Taking aspects from a variety of psychoanalytic theories, Susan Carr proposes that paintings or drawings portraying patients’ afflictions and pain can bring about empathy in viewers, and a sense of being seen and known, with the outcome of aiding recognition of the self in the patient
Susan M D Carr
The portrait discussed in this paper was one of many produced as part of a PhD project developing portrait therapy as an art therapy intervention for people who experience life threatening and chronic illness as a disruption to their self-identity. This is investigated through studying recent neuroaesthetic research and combining this with findings from project analysis, as well as evidence from evaluation cards completed by visitors to the exhibition. This project staged a major exhibition of the portraits at Swindon Museum and Art Gallery during the summer of 2017, entitled “Paint me this way!”
The National Research and Ethics Committee granted permission for the PhD project in 2010, and informed consent was obtained from all individual participants included in the study, which included permission for the publication and exhibition of the clinical work and portraits deriving from the project.
Introduction: Portrait therapy and its theoretical underpinnings
As an art therapist with twelve years experience practicing in palliative care I have worked with many patients who experience the diagnosis of a life-limiting illness and the steady deterioration of a chronic illness as a disruption to their sense of self-identity. Self-identity is a complex phenomenon, however for the purposes of this article I understand self-identity to be that part of our consciousness which “allows us to define what is important to us and what is not” (Taylor, 1989).
Listening to patients I would often hear them say … ‘I don’t know who I am any more’, ‘I’m not the person I used to be’ or ‘I look in the mirror and I say … who’s that?’ This disruption may also be characterised by increases in stress, loss of meaning, social isolation and depression. Jaremka et al. (2012) demonstrated that social isolation reduces immune function, causes depression and shortens life expectancy, suggesting the importance of developing effective interventions. This disruption can also negatively impact upon patients’ creative capacity to adapt to illness (Reeve et al. 2010; Charmaz, 1995) and their overall quality of life (Mathieson & Stam, 1995 ).
Patients living with life threatening and chronic illnesses are often given medication to treat psychological pain such as depression and anxiety caused by self-identity disruption, and I agree with Bloom (1997:157) that it is “bad treatment” to prescribe drugs to treat something that can only be alleviated by “psychological and behavioural change”. Portrait therapy (Carr 2014, 2015, 2017) grew out of a search for an effective art therapy intervention that would help patients rediscover their sense of self-identity at end of life.
When developing a theoretical basis for portrait therapy I discovered writer and psychoanalyst Kenneth Wright’s theory of ‘mirroring and attunement’ which supports the idea of using portraiture as a way to re-vision self-identities. Wright’s theory develops and connects Melanie Klein’s object relations (1952), Donald Winnicott’s mirroring (1971) and Daniel Stern’s theory of attunement (1985) and applies them to the artist and the art object (Wright, 2009). Stern’s concept of attunement is an important theory for portrait therapy, as it describes the process whereby the (m)other reflects back her baby’s affective states, in order to promote self-awareness, and therefore help the baby build a sense of self-identity. However Stern observed that the (m)other doesn’t just reflect the baby’s affective state, she changes or ‘attunes’ it subtly, and the response will either validate the baby’s experience or modify that experience. The (m)other does this by adding something of her own to the reflected experience – e.g. by downplaying distress or exaggerating surprise. Within portrait therapy I have developed these ideas further to include the portrait painted for the patient as an embodied, mirroring device, which acts as the attuning (m)other, enabling the revisioning, validation and integration of aspects of a person’s self-identity.
Portrait therapy utilises Edith Kramer’s ‘third hand’ techniques and the therapist paints the portraits for patients within which “artistic competence and imagination are employed in the empathic service of others” (Kramer, 2000:48), “without distorting meaning or imposing pictorial ideas or preferences alien to the client” (Kramer, 1986:71). Kramer herself drew portraits for her child clients, saying “my actions seemed to reassure them and to strengthen their feelings of identity” (Kramer, 1971:40).
There is however, an expectation within art therapy that patients will create their own artwork, which can then be discussed within the therapeutic session. However within palliative care, patients are often too unwell, fatigued or disabled to create art themselves, and as is the case with clients in other fields of art therapy, some people, for a variety of reasons, are unwilling or unable to make art, despite an expectation that they do so. These sessions then become reliant on ‘talking therapy’, which, while beneficial in its own way, is not the point of art therapy. The art therapist therefore uses their own artistic practice which makes the therapy available to all. It is also empowering for the art therapist to recognise that the ‘good enough (m)other’ can also be translated into the ‘good enough artist’, and I felt liberated as a portrait artist through the recognition that in the context of portrait therapy, I only needed to be ‘good enough’.
When I began developing portrait therapy it was with the belief that portraiture had the potential to act as an attuning ‘mirror’ for the patients to see themselves in more clearly, a way to revision and remember their sense of self-identity. The construction of self-identity is made possible during interpersonal interactions, where “other people corroborate a person’s me” (Grytten & Måseide, 2006:196). The building of self-identity is therefore intensely relational, a process where ‘self-stories’ are told to others, but also to one’s self, and the ‘act of telling’ becomes a ‘dual reaffirmation’ (Frank 1997).
The Power of the Visual
Elkins talks about a ‘need’ to be seen both by people and objects, a need to “be caught in that intersection of gazes” (1996:70). He also cites Lacan’s theory saying it is equally important to recognise one’s self in the mirror; he says “by looking into the mirror each morning I check to make sure that I am the same person who went to bed last night – the person who dissolved into darkness and dreams” (ibid.). The portraits, created within the collaborative therapeutic relationship provided within portrait therapy, therefore work as attuned mirrors for patients to view themselves in, offering a reflective space within which to rebuild their sense of self-identity.
Neuroscientist Vittorio Gallese writes that vision is ‘multimodal’, meaning it activates, not only the visual part of the brain, but also the motor, sensory and emotion-related networks, as well as parts of the brain implicated in memory and imagination. Therefore, what we ‘see’ is not a simple replication by our brains of that which is before our eyes, instead what we see is a ‘complex construction’ whenever our eyes touch anything (Gallese, 2017). The idea that our eyes touch things highlights the embodied nature of vision; “our eyes are not just optical instruments, but are also a “hand” touching and exploring the visible, turning it into something seen by someone” (ibid:14). However, by exhibiting these portraits within high-social status venues such as museums and art galleries (Colbert et al. 2013), further benefits can be found, as their portraits are “caught in that intersection of gazes” (Elkins 1996:70).
Portrait Therapy in the Museum and Art Gallery: Portrayal or Display?
When viewing a painting in a museum or art gallery we find ourselves in a context where we believe the paintings to be ‘works of art’; however once the artwork captures our attention we can be drawn into it and be absorbed fully by the image. Despite all our perceptions being mediated through the body, our understanding of imagination is usually explained purely in ‘cognitive terms’ as (to use Coleridge’s expression) a “suspension of disbelief” (Gallese, 2017:6). However, one has to add to this suspension of disbelief the feeling of ‘embodied simulation’, activated by mirror mechanisms, where we feel the action in the painting ‘as if’ it is happening to us.
The portrait I am going to discuss here is called Broken Lungs (see Figure 1.), which was co-designed with a 49-year-old single gentleman called Paul. Paul was diagnosed with chronic obstructive pulmonary disease (COPD), which is a progressive lung disease for which treatment is limited and there is no cure. Paul was dependent upon oxygen both day and night and the slightest exertion left him fighting for breath. Consequently he was no longer able to live independently and had returned to live with his mother. Paul’s life was characterised by estrangement and isolation, poor self-care and self-image, as well as depression and anxiety attacks.
Figure 1. Broken Lungs (after Frida Kahlo) by Susan Carr (co-designed by Paul), 2013.
This prose poem was written to accompany the portrait:
Paint me like Frida Kahlo
In her portrait Broken Column
I can feel her pain and suffering
You can show my Broken Lungs …
During the phenomenological analysis of this portrait the following phenomenological essence statement was created:
My chest ripped open reveals my beating heart and broken lungs, a window on my invisible suffering, I am stripped back, laid bare, sharing my pain, I match my inner and outer realities … it is hard to look at … but even harder to be … me. Holding my breath, I open myself to hope, that by some stroke of luck someone may reach out and switch my faulty heart and lungs for some that work … allowing me to breathe … and love … life … once more …
Within the evaluation forms completed by visitors to the exhibition was a question asking visitors to state which portrait they ‘most’ and ‘least’ connected with and why. One visitor stated that they least connected with Broken Lungs because it was “too strong, shocking, difficult to look at?” However, another visitor claimed that they most connected with Paul’s portraits [including Broken Lungs], saying “My father died of COPD. I could see him [in Paul’s portraits]”.
One of the things that determines how we judge a work of art is the degree to which it has personal resonance, when it reflects our own “forms of feeling” (Langer, 1953:40) Despite health and illness being central issues in many societies and cultures, images that display illness are considered by some as distasteful (Radley, 2009), or painful to look at. This can be largely understood through recent neuroscientific studies which have shown that observing a person in pain (in life or in a portrait) will activate the same neural networks ‘as if’ the viewer was also in pain (Keysers et al. 2004). The ‘as if’ nature of empathic engagement also extends to viewing the facial expressions of others, suggesting that we not only recognise, we feel physically, others’ emotional states. This demonstrates how viewing facial expressions in portraits can influence the observer’s emotional state or mood.
Exhibition evaluation: Portrayal or intrusive spectacle?
The prospect of portraying portraits of patients within museums and art galleries gave the patients a future identity when the future looked highly uncertain. It also brought the often taboo subjects of severe illness, disability and death out of the shadows and into the public domain (Dodd et al. 2008). This suggests that exhibiting works from portrait therapy interventions in museum and art galleries can help increase understanding amongst the public of issues faced by people living with life threatening and chronic illnesses, which may in turn impact upon how they are treated by society.
A central theme of the project related to the inclusion of patients’ actual voices and personal narratives in the exhibition film alongside the portraits and had a powerful impact on many visitors. Exhibition visitors were also able to consider how they might face serious illness in the future and challenge their beliefs about how people live with life threatening and chronic illnesses. Families of patients who had died found the exhibition of their relatives’ portraits particularly helpful, with some saying that they visited the exhibition ‘many times’ during its three-month duration:
“What a wonderful exhibition. I was so overwhelmed when I walked in and saw the amazing portraits of my late husband and son, and to hear my husband’s voice again …”.
Neuroaestheticists Ishizu & Zeki (2011) carried out a study demonstrating that viewing images of a loved one enables the activation of pleasure and reward centres in the brain, which stimulates the production of feel good chemicals such as dopamine, suggesting that biologically, viewing the portraits had a beneficial effect on mood for patients’ bereaved relatives. Another important finding in neuroscience relates to our relationship to fictional worlds, as it seems that when viewing such worlds we become so immersed in them that it creates an important distancing effect from the real external world. This means that “Being forced to inaction, we are more open to feelings and emotions. The specific and particularly moving experience generated when immersed in fictional worlds is thus likely also driven by this sense of safe intimacy with a world we not only imagine, but also literally embody” (Gallese, 2017:7). This may be why so many visitors to the exhibition claimed that they were ‘moved’ by it or found it ‘emotional’
The findings from the PhD project researching portrait therapy suggested that there is a fundamental need or urgency to know the self or be known when one is faced with severe illness and impending death, and the findings further identified that knowing the self is intrinsically linked to being known. Therefore, patients have a need to be known in order to know themselves, and this relational view of self-knowledge highlights that knowing is offered through being known both by the artist/therapist and by others through the viewing of the portraits in exhibitions (Carr, 2015, 2017). As Wright says, “we feel loved when we feel recognized and known” Wright qualifies this statement further saying ‘I can only fully become the self I am through your recognizing me as that self’ (Wright, 2009:184)
Whilst acknowledging that the portrayal of self-identity is a complex issue, and not wanting to fall into the trap of “dangerous and foolish reductionism” (Bloom, 1997:8), this project provides evidence that conclusions reached in the humanities are relevant to those reached in neuroscience (Zeki 2014) and vice versa. When we are looking for facts we look to science, but when we are looking for meaning we look towards the arts. However, by combining the two “we can achieve binocular vision”, after all “looking through one eye never did provide much depth of field” (Eisner, 2005:74).
For the patients involved in the collaborative co-designing process within portrait therapy it was a chance for them to re-establish control over how they are presented to the world and give meaning to events that have caused disruption to their sense of self-identity, finally presenting a visualisation of self-identity that made sense of their past, present and future self-identities. Knowing that these were going to be exhibited and seen by others was, I believe, an important part of the therapeutic process for each of them. This suggests that, in certain circumstances, particularly when validating self-identity, confidentiality may be inappropriate or even counterproductive, and that a blanket confidentiality policy also serves to keep those who are ill or disabled separate and hidden, and to silence their voices.
This study has also highlighted the need for increased awareness by healthcare professionals regarding the power they possess through their actions, words or interventions, to either validate or demean the self-identities of their patients/clients, and the importance of recognising the ‘person’, even when both the patient and those around them can see only illness.
Ultimately, despite initial concerns about whether exhibiting patients’ portraits equates to empathic portrayal or intrusive spectacle, the evaluation cards completed by visitors and patients’ families offered overwhelming support, connection and empathic engagement with the portraits and the project as a whole. This demonstrates that the museum and art gallery is a space where important issues relating to illness and disability can be raised and attitudes changed, demonstrating that “…far from separating art and illness, there is much to be gained from allowing them to travel over each other’s territory.” (Radley, 2009:21)
Dr Susan Carr is a qualified art therapist working in private practice, with 12 years experience working in Palliative Care, supporting people living with life threatening and chronic illnesses. Susan is also a writer, with her first book entitled Portrait Therapy published in September 2017, and has been an associate editor for The International Journal of Art Therapy since 2014. She is a BAAT Member and HPC Registered
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Funding for this exhibition was given by:
The Arts Council England
Swindon Does Arts
Swindon Museum & Art Gallery
Mr Alf Fortnam
Swindon Lions Club