the study contributes by presenting a new theoretical

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framework to art therapy. The Relational approach seems highly suitable for art therapy since art-making in general and particularly in therapy evokes an emotional response from both the

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Declarations of interest: none.

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a dialogue and to co-construct meaning.

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creator and the viewer, and the ambiguous nature of art naturally invites the two to engage in

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This research did not receive any specific grant from funding agencies in the public, commercial, or

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not-for-profit sectors.

Acknowledgements We would like to thank Gali Levin, Regina Polak, Yoni Schur , and Daniela Zilber for

their time, commitment, and willing to share their experience with us.

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VanScoy, A. & Evenstad, S. B. (2015). Interpretative phenomenological analysis for LIS research. Journal of Documentation, 71, 338-357. doi: https://doi.org/10.1108/ JD-092013-0118 Windle, E., Hichling, L. M., Jayacodi, S. & Carr, C. (2020). The experiences of patients in the synchrony group music therapy trial for long-term depression. The arts in psychotherapy, (67), 1-8, 101580. Winnicot, D. W. (1951). Transitional objects and transitional phenomena. In D. W. Winnicot,

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Playing and reality (pp. 1-25). London, UK: Tavistock, 1971. Retrieved from

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https://www.pep-web.org

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Running head: A RELATIONAL APPROACH TO ART THERAPY

Table 1 Therapists' demographics and background Age

Gender

Education

Qualifications

Art therapy experience (years)

Adi

56

female

art therapy (M.A.)

CBT, EMDR, DBT, focused psychotherapy, women's psychology and modes of care, group analysis

10

Dana

44

female

art therapy (M.A.)

Gabi

47

female

art therapy (M.A.)

15 couple and family therapy, group guidance, psychoanalytic psychotherapy psychodynamic 13 psychotherapy, sexual abuse victims therapy

-p

re

lP na ur Jo Ziv

63

male

art therapy (M.A.)

34

Current workplace as an art therapist therapeutic treatment and counseling center for women, school for children with learning disabilities, private clinic mental health clinic, private clinic

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Participants

focused psychotherapy

31

family counseling and therapy center, treatment center for conflict zone trauma victims and sexual trauma victims, private clinic private clinic