gms | German Medical Science

The question in the title of the essay seems paradox: what is unseen cannot be seen. And yet, it implies that there are people who can see what is not visible to others (Figure 1 [Fig. 1]).

Many visitors swarm to museums to look at art, to admire the work and – they are fascinated of what they catch sight. They experience more than the act of seeing – feelings come into play, fantasies and memories are stimulated, something beyond the painting is set in motion. Appreciating art, we get to know much more about ourselves than in everyday life.

This attraction is impressively revealed in Thomas Struth’s photo, taken at the Academia in Florence: the audience is looking at Michelangelo’s famous sculpture of David. Any visit in a museum or gallery is usually accompanied by concentrated communicative engagement with the art (Figure 2 [Fig. 2]) – an investigation about what is there to find and possibly to be understood.

Searching the unknown is a major impulse driving the artist. When he/she begins to work, he/she does not know how the painting will look like, which form it will assume, what kind feelings and associations and insights he and eventually also his audience will relate to it. If he wants to be successful in this venture, he/she must be open for the unknown, ready to leave earlier knowledge and findings behind.

One of the most fascinating testimonials for the artist’s disposition for permanent transformation is Clouzot’s film from 1955 about Picasso working [9]. A canvas, illuminated from the backside, allows us to follow the unfolding of a painting and how it literally goes through many stages of transformation until the artist finally considers the image as completed. The spectator remains in an excited state of tension – presumably because he will never get to the bottom of the mystery about the artist’s ever-changing decisions while creating his art work.

The search for change and transformation brings patients into a therapy. Their motivation may be looked at like a similar kind of process like the artistic one, when they strive to get to the bottom of their problems. They hope to find out more about themselves, to find solutions, changes and enrichment. The psychodynamically oriented therapist provides the framework where the patient can immerse in his inner, unseen worlds. However, for the patient this journey is more difficult than for the artist. The less a patient blocks this encounter with himself and his inner life, the more insight (sic) he will receive.

In the following, the topic about working with the unseen will be researched under three premises:

1.

There are two well-known protagonists for the unseen: the artist and the psychodynamic therapist/psychoanalyst.

2.

It is the unseen what both professions have in common: in psychoanalysis, generally it denotes the unconscious; the domain of the artist is to provide what is absent with presence – in the artistic form.

3.

The processes in both areas – art and psychoanalysis – which lead to the unseen are different. Art therapists know both areas, bringing them together in their work. Knowing the differences and being aware of the overlappings are part of the important and exciting chores in art therapy.

I want to begin with outlining the unconscious in psychoanalysis. In many respects art therapists lean on concepts about the unconscious – most art therapists hold the opinion that especially in a patient’s art work unconscious aspects of his or her inner live become visible. Psychoanalytic research about the role of the unconscious in art making and the artwork has contributed immensely to the understanding about the efficacy of art and the artistic process in art therapy. Recent scientific research about the aesthetic aspects of affectivity provides further grounds to be useful for art therapy. Neighbouring disciplines like art theory speak about the affective turn. As Gehrig et al. ascertain, we notice that a new adoption of the unconscious in the media sciences is taking place ([22], p. 8).

Regarding the therapeutic relationship current discussions in psychoanalysis about consciousness and unconscious can be very beneficial for art therapists, since they provide further arguments for the efficacy of art therapy. This interdisciplinary view results in a change of focus in the art therapy process: it is no longer primarily directed at the artistic work and its potential unconscious components, but above all at the realization that the unconscious plays a far greater role in the entire process between therapist, patient and work than previously assumed.

The current conceptualization of the unconscious in psychoanalysis is based on two main perspectives formulated by Michael B. Buchholz and Günter Gödde. They distinguish two dimensions of the unconscious – the vertical and the horizontal direction. On the vertical axis the unconscious defines the repressed apparatus of the psyche, horizontally it refers to something like an encounter on equal footing – opening the social resonance space. Thus, the authors denote a repressive and a resonant model of the unconscious [6]. Accordingly, the vertical, the repressive model, contains the repressed and the defence. There is an “above” – the conscious and an “under”, where the unconscious is located. Linguistically this is captured when we speak about suppression, displacement control, or in everyday language talk about subconsciousness.

Sometimes patients themselves illustrate these hypotheses: a young woman treated in the psychiatric ward because of borderline symptoms, seemed to have the vertical model in mind when she drew herself above the line as a patient today, whereas below she intended to deal with her past as a punk and a needy child in several variations (see also [13]; Figure 3 [Fig. 3] and Figure 4 [Fig. 4]).

In psychoanalysis focussing the unconscious on the horizontal direction is new: it is not assumed “under”, but understood as a resonant unconscious, unfolding social relationships with other people, and likewise works according to the device: the unconscious understands the unconscious ([6], p. 9; [12], p. 174). Bollas and others emphasise that success in therapy particularly depends on the therapist’s capacity to receive his patient’s unconscious with his own unconscious [3]. Being sensitive for unconscious matters in the relationship and in the communication with the patient belongs to the prime qualities of the psychodynamically oriented therapist. This of course pertains also to the art therapist – who has crucial additional tasks, because she needs to provide understanding for the patient’s unconscious material in the art process and artwork – which will be discussed later in depth.

Indeed, these thoughts are not completely new. Already Freud advised the analyst to adopt a certain attitude allocating the “giving unconscious” of the patient “his own unconscious as a receiving organ, to adapt himself to the patient like the receiver of a telephone (...), where the sound waves, which are stimulated by the electric fluctuations, transform in sound waves again” ([19], p. 318). Despite the modern age of mobile-phones the receiver remains a metaphor and also the idea of transformation. Methodically Freud suggested the therapist to develop an attitude of evenly suspended attention, allowing the analyst’s unconscious via the patient’s free association to get access to his unconscious mind.

Reik’s “listening with the third ear” is another early approach to conceptualise the inner work of the therapist. A special kind of attentiveness and receptivity for seemingly insignificant and incidental things characterises the therapist providing a sensitized appreciation of such impressions and perceptions attributing meaning to them [29]. Stern’s “attunement” [34], Tronick’s “dyadic states of consciousness” [35], describing the highly satisfying state of being in accordance with somebody, Bion’s container-contained model [2] are continuations of these resonances needed in the treatment situation and certainly they were confirmed by neuroscience with the discovery of the “mirror neurons” [6].

Psychotherapy research developed the model of the resonating minds to evaluate the processes and requirements for change in psychotherapy. The concept describes an interactive, cyclic system between the interventions of the therapist and the modalities of behaviour and the mental and emotional states of the patient [26]. Other authors define and emphasise the rhythmic interactive relatedness in therapy as most important rhythmic synchronisation when being together with a patient ([4], [12], [31], [33]).

Thus, the horizontal dimension of the resonances in the unconscious is of utmost importance in therapy: for the relationship, the contact and understanding and thus the overall success of treatment. According to Buchholz and Gödde therapeutic work needs a concept of the unconscious as an overlap of vertical and horizontal dimensions. Buchholz refers to the Sociologist Polany, who said: “Because seeing a problem means to see something hidden. It means, to have a hunch of a connectivity of as yet un-comprehended details” (Polany, 1985 in: [5], p. 374). Intuitive and implicit apprehension in therapy happens before the development of cognitive and researched knowledge. Therefore, therapeutic competencies particularly are related to non-conceptuality [5], (p. 374).

When art is part of the therapeutic relationship there is intrinsically no cognitive concept. Meanings in art are not fixed, interpretations are open, effects are multidimensional. Thus, the art itself compels the art therapist to be capable to dedicate her- or himself to non-conceptuality in the dynamics of the triadic relationship.

At this point we will return briefly to the vertical mode of thinking about the unconscious in psychoanalysis, assuming that processes take place in the human psyche, which exist on an unconscious level and may unfold high degrees of impact. I want to begin by referring to Goethe who coined the unconscious long before its introduction to psychoanalysis. The term “unknown” (“nicht gewußt”) occurs in his poem from 1777

In these lines Goethe approved again the artists’ apprehension of psychological phenomena much earlier than the scientists. Their seismographic unconscious absorbs the society’s unconscious themes of their time.

In 1844 he philosopher Nietzsche wrote in his aphorisms: “I have done this, says my memory. I could not have done this, says my pride and remains merciless. Finally – the memory gives in“. Freud admired Nietzsche’s lines as an impressive example for illustrating the act of repression. ([17], p. 162, note 2) His observations of human utterances like dreams, slips of the tongue, parapraxis and symptoms led him to think that there are forces, which become apparent in such phenomena while secretly keeping their sources hidden. He supposed that especially fearful, embarrassing and unpleasant fantasies need to become repressed and, by means of censoring, are deposited in the unconscious. Hence repression solves the inner conflict, “because the unbearable fantasies and ideas are not annihilated out of the conscious part of the Ego, but pushed into the unconscious and there continue to produce effects” (in: [6], p. 54). The fantasies, which cannot be accepted in the state of consciousness, are suppressed into the system named unconscious, where they are submitted to primary processes, the features attributed to the pleasure principle and the timelessness. Once the fantasies are suppressed one does not know anymore, that they are not true, and they cannot be distinguished from memories. In the system “unconscious” fantasies multiply themselves in the dark (Freud, in: [14], p. 8). By this means repression can lead to a relentlessly growing set of diseases, absorbing increasingly more vigour to maintain psychological balance [6].

In what manner these forces relate to each other can be illustrated with the shape of an iceberg – the so-called iceberg model (Figure 5 [Fig. 5]). From an iceberg only a small fraction is visible above the surface, while the dimensions in the deep seem huge and uncanny. Applying this image as a metaphor psychoanalysts assume, that thinking, feeling and acting are executed by 20% of the consciousness, and the predominant 80% are operated by the unconscious. On the surface of the sea, unconscious and conscious meet. It is here, where consciousness enters into the invisible continent of the deep.

Freud later developed the tripartite instances model, allocating to the unconscious and the repressed to the realm of the Id – encompassing the drives, which push for immediate discharge, whereas the Superego represents the demands, morals and rules of the external world.

The Ego is the agency, whose task is to mediate and to find compromises, which are bearable for the Ego – for the subject. The Danish science journalist Nørretranders ostensively formulated in 1991 ostensive: “In a small boat man floats on the immeasurable ocean of the Unconscious” (Nørretranders, in: [10], p. 44). The strong forces in the deep constantly push for release. Freud talks about “the return of the repressed”, because the Id-contents of the unconscious keep striving for gratification. The better the Ego succeeds in linking Id-contents from the unconscious with the demands from the external world, the more successful the coping strategies operate. The psyche then can lessen the efforts to keep the upper and the underworld apart by means of the censoring barrier.

At this point I want to draw the attention to stay with the metaphor of the boat. In the graphic image we see the boat and its colourful container freight, the body of the boat is blue and red. This is not by coincidence, because here we meet the art and the artist. Thus, we will follow the question, where indeed art is placed in relation to consciousness and unconsciousness, beginning with a clinical example [13].

A woman patient, Frau S. being treated in a psychosomatic department, suffering from a lot of pressure of private stress and enmeshed family dynamics, solely worked with pastels. Each picture she began with rubbing pastels into the papers with her fingers or drawing lines and squiggles.

Already in her initial drawing when it was finished, she was surprised how it conveyed her actual themes and her bodily feeling of being at other people’s mercy and her regressive self-image (Figure 6 [Fig. 6]).

In later drawings this repeated (Figure 7 [Fig. 7]).

Finally, she seemed to have gained more distance and not having to be in the middle of the stormy fuss, becoming a spectator and no being a helpless victim anymore. A small figure is observing the mizmaze from a distant position (Figure 8 [Fig. 8]).

To each drawing she had found access by smearing and rubbing of the pastels, making loose lines she found her motives [12]. When we talk about “access” to the image we metaphorically refer to the vertical model of the unconscious. Frau S. knew the material and let herself be stimulated by it. The choice of material was a conscious act. She knew its qualities and how to use it. From this safe point of knowing she surrendered to the phase of rubbing and smearing and submerged a little from the outer world and – being stimulated from the lines and coloured surfaces – she gave form to the rising fantasies.

Now we may ask: what has been going on here from a psychodynamic point of view? Initially, most probably something has been within the patient, which had no conception and no concrete imagination of a form. Frau S. immersed in moments of uncertainty to gain access to her inner fantasies, to her unconscious. However, while smearing the pastels as part of the outer world, she was connected to inner hunches. Touching and working with the material has been vital to foster this process in order to gain access to her inner world.

From this viewpoint the art materials are crucial in the boat on the surface of the Ego. As containers they contain the content of the unconscious. This is the reason why in art therapy we prepare the kind of setting, which is stimulating as well as allowing to submerge into fantasies. It is vital for getting in touch with the inner world. At the same time, when this all happens, the environment needs to be without disturbance, here should be no pressure or directives what to do or create.

Convincingly this can be illustrated with the image of a girl in Florence Cane’s classic book “The Artist In Each Of Us” [8], Figure 9 [Fig. 9]).

It is a state of passive reception, when the mind can withdraw and wander and get in touch with whatever wants to emerge (Figure 9 [Fig. 9]). Then in the next phase the active and more conscious creative process can begin (Figure 10 [Fig. 10]).

There are a number of psychodynamic theories about the creative process, only a few can be mentioned here. Sigmund Freud spoke about the artist’s “ease of the repression”. He saw the artist as someone who is more capable to overcome the barriers of repression than other people, and who can deal better with the impulses arising from the Id pushing towards the Ego [18]. Kris looked at the artist as someone possessing a strong Ego, using its strengths to control regression and which releases creative powers through inner conflict entanglement [23]. According to Ehrenzweig the artist is someone who must overcome boundaries between inner and outer world, and who constantly must swing back and forth between states of differentiation and de-differentiation. He described the artist’s experience in his work as “oceanic engulfment”. After having been deeply immersed it enables him to find coherence and integration [16]. Ehrenzweig refers to Klee, who used the term “multi-dimensional attention” for the artist’s state of mind, pointing out that the artist is more than the non-artist able to crack the incrustations of the surface bearing the dissolution of space and time [16]. We are reminded that Pollock did experience this profoundly absorbed state of being as well as patients do as we can observe in Figure 11 [Fig. 11].

However, what the artist does for himself – creating the environment to work, retreating to his studio, patients need the art therapist to provide the respective frame: a kind of setting where they can feel safe, hold and stimulated at the same time. Only then, they can trust the process, handing themselves over to states of exploring concentration needed to make art.

Today most authors agree that art is a fusion of inner and outer reality, determined through individual, historical, social and cultural contexts. To name a few psychoanalytic contributors: Winnicott, Noy, Bush, Bollas, Meltzer, Harris, Danckwart, Gattig. From a vertical perspective these writers emphasize the conscious aspects of the art making process – considerably more than former pathographic views, which understood art mainly as a compromise fulfilling unsatisfied wishes of the drives.

However, the metaphor of the ocean is still valid: it is the intense moment of the aesthetic experience, the “aesthetic euphoria” [1] defined as an ecstatic or oceanic state of being.

Whatever becomes visible on the pictorial surface can always be recharged with new meanings. We look at a painting in a museum at different times – the painting stays the same, but each visit we perceive new aspects, it provokes different fantasies and feelings. A patient may look at his drawing from the previous session and discover new aspects in the following week. Something takes shape on the surface that can be described, but whose unconscious reference naturally never becomes visible. Therefore, as Raimund Reiche writes, the unconscious does not reside in the deep of the painting but on the surface [28]. For this reason, we never can come to final terms and interpretations with a work of art. Herein lies the tension producing the mystery and interminability of the aesthetic process.

These unfolding and changing processes are also true for the beholder’s perspective. His fascination is caused by the experience that a piece of art can make something present which resonates his own unconscious feelings. Art allows working through complex intrapsychic contents in a way, that they come to be bearable and understandable. The pleasure of the spectator is based on the dynamics of gaining access to the unconscious by putting it into form – a solution, which the Ego unconsciously can accept and identify with. Danckwardt describes it as the unconscious identification in the image-making process [10] as he also shows in Steinberg’s caricature (Figure 12 [Fig. 12]; [30]).

The cartoon, drawn by Steinberg for the New Yorker (1965), caricatures the encounter of a visitor in a museum with a picture. The visitor takes in the meandering form – he seems to completely identify with what he sees and his self has structured itself according to the picture. But just not quite. He took over the basic structure of the drawing on the wall, but he is still different from the image. Some details he left out, others he adapted to his person.

What we choose to see always has to do with our own needs and stories. Bion borrowed the term selected fact from the French mathematician Henri Poincaré to refer to the element that makes it possible to give coherence to a group of scattered data which previously had not been put in connection, but now can unfold in a situation and be synthesised. From the material the patient produces, there emerges, like the pattern from a kaleidoscope, a configuration which seems to belong not only to the situation unfolding, but to a number of others not previously seen to be connected and which had not been designed to connect ([2], p.127). Magherini denotes the selected fact as a complex selection process, in which a work of art (…) and a person with all his or her peculiarities and a context of special time and spatial coordinates as crucial elements come into play, where the process works as the transforming factor [24].

Similarly, this happens in art therapy on dual levels: when a patient works and gradually his story begins to unfold – often becoming visible in a series of images and encounters with art. When the art therapist is able to use her sensitivity, she will perceive patterns of depictions, of behaviour, which at first and might seem scattered, but lastly connect to a larger coherent picture of the patient and his work. Necessarily, she must be able to put aside conscious knowledge before coherence and insight may emerge. An example will be the last case vignette below.

How can we understand now the horizontal level of communication in art therapy? An important factor is the assumption of different levels of structures and intensities in the triangular relationship between inner and outer worlds of the patient, the therapist and the artwork. These complex interconnections are depicted in a diagram (Figure 13 [Fig. 13]).

The lines differ in their thickness indicating the intensity of the effect. There is a dense connectedness between the unconscious of the therapist and the patient, the intense participation of the patient’s unconscious in the form giving process, also his choice of material. The therapist brings in a stronger and trained consciousness based on self-knowledge through personal therapy, acquired information and experiences, directing her attention to the rising form as well as to the content of the artwork. Her unconscious is still active, but takes less psychic space than the patient’s. She has the ability to take a standpoint outside and still let herself surrender to the dynamics of the unconscious ([14], p. 142). The artwork simultaneously contains unconscious, preconscious and conscious aspects.

Based on the assumption, that unconscious processes of the patient are reflected in his developing work as well as in the relationship, the art therapist has the task to attune herself in a very specific way to the patient and his art. As Bollas writes, the therapist must get lost in a kind of rêverie, which does not serve to consciously reflect the emerging material, but enables unconscious work ([3], p. 206). This includes watching and listening with an open, nonbiased mind, developing a feeling for the insignificant while surrendering to the ambiguity of the processes and thoughts, letting go from a-priori knowledge about the patient, the art, the rising forms and contents that are created. For the art therapist it implies staying in clouds of not-knowing.

During these moments, when matters develop in the artistic process, the patient should not be interrupted with questions or actions, but accompanied quietly; sometimes a harmless seeming remark or a sound or a gesture could be uttered.

These resonances aim at supporting the patient’s associations and helping him to feel freer and without embarrassment. Bollas describes it as the “echo of experience” ([3], p. 207). Thereby no interpretative evaluation should be given about what happens. Instead the process with an unknown outcome should be productively brought forth. Then from the uncertain something emerges what Bollas calls the “un-thought known” ([3] p. 220), forms of knowledge we acquire with early life experiences. It is “the endless question” about the sense of experience “What does this mean?” which Bollas calls the interrogative function of the unconscious ([3], p. 221).

How this very special kind of being and communication in art therapy might look like will be shown in the last case vignette. We can observe, how the therapist’s task almost seems to be paradoxical: we know, aesthetic experience cannot be geared towards a certain goal or stimulated with directives, hence, the art therapist must be the attentive companion who intervenes actively but unobtrusively when needed, providing every possible freedom for the patient. Maintaining this balance constitutes the art of the art therapist. Herein lies the premise for change – in other words: for aesthetic experience.

A 30-year-old patient, Herr L., was in the psychiatric ward for the first time in his life. He suffered from a psychotic break down, appearing to be withdrawn and stifled. With tempera paint he created several abstract patterns and designs, reflecting intense emotional sensitivity, which seemed quite opposed to his withdrawn slow and undifferentiated behaviour (Figure 14 [Fig. 14]; [14], p. 252).

After some sessions he said, that he had no idea what more to paint and that the other group members’ images were much more imaginative. I suggested to make a little painting game together. My role would be to paint simple geometrical shapes, which he should copy with another colour. With this colour I would again develop a new shape, which he should again copy with a new colour. My thoughts were twofold: he should be able to bring into the game his special strength, the sensitivity for colours, while I would think about a new form, the “intellectual” part, which seemed to be more difficult for him. On the other hand, I had sensed that he felt isolated and this dyadic situation might allow him to experience some moments of togetherness. The result of our mutual endeavour are two images, which cannot be distinguished which was done by whom (Figure 15 [Fig. 15] and Figure 16 [Fig. 16]).

During the following session Herr. L. appeared much more alert. Without my direct participation he created an image which incorporated many of our mutual designed elements reflecting a complex interplay of forms (Figure 17 [Fig. 17]).

In the following session a kind of surprise and wonder happened (Figure 18 [Fig. 18]).

Highly concentrated Herr L. painted three figures who were composed of the formerly developed elements, evocating the Bauhaus Ballet from Oskar Schlemmer. All three of them look different but they seem to be from one form-family.

In the weekly round his doctor was astonished. She reported that Herr L. had two schizophrenic brothers. The painting shows, that most probably now he felt himself part of the row of his brothers. All three of them were diagnosed with the same mental condition. All three figures were composed of different fragmented parts. It became even more obvious, that Herr L. had now found his theme, when he created the following images which all revolved around the number 3. The figures in three colours appeared again in a water colour painting (Figure 19 [Fig. 19]), emphasising the dissolution of the persons, probably reflecting Herrn L’s own feelings about himself and his brothers. In the next one, the 3 always was the result in a game with numbers (Figure 20 [Fig. 20]), revolving around a three coloured cycle.

The story of Herr L. illustrates, how small artistic interventions of the therapist can lead to most expressive works of art, which, for this man, were unusual and unexpected.

We can be rather certain, that it was the suggestion to do the painting game together, which initiated this process. At the right moment I had somehow unconsciously perceived that Herr L. was susceptible for this intervention, sensing his need for human closeness and exchange. Consciously, I turned it into an intervention with eventually led to an unfolding of very personal themes.

Such moments reflect the power of the unconscious in the art therapy relationship. If the art therapist provides the space for it to be used, the experience can be transformed into most impressive works of art. The sense for the seemingly unimportant can be extremely momentous. Working with it means to be less focussed on insight and interpretation, but on the unconscious, resonant and affective encounter with the patient and his visually emerging art.

To see the unseen is a wonderful result of these complex and exciting processes.

The author declares that she has no competing interests.