Art Therapy Portuguese Magazine

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Art Therapy Portuguese Magazine
ArteViva
International Edition
Nº4 . October 2014
Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

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Arte Viva
Nº 4
International Edition
Art Therapy Portuguese Society
SPAT
LISBON 2014

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Arte Viva
Nº 4 – October 2014
Sociedade Portuguesa de Arte-Terapia

Campo Grande, 30 – 10ºC
1700-093 Lisbon – Portugal
Tel. (351) 210998922
spat.pt@gmail.com
www.arte-terapia.com
Propriety and Editor Collaborators

Sociedade Portugesa de Arte-Terapia - Catarina Capinha, Christian Prim, Claudia
Campo Grande, 30 - 10oC - 1700-093 Cavicchia, Daniela Martins, Diane Waller,
Lisboa - Portugal Frédéric Sanguignol, Gerry McNeilly,
Jean Luc Sudres, Judith Rubin, Khalid Ali,
NIF: 504339729 Lony Schiltz, Régis Bernadet, Rita Branco
de Brito, Rita Nunes da Ponte, Ruy de
E.R.C. Register Carvalho, Tony Gammidge, Vanessa
125717 Roma.
Legal Deposite 298498/09 Grafic Project

Daniela Martins
Diretor
Ruy de Carvalho On line distribution
http://arte-terapia.com/
Editorial office
SPAT - Campo Grande, 30 - 10oC The views expressed in the articles are
1700-093 Lisboa - Portugal their authors´ responsibility.
Periodicity Any kind of layback is forbidden without

Anual the written permission of the magazine’s
director.

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Editorial
Daniela Martins
Because in almost every part of the world there are Art-Therapy and Art-Psychotherapy
professionals, SPAT releases another number of ARTE-VIVA, Portuguese Magazine of
Art-Therapy, inviting colleagues from other countries to collaborate on this international
edition. With texts in English and French we gather great names who are considered
Art-Therapy/Psychotherapy references in their working countries.
This edition also reflects the interchange SPAT has promoted with Art-
Therapist/Psychotherapists of several countries in Europe, EUA, Asia, Brazil, along its 17
years of existence. The exchange of information is very rich and the sharing enriches
everyone’s work! SPAT is recognized by international associations like the International
Society for Expression Pathology and Art-Therapy (SIPE), based in France and the Brazilian
Union of Associations of Art-Therapy. We have also been present in several Art-Therapy
events in other countries.
In this international edition we have the participation of professionals with a broad

experience in our area showing in their articles the works done in private clinic and
institutions. Most of them have been present in our Congresses in Lisbon. Gerry McNeilly
has been giving classes at SPAT for the last 12 years.
My contribution to International ARTE VIVA is an article presented in 2009 in Lisbon at the

19º International Congress of SIPE, 10th Portuguese Congress of Art Therapy,
Commemoration of The 50 Years of SIPE.
SPAT’s president, Ruy de Carvalho, closes this edition with a paper presented in the 3rd
International Congress of Art-Therapy/Psychotherapy, 14º Portuguese Congress of Art-
Therapy, organized by SPAT in 2013.
We greatly appreciate the participation of all Art Therapists and Art Psychotherapists who
sent us their articles to our Magazine.

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Authors
Claudia Cavicchia born in Araraquara, Brazil; living in Nantes, France since 2000. Actress of
experimental danse-theater in São Paulo. Art-therapist graduate at the Faculty of
Medicine of Poitiers, France. Accredited member of Fédération Française des Art-
Thérapeutes (FFAT). Bachelor of Theater at the University Paris 3, Teacher of Theater
Expression at the University of Angers, author of numerous articles about the mobilization
of the creative energy stemming from Eros. Initiator of the support of children and
teenagers in art-therapy at te School Center Notre Dame du Bon Accueil and with
adopted children at AGSA 44 (Association des Groupes de Soutien à l'Adoption en Loire
Atlantique), in Nantes, France.
Daniela Martins - Degree in Art History and Master in Arts Education. She is Art
Therapist/Psychotherapist, member, trainer and training manager of the Art Therapy
Portuguese Society (SPAT). Conducts Art Therapy groups in various institutions and makes
individual Art Psychotherapy in private practice.
Diane Waller - Professor Diane Waller is an art psychotherapist and group analyst
currently engaged in research concerning the well-being of older people. She has
conducted numerous research projects in the UK and abroad, for example, in Bulgaria
(1981-87) introducing art therapy services within long term psychiatry and community
drug rehabilitation projects sponsored by the WHO; Rome (1984-1997) in addiction
settings; in Lausanne (1992-2001) in acute and long term psychiatry; in Berlin (1995-
present) within out-patient psychiatry, in a Health Foundation funded project in East
Sussex (2000-2005) with older people with moderate to severe dementia (Waller, 2002;
Waller and Sheppard, 2006a and Rusted, Sheppard and Waller Dec 2006), with individuals
with Parkinson’s (Strand and Waller 2010) and most recently with people with long-term
schizophrenia on an HTA funded project (Crawford, Killaspy and Waller 2012). She has
published extensively on the history, sociology and clinical practice of the arts therapies.
Gerry McNeilly - Before his retirement in 2011 Gerry McNeilly was a Consultant
Psychotherapist, Group Analyst, and Art Psychotherapist, having worked in the British
National Health Service, Social Services and University Education since 1969. He owes a
great deal to a limited formal school education, leaving school at 15 with no academic
achievement on a Friday and starting work in the local linen Mill the following Monday.
Before settling into a sequence of careers of Nursing, Art Therapy and Group Analysis he
worked in various factories, shops, breweries, hairdressers and as a professional musician
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playing saxophone, flute and singing, touring Ireland, the Country of his Birth. All of the
afore mentioned has served as a foundation to his later work.
During his psychotherapeutic career since 1975 he has been involved in art therapy and
psychotherapy on many levels, and has directed a number of counselling and
psychotherapy teams. He has also been involved in many training capacities in respect to
psychotherapy, art therapy and group analysis in Britain, Ireland, Greece, Russia, Portugal
(where he is still involved with the Sociedade Portuguesa de Arte-Terapia, a happy
alliance) and has lectured in other Countries. He is the originator of the term ' Group
Analytic Art Therapy'. He has published in a number of International art therapy and
psychotherapy journals (some of which can be accessed through the Internet ). He has Co-
Editided with Andy Gilroy ' The Changing Shape of Art Therapy' 2001 and written 'Group
Analytic Art Therapy' 2006, both of which are published by Jessica Kingsley Publications.
He is currently writing a new book: 'Heartfullness and Therapeutic Love: (meanderings
through group analysis, group analytic art therapy and individual psychotherapy for 40
years - subtitle). It is also planned to be published by Jessica Kingsley.
Jean Luc Sudres - Parallèlement à une formation en Psychomotricité, Jean-Luc Sudres, né

en 1958, a réalisé un parcours universitaire en Psychologie (psychopathologie, psychologie
clinique de la vie quotidienne et psychologie de la santé) qu'il a ponctué par le titre de
Psychologue Clinicien et de Psychothérapeute mais aussi un Doctorat en
Psychopathologie et une Habilitation à Diriger des Recherches. Au fur et à mesure de ce
parcours, J.L. Sudres s'est intéressé à la Sexologie, aux Thérapies corporelles/image du
corps et à l'Art-thérapie/Thérapies à Médiations avec les populations aussi diverses que les
adolescents/jeunes adultes et les âgés présentant des psychopathologies de l'agir, des
addictions et des troubles des conduites. Tous ces axes validés par des formations et/ou
des Diplômes Universitaires ad hoc se sont doublés de pratiques/applications sur divers
terrains cliniques, de recherches et de publications.
Actuellement, J.L. Sudres est Professeur de Psychologie à l'Université Toulouse-Jean

Jaurès (France) où il mène des recherches sur "Clinique et Psychopathologie du corps et de
la créativité" dans une approche intégrative et éclectique. Il exerce aussi comme
Psychologue clinicien au CHU de Toulouse et comme Art-thérapeute à la Clinique
Castelviel (Castelmaurou - Toulouse).
En 2009 J.L. Sudres a créé à l'Université Toulouse-Jean Jaurès un Diplôme Universitaire

d'Art-thérapies dont il assure à ce jour la responsabilité pédagogique. Il est aussi
Secrétaire Général de la SIPE-AT (Société Internationale de Psychopathologie de
l'Expression et d'Art-thérapie) présidée par le Professeur Laurent Schmitt.

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Judith Rubin - “Judith Rubin has contributed to the field of art therapy by serving in a
number of professional positions as well as writing numerous articles, books, lectures and
films. Rubin became a Registered Art Therapist (ATR) in 1970 and a Board Certified Art
Therapist (ATR-BC) in 1994 (Rubin, 2010a). She served on the American Art Therapy
Association (AATA) board from 1973 to 1979, including as president from 1977 to 1979. In
1981, she received the award for Honorary Life Member (American Art Therapy
Association, 2010).
In addition to her writing, Rubin has worked in private practice and has taught at many
universities in the U.S. and abroad. She is currently an Assistant Professor in the
Department of Psychiatry at the University of Pittsburgh where she has been on the faculty
since 1974 and also has served as faculty-by-invitation at the Pittsburgh Psychoanalytic
Institute since 1983. She is also a co-founder and president of a nonprofit educational
organization called Expressive Media Inc. (Rubin, 2010a)”.
In wikipedia.org/wiki/Judith_A._Rubin
Khalid Ali is a stroke specialist involved in caring for stroke patients in the acute phase and
in the rehabilitation setting in Brighton and Sussex University Hospitals NHS Trust, and an
academic (senior lecturer in Geriatrics at Brighton and Sussex Medical School). He is also a
member in the GDG (Guideline development Group) of stroke rehabilitation NICE
guidelines currently being drafted. He is also the lead for the Age and Ageing speciality
research in Surrey and Sussex. He is also an active member of the South East of England
Stroke Research Network (SE-SRN). Dr Ali has engaged with arts and humanities with
particular emphasis on the use of film in teaching and research in relation to patient care.
He has published 18 film reviews with 14 published in the BMJ. He has wide experience in
engaging with stroke patients and carers, and this patient and public involvement (PPI)
work has informed the design of a current multicentre UK study; the Stroke Oxygen Study
(SOS) (Ali et al 2006). His interest in the concept of well being in stroke patients
undergoing rehabilitation has originated in 2004 when his work was published in the
Canadian Journal of Geriatrics (Ali K 2004).
Lony Schiltz - PhD in Clinical Psychology, Habilitation to Direct Research,

clinical psychologist, psychotherapist, arts psychotherapist, professor in clinical
psychology. Director of the research unit in Clinical Psychology (PCSA) at Hôpital
Kirchberg in Luxembourg (CHU University of Heidelberg). Head of studies of the DESS en
Art thérapie de l'Université du Luxembourg. Head of studies of the postgraduate
curricula in arts psychotherapies and and multimodal arts therapies (Hôpital Kirchberg,
Luxembourg).
Régis Bernadet - Doctor of psychopathology and psychologist, he write a doctoral thesis:

Obese in Theater or Theater of Obesity: An Experimental Approach of Dramatherapy for
obese person. He used to do some acting in his childhood and continued acting at
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University (Jordan Plevñes, Jean Jouanneau, Jean Sénac, Arezki Mellal, Zouc and Hervé
Guibert). Now, he teaches Psychology and Art Therapy at Jean JAURES University in
Toulouse and for IFSl. He works with person who suffer from eating disorder as a
Psychologist and a Dramatherapist. He is project manager of the SIPE-AT
Ruy de Carvalho - Degree in medicine, Art Therapist/Psychotherapist. Founder and

President of SPAT and Vice President of the International Society of Psychopathology of
Expression and Art Therapy (SIPE). Portuguese Art Therapy Magazine Director.
Tony Gammidge is an Art Psychotherapist, registered with the Health and Care Professions
Council and the British Association of Art Therapists. He is also an artist, filmmaker and
part-time lecturer in the School of Art, Media and Design, University of Brighton on the
Inclusive Arts Practice M.A. As well as working as part of the stroke project he has
experience in working in forensic and adult psychiatry and has led a number of video and
animation projects on medium secure psychiatric wards of which many of the films made
have won Koestler awards. He has spoken and presented his work at several international
conferences including the I.A.F.P. (International Association of Forensic Psychotherapy)
Murder in Mind conference in Edinburgh and the BAAT 2010 conference on Attachment
and the Arts. In 2009 he won a special commendation to the field of arts and mental health
by the Royal Society for Public Health.

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Contents
La médiation théâtrale et l'obèse. Application et évaluation clinique

Régis Bernadet, Jean Luc Sudres, Vanessa Roma, Frédéric Sanguignol et Christian Prim
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Lárt dáccompagner ládolescere

Claudia Cavicchia 41
The Sad Look of Medusa - Mythology and Depression in Art Therapy

Daniela Martins 48
A novel approach of using art therapy (AT) in reducing anxiety and depression in stroke
patients undergoing rehabilitation
Diane Waller, Khalid Ali and Tony Gammidge 54
Therapeutic love. A Necessary Convergence

Gerry McNeilly 75
Art as Therapy in Times of Crisis

Judith Rubin 85
The Archetype of the Double: Favouring the Identity Quest of Adolescents with the Help
of Stories Written under Musical Induction
Lony Schiltz 94
Apollo, Venus and Pan: Internal myth, object relation, creation in an art-psychotherapeutic
relational context and reality
Ruy de Carvalho 107

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La médiation théâtrale
et l'obèse.
Application et évaluation
clinique
Régis Bernadet*, Jean Luc Sudres**,
Vanessa Roma***, Frédéric Sanguignol**** et Christian Prim*****
1. INTRODUCTION
Dans le passé, le très gros sera tant tôt perçu comme malade, pécheur ou encore oisif
(Vigarello, 2010). De nos jours, il est aisément compris comme manquant de volonté,
négligeant, anxieux, ou encore déprimé. Le 21ème siècle, avec l’avènement de la
statistique, place l’obèse en sursis, sont surpoids réduit son espérance de vie. Aujourd’hui
l’obésité est perçue comme une épidémie dont on craint la transformation en pandémie.
En 2008, selon l’OMS le surpoids et l’obésité tuait plus que l’insuffisance pondérale. C’est
une maladie dont on n’arrive pas à contrôler l’augmentation. Cette maladie rend l’obèse
en position de perturbateur de la société ; ses soins sont onéreux et doivent lui être
prodigués seulement à cause de son manque de volonté. Or le traitement et la prévention
de l’obésité ne sont pas une chose facile, sinon le taux d’accroissement de la prévalence de
l’obésité ne serait pas encore aujourd’hui en France de 0,5% par an (OBEPI 2009 et 2012).
Auparavant, l’obèse était perçu comme mangeant trop, sujet aux excès, aujourd’hui il est
vu comme incapable de maigrir, de se maitriser, il est sans volonté. Le surpoids entraine de
la stigmatisation et donc des comportements pour tenter de faire face comme l’isolement
social, ou le recours à l’humour et l’autodépréciation. Face à la stigmatisation, l’obèse peut
soit s’isoler pour qu’elle cesse, soit utiliser l’humour (souvent à ses dépens) pour s’en
accommoder et y faire face et ainsi devenir le « gros rigolo », le bon gros plutôt que le
gros faisant du gras dans le canapé de son salon.
Dans la littérature, l’obèse souffre généralement d’alexithymie(Mariage, Cuynet, Godard

2008, De chouly de Lenclave, Florenquin, Bailly 2001), d’une faible estime de soi (Giusti,
Panchaud 2007, Ketata, Aloulou, Charfi, Abid, Amani, 2010), et le seul facteur prédicteur

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de maintien de perte de poids est l’utilisation des stratégies de coping tournée vers le
soutien social (Wing & Jeffery 1999, Perri, Lauer, Yancey, McAdoo, McAllister, Jordan &
Nezu 1989, Eddins 2009, Pinaquy, Chabrol, Louvet & Barbe 2003, Farris 2000,).
La prévalence des troubles du comportement alimentaire dans la population des patients

obèses varie selon les études de 15% à 50% (Kalarchian, Wilson, Brolin & Bradley 2000,
Wilfley, Schwartz & Spurell, 2000, Ricca, Mannuccin & Moretti 2000).
Le patient obèse (DSM IV-TR, CIM 10) est le plus souvent atteint d’hyperphagie prandiale
(augmentation des apports caloriques au moment des repas). Il va manger plus, soit plus
vite, soit plus longtemps. Ainsi la quantité de nourriture consommée sera fonction des
circonstances du repas et non plus en fonction des sensations physiologiques de régulation
alimentaire (satiété, augmentation de la fin…). Parfois il peut être grignoteur, atteint de
compulsions alimentaires ou être Binge Eating Disorder (très semblable à la boulimie, les
comportements compensatoires en moins). Enfin le patient obèse peut faire de la
restriction cognitive, il va consciemment limiter sa prise alimentaire, mais la prise
alimentaire n’est plus régulée par la satiété mais par le contrôle cognitif. Quand
l’inhibition est levée le sujet rentre dans un état de désinhibition et de perte de contrôle,
prenant la forme d’accès hyperphagiques (Pinaquy, 2002).
2. TROUBLE DU COMPORTEMENT ALIMENTAIRE (TCA) ET ART THÉRAPIE: UNE

EFFICACITE ENCORE A DÉMONTRER?
2.1. La controverse classique et stérile ?
Dans la méta-analyse de Frisch & al (2006) sur l’évaluation de l’efficacité des arts thérapie
dans la prise en charge des patients atteints de troubles du comportement alimentaire,
ceux-ci ne trouvent aucune étude empirique. Ils notent que la majorité des prises en
charge dans ce domaine utilisent au moins une thérapie dont l’intérêt en tant que
traitement primaire, ou secondaire n’a pas été validé empiriquement. Ils accordent que la
validation des thérapies par les arts des patients TCA est complexe et ne doit pas être
évaluée seulement sur les critères qui constituent le trouble. De plus ils notent que les
pratiques n’ont pas été standardisées, et sont créées spécifiquement en fonction de celui à
qui elles sont prodiguées. Ainsi la littérature comporte-t-elle de nombreuses études de
cas, qui ne sont pas comparables entre elles pour les auteurs. C’est pourquoi ils
préconisent de conduire avec ces patients une « petite série » d’études randomisées,
contrôlées, aux pratiques standardisées, et comportant des follow up à court et à long
terme.

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Pour résumer, même si aucun effet délétère des arts thérapies auprès des patients TCA
n’est connu, ils sont utilisés depuis des décennies ; sans études empiriques systématiques,
des questions importantes restent sans réponses.
Cette méta analyse a amené une réponse tout aussi intransigeante d’un autre groupe de
chercheurs (Hanauer &Rehavia-Hanauer, 2007). Ceux- ci parlent d’un point de désaccord
fondamental dès la première phrase du premier article. Dans le premier travail, « les arts-
thérapies » et « les thérapies traditionnelles empiriquement validées » sont comparées. La
méta analyse compare avec la méthodologie de l’évaluation quantitative des
méthodologies différentes (qualitatives notamment). Pour les deuxièmes, Frisch & al
(2006) ne connaissent pas les méthodologies de recherches qualitatives et n’ont donc pas
produit une méta-analyse des recherches en art-thérapie mais plutôt un constat à charge
contre les arts-thérapies. Ce à quoi répondent Frisch & al (2007) disant qu’ils ne
souhaitaient pas créer une telle polémique en employant cette expression
d’empiriquement validé, que les directives soutiennent leur définition d’empiriquement
validé et que les arts thérapies n’ont pas encore fait l’objet d’une telle évaluation.
2.2. Ce que nous pouvons dire de la recherche actuelle
Les pratiques d’art-thérapie avec les patients atteints de TCA sont courantes et variées. Les
publications dépeignent la multitude de techniques employées et de courants théoriques
qui les sous-tendent (Dokter, 1994). Quelques ouvrages tentent de dépeindre toutes les
pratiques d’arts-thérapies avec plus ou moins de succès (Brooke, 2008, ou encore Hinz
2006).
Les ouvrages qui présentent les arts thérapies avec les patients atteints de TCA et qui
tentent une théorisation des processus mis en jeu n’y parviennent pas. La première
explication peut être justifiée par le manque d’études ECR (étude avec comparaison de
groupes, (Thurin 2006), et un manque de rigueur dans le recueil de données des cas
uniques, rendant impossible de croiser les observations. Les ouvrages rapportent aussi une
répétition de présentation des pratiques qui ne sont suivies que d’interprétations
parcellaires rapides.
La revue de la littérature fait tout de même apparaître un certain nombre d’objectifs

thérapeutiques. Les objectifs sont souvent confondus avec les résultats qui n’ont pour leur
part que très rarement d’indicateurs précis.
L’utilisation des arts thérapies avec les patients atteints de TCA devrait tout d’abord leur
permettre de favoriser le recours à l’imaginaire et améliorer leur créativité (Dokter 1994) ;
ensuite, favoriser l’expression des émotions (Matto 1997, Dubois 2010, Krantz 1999,
Wood 2000).
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Cet objectif thérapeutique a pour résultat de diminuer l’émotivité alimentaire des patients
(Johnson & Parkinson 1999). La nourriture n’est donc plus une alternative aux émotions ; ni
dans le contrôle, ni dans le débordement. Par l’expression des émotions, les patients vont
mieux se connaître, donner du sens (Matto 1997). Ils vont alors explorer les conflits
inconscients qui sous-tendent leur maladie (Kleinman 2009, Payne 1994, Rehavia-Hanauer
2003).
C’est là que nous arrivons à l’hypothèse la plus spécifique et centrale dans ce type de prise
en charge avec ces patients ; la question du lien soma psyché. En effet, par l’exploration
des conflits qui sont décrits comme liés d’un point de vue phénoménologique à des
questions d’image du corps (Vandereycken, Van Coppenolle & Pieters 1999) et d’un point
de vue étiologique au corps inconscient (Rust 1994), ainsi que par la mobilisation du corps
et l’expression des émotions qu’elle induit, les arts thérapies vont permettre de
« reconnecter » corps et émotions (Krantz 1999, De Tommasi 1999), soma et psychique.
Les arts thérapies vont permettre par la mise en jeu du corps, et l’exploration des conflits
de déplacer les conflits non-mentalisés du corps vers la psyché, et ainsi amorcer un travail
psychique.
Le travail psychique va pouvoir se situer sur l’image corporelle ainsi que sur
l’assouplissement des défenses (Wolf & al 1985) et l’utilisation de stratégies de coping
plus adaptées. (Matto 1997). Quant au travail de création étant souvent réalisé en groupe,
les relations interpersonnelles s’en voient généralement améliorées (Dubois 2010,
Lemieux 2001, Johnson & Parkinson 1999).
La prise en charge par les arts thérapie est le plus souvent réalisée en parallèle avec
d’autres thérapies. Les arts thérapies viennent comme « alibi » à la thérapie. Ils vont
permettre de réaliser un travail psychothérapeutique de manière détournée, médiée par
la création. Mis dans des conditions favorables par tout ce qui a été dit précédemment, les
patients vont pouvoir s’inscrire plus aisément dans un suivi psychothérapeutique verbal
plus traditionnel (Wolf & al 1985, Hilliard 2001).
Les arts thérapeutes des TCA ont généralement des stratégies thérapeutiques semblables,
et des tactiques différentes. Les objectifs thérapeutiques qui soutiennent les pratiques
sont proches, les média et les techniques utilisées sont quand à elles plus variés.
Les arts thérapies vont développer l’imaginaire et l’expression des émotions, permettant
ainsi l’exploration des conflits inconscients logés dans le corps et le déplacement vers le
psychique, c'est-à-dire l’amélioration du lien somato-psychique. Cette prise en charge
renforcera donc le Moi, assouplissant les défenses, facilitant la relation à autrui.

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En d’autres termes, la prise en charge de patient TCA dans des ateliers d’arts thérapie va
permettre l’expression de soi des patients, va favoriser l’exploration des conflits et
améliorer la connaissance de soi et l’image du corps. Enfin, dans une prise en charge multi
modale, elles sont présentées comme favorisant l’alliance thérapeutique dans les thérapies
verbales plus traditionnelles.
2.3. Troubles du Comportement alimentaire et psychodrame
Le psychodrame avec les patients TCA semble utiliser les mêmes leviers thérapeutiques
que les autres médiations. Semble car la littérature sur ce sujet n’est pas prolixe. Par le jeu
dramatique, le psychodrame va permettre aux patients une prise de conscience des
conflits inconscients (Ancelin Schützenberger 1970). Le psychodrame avec les patients
atteints de TCA vise spécifiquement les conflits inconscients logés dans le corps, via la
créativité propre du patient, via sa spontanéité propre. (Izydorczyk 2011). Il va aussi
permettre de retravailler les liaisons entre représentation et affect sur la problématique de
perte d’objet (Chabert, 1997).
Les études rapportent des résultats qui vont dans ce sens. A l’issue de la prise en charge
psychodramatique, les cliniciens observent une amélioration de l’insight émotionnel et
cognitif. Les interactions sociales et familiales se voient améliorées (Ozdel, Ateşci &
Oğuzhanoğlu 2003) ; les distorsions de l’image du corps réduites (Frismand 1995).
Le psychodrame, comme les autres formes de thérapies médiatisées, a aussi l’avantage de

faciliter la prise en charge par des psychothérapies verbales plus traditionnelles (de
groupe ou individuelles) (Diamond-Raab & Orrell-Valente 2002).
2.4. Trouble du comportement alimentaire et dramathérapie
La littérature spécifique à cette question est encore moins étoffée. Certaines pratiques
sont connues et rapportées (Dokter 1994, Wurr & Pope Carter 1998, Martin 1985), mais
les écrits sont trop parcellaires pour pouvoir en tirer des observations générales quant aux
objectifs et effets thérapeutiques spécifiques à cette médiation appliquée à cette
population. Cependant, on peut aisément supposer des objectifs thérapeutiques quant
aux liens somatopsychiques (Mitchell 1996) aux rapports interindividuels (Young 1994), à
l’image du corps (Dokter 1994).
2.5. Obésité et Théâtre thérapeutique
La littérature à ce sujet est très peu nombreuse. La majorité des écrits porte sur la
prévention de l’obésité infantile et adolescente par la représentation théâtrale. (Wyatt,
Lloyd, Creanor& Logan 2011, Sanborn 1999, Duffin 2006). On trouve deux articles anciens
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sur des activités de psychodrame réalisées avec des patients en surpoids ou obèses afin
d’améliorer l’image du corps. (Staven 1985, Naumburg & Caldwell 1959). Enfin, une seule
étude sur traite réellement d’obésité et théâtre. Fisher (2012) utilise le théâtre de
l’opprimé, et plus particulièrement le Théâtre Image et le Théâtre journal afin d’aider le
sujet à comprendre que le problème de l’obésité réside à la fois dans le corps et l’esprit. Il
semble donc que l’idée d’une personne obèse faisant du théâtre, et qui plus est en vue
d’un mieux-être psychologique soit étonnante.
En somme, l’étude des courants théâtraux et des différents dispositifs de théâtre

thérapeutiques nous ont permis de constater qu’il existe une multitude de pratiques de
dramathérapie ou théâtre thérapeutique. En effet, les pratiques actuelles d’art-thérapie
avec les patients atteints de troubles du comportement alimentaire sont courantes mais
mal étudiées, elles sont réalisées en vue de multiples effets (cf. annexe 1). Les études à leur
sujet ne conviennent pas au modèle d’essai contrôlé randomisé préconisé par des
chercheurs comme Frisch & al (2006), ni au modèle de la méthode à cas unique (Thurin &
al 2006, Thurin 2006). La grande majorité des travaux sur ce sujet ne permettent donc pas
d’affirmer avec certitude comme nous venons de le voir l’efficacité de telles pratiques.
Cependant, le nombre de récits d’expériences cliniques sur le sujet indiquant des
bénéfices est tel que l’on ne peut qu’avoir envie d’essayer d’explorer cette « légitimité
scientifique » à l’art-thérapie.
On comprend aisément la question provocatrice de Frisch & al (2006), l’art-thérapie avec

les TCA n’est-il pas plus une norme de soin qu’une thérapie au sens littéral du terme. Nous
voulons essayer de concourir à faire la preuve de l’effet thérapeutique, des changements
qu’entraine une telle pratique. C’est pourquoi dans nos travaux nous avons utilisé les deux
méthodes, la recherche contrôlée randomisée, ainsi que la méthode à cas unique.
En poussant plus loin notre investigation sur les pratiques d’arts thérapie avec les patients
TCA, nous nous sommes rendu compte que l’immense majorité portait sur les patients
anorexiques et quelques-unes sur les boulimiques. Quid des binge eating et/ou obèses ?
De même, la majorité des écrits portant sur les arts-thérapies pratiqués avec les patients
TCA rapportent des pratiques, et des effets d’art thérapie mais moins fréquemment sur du
psychodrame et encore moins sur la dramathérapie (cf. Annexe 1). Les écrits sur obésité et
théâtre thérapie ou psychodrame sont inexistants.

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3. MISE EN PLACE D’UN DISPOSITIF DE THÉATRE THÉRAPEUTIQUE POUR LES PATIENTS

OBÈSES
Les ateliers se sont déroulés dans une clinique qui compte différentes unités. Les patients
obèses sont recrutés dans le cadre de cette clinique qui a une tradition d'éducation
thérapeutique et de thérapie médiatisées. Ils effectuent un séjour de trois semaines.
3.1. L’activité de théâtre thérapeutique
Les séances de théâtre thérapeutique se déroulent dans une salle de réunion comportant
des rideaux afin de créer un aspect intime aux séances. Les groupes sont fermés, et
composés de 6 à 9 participants. Les séances de deux heures ont lieux de fois par semaines
pour un total de cinq séances. L'atelier est soumis à quelques règles intersubjectives:
« l'atelier est fait pour se faire du bien, si on ne peut pas ou ne veut pas faire on ne fait
pas... Il est très bien de faire, même qu'un peu... ». Les principes d'abstinence (sexuelle et
agressive), de libre expression (laisser-dire, laisser-créer, laisser-faire, laisser-aller), de jeu
(on joue le « je-nous » comme dans le réel) et de confidentialité sont respectés. Tous les
sujets participent dans une position tournante de spec-acteur.
Les séances sont menées par un animateur unique formé à la pratique théâtrale et à la
psychopathologie. La structure des séances est toujours identique. Les sujets entament les
séances par trente minutes à quarante-cinq minutes d'exercices ou jeux théâtraux destinés
à les « échauffer » comme un sportif doit s'échauffer avant tout sport. Là il s'agit d'un
échauffement de la voix, du corps, émotionnel... Ensuite dans un deuxième temps il est
proposé aux sujets de réaliser des improvisations dont les thèmes leurs sont imposés par
l'animateur. Les séances sont toujours suivies d'un temps de mise en commun des ressentis
d'une demie heure trois quarts d'heures dans lequel chacun fait part de ses ressentis
(élément perturbants, plaisir, difficultés, souvenirs apparus au cours de la séance...).
Les exercices proposés sont issus de la pratique théâtrale de l'animateur ou encore des
ouvrages de pratiques théâtrale existant (Boal 1977, Stanislavsky 1936, Jouvet 1941...). Les
exercices ont été adaptés à nos objectifs thérapeutiques et aux sujets (particulièrement à
leur poids entrainant des difficultés dans les déplacements).
3.2. Les séances
3.2.1. Séance 1
- présentation de l’un par l’autre : il est demandé aux patients de présenter son voisin
après quelques minutes d’échange.

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- présentation du théâtre-thérapeute, de l'atelier, des règles intersubjectives et de la

recherche.
- aveugle : Un des patients est « le guide ». Il dirige les paumes de ses mains vers le ciel. Le
second, « l’aveugle », effleure avec les paumes de ses mains celles du premier. Le guide
commence à le faire se déplacer dans l’espace, en prenant toujours grand soin de lui.
- détente corporelle par des mouvements circulaires : Les acteurs sont debout (mais si cela
n’est pas possible, ils s'assoient), commencent par essayer de se détendre, les bras le long
du corps, les jambes dans l’alignement des épaules, les yeux fermés (ou ouverts pour ceux
ne voulant ou ne pouvant les fermer). L'animateur commence par leur dire d'essayer
d'adopter une respiration abdominale.... puis « l'index droit commence à bouger
doucement dans un mouvement circulaire, puis entraîne lentement les autres doigts... puis
la main... puis la main entraîne lentement, doucement le poignet, qui tourne de plus en
plus; le poignet continue, la main s'arrête, le poignet entraîne tranquillement le coude » et
ainsi de suite... l'épaule droite, l'épaule gauche puis le coude. Puis de même pour les
jambes et la tête.
- adresse bonjour : Les acteurs en cercle se « passent » le mot bonjour. C'est-à-dire que le
premier adresse le « bonjour » à un deuxième acteur en utilisant son regard et sa voix. Il
signifie en même temps à cet acteur que c’est à lui de passer bonjour à quelqu’un d’autre
et ainsi de suite. Après quelques instants, il est demandé au groupe de continuer en faisant
varier l’intonation des bonjours, en cherchant tous les bonjours possibles, tout en restant
spontané.
- les statues: Les acteurs se déplacent dans l’espace, ils doivent s’arrêter au claquement de
main de l’animateur. Après quelques essais, l’animateur donne un sentiment (la colère,
l’amour, la peur, la convoitise, la frayeur…) et au « clap » les acteurs arrêtent de marcher et
deviennent des statues de ce sentiment. Au clap suivant ils repartent dans l’espace. Les
sentiments proposés suivent une gradation dans la finesse et la difficulté des sentiments
proposés (inquiétude, peur, anxiété, frayeur, terreur…).
- entretenir une conversation avec une personne pressée : Deux acteurs. Deux amis,
connaissances se rencontrent dans la rue. L’un d’entre eux est pressé pour une raison de
son choix (aller chercher les petits enfants à l’école, le temps du parcmètre écoulé…).
L’autre a tout son temps et tente de faire durer la conversation. Entre ces improvisations
l’animateur met en évidence les différentes stratégies utilisées par les patients (donner de
ses nouvelles, demander des nouvelles de l’autre, proposer un de partager un moment…).
L’intérêt des questions ouvertes est mis en évidence.

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- envahissement des voisins : Pour cette improvisation, tous les acteurs sont mobilisés. L’un
d’entre eux, habite un immeuble. Il est tranquillement chez lui, en train de faire une
activité de son choix, qu’il aime faire lorsqu’il est seul chez lui. Dans un deuxième temps,
les voisins de l'immeuble (les autres acteurs) viennent frapper à la porte dans le but
d’entrer et de passer un peu de temps. Les voisins se succèdent, venant déranger sans
cesse le premier. Cette improvisation amène les sujets à considérer la notion d'espace
privé et d'espace public, et les stratégies efficaces ou non qu'ils peuvent mettre en place,
puis enfin les ressentis que cet envahissement et les tentatives de refus occasionnent
(culpabilité, sentiment d'auto-inefficacité ou d'efficacité...)
3.2.2. Séance 2
- aveugle : Pour cet aveugle il est simplement demandé aux patients de changer de
partenaire.
- la relaxation de Jacobson : Les acteurs sont allongés. Ils ferment les yeux et commencent
à adopter une respiration abdominale proche de celle du sommeil. Sur une inspiration ils
tendent le bras droit puis relâchent la tension sur l'expiration. Ils recommencent une
seconde fois. Sur l'inspiration suivante, ils serrent le poing droit, le ramènent sur l'épaule
droite afin de serrer le biceps, et sur l'expiration relâchent. Ils recommencent une seconde
fois. A ce moment-là, le meneur explique que « après avoir détendu le bras droit, on va
détendre le bras gauche. » Les sujets refont avec le bras gauche ce qu'ils viennent de faire
avec le bras droit. « Après avoir détendu le bras droit et le bras gauche, on va détendre la
jambe droite » (phrase énoncée par le meneur), pour cela les sujets sont invités à tendre
leur jambe droite pied en flexion, et sur l'expiration à relâcher la tension. Ils
recommencent une seconde fois. Puis ils doivent amener leur genou droit sur la poitrine, la
pointe de pied tendue. Sur l'expiration ils relâchent puis recommencent une seconde fois
sur la prochaine inspiration. « Après avoir détendu le bras droit, le bras gauche et la jambe
droite, on va détendre la jambe gauche ». Pour cela les acteurs sont invités à refaire pour
la jambe gauche ce qu’ils viennent de faire avec la droite. Ensuite selon les besoins, le
meneur peut les inviter toujours sur le même principe d'inspiration/tension versus
expiration/relâchement à détendre le dos ou les différentes parties du visage. Une fois
tout ceci fait, les sujets sont invités à penser à un endroit naturel qu'ils aiment bien, où ils
se sentent bien. Ils doivent ensuite y observer chaque détail, y sentir les odeurs, y entendre
les bruits, et sentir le soleil ou l'ombre sur leur peau... Puis le meneur entame le réveil par
cette phrase : « si vous voulez retrouver cet état de détente il vous suffira de refaire ces
quelques exercices et de repenser à cet endroit », puis il fait porter l'attention du groupe
sur les bruits extérieurs, et suggère que les doigts et les orteils commencent à se mettre à
bouger. Les acteurs s'étirent, s'assoient et peuvent ouvrir les yeux.

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- dire une chose agréable versus désagréable à son voisin : Assis en cercle, le premier
acteur dit à son voisin de droite quelque chose de désagréable mais non personnel (ce
matin, tu m’énerves, tes chaussures sont hideuses… ») . Celui-ci dit à son voisin de droite
quelque chose d'agréable (« ton sourire et radieux, tu a l'air en forme ce matin… »), et
celui-ci dira quelque chose de désagréable à son voisin de droite, et ainsi de suite. Le
théâtre- thérapeute s'arrange pour que chaque patient expérimente les deux situations,
recevoir quelque chose d'agréable et dire quelque chose de désagréable, versus recevoir
quelque chose de désagréable et dire quelque chose d'agréable.
- disque rayé : Deux acteurs, l’un n'a pas envie de satisfaire la demande de l’autre
(demande d’achat, de service) et doit donc refuser cette action. Ce jeu de rôle permet au
patient de travailler le refus face à des propositions ou demandes faites par un inconnu. Le
refus est généralement vécu par les patients comme difficile à faire et générateur de
culpabilité. Le demandeur peut être un démarcheur tentant de vendre, ou simplement un
inconnu demandant un service. Cette improvisation permet au patient de mettre en
pratique et d’apprendre la technique du disque rayé. Elle consiste à formuler son refus
sans donner d’explications ni de justification, et de le répéter à chaque fois que nécessaire.
- rester flou : Cette improvisation est identique à la précédente, hormis le fait que cette
fois-ci les deux acteurs sont des amis ou de bonnes connaissances. La technique du disque
rayé n’est plus satisfaisante dans ce cas précis car manquant de sensibilité à l'égard de son
ami. La technique du rester flou consiste à exprimer que l’on a bien compris la demande de
l’autre, puis à exprimer de la compassion, et à formuler son refus, et toujours sans donner
d’explications. Cela s’énonce comme ceci : « -j’ai bien compris que tu me demandes de …,
mais je suis désolé, je ne peux/veux pas. » Cette nouvelle forme de refus doit être répétée
à chaque fois que nécessaire et ainsi devenir un disque rayé.
Ces deux jeux de rôle viennent apporter une aide à formuler et à exprimer son refus.
- improvisation de la prison : L’un des acteurs est en prison. Il va bientôt être libéré. Dans
ce premier moment, l’acteur nous fait part de ses pensées. Ensuite un gardien sympathique
ou désagréable vient libérer le prisonnier. Une fois dehors, l’acteur fait part encore une
fois de ses pensées. Cette improvisation est une double métaphore de la situation du
patient. Celui-ci est pris dans des comportements compensatoires inadéquats entraînant
notamment le surpoids. Une fois « guéri », sorti de ses comportements : que va pouvoir
faire le patient ? Ne se retrouve t-il pas perdu?... Perdre ces comportements appris est
source d'angoisse, car les perdre, c’est se retrouver dans un nouvel environnement sans
moyen de se défendre. La prison est aussi une métaphore du corps de l’obèse vécu de
manière ambivalente comme corps/prison entraînant des difficultés de déplacements,
l’isolement social… Cependant ce corps est source de bénéfices secondaires, il est aussi

20
corps/amure face à la stigmatisation (Rousseau 2004), il protège des relations

interpersonnelles souvent vécues comme difficiles.
3.2.3. Séance 3
- retour sur les deux séances précédentes
- rappel des règles intersubjectives
- aveugle : Pour cet aveugle, il est demandé aux acteurs de changer et d’explorer toutes
les manières de guider. Ils peuvent guider par une seule main, par le bras, le dos, la
nuque…
- la relaxation de Schultz : Les acteurs sont dans la même disposition de départ que pour la
relaxation de Jacobson. Ils adoptent une respiration abdominale. Le meneur suggère aux
acteurs que leurs mains sont lourdes et envahies par une douce chaleur, et cette douce
chaleur irradie la main droite et se propage jusque dans l'avant-bras, qui devient de plus
en plus lourd, qui s'enfonce de plus en plus profondément dans le sol. Et cette chaleur,
sous les indications du thérapeute va circuler dans les différentes parties du corps. Une
fois tout le corps passé en revue, les acteurs sont invités à penser à une plage qu'ils aiment
bien, réelle ou inventée, ils doivent observer chaque détail, sentir la chaleur du soleil, les
embruns, le vent chaud, sur leur peau, entendre le bruit des vagues, des oiseaux, sentir les
odeurs de la mer... Comme dans la relaxation de Jacobson, le meneur entame le réveil par
cette phrase : « si vous voulez retrouver cet état détente il vous suffira de refaire ces
quelques exercices et de repenser à cet endroit », et il finit ensuite le réveil.
- les statues phrases: L'exercice est le même que la fois précédente, hormis le fait que
cette fois-ci, à la demande du théâtre-thérapeute, le patient devra dire une phrase ou une
onomatopée avec la bonne intonation exprimant ce qu'il ressent.
- lettre à quelqu’un d’important : Il est demandé aux acteurs de jouer l’écriture d’une lettre
à voix haute à quelqu’un d’important pour eux, à quelqu’un pour qui ils ont des sentiments
forts très positifs ou très négatifs. Cette improvisation est portée par de fortes émotions.
L'écriture à voix haute de la lettre peut permettre aux patients de mettre en place un
mécanisme d'affirmation de soi ou d'abréaction sur des événements pathogènes tout en
prenant du recul sur une situation et des difficultés souvent rarement énoncées et ainsi
mal mentalisées.
- ouvre : L’acteur est devant une porte imaginaire fermée. La consigne est de dire
principalement le mot « ouvre » et de s’arrêter, soit quand il désire arrêter l'improvisation,

21
soit quand l’acteur derrière la porte imaginaire décide de l’ouvrir. Ce dernier n’a pas le
droit de parler.
Cette improvisation peut renvoyer le patient à ses difficultés de communication, pour

celui derrière la porte à son hyper empathie (Apfeldorefer 1991) source de
comportements non désirés, et pour celui qui tente de faire ouvrir la porte au mécanisme
d'affirmation de soi et d'abréaction lorsque des relations sont mises en scène par le
patient.
3.2.4. Séance 4
- aveugle : Pour cet aveugle, après quelques instants, le guide lâche les mains de « son
aveugle ». Pour le faire se déplacer, le guide ne peut utiliser que le prénom de l’aveugle et
éventuellement le mot « stop », en cas d’obstacle. L’aveugle se déplace en fonction de la
provenance de la voix du guide.
- relaxation : Pour cette relaxation, les sujets sont assis. Ils prennent une respiration
abdominale, proche de celle du sommeil. Ils doivent ensuite se représenter mentalement
un lieu naturel qu’ils aiment bien. Ils en regardent tous les recoins, écoutent les sons
familiers de ce lieu, sentent les odeurs, sentent sur la peau le soleil ou l’ombre. Ensuite
l’animateur leur indique qu’il y a derrière eux un chemin boisé de quatre kilomètres. Ils
empruntent ce chemin. A la première borne, leur corps est plus détendu et leur esprit plus
vif. Ils continuent à avancer pour arriver à la deuxième, puis à la troisième et enfin à la
quatrième borne. A ce moment leur corps est totalement détendu et leur esprit
totalement vif et à l’écoute. Plus loin se trouve une grande et belle porte. Ils l’ouvrent et
derrière se trouve leur laboratoire intérieur qu’ils observent. Sur un mur un tableau noir sur
lequel il peut y avoir quelque chose d’inscrit ou non. Dans un coin, un bureau devant
lequel ils s’assoient. Dessus, se trouve un album de photographies, l’album de leur vie. Il est
possible de passer des pages. L’album commence par des photographies d’eux enfant, puis
adolescent, puis adulte et enfin une photographie d’aujourd’hui. Ensuite les pages sont
vides, les sujets sont invités, s’ils le désirent, à y inscrire quelque chose pour eux. Ensuite ils
se lèvent et vont vers un rideau blanc. Ce dernier se lève progressivement, laissant
apparaître deux paires de pieds, puis deux paires de jambes, pour arriver à deux
personnes, un assistant et une assistante. Ces deux assistants vont prendre le sujet par le
bras, ils lui diront peut-être un mot ou une phrase. Ils l’amènent ensuite dans un coin du
laboratoire pour qu’il puisse prendre une douche de lumière blanche revitalisante. Le
réveil se fait suite à cette dernière image.
- courant électrique : Les acteurs forment un cercle, les yeux fermés, en se tenant les
mains. Ils se font passer « un courant » en se serrant la main et en le faisant passer à leur
voisin.
22
- machines : Chaque élément de la machine est un acteur. L'un après l'autre, les acteurs
vont se placer sur la scène en répétant chacun un son et un mouvement, indéfiniment,
formant en définitive la machine. L'animateur peut faire accélérer la machine, la faire
ralentir, la casser... L'animateur donne une fonction à la machine avant qu'elle soit créée
par les acteurs (machine à bulles du paradis, à oiseaux de guerre, à maladies...).
- chez le notaire, un héritage surprise «quasi ridicule » : L’improvisation se déroule chez le

notaire qui annonce un héritage inattendu. Mais cet héritage est soit infime soit d’un
premier abord intéressant mais avec des clauses qui le rendent difficile à accepter ou du
moins très contraignant.
Cette improvisation permet d'aborder la notion d'héritage familial. Il s'agit de prime abord
d'héritage matériel, mais aussi des héritages comportementaux.
3.2.5. Séance 5
- aveugle : Les guides racontent une histoire à leur aveugle, ils imaginent une promenade
dans un lieu qu’ils lui font partager.
- tout sauf ça : L'animateur donne un objet quelconque et il s'agit pour les acteurs de
mimer une situation dans laquelle l'objet sera détourné de son utilisation habituelle.
L'objet est alors tout ce qu'on veut sauf ce qu'il est réellement (Une chaise peut servir à
bêcher un jardin).
- les phrases dépourvues de sens : Chaque patient choisit une phrase assez courte, sans
souci de sens (« le canard s'est coincé la tête dans le caniveau », « les arbres poussent »). A
deux sur scène, ils vont « discuter » en n'utilisant que leur phrase. Pour cela ils devront
s'ajuster aux intonations et aux postures corporelles de l'autre et répondre en fonction. Par
exemple, si le premier dit sa phrase sur un ton menaçant, le second répondra sur un ton
encore plus menaçant, ou au contraire sur un ton apeuré...
- l’interprète et l’indigène : Un des acteurs est un indigène qui raconte une légende
typique de son pays dans sa langue natale (inventée par l’acteur). Le second acteur est
l’interprète chargé de traduire la légende pour le public.
- ça ne va pas, je ne parle pas, les autres viennent m’aider, y arriveront-ils ? Un acteur est
sur la scène. Il peut décider d’être un enfant ou un adulte qui ayant un problème s’est
enfermé dans le mutisme. Les autres acteurs vont tenter de lui venir en aide, de
comprendre ce qui ne va pas. Cette dernière improvisation permet d'aborder les relations
non satisfaisantes. Il peut s'agir des relations parentales précoces ou bien des relations à

23
l'autre. Cette improvisation amène aussi à aborder la culpabilité que la non-

compréhension de l'autre entraîne et de revenir ainsi sur l'hyper empathie.
4. MÉTHODE
Une activité de théâtre thérapeutique réalisée auprès d'un groupe de patients obèses est
susceptible d'amener un changement positif chez ces derniers. Ce changement est
observable au niveau de l'alexithymie, de l'estime de soi, d'utilisation des stratégies de
coping
4.2. La population
Après application des critères d’inclusion et d’exclusion, nous en avons retenu 44 patients
pour former le groupe expérimental (GE). Parmi ces 44 patients qui ont répondu aux deux
vagues de questionnaire, 28 ont répondu en plus à l'issue des teliers à l'ECTM et ont été
retenus. Pour former le groupe contrôle (GC), après application des critères d'inclusion,
nous avons retenu 50 pour participer à l'étude.
Les 94 patients retenus (76 femmes – 18 hommes) sont âgés de 20 à 80 ans (m= 61,6 et
SD= 13.6). 44 appartiennent au groupe expérimental (GE) et 50 au groupe contrôle (GC).
Tous les patients, au moment de leur entrée à la clinique, sont obésité à minima de classe I
(BMI ≥ 30 )
4.3. Les outils utilisés
- Le Toronto Alexithymia Scale 20 (TAS-20) de R.M Bagby, J.D.A Parker et G.J. Taylor
(1994) permet d'évaluer en 20 items « la difficulté à identifier ses sentiments », « la
difficulté à décrire ses sentiments », « la pensée orientée vers l'extérieur » avec 5
modalités de réponses (de « désaccord complet » à « accord complet »).
- L'Echelle Toulousaine d'Estime de Soi (ETES) de S. Esparbès, F. Sordes-Ader, N. Oubrayrie

et P. Tap, (1993) explore en 60 items « le soi émotionnel », « le soi social », « le soi
professionnel », « le soi physique », « le soi futur » et le « soi global » avec deux modalités
de réponses pour ce questionnaire : « oui » et « non ».
- La Brief COPE dispositionnelle de L. Muller et E. Spitz (2003), apprécie en 28 items « self

distraction », « active coping », « denial », « substance use », « use of emmotionnal
support », « use of instrumental support », « behavioral disengagement », « venting »,
24
« positiv reframing », « planning », « humor », « acceptance », « religion », « self blame »

avec 4 modalités de réponses (de « pas du tout » à « tout à fait »).
- Le Eating disorder inventory (EDI-2) de D.M. Garner (1991), expertise en 92 items

répartis « la recherche de la minceur », « la boulimie », « l'insatisfaction par rapport à son
corps », « l'inefficacité », « le perfectionnisme », « la méfiance interpersonnelle », « la
conscience intéroceptive », « la peur de la maturité », « l'ascétisme », « le contrôle des
pulsions » et « l'insécurité sociale » en 6 modalités de réponses allant de « toujours » à
« jamais ».
- Le questionnaire qualitatif d'enquête sur le vécu des activités d’atelier (ETCM) de J.L.
Sudres (1993) qui traite du vécu des activités d'art-thérapie utilisant le médiateur arts-
plastiques, a été adapté à la médiation théâtrale. Il évalue en 30 items « la définition de
l’atelier », « le travail psychique », « la performance théâtrale », « la perception du groupe
et des praticiens », « les apports et changements estimés ».
4.4. Procédure
Tous les questionnaires ont été remplis par tous les patients, à leur entrée à la clinique et
juste avant de la quitter.
Pour le traitement des données, il a été utilisé l’analyse de variance (Anova) SPSS 19 et
Statistica 10. Nous avons réalisé une Anova pour plan mixte, utilisant un facteur inter-sujet
(Théâtre thérapie/ pas de théâtre thérapie) et un facteur intra-sujet (T0/T1).
5. RESULTATS/DISCUSSION
5.1. Résultats de la dimension qualitative
Pour les patients, l’atelier peut être défini comme : une activité agréable durant laquelle
on utilise la technique théâtrale et l’expression de soi, en vue d’une meilleure
connaissance, de soi et des autres et d’une plus grande affirmation de soi ; le tout encadré
par un animateur.
Le théâtre d’improvisation, médie la relation individu/groupe de pair, et le groupe pair,

médie la future relation individu/groupe de non pairs.
Les patients rapportent des difficultés ressenties face à l’expression de soi et des émotions,
démontrant un travail psychique intense. En effet du fait de l’alexithymie, les émotions
25
ressenties pendant les improvisations et l’expression de celles-ci sont décrites comme

difficiles. La résurgence des émotions et leur expression sont aussi décrites comme le
moment préféré des patients, signant ainsi l’insight nécessaire au changement quant au
rapport aux émotions, ainsi que l’augmentation de l’estime de soi émotionnelle et la
diminution de l’alexithymie.
L’atelier a permis la résurgence de souvenirs passés, ou même parfois de les rejouer,

permettant ainsi un phénomène d’abréaction et une meilleure compréhension par le
patient.
Au fil des séances, la difficulté des improvisations croissantes, la créativité des patients à
augmenté. Ils ont pu passer d’une position dans laquelle ils subissent et sont surpris de
leurs émotions, à une position dans laquelle l’émotion est comprise et mobilisable pour
l’improvisation.
Le groupe, animateur compris, est perçu comme moteur à la création ainsi qu’à
l’expression. Par ce travail, les stratégies de coping tournées vers le soutien social vont
pouvoir être mobilisées.
Enfin Chaque patient écrit avoir perçu des changements subséquents à l’atelier. Grace à
l’atelier, les patients commençaient par se reconnaître à travers l’autre, pour pouvoir
s’exprimer, se livrer, et enfin prendre du recul sur leurs situations singulières
5.2. Illustrations cliniques, entre réussite et écueil
5.2.1. Mme Oneil une réussite (anex 2)
La première fois que je rencontre Mme Oneil, elle me dit ne pas vouloir venir à l’atelier,
qu’elle ne sera pas capable de faire du théâtre. Je lui explique que les autres participants
n’ont surement pas fait plus de théâtre qu’elle avant de venir et lui dit que le but de
l’atelier est de faire quelque chose, même qu’un peu. Je lui dis qu’elle peut venir aux deux
premières séances et si elle veut ensuite elle peut arrêter. Je lui propose de participer à
l’étude, elle accepte.
Le jour de la première séance je vois Mme Oneil près de l’accueil. Je lui dis que la séance
va commencer. Elle me dit qu’elle pense ne pas venir mais qu’elle a rempli les
questionnaires. J’insiste un peu en lui proposant d’essayer cette première séance. Elle vient
avec moi.
Mme Oneil est en rentré par rapport au reste du groupe. Le nombre de participants est
impair, je fais donc avec eux l’exercice de la présentation croisée et de l’aveugle. Je suis les
26
deux fois en duo avec Mme Oneil. Elle ne me présente que partiellement (prénom, nom et
oublie le reste). Je reprends la parole en finissant de me présenter et en y ajoutant la
présentation de l’atelier et de la recherche. Pour l’aveugle, Mme Oneil est très à l’aise en
position d’aveugle, elle n’a aucun mal à se laisser guider. A l’inverse, elle se montre plus
tendue au moment d’être l’aveugle, surement renforcée par le fait que ce jour-là j’ai moi-
même du mal à être détendu en position d’aveugle, même si je tente de ne pas le montrer.
Les statues de Mme Oneil ne sont pas très expressives, elles sont dans la retenue même si
le ton général de l’émotion demandée est respecté.
Mme Oneil ne participe pas aux autres improvisations, trop timide. Pendant la mise en
commun des ressentis, je la rassure sur ce point, en lui rappelant la règle intersubjective :
« on ne fait que ce que l’on peut ou veut ». Elle ne parlera presque pas pendant la mise en
commun des ressentis même si elle semble partager les réflexions des autres patients sur
le ressenti face à l’envahissement des voisins et sur les difficultés que l’on a à dire non.
La séance suivante, Mme Oneil m’attend cette fois –ci devant la salle pour me dire qu’elle
ne viendra pas. Elle l’explique par le souci de ne pas vouloir déranger les autres en ne
participant pas aux improvisations. Je la rassure à ce sujet en lui rappelant qu’il n’est pas
obligé de participer à tout, que si cela dérangeait les autres ils en auraient probablement
déjà parlé, et que par rapport aux improvisations, elle y participerait seulement quand elle
se sentirait prête.
Elle intègre le groupe pour la deuxième séance. Pour cet aveugle il faut juste changer de
partenaire, Mme Oneil se met avec une autre femme du groupe. Elle ne participe pas aux
improvisations suivantes (disque rayé, resté flou, prison) mais semble s’amuser à regarder
les réalisations des autres acteurs et être attentive à la dernière. Pendant la mise en
commun des ressentis, au moment de parler des improvisations sur le dire non, je
demande aux autres si la non participation de Mme Oneil les dérange. Une autre
participante commence par dire qu’elle n’a elle-même pas participé à une improvisation
depuis le début. Les autres les rassurent en leur indiquant que non. Pour l’improvisation sur
la prison les patients parlent encore une fois de la notion de bénéfice secondaire, ou du
fait qu’ils éprouvent des difficultés situées à d’autres niveaux que leur poids, et qu’enfin il
leur faut prendre soin d’eux-mêmes (au point de vue physique et psychologique).
Pour la troisième séance Mme Oneil m’attend de nouveau à l’accueil. Je lui demande où
sont les autres patients. Elle me répond qu’elle ne sait pas, qu’elle ne fait pas partie de leur
groupe de cure, ne faisant pas les autres activités en même temps qu’eux, mais avec un
autre groupe de patients. Nous nous dirigeons vers la salle, et y attendons le reste du
groupe retenu par atelier de diététique.

27
La séance débutée, les phrases des statues de Mme Oneil ont des difficultés à sortir. La
première véritable phrase dite et réellement jouée, sera « Tu m’énerves ! » pour la statue
de la colère. Mme Oneil participera pour la première fois à l’improvisation de la lettre. Elle
écrit une lettre d’explication à sa mère. Dans la lettre elle la décrit comme intrusive et
étouffante. Du fait du retard des autres patients nous n’avons pas pu faire l’improvisation
« ouvre ». Pendant la mise en commun des ressentis je félicite Mme Oneil pour les statues
et lui dis que je n’aurais pas aimé être celui qui l’énerve. Enfin, le groupe se joint à moi
pour la féliciter pour sa première improvisation et de la qualité de celle-ci. Mme Oneil un
peu gênée sourit.
La séance suivante Mme Oneil m’attend devant la salle, mais cette fois-ci en discutant
avec une autre participante. La séance suivante se déroule simplement pour Mme Oneil,
elle ne semble pas éprouver de difficultés. Pour l’improvisation sur l’héritage elle participe
en jouant une des sœurs héritant d’un ranch aux Etats-Unis à la condition d’aller y habiter,
de devenir une cowgirl et d’élever elle-même les vaches. Elle n’interviendra que pour
refuser l’héritage à la fin de l’improvisation. Pendant la mise en commun des ressentis elle
évoquera succinctement la relation à sa mère et le travail à ce sujet qu’elle réalise avec le
psychiatre de l’institution.
Maintenant bien intégrée à son groupe de théâtre, nous nous voyons pour la dernière
séance. Mme Oneil a des difficultés pour faire l’exercice de la phrase sans sens et ne
participera pas à l’improvisation de l’indigène. Pour la dernière improvisation elle décide
de jouer la personne qui ne parle pas, se sera un enfant. Les autres patients se succèdent et
n’arrivent pas à la faire parler, à comprendre ce qui ne va pas. Ils n’arrivent qu’à énerver
l’enfant. Comme d’habitude quand l’improvisation stagne, je demande aux acteurs de
« trouver une fin ». C’est Mme Oneil qui la trouve. Les acteurs autour d’elle ne savent plus
quoi proposer pour essayer de la comprendre. Un autre acteur venant vers elle pour lui
parler (et surement amener à une fin), Mme Oneil se lève d’un air décidé, sort de scène
laissant tous les autres personnages. Pendant la mise en commun des ressentis, Mme Oneil
ne dira pas grand-chose sur cette improvisation hormis le fait qu’elle a aimé la fin, qu’elle
avait bien compris les intentions du dernier acteur se dirigeant vers elle mais que c’est elle
qui a décidé d’arrêter là.
L’atelier a permis à Mme Oneil de se sentir plus à l’aise avec les autres. Il lui a aussi permis
d’enclencher, de continuer et consolider par la réalisation pratique un travail de
séparation avec sa mère. Les résultats aux questionnaires viennent confirmer cette analyse,
la propension à utiliser les stratégies de coping tournées vers le soutien social augmente,
ainsi que l’estime de soi de Mme Oneil.

28
5.2.2. M. Jean : écueil relatif, écueil statistique ou réels bienfaits (anex 3)
Je rencontre M. Jean dans sa chambre. Il me dit ne pas très bien savoir pourquoi on lui
propose d’intégrer l’atelier. Je le rassure en lui disant qu’il peut essayer la première fois
puis s’il me le dit qu’il peut ne pas revenir ensuite. Je lui donne aussi les règles de l’atelier.
Les questionnaires distribués, je laisse M. Jean dans sa chambre et lui dit à mardi.
La présentation inversée du début de première séance se passe bien pour M. Jean. Il

explique sa prise de poids par un accident lui empêchant à regret toutes activités
sportives. M. Jean réalise facilement tous les exercices demandés et sourit fréquemment.
De même il réalise facilement l’improvisation. Ensuite il se montre adroit dans
l’improvisation qui consiste à entretenir une conversion avec une personne pressée. Pour
l’improvisation de l’envahissement des voisins, il joue, avec un plaisir certain, un pompier
qui alerté par des fumées suspectes arrive à s’imposer et ainsi permettre la première
ouverture de la porte restée close jusque-là. Pendant la mise en commun des ressentis les
autres le félicitent pour avoir réussi à faire ouvrir la porte lors de l’improvisation. En effet,
la patiente jouant le fait d’être tranquillement installée chez elle, avait décidé de faire la
sourde oreille à toutes sollicitations. M. Jean a trouvé le moyen « d’enfoncer » la porte en
ajoutant la fumée suspecte, et ainsi créer une brèche suffisamment grande pour que tous
les voisins inquiets puissent venir s’enquérir de la situation chez notre pauvre patiente qui
voulait rester tranquille à regarder son feuilleton favori. M. Jean semble content de lui. La
suite de l’échange se poursuit tout d’abord sur le ressenti de la patiente envahie puis sur
celui des autres quant à leur position d'envahisseurs ou en imaginant être envahis à leur
tour. M. Jean n'est pas très concerné, il semble comprendre les difficultés des autres
patients, mais ne pas les partager. La séance suivante, M. Jean prend du plaisir à faire les
exercices et à jouer. « Dans une vie antérieure » il a été représentant, et comme il n'a rien
perdu des techniques commerciales il arrive sans difficulté à faire acheter 2 « aspiros
2000 » à la personne qu'il démarche. Il décide de ne pas jouer l'improvisation de la prison,
il regarde ce qui se joue et semble être touché par l'émotion de la prisonnière. Elle
préfèrera ne pas sortir et rester en prison, l'improvisation s'arrêtant au milieu de la
consigne.
Pendant la mise en commun des ressentis le groupe associe sur la notion de corps prison.
M. Jean parle de son passé de sportif. Il est reconnu depuis peu comme handicapé et ne
peut plus pratiquer aucun sport comme il aimait tant. Sa prise de poids lui importe assez
peu en définitive, il est plus préoccupé par sa nouvelle situation de personne handicapée.
Le groupe accueille ce qu'il vient de dire, mais n'étant pas dans la même situation n'y fait
pas directement écho.
A la séance suivante M. Jean est toujours aussi content de participer. Il n'a pas l'air de se
lasser des exercices de l'aveugle qui se répètent, contrairement aux autres patients qui
29
soufflent dès la proposition de l’exercice. Il se débrouille bien dans l’exercice « des statues
phrases », produisant sans difficulté les phrases en rapport avec les statues demandées. Au
moment de réaliser la lettre à quelqu’un d’important, M. Jean est ému, il « écrit » une belle
lettre très sensible à sa fille, avec laquelle il dit pendant l’improvisation être brouillé.
Pendant la mise en commun des ressentis M. Jean ne veut pas en dire plus sur la situation
avec ses enfants. Je n’insiste pas. Je vois qu’il vient de comprendre que les improvisations
que nous faisons ne sont pas anodines. Je crois qu’il a été surpris de sa lettre et des
émotions qu’il a ressenties.
Les deux séances suivantes M. Jean est plus en retrait que d’habitude. Il ne participe pas à
l’improvisation chez le notaire. Il participe à la dernière improvisation mais seulement
comme personne essayant de comprendre ce qui ne va pas. Au moment de mise en
commun des ressentis M. Jean ne s’implique pas personnellement, il écoute les autres,
peut leur poser des questions sur ce qu’ils ressentent, se mettre à leurs places, mais sans
parler de lui.
Pendant les séances M. Jean a apprécié de participer, il s’y est bien amusé. Ses difficultés
par rapport à son corps étaient différentes de celles des autres. Elles portaient sur son
incapacité à faire (handicap), sur son impression d’être diminué et non sur le rapport à
l’autre que les autres patients obèses peuvent éprouver (stigmatisation, crainte de la
proximité physique et psychique…). Ensuite M. Jean s’est désinvesti de la part
émotionnelle des dernières séances. Surpris par l’émotion qu’il ressentit pendant
l’improvisation de la lettre à sa fille, il n’a pas voulu que puisse se reproduire un moment
comme celui-là, surement pas prêt à aborder ses difficultés familiales. Il avait d’ailleurs
décidé de ne pas venir aux consultations du psychiatre.
Quand on observe les résultats aux questionnaires de M. Jean, ses résultats restent
globalement stables, ne diminuant que légèrement. Il a une bonne estime de lui-même
comparé aux autres, il n’est pas alexithymique. Cependant son score d’inefficacité diminue
beaucoup. Ce résultat atypique par rapport aux autres patients fait de M. Jean un « écueil
statistique ». L’atelier de théâtre thérapeutique ne l’a pas fait réagir comme la globalité
des autres patients, cependant son sentiment d’inefficacité qui diminue sensiblement (de
11 à 4 points) est un bon point pour M. Jean qui se sentait diminué de par sa situation
nouvelle d’handicapé.
M. Jean avait donc un profil différent des autres patients obèses.

30
6. RÉSULTATS QUANTITATIFS
Les résultats quantitatifs (annexe 4) mettent en évidence des changements significatifs

(pensée orientée vers l’extérieur, stratégies de coping tournée vers le soutien social,
estime de soi émotionnelle…), induit par l’atelier de théâtre thérapeutique que nous avons
mis en place.
En se proposant d'évaluer les effets du théâtre thérapeutique chez des sujets obèses, cette
étude nous amène à avancer les points suivants :
- émergence d’un accès à leur vie psychique et imaginaire qui se répercute au niveau de
l'estime de soi et de stratégie de coping. Trop souvent les sujets obèses affichent une
alexithymie les prédisposant à l'adhésion à un régime de type restrictif (Pinaquy, Chabrol,
Simon, Louvet & Barbe 2003). De fait, le retour des émotions somato-psychiques et des
frustrations les amènent à un agir corporel hyperphagique et/ou boulimique les projetant
dans une sorte de boucle systémique compulsive. Le retour de l’émotionnel constitue
paradoxalement pour eux un danger. Ainsi, le sujet va-t-il pouvoir, grâce au cadre du
théâtre thérapeutique, redécouvrir ses émotions, s'y intéresser et les apprivoiser.
- mise en place de stratégies de coping tournées vers le soutien social qui sont donc
prédictives d’un meilleur maintien à long terme des résultats obtenus par une éducation
thérapeutique visant une perte pondérale (Farris 2000, Elfhag & Rössner, 2005).
Autrement dit, le théâtre thérapeutique contribue à l’installation dans la temporalité d’un
recours étayant à l’autre et l’intersubjectivité.
- amélioration de l’estime de soi des sujets les conduisant à différencier image corporelle
et estime de soi qu’ils confondent souvent (Miller 1999). Cependant, la clinique
quotidienne montre que tout échec dans le traitement s'accompagne d'une baisse de
l’estime de soi générant d'abord des écarts alimentaires, puis des épisodes
hyperphagiques et enfin des conduites boulimiques. C’est pourquoi, il est important de
restaurer sans cesse l’estime de soi des sujets indépendamment de l’image corporelle
comme le permettent les techniques de théâtre thérapeutique. Jouer de son soi corporel
avec son soi psychique sous l'égide d'une improvisation encadrée restitue donc la liberté
d'être soi avec un dialogue avec son corps, là où il est comme il est.
7. CONCLUSION
Ce travail de recherche permet d’affirmer que le théâtre thérapeutique avec des patients
obèses a une efficacité à même de se traduire au niveau de l’alexithymie, de l’estime de soi
31
et des stratégies de coping. Il apparait donc aujourd’hui utile de diffuser cette information
aux praticiens. Ces trois points tendent à prédire une amélioration de qualité de vie aux
patients obèses, avec des relations à autrui plus satisfaisantes, non gouvernées par la
crainte du rejet social et par le désir d'isolement.
Nous avons dû adapter notre pratique à notre recherche par la randomisation (seul les
patients arrivés le mardi pouvaient intégrer les ateliers), par l’emploi de questionnaires
raccourcis au maximum (mais longs à remplir), par la reproductibilité des séances, et par la
création d’un groupe contrôle. Cependant, nous avons aussi essayé dans notre pratique de
théâtre thérapeute, de laisser à chaque patient un espace de création singulier, et de leur
prodiguer une attention particulière, par la participation aux réunions de synthèse, par les
entretiens fréquents avec le médecin psychiatre en charge de ses patients qui lui-même
avait déjà travaillé sur cette question de l’obèse et du théâtre. Pour faire ce travail de
recherche-action, nous nous sommes aussi adaptés à l’institution et aux patients qu’elle
abrite, créant ainsi un atelier spécifique à ce lieu, pour une population spécifique.
Cependant, nous n’avons pas réussi à réaliser le follow-up initialement prévu, le nombre
de retour n’étant pas suffisant. Le follow-up nous aurait permis de savoir si les résultats
obtenus perduraient dans le temps. Nous aurions aussi souhaité réaliser un troisième
groupe à évaluer. Ce groupe aurait suivi un atelier médiatisé sans mobilisation corporelle
afin de nous permettre d’évaluer de manière plus spécifique l’impact de chacun des
aspects, somato et psychique de la prise en charge de théâtre thérapeutique.
Cette recherche s’est donc déroulée en milieu naturel, et non en laboratoire, ce qui
génère certaines contraintes et difficultés. Ce qui explique le nombre important de
patients qu’il a été nécessaire de rencontrer au sein des ateliers pour pouvoir constituer un
groupe expérimental d’une taille suffisante pour mener un travail statistique de qualité. Il
peut d’ailleurs paraître étonnant que nous n’ayons eu à rencontrer « seulement » que 157
patients pour former le groupe contrôle in fine constitué de 50 patients, qui n’avaient eux
rien à gagner à participer à l’étude. Mais ce résultat montre la crainte ressentie par les
patients de participer à un « atelier de théâtre ». Répondre au premier questionnaire
pouvait signifier pour eux de devoir venir à l’atelier. Or pour nombre d’entre eux, il était
évident qu’ils n’étaient pas certains de venir la veille du premier atelier. D’où ce nombre
important de personnes qui ont participé à l’atelier, et qui n’ont pas répondu aux
questionnaires.
Par ce travail nous avons donc pu explorer quantitativement, qualitativement et

cliniquement une pratique de théâtre thérapeutique avec des patients obèses. Les séances
sont manuélisées et donc reproductibles par d’autres chercheurs et/ou praticiens. Ceci
permettra aux professionnels de développer une clinique de l’ordre de l’efficacité et
l’efficience.
32
Enfin, Il serait souhaitable d’être dans une perspective de psychothérapie comparée des
pratiques médiatisées. Ainsi pourrions-nous évaluer des thérapies médiatisées sollicitant
les émotions, l’imaginaire, de type actives (théâtre, les expressions corporelles…), versus
de type passives (relaxation, Mindfullness, groupe de résolution de problèmes.)
1) Annexe 1 : De l’art thérapie au théâtre thérapeutique, les effets sur les patients TCA
Effets de l’art-thérapie sur les patients atteints de troubles du comportement alimentaire
Favoriser le recours à l'imaginaire (Dokter 1994)

Favoriser l'expression des émotions (Matto 1997, Dubois 2010, Krantz 1999, Wood 2000)
Diminuer l'émotivité alimentaire (Johnson & Parkinson 1999)
Meilleure connaissance de soi par l'expression des émotions (Matto 1997)
Exploration des conflits inconscients (Kleinman 2009, Payne 1994, Rehavia-Hanauer 2003)
Améliorer, recréer le Lien soma psyché (Krantz 1999, De Tommasi 1999)
Améliorer l'image du corps (Wolf & al 1985)
Assouplir les défenses (Wolf & al 1985)
Favoriser l'utilisation de stratégies de coping plus adaptées (Matto 1997)
Améliorer les relations interpersonnelles (Dubois 2010, Lemieux 2001, Johnson & Parkinson 1999)
Faciliter la prise en charge par une psychothérapie classique (Wolf & al 1985, Hilliard 2001)
____________________________________________________________________________________________________

____________________________________________________________________________________________________
Effets psychodrame sur les patients atteints de troubles du comportement alimentaire
____________________________________________________________________________________________________
Exploration des conflits inconscients logés dans le corps (Izydorczyk 2011)

Travailler les liaisons entre représentation et affect sur la problématique de perte d'objet (Chabert
1997)
Améliorer les interactions sociales et familiales (Ozdel, Ateşci & Oğuzhanoğlu 2003)
Réduire les distorsions de l'image du corps (Frismand 1995)
Faciliter l'adhésion thérapeutique à des psychothérapies traditionnelles de groupe ou individuelles
(Diamond-Raab & Orrell-Valente 2002)

33

Effets du théâtre thérapeutique sur les patients atteints de troubles du comportement
alimentaire
- Améliorer les liens somato psychiques (Mitchell 1996)

- Améliorer les rapports interindividuels (Young 1994)
- Améliorer l'image du corps (Dokter 1994, Staven 1985, Naumburg & Caldwell 1959)
Annexe 2: Résultats bruts de Mme Oneil et M. Jean questionnaires à T0 et T1 et les

résultats des Anova
Mme M. Moy.
Oneil Jean groupes Anova
T0 T1 T0 T1 T0 T1 F p d
TAS 20
difficulté à identifier ses sentiments 21 19 13 12 20,81 18,84 0,26 0,61 0,11
difficulté à décrire ses sentiments 18 16 19 11 15,74 15,29 0,05 0,82 0,05
pensée orientée vers l'extérieur 24 21 20 24 21,71 17,97 10,31 0 0,66
alexithymie 63 56 52 47 57,87 52,87 0,69 0,41 0,17
ETES
soi émotionnel 2 5 9 10 4,39 5,45 2,85 0,09 0,35
soi scolaire 3 5 12 12 7,61 7,84 1,24 0,27 0,23
soi social 4 5 12 12 7,77 8,26 0,56 0,45 0,16
soi physique 2 4 6 4 3,81 4,55 0,28 0,6 0,11
soit futur 3 3 11 11 7,84 7,97 0,23 0,63 0,1
soi global 14 22 50 49 31,42 34,06 1,55 0,22 0,26
Brief COPE
self distraction 4 4 8 6 5,73 5,97 1,19 0,28 0,23
active coping 4 5 8 6 5,17 6 4,69 0,03 0,45
denial 5 2 2 2 4,27 3,73 1,05 0,31 0,21
substance use 2 2 4 4 2,47 2,57 0,02 0,88 0,03
use of emotional support 2 6 2 5 3,93 4,77 4,48 0,04 0,44
34
use of instrumental support 3 5 2 5 4,13 5,07 3,07 0,08 0,36

behavioral disengagement 5 5 5 2 3,9 3,37 1,95 0,17 0,29
venting 3 2 2 3 3,87 4,4 1,74 0,19 0,27
positiv reframing 3 4 8 5 5,23 5,47 0 0,94 0,01
planning 4 5 7 4 5,4 5,2 1,18 0,28 0,22
humor 4 4 3 3 3,17 3,73 0,56 0,45 0,16
acceptance 6 4 8 6 4,93 6,47 5,53 0,02 0,49
religion 2 2 8 8 4,03 3,97 0,16 0,69 0,08
self blame 6 6 6 5 5,7 5,33 0,7 0,4 0,17
EDI 2
recherche de la minceur 9 8 3 6 11,66 10,84 3,32 0,07 0,38
boulimie 5 6 0 0 1,8 1,71 0,27 0,61 0,11
insatisfaction corporelle 20 14 8 2 20,07 17,4 0,43 0,52 0,14
inefficacité 12 15 11 4 9,7 7,9 0,72 0,4 0,18
perfectionnisme 2 2 6 6 6,6 6,2 0,48 0,49 0,15
méfiance interpersonnelle 11 7 9 7 6,03 5,4 0,84 0,36 0,19
conscience intéroceptive 12 14 1 0 5,7 5,2 1,69 0,2 0,27
peur de la maturité 5 3 4 3 5,2 4,63 0,33 0,57 0,12
ascétisme 8 3 2 4 4,93 5,37 0,12 0,73 0,07
contrôle des pulsions 6 10 6 5 6 6,73 1,05 0,31 0,21
insécurité sociale 11 10 7 6 6,57 5,8 0,08 0,78 0,06
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* Régis BERNADET. Psychologue, Docteur en Psychopathologie, acteur et metteur en scène. 22 rue

Caffarelli 31000 Toulouse. – France. Mail: regis.bernadet@gmail.com
** Jean Luc SUDRES. Professeur de Psychologie (Psychopathologie Clinique). Docteur en

Psychologie.Responsable Pédagogique du D.U. Art-Thérapies. Université Toulouse - Jean Jaurès.
UFR de Psychologie. 5 allées Antonio Machado. 31058 TOULOUSE Cedex 9 - France. Mail:
jeanlucsudres@orange.fr
*** Vanessa ROMA. Docteur en Art du Spectacle. Mail: vanessaroma.mtc31@gmail.com
**** Frédéric SANGUIGNOL. Médecin Directeur. Clinique du Château de Vernhes. Route de

Villemur, 31340 Bondigoux (France).
***** Christian PRIM. Médecin Psychiatre. Clinique du Château de Vernhes. Route de Villemur,
31340 Bondigoux (France)

41
Lárt dáccompagner
ládolescere1
Claudia Cavicchia
La symbolisation à l'adolescence
Il est courant de poser l'indication d'un accompagnement en art-thérapie aux adolescents

qui éprouvent des difficultés avec le langage verbale ou qui refusent les démarches
thérapeutiques centrées sur la parole. Néanmoins, je crois qu'au-delà de ces indications
"par défaut", il existe bien des indications plutôt centrées sur la spécificité des mécanismes
qui rentrent en ligne de compte dans un accompagnement en art-thérapie.
Que l'on suive une orientation diagnostique du modèle structural (représenté, en France,
par Jean Bergeret) ou des pôles d'organisation (René Roussillon), l'adolescence est
considérée comme période d’excellence pour les réaménagements psychiques.
Pour le modèle structural, elle est bien la seule période de la vie où l'être humain a la
possibilité de basculer de structure, aussi bien dans le bon que dans le mauvais sens. Cela
est particulièrement intéressant d'un point de vue clinique pour les états-limites, ou
astructurations selon Bergeret, pour qui celles-ci constituent la seule organisation à priori
pathologique - contrairement aux structures névrotiques ou psychotiques, qui ne posent
problème que lors d'un état de décompensation.
Pour les théoriciens des pôles d'organisation, l'adolescence est le moment de la crise de la
symbolisation, pendant laquelle l'adolescent met en cause toute l'organisation psychique
de l'enfant fondée sur l'impossibilité de celui-ci à accomplir ses poussées pulsionnelles,
1
Du latin: 1. grandir, pousser, se développer; 2. Se transformer en vapeur, brûler, être allumé.

42
faute de maturation sexuelle. Avec l'avènement de la capacité à éprouver l'orgasme,

l'adolescent disqualifie une symbolisation qui remplace l'acte par la représentation, car
cette voie est désormais, pour lui, potentiellement "dépassable". Si pour l'enfant l'acte
s'oppose à la représentation, l'adolescent a besoin d'une mise en acte qui autorise une
certaine dose de décharge pulsionnelle, tout en sublimant une partie. Il lui faut donc
trouver d'autres modalités de symbolisation. Cela implique une modification de
l'ensemble des rapports de l'adolescent au plaisir, donc de toute son organisation
psychoaffective (Roussillon 2007).
Il est donc évident qu'une démarche d'art-thérapie centrée sur l'opposition entre l'acte et
la représentation, sans aucune ouverture au plaisir de la décharge pulsionnelle (catharsis),
risque fort de ne pas intéresser l'adolescent, voir de l'inviter à attaquer le cadre un peu
rigide de l'accompagnement.
Dans ce sens de prendre en compte les spécificités de l'accompagnement thérapeutique

de l'adolescent, Fourasté, Moron et Sudres ont développé la notion de L'Être-corps
"exister par et avec son corps", appliquée aux prises en charges médiatisées de
l'adolescent (Fourasté, Sudres 1994).
J'ai développée moi-même l'idée d'art-thérapie animée par Éros pour accompagner des
pré-adolescents et adolescents en mal de symbolisation via une auto-sublimation non-
répressive (notion de Herbert Marcuse). D'après cette idée, il ne s'agit pas de détourner la
libido de ses buts sexuels en la refoulant, mais de la transformer en puissance érotique qui
agit au-delà du domaine sexuel stricto sensu. L'auto-sublimation non-répressive est une
voie qui suppose l'érotisation de l'organisme comme un tout, provoquant un élargissement
qualitatif et quantitatif de la sexualité au-delà de la sphère corporelle, dans une évolution
qui va de l'amour de soi, de son corps, vers l'amour de belles occupations, en passant par
l'amour des autres (Marcuse 1998).
Mais si le fait que la personne adolescente accepte l'accompagnement (ou, en d'autres

termes, établisse une alliance thérapeutique) est condition sine qua non à la mise en place
de la démarche, cela ne suffit point pour en garantir l'efficacité. En clair, dans le cas
d'enfants souffrant d'organisations douloureuses de leur vie psychoaffective, comment un
accompagnement en art-thérapie à cette période de passage qui est l'adolescence et qui
favorise les transformations, peut les aider à réaménager ces organisations qui les font
souffrir?

43
L'art transformationnel
Henri Saigre développe la notion d'imagination créatrice, qui génère du nouveau à partir
d'un mouvement chaotique, par opposition à l'imagination reproductrice, fondée sur la
mémoire qui reprend des contenus déjà vus (Saigre 2009).
D'après Saigre, l'imagination reproductrice procède par métaphore, soit association,

comparaison, analogie d'images, selon la logique de la pensée opératoire telle que
formulée par Piaget. L'imagination créatrice, elle, agit par le mécanisme de la métonymie,
ou plus exactement de la synecdoque, supposant une relation de continuité et d'inclusion
entre les parties, selon la logique de la pensée symbolique (stade intuitivo-pré-logique de
Piaget). Pour aller vers la santé, il s'agirait de créer des symboles qui engendrent un accord
entre les réflexes sensorimoteurs (nature) et leur représentation spirituelle (culture).
L'imagination créatrice n'agit pas par refoulement ou à partir des contenus refoulés, mais
plutôt par un jaillissement joyeux de l'Être à partir des choses telles qu'elles se présentent
(et non pas de leurs représentations déjà traitées). C'est pour cela que l'imagination
créatrice génère du nouveau, du "frais".
Saigre se pose la question de l'efficacité d'une démarche fondée sur l'association d'idées,
esthétiques et libres soient-elles, dans une logique opératoire de l'imagination
reproductrice, pour changer en profondeur les dynamiques psychoaffectives des
personnes qui en souffrent. Pour lui, quoique les associations aient leur place dans un
processus de soin (car peuvent aider les réaménagements d quelques contenus), seule la
créativité, entendue comme œuvre de l'imagination créatrice, qui fonctionne dans un
système symbolique, peut favoriser les transformations profondes de l’Être). C'est pourquoi
il a choisi l'appellation art transformationnel plutôt que art-thérapie pour
l'accompagnement proposé au sein du Mouvement des Arts Thérapeutes, dont il est co-
fondateur (Saigre 2011).
Dans ma pratique d'art-thérapeute, la différence d'un mouvement métaphorique (via

associations) ou orienté par les processus métonymiques apparaît très clairement dans la
production des enfants et adolescents que j'accompagne. Je ne néglige nullement
l'importance des productions métaphoriques, qui glosent les maximes2 de la personne en
souffrance. Il est vrai que le filtre métaphorique permet d'exprimer l'incommunicable par
la parole et rien que l'expression de ses maximes devant un autre peut produire
soulagement et donc, des effets thérapeutiques. Poser ses maximes autrement peut être
une étape nécessaire avant de procéder à des réaménagements plus importants. Cela peut
2
Maximes dans le sens de sentences qui déterminent les vérités de la personne, ses limites, ses traumatismes, ses
difficultés.
44
même suffire à ceux dont la problématique est tout simplement une difficulté ou une non
affinité avec l'expression verbale et qui, face aux exigences d'un monde où la
communication verbale est impérative, ne trouvent pas d'autre voie d'expression.
Je constate, cependant, que lorsque j'arrive à orienter la personne accompagnée, ou

lorsqu'elle y va d'elle même vers des productions de type plutôt symbolique, qui
n'illustrent pas, qui ne glosent pas des maximes, mais qui s'expriment autrement (ce qui ne
va pas de soi et qui est bien loin d'être simple, car demande de la patiente et des stratégies
thérapeutiques au cas par cas), cela coïncide maintes fois avec des changements de
certaines de ses façons d'être, que j'observe et qui sont quelquefois remarqués par elle-
même et par mes collègues de l'établissement pédagogico-éducatif , ou encore par la
famille. Néanmoins, ce lien, qui constitue une hypothèse, reste sinon à prouver, tout du
moins à explorer.
L'art-thérapie à orientation art transformationnel serait donc à priori une bonne indication
à toute personne en souffrance au moment de l'adolescence, dans le sens où cette
démarche peut inciter ou potentialiser les réaménagements de l'économie
psychoaffective nécessaires à la conquête d'un équilibre de l'Être en ce moment privilégié
pour les changements.
Le rite de passage
Cette réflexion sur le rôle de l'art et de l'imagination créatrice au moment de

l'adolescence serait sans doute à relier avec les pratiques initiatiques (aborigènes, Grèce
antique, chamanisme...) qui favorisent les rites de passage dont nos sociétés pragmatiques
et peu sensibles aux besoins de la vie symbolique font fi. Sudres rappelle les composantes
de rite de passage des activités créatives spontanées ou dirigées des adolescents.
(Fourasté, Sudres 1994). Cela témoigne d'une nécessité à laquelle l'art-thérapie en groupe
peut répondre, sur le champ de la prévention, à travers des scenarii à mettre en acte, en
faisant appel à la puissance et à la fonction symbolique avec l'efficacité symbolique de
l'imagination créatrice avant qu'elle ne soit refoulée.
Joseph Campbell distingue deux phases dans les rites de passage qui accompagnent les
moments cruciaux de la vie de l'homme:
1. des exercices formels de rupture à fin de clôturer de façon radicale les attitudes et
normes typiques du stade de la vie que l'on quitte.
2. un isolement plus ou moins long de la personne à fin de lui présenter, de façon

ritualisée, des formes et sentiments appropriés à sa nouvelle phase, auxquels il devra faire
face face dans sa nouvelle condition.
45
Selon Campbell, la fonction première des rites (comme de la mythologie) est celle de
fournir des symboles qui amènent esprit humain à avancer, en s'opposant aux fantaisies qui
le tirent vers l'arrière (Campbell 1990).
Au-delà de toute structure saine ou pathologique, l'adolescent a besoin de supports

symboliques pour l'aider à "passer un cap". Dans une société qui manque à cette fonction
"nourricière", l'art-thérapie peut accompagner l'adolescent dans le sens de créer ses
propres rites et symboles en rapport à la fois avec son aventure intérieure et avec sa
culture - car il est également fonction des rites de préparer l'individu à s'inscrire avec sa
nouvelle condition dans la culture.
La notion de créativité appliquée développée par Jean Poitevin pointe le besoin de

l'adolescent d'une ouverture vers autrui pour l'accompagner du narcissisme primaire vers
des formes moins égocentriques de la construction de la personnalité. Ce besoin trouve
réponse dans une démarche d'art-thérapie groupale, où il y a confrontation et compromis
entre trouver des degrés de liberté et s'inscrire dans l'étayage d'une appartenance bio-
psycho-socio-culturelle de cette pulsation fondamentale qui, selon Sudres, agite
l'adolescent (Fourasté, Sudres 1994).
La prophylaxie de la créativité3
Louis Astruc met en avant la notion de tempérament intuitif" pour évoquer les difficultés
rencontrées à l'adolescence par 50% d' enfants de notre culture occidentale dont la
pensée est intuitive (d'après les études de J. Berret : 1978). Selon Astruc, les grands
enfants qui fonctionnent de manière intuitive, dans la pensée autonome créatrice
cohérente du stade intuitif de Piaget, sont dotés d'une créativité latente qui risque fort
d'être bloquée à l'adolescence, lorsque les exigences d'une logique opératoire s'imposent
pour la réussite scolaire et sociale. Face à cette exigence, soit l'adolescent s'adapte en se
faisant violence, soit il se retrouve en échec scolaire, social et parfois, plus tard,
professionnel. Astruc rappelle que paradoxalement, les travaux américains sur les
inventions scientifiques et industrielles attribuent cette capacité d'inventer à la
conservation de la spontanéité de l'enfance avec le besoin d'expérience, typiques du
tempérament intuitif.
L'une des alternatives à la drogue, souvent utilisée par les adolescents intuitifs en mal
d'adaptation, serait, selon Astruc, les aider à retrouver leurs richesses créatrices oubliées,
car elles vont de pair avec la pensée autonome, que l'environnement et les exigences de
la pensée opératoire ne mettent point en valeur. Pour revenir à Saigre, l'imagination
3
Titre de l'article de Louis Astruc. Prophylaxie de la créativité in Fourasté, Sudres L'adolescent créatif.
46
créatrice n'est pas un produit du refoulement, mais l'origine même du défoulement

(Deviens p.116). Sans faire d'amalgame entre deux positions théoriques à fondements bien
différents, nous pouvons voir quelques similitudes entre les propriétés de l'imagination
créatrice de Saigre et celles de la pensée autonome créatrice chez les personnes dites de
tempérament intuitif tel que formulé par Astruc. Le fait le plus marquant est que, selon les
auteurs respectifs, l'une comme l'autre fonctionnent dans la logique intuitivo-pré-logique.
Ces pré-adolescents ou adolescents intuitifs en souffrance constituent donc une

population à qui l'art-thérapie à orientation art transformationnel serait fort indiquée. Si
les études réalisées par Berret en 1978 sont toujours d'actualité, on retrouve le
fonctionnement de la pensée intuitive ou autonome créatrice chez 50% de notre
population d'enfants. Si tous ne seront heureusement pas en souffrance (il y a des milieux
que les accueille bien, ainsi que des capacités de résilience qui fonctionnent), nous
pouvons supposer sans trop de risque de nous tromper qu'une bonne partie d'entre eux
sera en difficulté à l'adolescence.
En résumé, l'art-thérapie - tout de moins dans son orientation art transformationnel -

semble répondre à plusieurs paramètres à considérer dans une indication
d'accompagnement thérapeutique pour les adolescents:
- le besoin de trouver un compromis entre le plaisir sensorimoteur et les activités de

l'esprit (symbolisantes);
- le besoin de trouver d'autres organisations psychoaffectives face à la crise de la

symbolisation;
- et pour cela, le besoin de mettre en route l'imagination créatrice;
- le besoin d'être accompagné et soutenu dans ces réorganisations;
- le besoin de s'appuyer sur des symboles pour passer de l'enfance à l'âge adulte;
- et pour cela, le besoin de mettre en acte des rites de passage;
- le besoin d'affirmer son identité en trouvant des degrés de liberté dans une
appartenance;
- le besoin de retrouver ou sauvegarder (et par conséquent, de trouver des stratégies pour
vivre avec) la pensée autonome créatrice, présente chez 50% d'enfants de notre culture
occidentale dits intuitifs, pour que ceux-ci soient heureux mais également pour que notre
société puisse bénéficier de l'inventivité de ses citoyens.
47
BIBLIOGRAPHIE
Astruc L.(1994). Prophylaxie de la créativité in Fourasté, Sudres : L'adolescent créatif. Toulouse :

Presses universitaires du Mirail.
Bergeret J. (1996). La personnalité normale et pathologique – les grandes structures de base. Paris :
Dunod.
Campbell J. (1990). O poder do mito. São Paulo : Palas Athena.
Campbell J. (1997). O herói de mil faces. São Paulo : Cultrix / Pensamento.
Fourasté, Sudres (1994) L'adolescent créatif. Toulouse : Presses universitaires du Mirail.
Lévy-Strauss C. (1949). L'efficacité symbolique in Revue de l'histoire des religions. vol 135, 5-27.
Marcuse H. (1998). Eros e Civilização : uma Interpretação Filosófica do Pensamento de Freud, trad.
Cabral A. S. Paulo : Guanabara-Koogan.
Roussillon R. (2007). Manuel de psychologie et de psychopathologie clinique générale. Paris :
Elsevier-Masson.
Poitevin J. (1994). La créativité appliquée à l'adolescence in Fourasté, Sudres : L'adolescent créatif.
Toulouse : Presses universitaires du Mirail.
Saigre H. (2009). Deviens qui tu seras. Paris: l'Harmattan.
Saigre H. (2011). Manuel d'Art Transformationnel. Paris: l'Harmattan.
Sudres J.-L. (2005). Soigner l’adolescent en art-thérapie. Paris : Dunod.

48
The Sad Look of Medusa.

Mythology and Depression
in Art Therapy
Daniela Martins
My paper will talk about studies on the art psychotherapy plan of a patient, a 14 years old
teenager, under my attention since the beginning of this year. I will call her ‘the patient’.
The patient arrived at the session escorted by her grandfather on her mother’s side, which
had the advice of the local Child Protection into taking her to art therapy. She is under her
grandparents’ tutelage since her mother is legally interdicted from toxic dependency and
doesn’t show either social or emotional conditions to raise her daughter. At that moment
the patient’s mother was interned in toxic dependence rehabilitation facility.
In the first consultation, the grandfather talked about the need for an art
psychotherapeutic accompaniment so the patient could learn how to emotionally
overcome the mother’s problems and the distance between them. According to the
grandfather, the patient showed risky behaviors, as reclusion, failure to express feelings,
sleep disorder, and even self-abuse episodes with shallow cuts in the arms
Another reason for using art psychotherapy was the patient had a ‘knack for arts’, like
drawing and, very important, had great difficulties on expressing herself verbally, talk
about her feelings and get attached to therapeutic treatments. She had been in contact
with psychologists and therapists, but didn’t get attached to the treatment.
In this first contact, the patient agrees on her difficulty on trusting professionals, therapists
or even professors, to the point of speaking freely about herself and her feelings, since she
was afraid they would tell everything she talked about to her grandparents.
The first sessions went with little talking. The patient was reticent and, out of respect, I
avoided asking much as well. I would make creative propositions, like drawing, painting,
49
plasticine modeling. She was always receptive and worked joyfully. Her creations were
very expressive, but she would not talk much about them. And I wouldn’t insist.
Little by little, I could develop a trust relationship with the patient and conversations
started naturally. She began talking about her, about her life, of her feelings towards all
the drama she was going through, being distant from her mother, the toxic dependency of
her mother, on how the problem was brought to her and how she saw everything from her
infant-juvenile point of view. She started about what she missed, of the hardships of living
with the grandparents, which, in spite of loving her, sustained a very complicated family
dynamics. Unbearable was her word of choice. Living with her grandparents could be
good, but nothing would replace the absence of her mother.
At one particular session the patient mentioned feelings of injustice, guilt and sadness, I
suggested we try to know better this sadness; how it felt, from where it came from, how it
looked like. I suggested then she drew the face of sadness.

50
The patient then comes up with this drawing. She seemed to invest much at this, taking about 20
minutes to finish. Then she said the figure at the right was “sadness” and then, as if narrating a
sequence of situations caused by sadness, she said: From sadness comes chaos, a hurricane that
takes all happiness away. It takes away our home. Only despair is left...
I ask about the laying figure at the left and she tells me that’s a person at the verge of
suicide. In the middle is a withered rose, representing hopelessness.
After that I question her about the ‘snakes’ at the head of the figure representing sadness. The
patient says they are the bad things; the evil ideas; the specter of despair. Worms of despair.
I jest, commenting those were well-fed worms, and we laugh together at the pun. I ask her
what was feeding those ‘worms/snakes’ and she says: Everything bad that happens to me.
I tell her the sadness figure looks like a Medusa and she looks at me bemused as she
doesn’t know what a Medusa is. I was sincerely surprised with the fact she could draw this
image without the knowledge of the mythological Medusa.
She asked me what it was and I briefly told her the Medusa was a mythological creature, a
woman with snakes instead of hair, with glassy eyes (please notice the eyes drawn by the
patient are gray) which could turn into stone a person who looked directly into her eyes.
The patient was scared by the story, as if saying: No, my sadness can’t be as evil as this.
I decided to exercise subjectivity in that session, my own point of view on the image the
patient drew, which, for me, was obviously a Medusa. The memory that surfaced was the
image of a Medusa in an old movie of the sixties called 7 Faces of Dr. Lao4, 1964, which I
watched many times in television as child.
Well, coincidentally or not, on the same day, I watched a re-run of this movie on TV, at
night. I was bemused. An old movie, one we don’t see every day on TV, maybe not even
once a year and it was re-ran at that very day. And then, zapping the TV channels I found
the Medusa.
The Circus of Dr. Lao presents fantastic, mythical creatures and the attendees see
themselves reflected in each “threatening” attraction, learning valuable lessons.
4
The novel was later adapted by Charles Beaumont into the script for an effects-filled 1964 movie 7 Faces of Dr. Lao

51
I then started to think about the face of sadness drawn by the patient, about her Medusa,
on how that figure have spontaneously arisen, as a symbol of her pain and cause of all evil.
I’ve been introduced to the works of the brazilian psychologist Marise de Souza Morais e
Silva Santos, from 19965, about myths and depressive states and there I found a fantastic
psychodynamic analysis of the myth of the Medusa. In that analysis I found a great
similarity to the sadness of my patient and that helped me to better understand the
development dynamics of the patient’s depression and then find the correct therapeutic
intervention to help her.
Medusa means ‘higher feminine wisdom’ and can also represent the Great Mother or
Great Goddess; A naturally idealized and powerful figure. According Marise Santos,
Medusa as a monster and evil being represents the stale need of growing and evolving.
The Medusa also represents the unwanted woman, unable to love or be loved due to this
rejection. This woman hates men in the image of the god, who violates and abandons her,
and thus all women, since she turned from a beautiful woman to a monster due to the acts
of a man and a goddess.
In the process of developing an identification process with her mother, the patient feels as
rejected as the mother was by the father (the mother of the patient got pregnant at 15
years old, and the relationship with the father had never been steady). The patient’s father
is an absent figure with little participation in her life. The patient lived through being
abandoned by her father and then has to live through the absence of her mother, who
found refuge on drugs and always stays away trying a series of unsuccessful treatment.
The patient thinks herself as much a monster as her mother and because of her mother.
Medusa is the mother. She is the Great Goddess of her life; however she is her pain and
sadness as well. Medusa is the ambiguity of being a monster and a goddess at the same
time. The patient feels this ambiguity and sees herself in the image of her own sadness,
although idealizing it.
The patient victimizes herself as if she was her mother and blames herself, albeit knowing
she was not responsible for her own pain. When beheaded, the Medusa expelled a deadly
poison from the left vein and a powerful medicine, capable of raising the dead, from the
right vein. Just as the mother, responsible of bringing her to light and at the same time
“poisoning” her with absence and sadness.
5
http://www.artpage.com.br/marise/medusa1.html

52
The Medusa is unhappiness incarnate, her brethren are not human nor gods; they are
monsters. Medusa takes life, petrifies with a simple gaze, and can’t be seen face to face
unless the subject gets paralyzed and dead.
During this process, the patient’s self image gets distorted, making it hard to understand
her own self, to define herself, thus creating a false self. She can’t see her own positive
aspects, and they are many, in fact, such as Medusa’s monstrous brethren go through life
building up and reassuring their monstrosity. The patient, although genuinely beautiful,
sees herself and ugly and unimportant (notwithstanding a typical adolescent behavior),
she can’t recognize she has abilities and qualities of her own -- as can be seen by her
school grades -- and is unable to dream or plan for the future. Her current mirror image is
a monster. The “sons of Medusa” reflect the internalized mother's monstrous image.
Perception of self begins in the development of the relationship with the mother, the way
looks and is looked upon by the mother and in what she perceives as love or rejection. The
sons of Medusa can’t see her and can’t be seen by her. The gaze of this Medusa mother
turns to stone. And thus a defective bond is created, which will influence the formation of
her identity, based upon a defective image of herself.
The Medusa doesn’t look, doesn’t cherish, doesn’t guide. She paralyzes. Notwithstanding
depression causes indolence, the loss of vitality.
The patient also builds a distorted image of her mother, idolizing her and perceiving her as
Goddess or, at least, a martyr, victim of her own dependency. She feels her mission is to
save the mother, since she herself can’t be protected by her mother, as would be the
natural course of things. The mother is perceived as Goddess, whereas she can’t be seen as
woman.
The patient mentions she, as she first learned about her mother condition, felt rage.
However, she suppresses that emotion immediately, as more unbearable is to fuel the
rage, to nurture the idea of “destroying the monster”, and understand the enormity of the
pain. The image of the monster is currently directed to her grandmother on her mother’s
side, who has problems with alcoholism as well. Monsters, witches and savage beasts are
recurrent in her work, either drawings or sandplay, always forwarding to the grandmother.
Moreover, in her fantasy, it’s the grandmother that prevents her from living with her
mother; she is the one that took her mother away from her. The grandmother is “guilty” for
her condition.
Meanwhile, the patient stays depressed and paralyzed; empty of energy and hope. Just like
if made of stone. Those are the feelings that lead to self-abuse, with cuttings and suicidal
intents. The loss of the will to live… The feeling theirs is no solution for her problems… All
53
this also fills in as self punishment, since it keeps the guilt and the idea she’s is “an ugly,
spoiled girl” because of the hate she feels.
It may be interesting to mention the kickboxing national champion in her category. This is
a healthy way she found to channel her aggression, but curiously, according to her, she
feels so sorry for beating up the opponent, she can’t help but apologize at the end of a
fight she wins.
In the art therapeutic setting, the patient can see the Medusa. She draws and faces her.
She can gaze upon Medusa’s eyes and try to know her. She can find out about her feelings,
her pain and the causes. And then come by solutions. Through the mirror provided by the
creation she can look upon herself safely, with no fear of getting paralyzed and dying. The
art mirror the creator and, although enjoyable, this experience can be painful sometimes.
To feel this pain is inevitable and necessary for growing up, to create grief and to
transform inner experiences.
It is the Circus of Life. My therapeutic plan for the patient includes the Circus of Dr. Lao, so
she won’t lose, or better, to find the magic and fantasy of life again. To help changing
monsters into kind beings and recreating symbols, through grief and wound healing.
The psychotherapeutic relationship presupposes delivery, through a well established

partnership and a solid bond, of some of the tools necessary for this process.
The whole world is a circus if you know how to look at it.

The way the sun goes down when you're tired,
comes up when you want to be on the move.
That's real magic.
The way a leaf grows.
The song of the birds.
The way the desert looks at night, with the moon embracing it.
Oh, my boy, that's... that's circus enough for anyone.
Every time you watch a rainbow and feel wonder in your heart.
Every time you pick up a handful of dust,
and see not the dust, but a mystery,
a marvel, there in your hand.
Every time you stop and think:
I'm alive, and being alive is fantastic!
Every time such a thing happens, you're part of the Circus of Dr. Lao.
Dr. Lao, justifying to a little boy that asks him to work in the circus.

54
A novel approach of using Art Therapy

(AT) in reducing anxiety and
depression in stroke patients
undergoing rehabilitation
Diane Waller, Khalid Ali and

Tony Gammidge
Summary of the research project
In April 2011 the Age Research Centre Sussex, a multi-professional group of researchers
interested in improving the health and well-being of older people, consisting of
representatives from both the Universities of Sussex and Brighton, awarded our team
£8250 to enable us to carry out a pilot project within the Stroke Rehabilitation Unit of a
large general hospital in Sussex. We planned to investigate if and how art therapy groups
(AT) might be of benefit in stroke patients undergoing rehabilitation. There appear to be
several advantages for engaging stroke patients in art therapy sessions in hospital such as
reducing isolation, reducing anxiety and depression, and changing the rehabilitation
experience into a positive one shared with other patients. Prior to commencing the
project, the study was discussed and planned with input from the multidisciplinary team at
the rehabilitation unit in the hospital and two stroke survivors. Subsequently it was
conducted in 5 stages:
Focus group: the first stage of the study was a focus group meeting with former stroke
patients and carers to discuss the art therapy intervention, its appropriateness, assessment
tools, and follow up measures.
Recruitment, consent and assessment: a dedicated stroke research network nurse

identified, and consented patients and did the outcome assessments in the form of
questionnaires at the beginning and at the end of the art therapy intervention (Hospital
Anxiety and Depression scales-HAD). Six patients were recruited for six weeks.

55
Art therapy intervention: the third stage was the delivery of the art therapy intervention in
2 weekly sessions for approximately 50 minutes each for 6 weeks. The sessions were
facilitated by an experienced art psychotherapist and a speech and language therapist.
The model chosen was group interactive art therapy, a flexible approach combining
interpersonal group psychotherapy with art therapy, which enables patients to engage at a
level where they feel comfortable and where they have the opportunity to relate to others
who may share similar experiences (in this case, stroke and its after-effects). The model has
been tested with older people with dementia and others experiencing significant physical
and psychological impairment.
Semi-structured interviews for feedback: the fourth stage was one-to-one semi-
structured interview by the research nurse with the patients who had participated in the
art therapy sessions. The aim was to hear about their experiences of art therapy and
suggestions as to future provision.
Completion of Therapy Outcome Measures: in the fifth and last stage Therapy Outcome
Measures (TOM) were completed for the patients involved in the study and the other
stroke patients who were in the rehabilitation unit, but not involved in the art therapy
intervention.
Introduction and Rationale
Within the field of rehabilitation from stroke there is a serious lack of attention to
patients’ emotional state. Understandably, the focus (in the UK) tends to be towards
physical rehabilitation given the devastating impact of a stroke on speech and movement,
and often on cognitive ability. Prompt attention to medical care immediately following
stroke can make a difference between life and death, temporary impairment or long term
loss of facilities. Public health campaigns have emphasized the role of family, friends and
the general public in spotting the signs of stroke and taking immediate action to get
medical help. Paramedics are well trained to administer vital help to those experiencing a
stroke and ambulances are fitted with necessary life-saving equipment. However, what
happens after a period of intense rehabilitation is the concern of this paper.
There seems to be little research which is investigating how patients can be helped to
manage the severe changes in everyday living resulting from a stroke. Even fairly mild
strokes can impact memory and cognitive function. More severe ones can lead to loss of
movement or paralysis in limbs, inability to walk unaided, weakness in hands and arms,
poor balance. Patients’ report being frightened of having another stroke and anxious
about how they will continue to live their lives, whether the damage will last for a short
time, or for ever. They are beset by uncertainty. This affects their partners and families
who must endure a period of waiting to know the fate of their relative. Arrangements for
56
short and long term care and impact on employment, hence on finances, are major
concerns.
Drawing on insights gained from research with other patients experiencing life-
threatening and progressive illness, the team considered that creative strategies are called
for in stroke patients during the rehabilitation phase which can be tailored to the patients’
individual circumstances taking into account their own interests, talents, and concerns.
Previous studies engaging older people, some of whom may have experienced stroke,
have experimented with various forms of creative activity such as using clay with elderly
patients (Yaretzky 1996), Art, Dance and Music Therapy (Rebollo Pratt 2004), individual
non-directive art therapy sessions for older people with Parkinson’s (Strand 2010)
interactive art therapy groups for people with moderate to severe dementia (Rusted et al
2006). Interactive models of working with stroke patients such as reading to them has also
been found to enrich the rehabilitation experience (Higgins 2005). The specific use of AT
in stroke patients needs to be further explored in view of its potential advantages to assist
in recovery, both physical and psychological.
The benefits of AT groups are giving and sharing of information; installation of hope as
members learn from each other; the possibility of patients helping each other which
lessens isolation, relearning different ways of coping with their illness. In some patients
making a drawing or painting (or model) in the presence of other group members and the
art therapist provides a focus for thoughts and feelings and this, we suggest, can apply to
stroke patients.
The use of AT in stroke patients has not been fully explored in UK rehabilitation settings.
Gonen et al (1991) described a model of using AT for stroke patients in the rehabilitation
phase, and they concluded that it was appropriate and effective. Pachalska et al (2006)
used AT and films in stroke patients undergoing rehabilitation amongst concentration
camp survivors, and found pre-morbid experiences influence patients’ recovery from
stroke, and that coping strategies are shaped by emotional factors.
Symmons et al (2011) explored the use of visual arts in patients undergoing rehabilitation
in an outpatient setting. The qualitative narrative of the study showed that art has
contributed to the participants’ achieving specific rehabilitation goals, and helped them
use time efficiently, and boosted their confidence.
The majority of AT interventions in stroke patients have, though, not been thoroughly
explored in systematic qualitatively measured projects, nor in randomised control trials.
We do not know what aspects of these interventions is the crucial ingredient – the
relationships created in a group, making the art work, relationship with the facilitators, or
as is most likely, a combination of all of these. Well conducted studies investigating best
57
models of care in stroke patients undergoing rehabilitation are rare. The national stroke
research network organisations are calling for properly designed studies in stroke
rehabilitation.
Pre-study arrangements
The research group consisted of Khalid Ali, Stroke Consultant and Diane Waller, Principal
Art Psychotherapist, Co-Principal Investigators in the project, Tony Gammidge, Art
Psychotherapist and film-maker, Anne Jones, Stroke Association patient representative,
and Helen Simmonds, Stroke Association communication support officer, and the
Multidisciplinary team (MDT) (physiotherapist, occupational therapist, social worker,
dietician, speech and language therapist (SALT), clinical psychologist, nurse) conducted a
meeting at Sussex Rehabilitation Centre (SRC) to discuss the proposed study. One of the
main outcomes of that meeting was to obtain the agreement of the SRC to host the art
therapy intervention itself and to provide a member of staff, a speech and language
therapist (SALT) to co-facilitate the group, and an independent colleague who could use
the assessment tools for the study’s outcome: the Hospital anxiety and Depression (HAD)
scale, and the Therapy Outcome Measures (TOM) scale. The MDT team were supportive of
the planned study, and nominated a SALT who agreed to work in collaboration with the art
therapist and the hospital stroke research network nurse in identifying appropriate
patients. The group suggested that the stroke research nurse should do some background
work with patients informing them about the intervention, and that he/ she should also do
the HAD and TOM scales at baseline and at the end of the intervention.
The planned study draft was shared with two stroke survivors. Both were supportive of the
study and suggested that there should be an additional qualitative narrative component to
the research in the form of a written record of the proceedings of the AT session. Such
‘mixed-methods’ approaches to research in the arts therapies are increasingly used in
order to gain information from a number of perspectives including,
of course, from the patients themselves. This proved successful in a three-phase project
using art therapy groups with people with dementia with the first two phases being control
group studies and the third a qualitative analysis of all the art therapy sessions (Waller and
Sheppard 2006) and in a major trial exploring art therapy groups for people with psychosis
(Crawford et al 2012).
All comments received from the consultation group were discussed with the MDT again
and this helped inform some practical aspects in the design of the proposed study.
Further informal meetings took place at the Unit to discuss details about the groups and
materials. The art therapist attended a music group to gain an idea about the likely
58
interests of the patients and the kinds of challenges they may face in undertaking art
therapy. A focus group of past patients and several family carers was conducted by DW
and TG was held before the start of the groups where issues about structure, timing, and
potential needs of participants was discussed.
Aims and objectives
The aim of this pilot study was to explore the effects of 12 art therapy groups, twice
weekly for 6 weeks, this being the usual amount of time that patients spend in
rehabilitation. We wanted to see if stroke patients engaging in interactive AT group
sessions would have reduced anxiety, depression and stress, improved well being, and a
more meaningful engagement in the rehabilitation process. We emphasize here
exploration as we wished to discover which elements of the intervention were helpful and
which less so in order to inform further longer term research. We also wanted to look at
the structure of the project to see if the work could be integrated into the existing
timetable and practice of the Unit.
The participants
Inclusion criteria
The aim was to be as inclusive as possible but the following were criteria used:
Stroke patients undergoing rehabilitation in SRC
Age >16 years.
Ability to consent, or relatives providing assent
Medically stable according to the judgement of the clinical/ rehabilitation team.
Exclusion criteria
Medically unstable patients according to the judgement of the clinical and rehabilitation
team
Age <16 years
Refusal of consent or not able to provide consent due to cognitive impairment
Refusal of assent
The ground work prior to recruitment was very important in demonstrating to the patients
that this project was well supported by the staff of the Centre. There is much research
evidence to show that this is an essential element in the outcome of a project as DW et al
found in their research using art therapy with people with moderate to severe dementia
(2006).

59
Assessment tools
Hospital anxiety and depression scale (HAD).
Therapy Outcome Measure (TOM).
Research methods
As mentioned above, the study used both quantitative and qualitative approaches with the
aim of gathering as much information about the process and outcomes of the intervention:
Quantitative measures: The HAD scale is a questionnaire aimed at assessing patients’

mood. The TOM scale is an assessment tool undertaken by health care professionals giving
a score of 0-5 in 4 areas (impairment, disability, handicap, and well-being) in stroke
patients. 0 on the scale indicates severe impairment and 5 indicates no impairment in
patients.
Both the HAD and TOM scale are ordinal scales. However in many studies parametric
methods have been used to compare means on the HAD scales. Standard deviations of 3.5
– 4.5 have been reported. 30 patients in the intervention group and the same number in a
control group would have 80% power to detect a difference of the order of 2.6 -3.3 on the
HAD scale, using a two-sample t test with a 5% significance level.
However as we could not obtain a matched control group (matched for stroke severity,
background IQ, level of cognitive function, emotional and psychological states) we
collected demographics data on patients who were not involved in the art therapy
intervention. We analysed and compared data between the intervention cohort group,
and the rest of the stroke patient population who were at SRC at the time of the study, but
were not included in the study. This information although limited of necessity, was useful
in assessing the feasibility of this study, and will help in obtaining an adequately powered
sample size in a future study.
Qualitative measures: Participants observation by art therapist and speech and language
therapist as co-facilitator. As with other similar mixed methodology trials, the process
notes from the art therapist and co-facilitator were invaluable in gaining a sense of how
each participant used the art therapy groups. The art therapist provided a commentary on
each of the groups and circulated this to other team members. The art therapist was
supervised by DW and together they identified themes that reoccurred and ways of
enabling patients with very limited physical ability to both participate in and find a
satisfying role in the groups. The speech and language therapist kept her own process
notes and observations. The research nurse conducted individual interviews with as many
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patients as were able following the end of the groups. Furthermore, patients themselves
were very open about providing their feedback at the groups each week. In accordance
with ethics requirements of the professional body and the regulator (Health and Care
Professions Council) all art work was kept, stored safely and photographed or filmed with
the permission of the patients.
The art therapy intervention
As stated above the model used was group interactive art therapy, chosen because of its
flexibility and availability for patients who experience both psychological and physical
impairment (Waller 2014). The group ran for 6 weeks twice a week on a Wednesday and
Friday afternoon on L ward.
Six men joined the group though it was not specifically a men's group. The average age
was 69, though one person was in his early 30s.
A variety of art materials was available including paints, crayons, pencils and paper, clay
and also a camera and an I-Pad. Increasingly art therapists are introducing ‘technology’
into the sessions, such as lap-top computers, I-Pads, Tablets, digital cameras. These
materials are very familiar to young people who are used to making and deleting images,
but we were keen to see if an I-Pad might be helpful to older patients who were worrying
about ‘getting it wrong’ as they could experiment with making images and delete them
immediately if unhappy with them. Digital cameras enable people to see the image they
have taken, and either delete it or print it out on the computer in the room.
Experimentation with materials takes place within the boundaries of a group conducted at
the same time each week by the same facilitators and regular attendance is encouraged so
that the curative factor of ‘group coherence’ is activated. The model of group interactive
art therapy has been extensively tested with many groups, from trainee doctors, to art
teachers, to drug addicts, to people with moderate to severe dementia. To ensure it takes
account of the needs of the participants, the art therapist needs to be active in modelling
interaction and to seek ways to involve all members in the group – even if that means
supporting those who want to be part of the group but feel unable to make images.
Sometimes simply coming along to the group and quietly observing is a big step for very
anxious patients.
Thanks to the particular skill of the art therapist, there was an opportunity to do some
animation in the group and to test this out as a potential additional element in the art
therapy process. The participants were encouraged to use the art materials in whatever
way they wanted though most of them needed some kind of prompting and help to get
going. Some people found it very hard to use the art materials at all due to their disability
and cognitive function and needed to take time simply to be in the group with others. The
61
participants were encouraged to talk about whatever they wanted and to express
themselves and their feelings in any way they chose. All the participants in the group were
able to talk about difficult issues and use the space to express their emotions.
Numbers varied, the maximum being 5 people in one group and the least was just one.
One participant came to all but one group and another who joined late came to all that
were available to him. Two members of the group were discharged during the course of
the project and not able to get into the hospital for the group despite there being
transport funds available.
A serious and highly contagious virus on L ward disrupted the group for 2 weeks because
the ward was put into isolation so the group was moved to N ward which meant 2
members from L ward were not able to attend. This resulted in one member missing his last
group as he was due to be discharged and the other member missed his first 2 sessions.
Additionally the disruption was significant in that the group relied on continuity, being in
the same place and same time each week particularly in the context of working with stroke
patients who have experienced a life changing event. These events are unfortunately a
fact of life within public health services. The MDT made every effort to ensure that
disruption was minimal but nevertheless it did affect the art therapy group patients.
Of the materials, clay was the most popular material used in the group. When animation
was introduced, clay figures were needed in order to animate. Even members who found it
difficult to use the materials would take clay and at least kneed it in their hands for a short
while.
One person did drawings both using crayons and the I-pad, another person used the I-pad
to draw however it was sometimes difficult for people to control the I-pad as it needs a fair
amount of manual dexterity and sensitivity which most people in the group did not have.
Two people tried using the cameras and took some photos but the problem was in finding
anything that interested them enough to take a photo, and this exacerbated the feeling of
wanting to be somewhere else.
The group spent the last 2-3 weeks doing stop-frame animation using a simple stop frame
animation technique with clay and plasticine. This seemed to work quite well particularly
for people whose movement was limited as they could at least direct the action if not
move things manually. It also meant that the group could work together towards a
common aim and thereby feel more connected with their fellow patients. Certainly people
were much more engaged and absorbed in this process and the sessions went very quickly.
Because there was perhaps 'less space' for individual expression there was less time and
perhaps inclination for people to express themselves verbally.
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In terms of what was being expressed through the artwork it was the clay and the
animation that tended to reflect patients’ situations in terms of fragility and movement.
One member made a flat lying down clay figure that looked helpless and vulnerable which
obviously mirrored his own bodily state and feeling. When the clay started falling apart
there would be responses from group members of humour and recognition of their own
vulnerability. The figure was remade and animated and it was also interesting to note that
the participant who had made the figure only animated half of the figure's body thus
replicating his own paralysis.
The animation brought in a sense of narrative, like free-association, which could be made
up as the group progressed; in fact this was realistically the only way the story could
emerge as there was not enough time to work it out beforehand. One member of the
group found this approach difficult and had suggested doing storyboards and having
elaborate backdrops (he had made films in his past). This was unrealistic both in terms of
what he could achieve and the group as a whole and it showed he was not then able to
adjust to the reality of his situation. This psychological struggle was in itself debilitating as
he was not able to acknowledge any of the incremental progress he was making against
the huge loss he had suffered, leaving him depressed and not able to move forwards. This
was the case for another member of the group who could only focus on what he was not
able to do rather than the things he could so he was resistant to doing anything in the
group and could at times be quite disruptive.
For others the animation seemed engaging and fun. The problem-solving in terms of the
animation was relevant in that it echoed logistical and physical problem- solving as part of
their rehabilitation, so for instance when considering how to animate someone juggling, it
was recognised how difficult this would be but then as a group all made suggestions and
came up with a solution.
The film “Circus Dreams” is a collaborative work input from several patients. The narrative
is strung together from different people's ideas and clay figures and so can appear quite
random. However there is meaning and significance in the film; the lying figure appears to
be struggling and this is an obvious echo with the all of the group members’ situation. The
circus however with a clown juggling, a feat that requires skill and co-ordination, can be
seen to be about the skills members in the group have lost (the juggling was suggested by
a gymnastics teacher). All the members in the group made their living using their hands
and bodies either in building work, craft work or physical education so all would have
needed co-ordination and dexterity. The clown though keeps falling apart (accidently)
and then has his head bitten off by a lion, so even the clown is prone to illness and falling
apart and one could perhaps see the lion's attack as being a metaphor for having a stroke.
A clown is also a tragic-comic figure which reflects the importance of a grim humour
towards their situation.
63
This short animation film by the participants is a huge achievement for patients who have
recently had a stroke. There are a number of photos taken by several members of the
group, a quite detailed drawing that was made over a number of sessions, some drawings
made on the I-pad which again is an achievement for this particular member who had
never used an I-pad before. There were also a number of clay figures and sculptures made
by the patients.
Themes discussed in the groups
The members used the group to express feelings of frustration, anger and despair at their
situation. People were at different stages in their grief at the loss of their health and
autonomy. Some could not see any incremental progress they might be making against the
huge level of loss they have experienced. Others though could express progress they had
made and this provided hope for those that couldn't.
Missing their previous lives, home and family and independence, they could start to look
forwards and notice the changes they were making, 'Fight like a Ferret' was one of the
member’s sayings and he even had badges made up for everyone in the group with this
saying on it.
Patients lived with the uncertainty about their future: not knowing for how long they
would be on the ward, for one member not knowing where he would be living and
whether with his wife or not, and there was anger about these uncertainties which they
were able to at least get off their chests. There were also many tears in the group
particularly when talking about missing home and family and it is possible that being a
group made up of only men helped them feel less self conscious in this respect.
Lessons learned from the project
 The Art Therapy project was a feasible intervention on the 2 wards and provided
emotional support for the participants, an activity and means of expression which
some of them could make use of and a group environment in which members
could meet, talk and make work together as a contrast to the medical treatment
they were receiving elsewhere. One member particularly made a point that it was
beneficial to be with other people and do something other than be 'prodded',
moved about and have blood taken from him. So there was something
normalising about the art therapy group process.
 The pilot project provided some useful insights into what is helpful and what is
less so about art therapy in stroke rehabilitation. Engaging former and current

64
stroke patients in the design and conduct of studies has been essential and their
engagement could be increased.
 The fact that the art therapist was skilled in animation and film-making was a
bonus and not all therapists have these skills. However, we found it was a really
important element in the art therapy repertoire as not only could all join in at a
level appropriate to their abilities, either by making models or directing the
action, but the patients had a permanent record of the group which was shown in
public and contributed to a sense of achievement in patients who had previously
felt so diminished by their stroke. Using mobile phones to make videos or
recording on i-pads could achieve similar results depending of course on the
patients’ wishes.
 The regularity of the group was helpful and the fact that it was twice a week
provided a sense of continuity.
 The group ran for 45 minutes which sometimes was too short. Timing could be
more flexible, running from say between 45 minutes and an hour. Although
suggestions about time of day had come up in the focus group, patients felt that
the slot after lunch (1.45-2.30) was not perfect in that patients would normally be
in bed and asleep at that time.
 It was vital to have a co-facilitator who worked on the ward and who provided a
link to the rest of the staff. Liaison with staff on the Unit, keeping them informed
about patients and seeking information and feedback from them contributes to
the effective running of the groups. The speech and language therapist was
familiar to the men and was able to help in their communication difficulties. Her
feedback to the other staff was invaluable.
 The single sex of the group (all male) though unintentional had benefits in that it
enabled members to feel less self conscious in expressing feelings.
 In terms of numbers in the group, depending on the levels of disability, no more

than 6 people was desirable as it would have been hard to facilitate more,
particularly if a number of them were very disabled and unable to work
independently.
 A participant profile form could be designed to enable staff running the art
therapy group to gather information about members in advance: such as mobility,
transfers, communication, cognition, discharge plans and so on.
65
 There needs to be a one to one assessment with the art therapist before the
group starts and as part of the recruitment process. The therapist can then judge
suitability for the group and level of need. For instance for some people the art
therapy served as a reminder for what they could no longer do and this would be
best worked with in a 1:1 situation.
 The requirement for informed consent meant that some patients who had
cognitive and communication difficulties (who are also excluded from talking
therapies) were not able to be included. This could be reviewed for further
projects in the light of research on obtaining consent from severely impaired
patients, since this project successfully carried out with people with dementia.
 The therapist needs to be active in assessing needs within the group and
responding accordingly as most of the participants could not manage being left
to their own devises.
 It would be better if interruptions could be minimized. Frequent interruptions

can affect the dynamic and discourage expression of emotion. This reinforces the
need for liaison with and support from staff in the hospital.
 There needs to be a protocol in the case of an outbreak of infectious diseases,

such as norovirus. In a short intervention such as this, losing two weeks was very
disruptive and led to some patients being unable to complete all the sessions.
Feedback from the patients post-groups
Four individual face-to-face interviews were conducted by the research nurse with art
therapy group participants in the hospital after the end of the groups. Two telephone
interviews were also held at participants’ convenience. All patients were very happy to
feed back. Interviews were semi-structured (see Appendix A for questions) but were free
ranging following whatever the participants wished to discuss. Interviews ranged from
around 5-20 minutes and all felt relaxed. Notes were taken at the time of interview. The
responses broadly reflected the feedback from the art therapist, speech and language
therapist, participants in the groups at the time, and other colleagues and are summarized
in Appendix A).

66
Quantitative results from the art therapy study
These are indicative only. The numbers were too small to demonstrate conclusive benefits,
but when taken with the qualitative outcomes and feedback from patients and staff, there
is reason to be cautiously optimistic about using art therapy groups for patients in
rehabilitation from stroke. (Please see Appendix B)
Potential of further research for patient care
This study has showed that it was possible to conduct an art therapy intervention study for
stroke patients in rehabilitation. The study was limited by the small number of patients
recruited and the short duration. There is a great potential for conducting a larger study
across more centres in the UK and elsewhere to test the hypothesis that art therapy may be
beneficial for patients in different rehabilitation settings.
Research team:
Professor Diane Waller is an art psychotherapist and group analyst currently engaged in
research concerning the well-being of older people. She has conducted numerous
research projects in the UK and abroad, for example, in Bulgaria (1981-87) introducing art
therapy services within long term psychiatry and community drug rehabilitation projects
sponsored by the WHO; Rome (1984-1997) in addiction settings; in Lausanne (1992-2001)
in acute and long term psychiatry; in Berlin (1995-present) within out-patient psychiatry,
in a Health Foundation funded project in East Sussex (2000-2005) with older people with
moderate to severe dementia (Waller, 2002; Waller and Sheppard, 2006a and Rusted,
Sheppard and Waller Dec 2006), with individuals with Parkinson’s (Strand and Waller
2010) and most recently with people with long-term schizophrenia on an HTA funded
project (Crawford, Killaspy and Waller 2012). She has published extensively on the
history, sociology and clinical practice of the arts therapies.
Dr Khalid Ali is a stroke specialist involved in caring for stroke patients in the acute phase
and in the rehabilitation setting in Brighton and Sussex University Hospitals NHS Trust,
and an academic (senior lecturer in Geriatrics at Brighton and Sussex Medical School). He
is also a member in the GDG (Guideline development Group) of stroke rehabilitation NICE
guidelines currently being drafted. He is also the lead for the Age and Ageing speciality
research in Surrey and Sussex. He is also an active member of the South East of England
Stroke Research Network (SE-SRN). Dr Ali has engaged with arts and humanities with
particular emphasis on the use of film in teaching and research in relation to patient care.
He has published 18 film reviews with 14 published in the BMJ. He has wide experience in
engaging with stroke patients and carers, and this patient and public involvement (PPI)
work has informed the design of a current multicentre UK study; the Stroke Oxygen Study
67
(SOS) (Ali et al 2006). His interest in the concept of well being in stroke patients
undergoing rehabilitation has originated in 2004 when his work was published in the
Canadian Journal of Geriatrics (Ali K 2004).
Tony Gammidge is an Art Psychotherapist, registered with the Health and Care Professions
Council and the British Association of Art Therapists. He is also an artist, filmmaker and
part-time lecturer in the School of Art, Media and Design, University of Brighton on the
Inclusive Arts Practice M.A.
As well as working as part of the stroke project he has experience in working in forensic
and adult psychiatry and has led a number of video and animation projects on medium
secure psychiatric wards of which many of the films made have won Koestler awards. He
has spoken and presented his work at several international conferences including the
I.A.F.P. (International Association of Forensic Psychotherapy) Murder in Mind conference
in Edinburgh and the BAAT 2010 conference on Attachment and the Arts. In 2009 he won
a special commendation to the field of arts and mental health by the Royal Society for
Public Health. www.tonygammidge.com
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Waller, D (1993, 1996, 2014) Group Interactive Art Therapy: Its use in training and treatment.
Routledge, London and NY.
Waller, D (1993) Short term interactive art therapy groups. In Waller, D Group Interactive Art
Therapy, Routledge, London and NY pp 73-80
Waller, D and Sheppard, L (2006) Guidelines for art therapists using art therapy groups for people
with moderate to severe dementia. Goldsmiths, London (obtainable from diane.waller@virgin.net)
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Wood, C (1997) The history of art therapy and psychosis (1938-95) In Art, Psychotherapy and
Psychosis, Routledge, London and NY pp 144-175
Yalom, I (1983) In-Patient Group Psychotherapy, Basic Books, NY
Yalom, I (1985) The Theory and Practice of Group Psychotherapy, Basic Books, NY
Yaretzky A et al. Clay as a therapeutic tool in group processing with the elderly. Am J Art Ther 1996;
34 (3): 75-82.
Zigmond AS, Snaith RP. The Hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67:
361-70.
Acknowledgements: *Age Research Centre Sussex (ARCS) for funding the project; Ms Jacqui Pinney,
Co-ordinator, of ARCS; Professor C. Rajkumar, Brighton and Sussex Medical School, Ms Jane Gaylard,
Stroke Research Nurse; Ms Alice Howard, Speech and Language Therapist of Princess Royal
Hospital; Ms Sally White, Administrator, School of Applied Social Science, University of Brighton; Dr
Georgetta Fanea, Clinical Fellow SRC, Mr Robin Cant, Stroke Survivor, Dr John Palfrey, Stroke
Survivor, Ms Stephanie Goubet, Statistician at CRU. All the patients past and present who helped
with the design and gave feedback and all staff at the Stroke Rehabilitation Unit of Princess Royal
Hospital for their support throughout.
More information about the project and future plans can be obtained from diane.waller@virgin.net
and Khalid.Ali@bsuh.nhs.uk
A book (Fight like a Ferret) of text, images and a DVD (Circus Dreams) made by the patients is also
available from the above, details by email.
APPENDIX A
Art Therapy Interview Summary
Four individual face-to-face interviews were conducted by the research nurse with art
therapy group participants in the hospital. Two telephone interviews were also held at
participants’ convenience. All patients were very happy to feed back. Interviews were
semi-structured around the questions below but were free-ranging following whatever the
participants wished to discuss. Interviews ranged from around 5-20mins and all felt
relaxed. Notes were taken at the time of interview. A brief summary is included below.
1. Did you enjoy the art therapy group?
Interviewee 1: “Brilliant” - more open-minded (than usual treatments), great to interact

with adults and non-medical personnel. Felt like a person... felt ‘normal’ – a breath of fresh
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air. Very free style (of art therapist), really good and has a place in treatment. Everything
optional – didn’t feel forced felt like it has been the only thing the respondent has been
able to take control of.
Interviewee 2: Yes – like art it appealed to him – better than the respondent thought it
would be
Interviewee 3: Enjoyed the company but felt there should have been more thought on
what the group should be achieving specifically an example of what the animation would
look like at the end. (Respondent had done some film work before)
Interviewee 4: No – but only because I couldn’t do anything
Interviewee 5: Yes
Interviewee 6: Yes
2. What was most the most useful thing to you about attending the group?
Interviewee 1: Meeting ‘non-medical’ people. Be a person not a patient. Nurses ‘fantastic’

but you always feel like a patient. Art therapist professional but completely different
approach that made respondent feel like a person. Great to have a choice in what you do,
i.e. don’t have to carry on where you were last time. Art therapy group was one of the few
things the respondent felt he had had some control over. Speech therapist very good.
Interviewee 2: Getting together with others – something to talk about
Interviewee 3: ‘There wasn’t too much positive or appealing… I wouldn’t do it again if

asked’
Interviewee 4: Enjoyed being in the group (after gentle pushing by interviewer) – would
do it again if asked as it was ‘something to do’ – relieved the boredom of hospital life
Interviewee 5: Enjoyed being asked to visualise being somewhere else and being asked to
draw it “You walked across the common with the dog – I enjoyed imaging it – quite good
really…. Also liked the tea” (Joke)
Interviewee 6: Made a film – that was quite good – Did clay models (made a man) –
meeting people was good

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3. What was not useful about attending the group?
Interviewee 1: Too soon after lunch – respondent felt sleepy. Felt some people missed the
group as too sleepy, respondent wondered if this was frustrating for art therapist – missing
people not a problem for respondent
Interviewee 2: Nothing
Interviewee 3: Not everybody was involved, i.e. ‘some people only talked and didn’t take
part – some people were not capable of taking part’
Interviewee 4: ‘Couldn’t physically do anything so for me….. No good’
Interviewee 5: Nothing - Liked being part of a group
Interviewee 6: All good, nothing he didn’t like
4. In terms of organisation what was Good/Bad/Indifferent?
Interviewee 1: Good array of kit, didn’t feel like a trial (respondent felt he would pick up
on that easily if it had of done). Not intimidating at all on the art side. (Respondent has
declined an alternative music group in the hospital on the grounds of feeling intimidated
by a group). Wished he could have attended more sessions
Interviewee 2: Everybody could feel included and have a go at anything (respondent tried
clay and video). ‘Nothing bad’
Interviewee 3: Respondent declined to go to the group x2 as he didn’t feel it worthwhile –

i.e. felt critical re. the lack of direction or ‘storyboard’ for the filming/animation; felt it was
just ‘mucking about with plasticise’.
Interviewee 4: Good amount of things to try
Interviewee 5: “He done well doing the camera work… I would like to see the film” The
room was a bit cold
Interviewee 6: “All good”, nothing he didn’t like

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5. If we were running the group again what would you suggest we change/do differently
to improve the experience?
Interviewee 1: Ideally before lunch but feels it would be difficult to compete with other
hospital routine e.g. trying to get a shower in time etc
Interviewee 3: Respondent felt some ‘positive thought’ about who should be involved (i.e.
group participants) was needed and some ‘proper’ expertise on film-making to lead more
firmly.
Interviewee 5: “Do it in nursing homes – it’s a perfect place here (now residing in nursing
home)….. He (Art Therapist) wasn’t bossy – could do what you wanted… ideal man for the
job”Interviewee 6: No nothing
6. Anything else you would like to add?
Interviewee 1: Good to meet others and share. ‘Very safe emotionally’. Made the
respondent feel very positive about the NHS in being prepared to embrace something less
medical – felt it was very much the right approach for him personally and really
appreciated as a result (Interviewer note: respondent was quite emotional throughout the
interview and despite being a difficult day for him was extremely keen to participate – he
stressed that the art therapy had been a highlight for him for all the above reasons).
Interviewee 4: Difficult when you can’t do anything yourself
APPENDIX B
TOMS AND HADS OUTCOMES
Six patients recruited, all male stroke patients age range 38-85yrs, average age 69.
Attended art therapy for a range of 1-8 sessions, average attendance 4.8 sessions
(Mode=6).
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Total LOS (length of stay) in hospital ranged between 36-101 days (median 49), LOS on
SRC ranged between 44-120 days (Median 84 but all LOS figures based on 5 patients as on
still an in-patient).
First TOMS scores (4pts scored): Range 7-15.5

Mean 10.125
Median 9
Second TOMS scores (5pts scored): Range 7-13

Mean 10.4
Median 10.5
Difference between 2 TOMS scores (based on 3 scores)

Total 0.5
Mean 0.2
Median 0.5
First HADS ANXIETY score (6pts scored): Total 55

Mean 9.2
Median 8
Second HADS ANXIETY score (5pts) Total 27

Mean 5.4
Median 6
Difference between 2 HADS Anxiety scores

Total 28
Mean 5.6
Median 1
First HADS DEPRESSION score (6pts scored):

Total 57
Mean 9.5
Median 10.5
Second HADS ANXIETY score (6pts scored):

Total 21
Mean 4.2
Median 4

74
Difference between 2 HADS Depression scores

Total 36
Mean 7.2
Median 6
Results for stroke patients not involved in the art therapy intervention at the time of the
study (6 weeks)
21 patients, 10 women 11 men

First TOMS scores (21pts scored): Range 6-17.5
Mean 10
Median 9
Second TOMS scores (2pts scored): Range 10-14

Mean 12
Median 12
Difference between 2 TOMS scores (based on 2 scores)

Total -2 - +2-5
Mean 0
Median 0.5

75
Therapeutic love.
A Necessary
Convergence
Gerry McNeilly
INTRODUCTION
Let us begin by listening to a song by an Irish singer/songwriter: Brian Kennedy. This song
illustrates a convergence between Galileo and the songwriters questions about love.
I hope that you enjoyed that.
ln setting the scene in this way it draws our attention to the struggles between hard
scientific/astrological comprehension and intuitive, subjective love experience - an
everlasting polarity I assume that we all struggle within our professional positions.
I recently came across a beautiful small book by J.- B.Pontalis (the co-author of The
Language of Psychoanalysis) called 'Windows'. ln it he speaks of: The Congress
Participants, he says:
"I haven't set foot in a psychoanalytic Congress for years. One colleague, and only one:
that's just fine.(Remember the meetings between Freud, a bit lost in his mass of ideas, and
the slightly crazed Fleiss - they called those their congresses). Ten or twenty colleagues: no
problem, as long as they agree to be open, to say what they are doing, to articulate even
the most unreasonable ideas that occur to them. But when there are five hundred, a
thousand, two thousand of them, I want to vanish. Faced with this massive, public

76
affirmation of a supposed common identity- "We psychoanalysts, sworn experts on the

unconscious"- I disappear."( I)
Drawing a little from my Congress abstract I want to restate that the concept of
therapeutic love evolved in the closing years of my work as a psychotherapist, group
analyst and group analytic art therapist, before retirement. I emphasized that to love as a
therapist has meant a readiness to be immersed in the overall therapeutic experience. I
shall attempt an elaboration of my findings. As stated in the abstract there may be some
difficulty in accommodating a degree of therapeutic love within the areas of sexuality and
perversion. I am therefore moving the focus onto an array of other human emotions and
shared experiences within the therapeutic setting. A crude hypothesis could be that love
has been removed, diverted or perverted within sexual perversion. Through an
acknowledgement of therapeutic love I was more able to allow myself to be immersed in
the therapeutic process.
Unlike the areas of transference and countertransference I no longer felt a need to defend
through elaborate interpretations and I was therefore more able to tolerate the emotions
of the moment: that is what I define as a necessary convergence.
If we contrast the two words perversion and convergence (not conversion) there are
interesting points of note. A dictionary defines perversion as a deviation from particular
normal positions. Convergence, on the other hand, is about things meeting or coming
together. Of particular interest for me was the definition of 'convergence zone' in respect
to geology: 'a zone where Teutonic plates collide, typified by earthquakes, mountain
formation and volcanic activity'(2) I think that this particular definition is helpful in our
work as therapists and analysts. The overall holding embrace of therapeutic love as a
necessary convergence and framework allows for internal/external life movement i.e. a
mountain can keep moving but stays in the same place.
I do not intend to speak about perversion or sexuality specifically. There are probably
more eminent and wise presenters who can offer more, particularly from the
psychoanalytic perspective. Hopefully the concept of therapeutic love as I describe it, may
be a useful adaptation and not seen as a retraction or negation of psychoanalytic
principles. However, let me draw attention to some points of existing literature.
In respect to perversion Robert J. Stoller draws attention to perversion as a erotic form of

hatred. In the introduction to his book on the subject he says: "-- aberrant sexual practices
are found throughout animal species and are ubiquitous in human behaviour. It is easy,
then, to conclude that the widespread aberrance in man does not really signify willed
behaviour-- that is, sinfulness, disobedience to accepted morality- but rather to a natural
tendency of the sexual impulse in the animal kingdom.
77
Conversely, others-- philosophers and essayists rather than formal researchers-- who serve
a different but also admirable decency try to call us back from the abyss of licentiousness,
pointing up the de-humanized, unloving aspects of sexual behaviour that emphasizes
anatomical more than interpersonal gratification. To need to reduce another person to a
breast or a penis or a bit of cloth before one can succeed in concentrating one's lust is very
sad and dangerous; such severe failure of potency and degradation of lovingness only
augments the other processes that today disintegrate one's humanity"(3)
The closing sentence on 'degradation of lovingness' and the 'disintegration of humanity'

are in keeping with my views on therapeutic love which I trust will become clearer as we
proceed. Stoller emphasizes the need to understand each individual persons particular
perversion as compared to collective classification. ln his book, referenced earlier, there
are no inclusions of 'love' in his index which to me was somewhat surprising. I also
wondered about the absence of love in the following quote: "perversion, then, is the result
of family dynamics that, by inducing fear, force the child who yearns for full immersion in
the Oedipal situation--- to avoid it."(4)
Although Freud has written extensively about perversion, it was his views on love which
interested me more. In his chapter: ' Being in Love and Hypnosis he says: " even in it´s
caprices the uses of language remains true to some kind of reality and thus it gives the
name of 'love' to a great many kinds of emotional relationship which we too group
together theoretically as love; but then again it feels a doubt whether this love is real, true,
actual love, and so hints at a whole scale of possibilities within the range of the
phenomena of love."(5) Here I believe that Freud is saying that love is more than just
physical sexual drives although emphasizing it as the primary instinct. There is a beautiful
comment, which I have used in a previous publication that is worth sharing with you and
taken from his: 'Group Psychology and the Analysis of the Ego': "our hypothesis finds
support in the first instance from two passing thoughts. First, that a group is clearly held
together by a power of some kind: and to what power did this feat be better ascribed than
to Eros, which pulls together everything in the world? Secondly, that if an individual gives
up his distinctiveness in a group and lapses other members influence him by suggestion, it
gives one the impression that he does it because he feels the need of being in harmony
with them rather than in opposition to them-- so perhaps after all he does it 'ihen zu Liebe'
(for love of them)"(6)
There is a saying, I can't recall who coined it that under every psycho analytic couch there
are both the patient and the analysts groups.
For a more comprehensive account of various psychoanalytic/psychotherapy perspectives

on love, I would like to refer you to Richard Chessicks: A Dictionary For Psychotherapists,
1993, published by Jason Aronson Incorporated. (7)
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Now I shall move on to the main part of my presentation.
Previously I presented various permutations of therapeutic love within such areas as

despair when working with 'heart sink' patients (a term used to describe patients with
severe or psychological difficulties such as personality disorder) along with therapeutic
moments of 'heart break'; the therapeutic movement towards hope (one goal in a
therapeutic loving experience) from the depths of despair; and more recently how
therapeutic love has to be experienced as an ingredient of communication with a focus
upon group analytic art therapy. Unlike other cognitive processes, 'therapeutic love'
became crystallized through the development of physical sensations for me. What
emerged with increasing regularity in my clinical work had been a movement towards
physically feeling such things as my heart sinking, deep despair and at the time no other
word compared with heartbreak. These emotions emerged when disturbing, painful,
traumatic experiences were shared by my patients either in individual or group
psychotherapy. At these times I could literally feel and picture/imagine the patient's life
scenes. My long-held discipline of holding back the tears and not dissolving into a total
wreck held firm, apart from the odd tear. On the other end of the spectrum when points of
great joy and happiness were shared, likewise I had similar physical experiences of my
heart pulsating, but this time in harmony with the patient. Therefore, the sequence of
moving from ‘heart sink' dynamics to 'heartbreak' experiences were part of the process of
therapeutic love. When my patients have reached greater happiness, joy, resolution, these
were indeed unique and privileged positions in which I was honoured to have shared the
experience. I have previously coined the term: 'therapeutic interface' but I do not know if
anyone else uses this term or created it before me. When such intense experiences that I'm
describing occur, this interface between me and the patient, becomes palpable. But here I
do not suggest that I am fused/consumed with either my patient or my group, even though
it is a uniquely different experience. Like my earlier symbolic equation: the mountain stays
still while moving.
There are similarities between my postulations upon 'therapeutic love' with transference
and countertransference, but there are marked differences. For example, one of my
patients asked me if I liked her. Although I was a little hesitant I said that I did and went on
to say that it would be difficult for me to work with my patients unless I liked them. This
was important for the patient. In my hesitancy I was contemplating responding to such a
question based upon the transference and countertransference elements, which had been
dealt with at other times in the therapy. By simply answering the question I gave voice to a
recognition that there was much to like/value in the patient as well as recognizing
particular qualities in myself which were necessary in enabling me to work as a therapist.
This does not mean that at times I disliked/hated my patients. There have been many times
when I have, or would, not answer such a direct question. I am aware that many

79
psychotherapists would resist such a personal acknowledgment for fear of damaging the
transference relationship.
From Transference to the Fluid Space
I would now like to move on to some clinical illustrations which I trust will show how my
clinical experience changed my thinking and ways of working, almost without choice. The
concepts of transference/countertransference melted away to be replaced with a sense
that I was floating within the therapeutic interface. A marked difference emerged
between these two positions. With transference/countertransference I felt this to be
against my will. With the new position my will flowed with it and I no longer felt drawn
against my will. It is not my intention to present a detailed study of the following patient's
therapy, but rather to focus upon the relevant areas in respect to this paper.
Allison
Allison has a long history of severe psychological difficulties which can be understood
within severe depression and borderline personality disorder but there is much more to
her than these clinical diagnoses. I am not sure how particular changes began to change in
the early stages of the therapy, but I found an awakening within myself of empathic
emotions as we struggled with her powerful urges to kill herself, as well as enacting self
damage in various ways. Throughout this period, of many months, I had felt tested by her
in which she felt that I was wasting my time and that I was only putting off the inevitable=
death.
The origins of this paper began at this time in my work with Allison. I saw that her heart
sank so low within the depths of her internal world and extremely demanding life
circumstances. I had to hold onto some level of hope while not pushing her to get out of
this hopeless fluid mess quickly. There had to be a gradual building of her own inner
strength which would help her to see that change was possible. This could not be rushed.
To truly experience the depths of her 'heart sink' position there was a constant threat of
her heart breaking and indeed my own.
Throughout this process I held an unspoken sentence of: "if you kill yourself it will break
my heart!" Although I never said this to her I conveyed to her that I would experience a
great loss and sadness if she did kill herself.
When things had taken an upward swing into her sense of purpose and being able to alter
her life externally as well, the space between us was filled with joyous emotion. She
became brighter and this also showed in her healthier physical appearance. There was an
increase in warmth, humour and laughter between us. Moving from the deep 'heart sink'
80
position it entailed touching upon crucially painful experiences of 'heartbreak' between us

before we were able to move to more joyous positions. The willingness to commit oneself
to this process is one variant of 'therapeutic love'. This type of love is concerned with
keeping AlIison alive but more so that she will be able to learn to love herself and her
potential to embrace the future. One major decision that she made during this time was to
leave her husband after approximately a 30 year period of unhappiness. She seemed to
blossom and made major changes from this decision. On a personal level l felt happy, not
that she was getting divorced, but happy that now she was getting stronger and she had
mobilized herself into action. I told her that I was pleased that she had reached her own
decision against powerful fears of doing it. Whether she left her husband; stayed with him;
found some new meaning in the marriage, I would be there to support her.
Theresa
There were similar processes in place as had been there for Allison. The transitions from
the 'heart sink' to the 'heart break' positions within the framework of 'therapeutic love'
were in place and with the same intensity at times.
Clinically she struggled with severe neurotic symptoms: agoraphobia; eating difficulties;
severe obsessional disturbances (particularly the fear of spiders); preoccupation with
death and the desire to be with her dead mother. I shall only focus upon two areas: her
body image and her smile.
Initially Theresa came across in a very frightened and broken way. She was covered from
head to toes in clothes and the only part of her body that showed was her face. She wore a
hat and gloves, and although it was the wintertime it wasn't snowing in my consulting
room. During the course of her therapy we explored many areas within her internal world
and her historic interpersonal conflicts. Gradually she gained in strength and much more
of her body was beginning to show but she was not overexposed. There was an
improvement in the particular symptomatology noted earlier and, like Allison, she was
blossoming. From the initial covering of her whole body and sitting in a closed/hunched
way she was now more proudly present in the room with me. Also her choice of clothes
became brighter in colour and there was a greater use of facial makeup.
Looking more specifically at her body image and smile there were interesting points of
note. The therapeutic love that was beginning to develop between us led me to take more
risks which I generally resisted in the earlier years. We had been talking in one session
about her dislike of her body and I questioned whether there was any part of her body that
she liked and she answered: "No!" For some time I had been struck by her colourful nail
varnish. It sparkled with various colours which was almost jewel like. I eventually said that
the nail varnish was beautiful. Like other parts of her body she'd felt that her hands were
81
the same as her mother's but in this instance she was making her own stamp in her choice
of nail varnish. This helped me understand that although she felt burdened by her genetic
inheritance, as well as a great attachment to her mother, she was trying to find and mark
something of her own in the world.
Throughout her therapy she showed a great deal of pain and suffering on her face as we
dealt with things. However I was also struck by how beautiful her smile was. When she got
in touch with something that pleased her or she found funny her mouth opened and
showed beautiful teeth and a contagious sparkle in her eyes. I felt that this concretized the
transition from the heart sink/heartbreak position to an element of joy, if only briefly. I
could not resist being drawn in. I felt that she was unaware of how powerful this was. I did
not say anything about this for many months, hoping that she might get to this herself, but
this didn't happen. I was cautious in what I was saying in case she would interpret this
wrongly. Just like my comments about her nails I decided to take a risk and say what I fell,
although this was slightly modified. I asked her about her smile and she looked a little
puzzled. I said: "don't you know that you've got a wonderful smile?" I contemplated using
the word beautiful, but I was anxious that this may be seen as too personal and potentially
intrusive. However, it was a beautiful smile which lit up the room. I thought that if she
could start to acknowledge this and the impression that she has on others, it may help her
to be less isolated and fearful.
Certainly my comments where risky psychotherapeutically but I've come to believe that if
we see and feel things for and with our patients then why should we not openly
acknowledge these for the good of the patient and ultimately the therapy. Such a
wonderful smile as Theresas, like other wonderful things in our patients lives; should not
go unspoken about. I know that Teresa did feel good about my comments, although death
was a constant bedfellow for her that when the qualities that I saw in her were
acknowledged, then life did take over for those brief moments. In one of our following
sessions she came into the room wearing a blouse (a female garment) which had an
attractive face of a woman on it. I didn't say anything at the time but I'd felt I'd said
enough at the earlier sessions.
Therapeutic Love in Groups
As S.H. Foulkes has pointed out in much of his writings on group analysis the 'individual'
and 'group as a whole' are inextricably linked. Therefore, many of the points I have raised
so far in respect to my individual patients can be seen and understood when studying
groups. When we look at the 'group as a whole' phenomenon (a group analytic term), the
'heart sink/heartbreak' transitions that I highlighted earlier will be experienced. This will
be experienced in a great number of ways as part of each group members past life and

82
present group therapy experiences as they develop. However, the 'group as a whole' will
also be faced with collective 'heart sink' and 'heartbreak' experiences.
Can a 'group as a whole' have a heart? Is there a place for such a term as 'heartfullness' in
the similar way as we have 'mindfulness'? If Foulkes is correct in defining the group as
having a 'Matrix', which is aligned to the maternal/womb symbolism, then why should it
not have a heart? For those accustomed with group therapy/group analysis I think that this
is self explanatory however, we can see such struggles/dynamics when: individuals shared
deep past trauma through resonant associations; empathic dialogue regarding anxiety and
depression; the fears of suicide and dealing with actual suicide; attempts at medication
reduction with successes and failures; intricate workings in dialogue about relationships;
dealing with a whole range of emotions in the process of the group working through
material, as some points of reference. ln its most basic description 'common sense' prevails
when we think about human empathy of group members being utilized as they listen to
one another going through their trials and tribulations of their present and past life
experiences. When group members say: "that happened to me!"-"I know where you're
coming from"-"that's so sad"-"how can you not feel angry about what's happened to you
when I want to tear his eyes out?" In these matters I feel that it is the group's heart that has
been stirred, not only cognitive associations/resonances.
When the individuals in the 'group as a whole' go through the most difficult 'heart
sink/heartbreak' transitions, the sense of achievement and fulfilment is impressive. When
individuals in groups have gone through many weeks and months of struggling with
particular issues to a favourable conclusion, the relief is palpable. It's as if they reach a
higher gear, the top of the plateau or mountain, when this has been achieved. At these
times they've reached a point
of celebration and gratitude towards one another for what has been achieved. As well as a
sense of calm having been reached after the storm, other life-affirming feelings are
shared. Happiness and humour takes form; a sense of cohesion emerges with the feeling
that they do not want to leave one another and the group bond becomes extremely
tangible. Such a bond can be so strong when the group has reached this level of maturity
and any dynamics around closure and finishing become more difficult. They want to
protect one another and not let one another go. With increasing levels of insight and
accompanying change these are beautiful things to behold.
Conclusion
Reflecting upon what I have presented, I noticed that the only place I used the word heart
ache was in love in therapeutic groups. I then realized that this is a very different
emotional experience. Heartache can be experienced in matters of the yearnings, loss and
83
suffering. Possibly it can be ascribed the middle position between 'heart sink' and
'heartbreak'- a way of tolerating the intolerable. However, I recognize that further
development of this ingredient with a more comprehensive study is necessary.
What I have attempted to present are not necessarily new theoretical views solely of my
own making, but views that in my experience are seldom expressed openly within the
literature. I am not talking about falling in love with one's patients but merely attempting
to raise the emotional state/profile between patient and therapist in which the heart
becomes dominant. To do so may well court derision and criticism. I have postulated that
many risks have to be taken within this field. Spontaneity moves one without the safety net
of predicting cause-and-effect through careful analytic/intellectual interpretations, when
the heart is pushing the therapist to act differently from their own specific school of
psychotherapy training.
The well grounded theories and codes of practice which have equipped the therapist so
far are turned upside down, questioned and may well fall by the wayside if one considers a
theory of therapeutic love. Such modifications of therapeutic practice that I postulated in
my clinical illustrations show something new that emerged, almost out of my control, that
came into play. For those psychotherapists, psychoanalysts, art therapists who shape their
work around such theories as mindfulness; sexual drives; womb imagery in relation to the
matrix in group analysis, as just some theoretical structures, is it possible to stretch the
imagination to matters of the heart? ln my formative periods of training matters of love
within therapeutic settings were certainly discussed and written about, but primarily in the
negative as a possible fatal outcome if one was not careful in working with the erotic
transference.
However, this combined the complex dynamics of love in its many forms with
biological/sexual instincts with concepts of transference and countertransference. The
therapist's fear/suspicion of such matters of love was therefore accentuated. I have tried to
show that with these things in mind therapeutic chasms and barriers have existed in
mainstream psychotherapy practice. I have coined the term: 'therapeutic interface', which
I believe is a more fluid concept which can accommodate matters of the heart as well as
the more accepted theoretical concepts and techniques within a wide range of
therapeutic endeavours.
Beyond transference and countertransference the concept of therapeutic love acquires a

greater prominence and significance. In this, dare I say, new way of thinking it has allowed
for a greater therapeutic union to occur in my art psychotherapy, individual and group
psychotherapy practice. ln therapeutic love, as I have described it, new doors have been
opened. Rather than developing a process of dismantling what I've learned over the years
with the fear of not having safer theories and methodology, by moving into the concept of
84
therapeutic love, it has had a freeing influence and affect upon me and my patients. I have
also had feelings of hate emerging at times but this is the basis of a new paper.
A closing question that I ask myself. Was there something perverse in my having spent 40
years sitting with patients with a primary focus/concern on human suffering, the majority
of times at the extreme end of the spectrum i.e. the range of personality disorders; severe
depression; dissociative identity disorders, as some examples? lt was not uncommon for
patients to be referred to me that fellow psychologists and psychiatrists could not handle
or understand. Or! Was it more an expression of love, as I have explained it today that was
at the heart of these 40 years and it was only possible to see in my final years and more
clearly in retrospect since I was no longer working.
I hope that it was the latter of the two.
REFERENCES
I. WINDOWS: J.-B. Pontalis--translated by Anne Quinney. p.5, 2000.

Pub. University of Nebraska press: Lincoln and London.
2. Collins English Dictionary.
3. Perversion: The Erotic Form Of Hatred. Robert J. Stoller. p.x, 1986,
Pub: H. Karnak (Books) Ltd., London and New York.
4. ibid: as 3 above.
5. Freud, S. : Pelican Collected Works, volume 12, p.141, 1985.
Penguin Books Ltd, Harmondsworth, Middlesex, England
6. Freud, S.: Pelican Collected Works, volume 12, p.120-1, 1985.
Penguin Books Limited, Harmondsworth, Middlesex, England
7. Richard Chessick: A Dictionary For Psychotherapists-- Dynamic Concepts ln Psychotherapy. 1993
pp.212-21,
Pub: JASON ARONSON INC. Northvale, New Jersey, London.

85
Art as Therapy
in Times of Crisis
Judith Rubin
“Man creates, as it were, out of his mortal wounds”

Joost A. M. Meerloo, M. D.
From the cave man to the Sunday painter, ordinary people have long made art as a form
of self-therapy. Some-times it’s a way of dealing with the stresses of everyday life.
Sometimes it's to cope with a trauma--an event which is too much for the ego to
assimilate. This very fact--that creative activity is therapeutic--is the main reason for the
existence of the field of Art Therapy
Winston Churchill, for example, found painting helpful throughout his life, especially
during periods of stress like the kind he was under as Prime Minister of England during
WW II. Whether initiated independently or provided by another, people in all kinds of
crises can be helped to master them through art.
Art therapy began with the spontaneous art of the mentally ill, itself a response to the
crisis of psychosis—which involves a terrifying loss of contact with both the self and the
world. (Prinzhorn, 1922; MacGregor, 1989) While art therapy originated in hospitals and
clinics, it is also helpful for many problems which are not primarily psychiatric.
Indeed, art is therapeutic for a wide range of stressful—often traumatic--events. These

include illness, bereavement, abuse, dislocation, natural disaster, violence, and war.
Whether the trauma is a sudden shock or a prolonged strain, art can help. In order to be
available to those facing crises of all sorts, art therapy has migrated from psychiatric
settings into new places-- like general hospitals, hospices, and shelters.
Art therapy for people under stress is a form of "secondary prevention"--helping those
who are at increased risk for psychological problems, because of acute crises as well as
chronic conditions. Offering art to individuals in the throes of responding to overwhelming
events, like medicating at the first sign of an infection, can often prevent more serious and
prolonged emotional damage.
86
Physical Trauma & Rehabilitation
That art can give meaning to a life twisted by trauma is eloquently demonstrated in the
paintings of Frida Kahlo. (Herrera, 1983) Her spine and pelvis were crushed in a bus
accident at age 18, leaving her with chronic pain and the constant threat of illness. As she
told her biographer,"The only thing I know is that I paint because I need to.” Throughout
her life, Kahlo’s paintings were often eloquent cries of pain, as she endured repeated
traumas—the loss of a child, numerous operations on her spine, chronic pain, and long
periods in a body cast and/or in bed. At the end of her life, the images and words in her
Journal were also a creative way of coping with the amputation of a leg and an awareness
of impending death.
While Frida Kahlo only took up painting during the lengthy convalescence following her
fist surgery, artists naturally turn to creating as a way to cope. Darcy Lynn battled a life-
threatening lymphoma with art at every stage of treatment, drawing in intensive care and
during a long process of pain, fear, hope, and recovery.
Although making art comes naturally to suffering artists, most people need help to harness
its healing power. Happily, more and more patients dealing with illness and injury are
receiving art therapy as part of their treatment. A head trauma patient admitted to
MetroHealth Center in Cleveland, for example, might be referred to the Art Studio, a
program founded by Mickie McGraw in 1967. A child with severe burns entering San
Franciso General can deal with his pain through Pat Levinson’s art/play therapy program,
there since 1977.
A massive shock to the system elicits powerful feelings for which words are weak, but for
which images can be a welcome release. Art helps both to express and to contain
otherwise-overwheming emotions. Traumatic injuries are usually followed by long periods
of anguish, pain, disability, and treatment; and art therapy can be helpful at every stage.
When a teenager named Eddie became a quadriplegic after an accident, art therapist
Irene Rosner helped him to create, drawing and painting according to his instructions.
Gradually, Eddie was able to do more himself, using his mouth. At all stages, Irene
functioned as his “auxiliary ego,” supporting Eddie’s own creative strivings. This art therapy
program, at Bellevue Hospital in New York has been available for over 25 years. (Cf.
Malchiodi, 1998, 1999)
Bereavement
Once, on a walk in the woods, I discovered a rough sculpture hewn from a tree trunk, in
the driveway of a laborer whose young wife had recently died. He told me that he got the
87
idea while he was chopping wood, thus transforming his rage into a beautiful memorial, a
powerful totem.
Seven- year-old Christopher knew that I helped children through art. When I visited his
home after his mother had made a suicide attempt, he showed me his "magical" creation.
Using cut paper and glue he had created a flag, writing "Save Me" on one side and
"Trouble" on the other. Inside, he had hidden a cardboard hatchet and knife. It was a
poignant attempt to keep her from destroying herself.
Alas, it was not successful, but Christopher himself requested an art session following the
funeral. His visit to my clinic was just a few weeks after his mother's death. He worried
about getting messy with chalk or fingerpaint, because "my Mommy would yell at me."
Projecting an image of "A Dog" onto his scribble, he said it must be the one he had wanted
so badly, but was not allowed to have because of his mother's depression.
Christopher then made a dark, messy finger painting, commenting anxiously on how mad
his mother would be if she could see him. He wondered aloud whether she was angry at
him, and if his being naughty or wanting bad things like the dog had anything to do with
her leaving him.
His story about the finger painting, as he drew lines in it with a stick, was that it was "A
Road. But," he continued, "You'll never find your way out . . . No one can stop me . . . They'll
never find their way out. They'll feel so sad . . . They'll be stuck there forever." I asked what
"they" would do. Christopher placed his hand in the black paint, lifted it up to show me,
and then smashed it onto the paper, splattering the paint.
One year later, Christopher asked to come in again. This time he symbolically represented
his mother's suicide in his drawing: A person "falls" off a road, as she had "fallen" (jumped)
off a bridge. Later, he dramatized with clay and tools a crash, an emergency, and an
operation in which he, as the doctor, tried unsuccessfully to restore the injured patient.
Creating in the presence of another gave Christopher a way to release his overwhelming
rage and frustration. It also gave him an opportunity to clarify the event, and to cope with
the painful reality he needed to accept.
Whenever you lose a loved one, you need to grieve, to deal with feelings like survivor guilt
and anger at abandonment. Making art allows for a visceral expression of emotions too
raw for words. I remember how badly I needed to paint after my friend Peter's sudden
accidental death, when I was about to turn 17.
Numbly, I went home to the funeral from the camp where I was working as an arts & crafts
counselor. Numbly I returned, then succumbed to a high fever for several days and nights.
88
When I awoke, I felt a strong need to go to the woods and paint. I did so on my first day
off, and it felt good. The painting was not of Peter, but of someone playing the piano,
making music in dark reds, purples, and blacks. It was a cry, a scream, caught and tamed. It
was a new object in the world, a mute, tangible testament. The doing of it afforded
tremendous relief. It did not take away the hurt and the ache, but it did help in releasing
some of the rage, and in giving form to feelings which threatened to overwhelm me.
Years later, I was surprised that my mother--never an artist-- became deeply involved in
sculpting my father’s head after he died. She was able to discharge her feelings by
squeezing, forming, and caressing the clay; while at the same time creating a concrete
image of her lost spouse--a lasting memorial. Just a week after her death, I found that
making a series of "free association" drawings was amazingly helpful to me in the work of
mourning.
The loss of loved ones is a normal crisis, which, if not mastered, can lead to depression. Art
activities can be a form of prevention, as vital in mental as in physical health. One art
therapist decided to use ssome of her dwindling savings for art supplies, saying that she
knew that only creatingwould help her to cope with an unanticipated series of dreadful
losses.
After a 1995 terrorist bombing in Oklahoma killed and injured many innocent people, art
therapy was found to be especially helpful to survivors. Thousands were bereaved in the
massive attacks on the United States of September 11, 2001. In the wake of this tragedy,
many programs used art therapy to help survivors to deal with their loss.
These deaths were all the more traumatic, because in most cases there was no body to
bury, no face to kiss goodbye, nothing physical from which to separate. Art, because it
involves touching materials and creating concrete objects, was especially helpful for those
who lost loved ones in this terrible trauma. Even for those far away, who watched the
horror on television, the event was overwhelming, terrifying and for many, traumatic.
I once treated a child who had witnessed a similarly unbearable sight at age five: her
mother shooting and killing her younger brother. (Cf. also Cohen, 1971)
Jackie suffered from nightmares and intrusive waking imagery. She was also miserable,
because her grumpy behavior with both adults and peers left her feeling very lonely. She
had gone to play therapy for almost a year, with no change in her symptoms. After
attending an art therapy workshop, her child care worker decided to drive a great
distance, in order to see if that modality might help.

89
Like most children with abusive parents, Jackie could not safely acknowledge or feel anger
at her mother. She was afraid of losing what little good feeling she clung to on her rare
visits to the jail. But she could safely direct her rage at me as the mother in the
transference in "ugly" drawings of "Dr. Rubin's Face." For weeks, she put signs on my office
door, warning other children not to believe what I said, and--projecting her own neediness
onto me--accusing me of being "a beggar." Jackie was able to work through confused
feelings about herself and others, eventually integrating good and bad images of both of
us, leaving therapy with a warm attachment.
Abuse
When people flee violence at home, they sometimes end up in shelters. Art therapy,
because it is adaptable, portable, and permits instant expression, is finding its way into
many such challenging settings. For a person whose life is in chaos, art can provide order.
For someone in a state of impermanence, art can supply something durable. For example,
art therapy has been used with the homeless, as in Patricia Prugh’s mural work with
homeless women in Baltimore, MD, and Janis Timm-Bottos’ at “ArtStreet”—a storefront
studio in Albuquerque, NM.
Whether the abuse happens in childhood or adulthood, it is often unconscious, available

to neither patient nor therapist. Even if the victim can remember, s/he has usually been
threatened with reprisal if anyone is told. So whether the trauma is repressed or
suppressed, art is an excellent avenue for "telling without talking" (Cohen & Cox, 1995), as
it offers a way for a person of any age to utter "silent screams and hidden cries." (Wohl &
Kaufman, 1985)
There are a growing number of art therapy programs for both children and adults who
have been physically or sexually abused. “Amanda’s Easel,” started by the mother of a child
who died from domestic violence, is a program at the Women’s Shelter of Monmouth
County, NJ, where Cindi Whittingham and Laura Greenstone help mothers and children
to heal. (Cf. Malchiodi, 1997)
One of the most original efforts, “Free Arts for Abused Children,” was started in 1977 by
Los Angeles art therapist Elda Unger .(Virshup, 1993) It is a program in which artist
volunteers are helped by art therapists to offer art to vulnerable children in places like
residential care facilities, schools, and community centers. It has been extremely
successful, and had spread to other American cities, including Phoenix, Chicago,
Milwaukee, and New York.
By the time adult survivors of abuse seek treatment, they usually have problems in many
areas, and often carry multiple psychiatric diagnoses, especially Dissociative Identity
90
Disorder (formerly Multiple Personality Disorder). Virginia Art therapist Jim Consoli
developed “Psychimagery,” in which hypnosis, mental imagery, and art help patients to
recover repressed memories. Art therapist Linda Gantt and psychiatrist Lou Tinnin have
developed a unique approach at the Trauma Recovery Institute in W. Virginia, using
drawings to fill in memory gaps, especially those in the body.
Elaine was a middle-aged woman who had suffered from depression all her life. She was
referred for art therapy because, when she started to remember her own abuse, she could
not talk about it, but could only "say" it in fingerpaint. In art therapy, work in clay and
paint slowly brought forth even more memories.
Elaine not only created art during her therapy sessions, but also at home, especially at
times of deep distress. One painting was a vivid statement of how imprisoned she felt by
her psychic pain and depression . . . a puffy, sad grey face looking out from behind black
bars of raised paint. A false happiness was a “Look but Don’t Touch Tree,” with brightly
colored leaves, but hidden thorns
For Elaine, art therapy became a way of finding out what was inside in a place that felt
increasingly secure. She called the therapy space a "Holding Environment," a term coined
by analyst D. W. Winnicott (1972), and gave that title to one of her sculptures. In it, a
person holding an infant (her small victimized self) leans against a well-rooted tree, her
favorite symbol for support.
After many years of work, it was hard for Elaine to say goodbbye, even though she had
made a good attachment to another therapist. She took most of her art work home, but
left a good deal with me too . . . a “transitional object” ( Ibid.) between us.
In her last session, Elaine made a sculpture which reminded me of her “Holding
Environment” of four years earlier. The tree had not been in her work for a while, perhaps
because she felt more grounded. In its place was a hand, cradling a person holding a baby.
She called it simply “Therapy.” (Cf. Kluft, 1993)
Natural Disaster & Accidents
Art therapy is often part of public and private efforts to provide "crisis intervention," after
such things as a devastating hurricane in Miami, a tornado in Kansas, and an earthquake in
Armenia. After a firestorm destroyed many dwellings in Oakland, CA, art therapists went
into area schools to help the children and families deal with the emotional “fallout.”
(Rubin, 1999).

91
When a plane crash in Pittsburgh left no survivors, an art therapist helped students deal
with their feelings through drawings. When a train collided with a school bus in Israel,
killing 22 and injuring 15, making art helped youngsters to cope with the trauma. When a
nuclear reactor exploded in Pennsulvania, area children were invited to draw their
fantasies about radiation. (Rubin, 1999)
There were riots in many American cities after Martin Luther King's 1968 assassination.
Children in one torn-up Washington neighborhood were helped to sort out what they had
witnessed by writing and drawing about it. Following riots in Los Angeles in 1992, art
therapy was one of many modalities used to help. Because it was so effective, the Southern
California Art Therapy Association was asked by the city to write a Guide for artists and
teachers who volunteered their services. (Rubin, 1999)
Displacement
Because art is a truly unversal language, art therapy has also been useful with immigrants.
Janice Hoshino, for example, worked with a group of people from the Phillipines at a
Senior Center in San Diego, California. Being "a stranger in a strange land" is hard, even if
the person has left a dangerous situation. The German children who fled to
Czechoslovakia in the thirties were able to create with pioneer art therapist Edith Kramer.
Trude Wertheim-Cahen of the Netherlands helps adults who suffer from traumatic
memories of their childhood experiences in internment camps. (Cf. also Rubin, 1999)
War & Combat
Art as solace in times of anguish is older than the field of art therapy. Some events are so
devastating that words fail, and images become the best way to say what presses for
release. Two Jewish adolescents in hiding before dying in the Holocaust left their journals
for posterity. One is Anne Frank's Diary, a word portrait. The other is A Diary of Pictures by
art student Charlote Salomon, a series of paintings she made to deal with unthinkable
events. (Salomon, 1963) In the Nazi concentration camp of Terezin, children made art to
escape, under the guidance of Edith Kramer’s mentor, art teacher Friedl Dicker.
(Volavkova, 1962) Adult artists, who made propoganda pictures for their captors, secretly
drew to record the truth, art which survived the Holocaust. (Green, 1969)
Since the State of Israel was born in 1948, both Arabs and Jews have lived in a constant
state of strife. Children in shelters drew pictures while bombs burst outside during the Six
Day War of 1967. During the Second World War, the Red Cross sent logbooks to
Americans in prisoner of war camps. The prisoners not only wrote in them, they also made
drawings and paintings. Creating images--of people and places they missed--was a way to
hold on to good memories, and to relieve months or years of tension and boredom.
92
The trauma of war does not disappear with the end of combat, but is often carried in the
mind and body in the form of Post-Traumatic Stress Disorder. Making art is one way to
achieve some control over the intrusive imagery of flashbacks.
Thirty years after an atomic bomb was dropped on Hiroshima, a Japanese TV station asked
survivors of the attack to submit pictures of their memories. They were astonished by the
response; as hundreds of adults welcomed the opportunity to deal with the still-painful
trauma by creating images. So many made art to deal with traumatic memories that there
is now a Vietnam Veterans’ Art Museum in Chicago, Illinois.
September 11, 2001
One of the most impressive things about the public and private response to the World
Trade Center and Pentagon bombings of 9/11 was the extent to which people of all ages,
all over the U. S., created art spontaneously. Drawings were sent to policemen and firemen
on the front line, murals were created in many kinds of places, and shrines sprung up all
over. Many art therapists offered their services, and art therapy became one of the main
modes of intervention with survivors of all ages.
In addition, artists responded with passion and generosity, as they have done throughout
history. In Middletown, NJ, for example, where many people had lost husbands and
fathers, one woman created portraits of the deceased from photographs, refusing
compensation. A young stone sculptor, with the help of his Italian teachers, created a
powerful public piece, “Memoria,” and invited the bereaved to participate in its creation.
A plastic surgeon told this story at a conference 20 years ago . . . During WW I, the faces of
many soldiers were badly disfigured by chemical warfare. A volunteer sculptress carefully
made masks of the soldiers' pre-trauma faces from photographs. In an era before
reconstructive surgery, wearing the masks allowed these maimed men to move in the
world without excessive shame.
Whether created by artists to help people heal, used spontaneously by those in pain, or
offered to traumatized individuals by art therapists; there is no question that art is a
powerful therapy in times of crisis.

93
REFERENCES
Cohen, Barry M. & Cox, Carol T. Telling Without Talking: Art as a Window into the World
of Multiple Personality NY: Norton, 1995.
Cohen, Felice. Mark & the Paintbrush. Houston, TX: Hogg Foundation, 1971.
Green, Gerald The Artists of Terezin NY: Hawthorn, 1969.
Herrera, Hayden Frida: A Biography of Frida Kahlo NY: Harper & Row,1983.
Kluft, Estelle (Ed.) Expressive & Functional Therapies in the Treatment of Multiple
Personality Disorder Springfield: Charles C. Thomas,1993.
MacGregor, John M. The Discovery of the Art of the Insane Princeton: Princeton
University Press, 1989.
Malchiodi, Cathy A. Breaking the Silence: Art Therapy with Children from Violent Homes
NY: Brunner/Mazel, 1990.(2nd Ed. 1997)
Malchiodi, Cathy A.(Ed.) Medical Art Therapy with Children (1998); Medical Art Therapy
with Adultsw (1999) NY: Jessica Kingsley.
Prinzhorn Hans Artistry of the Mentally Ill (1922) NY: Springer,1971.
Rubin, J.A. Art Therapy: An Introduction. NY: Brunner/Mazel, 1999.
Salomon, Charlotte A Diary in Pictures NY: Harcourt, Brace & World, 1963.
Virshup, Evelyn (Ed.) California Art Therapy Trends Chicago, IL: Magnolia Street
Publishers, 1993.
Volavkova, Hanna (Ed.) I Never Saw Another Butterfly: Children's Drawings from Terezin
Concentration Camp NY: McGraw-Hill, 1962.
Winnicott, Donald W. Playing & Reality NY: Basic Books, 1972.
Wohl, Agnes & Kaufman, Bobbie Silent Screams & Hidden Cries NY: Brunner/Mazel,
1985
Judith A. Rubin, Ph.D., ATR-BC, HLM

94
The Archetype of the Double:

Favouring the Identity Quest of
Adolescents
with the Help of Stories Written under
Musical Induction
Lony Schiltz
1. INTRODUCTION
Without admitting Jung’s assumption of the collective unconscious (Jung, 1964), many
authors use the concept of archetype in the sense of collective representations that can be
found in fairy tales and the myths of every culture (Bettelheim, 1984), but that are also part
of the individual unconscious in the sense of symbolic figures favouring the creation of
coherent representations of oneself and the other.
From the point of view of ethno psychoanalysis, the fact that the same archetypes can be
found in every culture and in every age, can be explained, on the one hand, by the cultural
environment, by oral tradition, but also by the fact that the archetypes are linked to the
existential situation of mankind itself (Valabrega, 2001). Because every human being is
confronted with the same anxieties and has to live through the same crises, he tends to
form similar symbols.
In this acceptation, the concept of the archetype can help creating meaning during the
psychotherapeutic process and during the interpretation of research results (Schiltz,
2004).
One of the most fascinating discoveries during multimodal arts therapies with adolescents,
based on active music therapy and on writing of stories while listening to music, was the
more frequent appearance of archetypal themes as the therapeutic process evolved.
Students who had been limiting to banal descriptions during the first sessions wrote almost

95
mythical scenarios at the end of the year, which centred on love, birth and death, staging
the grand characters of the collective imaginary world. It was no longer about literary
memories, but about an imaginary and cognitive elaboration of the personal existential
situation and of the deep emotions linked to them.
Another interesting statement could be made: the appearance of these archetypal themes
and figures was generally accompanied by a sudden improvement of the formal and
stylistic qualities of the stories, as if these existential contents unsettled every layer of the
psyche and provided the adolescents with new resources.
2. The structuring role of the imaginary double in adolescence
The importance of the archetype of the double appeared to us during longitudinal studies
with adolescents suffering from emotional disorders (Allen & Sheeber, 2008; Silvermann &
Field, 2011), conduct disorders (Aboujade & Koran, 2010; Emerson & Einfeld, 2011) or
from an identity quest complicated by character pathology (Bergeret, 1996; Marcelli &
Braconnier, 1999; They were treated by the above mentioned type of multimodal arts
psychotherapy. Among the archetypes emerging during the psychotherapeutic process,
the category of the alter ego is one of the most interesting ones, because it is at the centre
of the identity quest of adolescence.
Already by the midst of the last century, Debesse had pointed to the structuring role of
juvenile imagination (1966). Later discoveries of cognitive psychology (Richard, 1990;
Lemaire, 1999) agreed with him: at adolescence, the development of juvenile imagination
conforms to the newly acquired cognitive possibilities. Thought becomes more subjective
and more objective at the same time, showing capable of making bold constructions and
combinations, anticipations and plans. The adolescent organizes his psychic time in
relation to the past and in relation to the future.
The texts written by the adolescents reflect this structuring role of imagination. In the
stories written under musical induction as well as in the protocols of the Thematic
Apperception Test, the category of the alter ego unfolds its different facets (Schiltz, 2005,
2008). The content analysis of the category of the double, a character of the same sex as
the author of the story, can provide us with interesting indications concerning the stages
of the subjectivization process that is unfolding: They can be aligned according to the
basic psychological needs that they seem to correspond to (Cahn, 1998; Richard, 2001).
The American school of Ego Psychology, describing the development of the Self at
adolescence, seem to be of particular interest in order to understand what happens in the
creation of the archetype of the alter ego: In his last book “How does analysis cure?”
Kohut (1991) distinguishes between 3 needs that have to be fulfilled by self-objects: the
96
need of a mirror experience (need of narcissistic satisfaction), the need to merge with a
strong and soothing self-object (need of an ideal) and the need to feel the presence of a
basic likeness (need of twinning). If the self-objects empathetically respond to these
needs, which implies the presence of optimum frustrations, the Self enables the realisation
of a person’s central life programme, which comprises a harmonious integration of the
narcissistic ambitions and ideals, in accordance with the innate and acquired talents.
3. Results of a qualitative study based on content analysis
In order to answer questions related to the existential significant of the archetype of the
double, we present some data of a qualitative study of protocols of the TAT and the stories
written under musical induction. The analysis was made in the phenomenological and
structural tradition (Mucchielli, 1983) with adolescents who had asked for consultation
and treatment because of emotional or conduct disorders.
3.1. The archetype of the double in the control group.
We will present two examples of images of the double appearing in a non-clinical

population, signalling the need to integrate the split part of the Self; it is the most
frequent category among the control group.
The topic of exaggerated evil and aggressiveness plays an important role with students
who are not at all inclined to act like that in day-to-day life. The forces of evil are often
reflected in the description of a character of the same sex and age as the author’s.
“«She» hit me and I staggered and fell. The knuckle-duster in her hand was
gleaming when «she» raised her fist again and hit me on the nasal bone. A
snap was heard and I felt an acute pain in my head. I felt warm blood
flowing down my chapped lips… «She» was standing in front of me and
smiled condescendingly. Her face seemed familiar to me; maybe I had met
her several times before. «She» approximately had my age, i.e. she was still
quite young. «So, is it enough now? It is fun, don’t you think? », «she» asked
me, almost whispering. We were so close to each other that I could feel her
warm breath. Her shining eyes were waiting impatiently for an answer. «I…
Please, stop! Please! What have I done to you? Please, stop!», I was
babbling, full of hope. «The fact to be begged by a person in a pitiable state
is really exciting. A satisfying feeling, do you understand? ». «She» was in a
state of sadistic excitement. My eyes hurt because of the numerous tears
that I had shed and the numerous punches I had received. Why did this have
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to happen to me? I could not find any plausible explanation. It was like a
nightmare, much too realistic. It was reality…”
TAT Plate 9GF
With the average adolescent, the appearance of an evil alter ego seems to promote the
imaginary and symbolic elaboration of his own destructive drives.
In the following story, the appearance of the double is used to elaborate a feeling of
helplessness and weakness.
"The others were always making fun of him, mocking him and teasing him.
He was somewhat different from the others. He was small and did not know
how to defend himself. He never reacted to the mockeries, he never
reciprocated; the others could have knocked him down, he would not have
made a move. He never ran away and gave the others their head. They did
not stop teasing him and he did not try to change the situation.
One day, during recess, a little boy from his class, who was even smaller than
he was, started slandering him. The little one felt very strong compared to
the one he was teasing. The latter lost control and hit him hard. He hit the
small one on the head and the latter fell. He had to be hospitalised. The
parents wanted the boy who had hit their son to be expelled from school.
And thus he disappeared from school, as discretely as he had arrived, the
boy who everybody else had teased. And all of this only because he had
answered back."
TAT Plate 3BM
In the control group of non-selected students, the images of the double are mostly about
the dimension power-weakness or about the transgression of the forbidden.
3.2. The archetype of the double in the clinical group
The clinical group was constituted by adolescents who had asked for consultation and
treatment for emotional disorders or conduct disorders (Total N= 52). They participated to
individual arts psychotherapeutic sessions during at least six months. For evaluation
purposes, they were included into two subgroups based on the criterion of direction of
aggressiveness: inhibition and direction against oneself: (subgroup I) or desinhibition and
tendency towards acting out (subgroup D). The multimodal arts psychotherapy was based

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on the alternative use of free instrumental and vocal improvisation and the production of
stories under musical induction.
a) Initial typology
Previous research results (Schiltz, 1999; 2004) allowed assuming that the archetype of the
alter ego differs according to the student’s initial symptomatology and that it can acquire
a compensatory dimension during the progress of therapy. In fact, we could confirm a
typology based upon the formal criterion of the quantitative productivity.
Within group I
 a morose type: quite unproductive, vague;

 an anxious type: more productive and inventive, where anxiety is freely
expressed.
Within group D
 a factual type, intellectualising and quite unproductive;
 an immature type, showing raw aggressiveness, with neglected protocols from a
formal point of view;
 a narcissistic type, very productive, showing intense emotional involvement.
Table 1: Typology of the TAT protocols and of the stories written under musical induction
Productivity Productivity Productivity

_ + +
-
Group I (inhibition) Morose type Anxious type
Group D Factual type Immature type Narcissistic type

(disinhibition)
(according to Schiltz, 2004)
The results of the longitudinal study, based on the treatment records of the adolescents
belonging to the clinical group, suggest that the archetype of the double actually varies
according to this typology.
As an illustration, we will present two representative examples of the archetype of the

double appearing at the outset of the therapy in the TAT protocols of the narcissistic and
anxious types:
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Narcissistic type:
"The violin was a part of him, it was his heart that made it come to life, and it
was his soul that made it become immortal. Without this half, he was not
worth more than anybody else. It frightened him to think about this, so he
devoted himself to it until he could not feel his fingers any longer. Despite
his ardent work, he thought that he played badly and that his music was
colourless; like he was playing one single minor note for a whole song. It
seemed to him that his violin was silent, that it did not tell any story… that
we was not able to move like he was supposed to. The little boy wanted to
be perfect. Everybody told him that he was among the best, but for him that
could not be encouraging, because it meant that he was not “the best”. This
thought offended him. His life became meaningless, because, according to
him, that half was dead and without it he was dead in any case. So, one day,
he decided to jump from the top of the hill on the first day of autumn and to
leave behind his violin that would thus remain silent."
TAT Plate 1
Like a vampire, the grandiose Ideal, symbolised by the violin, literally sucked its victim’s
blood. The Self, having completely lost its own vitality, is confined to immolate itself, at
the same time silencing the tyrant’s voice.
Anxious type:
“The mountaineer
The man is climbing at the top of a cliff without seeing the peak. Has he
really got a goal? For once he will see the world from above. Will the rope
not be torn? Does he wonder about this? No, certainly not. In reality, it does
not happen this way, the man lets the rope slip from his hands. Does he want
to commit suicide? Does he want to fly? Nobody knows."
TAT Plate 17 BM
The mentioned state is close to a feeling of depersonalisation. The apparent affective

disentanglement is expressed in a poignant manner by means of the stylistic procedure of
the repeated questions destined to the reader. It is a symbolic translation of the existential
fear in the face of the feeling of emptiness that the adolescent feels inside himself.

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b) Changes in the category of the Alter Ego during therapy
During therapy, a converging evolution appears in the qualitative and stylistic

improvement of the stories and in the fine-tuning of the playing of instruments. At the
level of the improvised music, there was an increasing tendency towards controlled
flexibility of dynamics and tempi, towards the integration of different musical parameters
and towards complex formal structuring. At the level of the stories, there was a parallel
evolution towards the appearance of more existential topics, of archetypal figures
reflecting an increasing degree of affective maturing, of a deepened realisation of social
problems, and, in general, of an expansion of the horizon of interests. Similarly, we witness
a decrease of the archaic defence mechanisms like denial and splitting, ad a progression
towards a more diverse vision of the other and of the self, towards the integration of the
positive and negative aspects of the parental images, and towards a maturing of the moral
authorities.
These tendencies were confirmed in several follow-up studies (Schiltz 2007; Schiltz & al.,
2009). Thus, a compensatory evolution in relation to the typology mentioned above takes
place during the arts psychotherapeutic process:
 In the protocols of the morose type, repression decreases, anxiety unfolds more
freely, and with a simultaneous increase of productivity and of creativity, the
aggressive topics decrease.
 In the protocols of the anxious type, the quality of the cognitive and artistic
elaboration improves, humorous standoff becomes possible.
 For the factual type, the imaginary and affective inhibitions are abolished,
conflictual topics proliferate and feelings of fear and guilt increasingly appear.
 In the final phase of treatment, the immature type is characterised by a decrease

of impulsiveness, the appearance of a better controlled aggressiveness and of
increased moral and social preoccupations.
 With the narcissistic type, the depressive topic becomes more frequent, the
needs of tenderness become more apparent and the quality of the symbolic
elaboration increases.
This change is reflected in the new facets of the double:

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Anxious type phase II:
"She is desperate and escapes out of the door, crying, running, in order to
leave that house behind. She ran without pausing, straight ahead, without
noticing her exhaustion, without thinking about anything at all, as far as
possible, freed from all the thoughts and the problems that oppressed her.
Because where she was going to land, there would not be any more
problems. No more wracking one’s brains: "What is bad? What is good?
Why is it thus and not differently?" It is possible that she was always looking
for problems where there were none. Why complicate one’s life if
everything can be easy? Unfortunately, there are no drugs against
pessimism and gloom… but to live like this and to hide one’s real state is
difficult. …. The day comes when one simply says: "It’s enough. I had
enough." And then, one escapes… not from one’s problems, but in order to
be free. And if it is not possible to leave, the moment comes when one blows
up. Unfortunately, she was desperate and disheartened and did not dare
showing her anger. That is why she did not find any remedy other than
escaping and crying. Let us hope that one day she will be happy and will
discover ease and inner peace on her way.”
Mozart: Symphony Jupiter
In this example, possibilities of cognitive elaboration start surfacing: the transition to

taking personal responsibility is accompanied by an increase in mentalizing (Fonagy & al.
2007). The destiny seems no longer implacable.
Narcissistic type phase II:
“A very long time ago, a poor little boy was looking for food in the forest. He
found a violin next to a dead man. He took the violin and ran away. Arriving
at home, he started playing the violin. He admired this instrument a lot and
played every day as much as he could. After some years, when he was 13
years old, he was the greatest artist on earth.
He started playing in the streets in order to earn some money and give it to
his mother. People admired him, and one day, when he had enough money
to rent a concert hall, he gave a concert with his own compositions. All the
people who had listened to him playing in the streets came to listen to this
talented young man. The concert hall was crowded to overflowing. The boy
gave a wonderful concert. With the money he earned, he rented an even
bigger concert hall. And again, many admirers came to applaud him. At the
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next concert, there were even more, and thus developed the career of a
great artist, who initially had been very poor."
Beethoven: Violin Concerto
In this story, the narcissistic needs and the aspirations towards the idealising summits of
the Ideal Self meet and lead towards a happy evolution. The topic of the poor boy who
becomes rich and famous thanks to his own efforts and not by means of the intervention of
an exterior magical power reflects the hope of a happy future and confidence in one’s own
capabilities.
Immature type phase II:
"Rancho was a little boy who lived with his family in Mexico. His family was
however not of Mexican origin, but of European origin. Rancho’s father had
set up a children’s hospital in Mexico, and that is why the whole family had
emigrated. Rancho is proud that his father sticks up that much for the poor
children. Even though there is neither television nor computer in this region,
he is comfortable. He also made new friends; he attends the same class.
Luckily, his mother spoke Mexican; she could thus easily help him.
Rancho gradually grows up and his parents are no longer very young. One
day, the boy would have to succeed his father as the director of the hospital,
after the former’s death. In the meantime, Rancho had met a young girl who
he married two years later. After three years they had a child. They called
him Jacques, like Rancho’s father. Rancho’s father became seriously ill. At
the beginning he had had a mild cold, but some days later, only machines
could keep him alive. Two weeks later, it was over. He died. Rancho became
director of the hospital."
Magic of the flutes of the Andes
This story, produced by a boy who was formerly immature and unstable, shows a
heightened sense of the succession of the generations and of the problem of filiations as
well as the identification with positive paternal values.

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4. Discussion
The results of the study allow giving answers to the questions asked during the preparatory
phase of the study:
Can we recognise in these symbolic characters compensatory features regarding the

subject’s initial problems?
In the different facets of the Alter Ego, imaginary self-objects, in Kohut’s sense, used for
fulfilling the basic needs of a Self in the making can be recognised. The creation of
negative heroes, who are exaggeratedly bad, corresponds to the imaginary and symbolic
elaboration of violence that the adolescents carry within themselves. The abundance of
topics centred on aggressiveness is not surprising, because, according to developmental
psychology (Bee, 1997), acquiring a personal moral conscience is one of the central tasks
of adolescence. The process of subjectivation is hence appearing through the archetype of
the double by confronting the adolescent with his own hidden parts, as well as with his
ideals and his unmet objectal and narcissistic needs.
Do they gradually expand during the therapeutic progress, so that they reflect the
integration of the hidden and split parts of the self?
The phenomenological content analysis allowed us to establish a typology among the

different categories of the double and the fact that the latter are related to the subject’s
initial problems, defends the hypothesis that they comprise specific compensatory
features and that the subsequent transformations of the double can allow us following the
progress of therapy in relation to a certain type of pathology.
If the adolescents from the control group often playfully mention the monsters inside of
themselves, the adolescents suffering from emotional or conduct disorders linked to a
borderline organisation of the personality seem to have lost the internal freedom and
flexibility vis-à-vis their own imaginary creations (Schiltz, 2005). They completely adhere
to it, not being able to cognitively or humorously elaborate. These are qualities that they
gradually acquire during therapy, depending on the expansion of the archetype of the
double. In Kohut’s words (1991), we witness the evolution of partial and distorted images
of self-objects towards more humanised representations of the self and the other. Our
examples illustrated this process.
By the way, the use of inferential non-parametric statistics corroborated the results of this
qualitative analysis (Schiltz, 2008; Schiltz & al., 2009).

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What is generally their role in the adolescents’ search for identity, beyond the realm of the
pathology?
As the stories can function like a mirror of the self, the archetype of the double with its
different facets can help to enhance self-awareness (Canfield, 1990), which is a crucial
factor in the development of a coherent representation of oneself and the other during
the identity quest of middle adolescence.
What can be the contribution of the content analysis of archetypal figures to traditional
models of verbal psychotherapy?
The use of stories written under musical induction favours the mentalizing capacities
(Schiltz, 2008). Mentalization is a promising concept for the understanding of the
psychotherapeutic process, even if its neuropsychological implications need further
investigations (Donders & Hunter, 2010; Kapur, 2011). It could help understanding why a
combination of an artistic mediation with a verbal approach belonging to the cognitive-
psychodynamic (Bateman & Fonagy, 2006) or to the existential tradition (Cooper, 2003) is
especially efficient with adolescents.
At the level of epistemology, the analysis of the different facets of the double can make a
valuable contribution to the meaning-making approaches of the psychotherapeutic
research (Neimeyer & Ruskin, 2000)
5. Conclusion
The archetype of the double is a message sent to the therapist by the client, a testimony of
his drive for life, i.e. of the self-healing power that he finds within himself. This symbol
allows us to communicate with him in an analogous language, by means of the code
suggested by the client himself.
Many questions still need to be answered, but in any case, the study of the archetype of
the Alter Ego seems to be promising from the point of view of basic research in
developmental psychology and in the psychopathology of adolescence.
The interpretation of the results is all the more fascinating that the concept of the
archetype inserts itself into a long cultural tradition (Bettelheim, 1984; Rogers, 1991;
Valabrega, 2011), exceeding the area of clinical psychology and allowing to make
comparisons with philosophy, musicology, ethno psychoanalysis and cultural anthropology
and to understand in a different way the identity quest of middle adolescence.

105
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Press.
Allen N.B., Sheeber L.B.(Eds). (2008). Adolescent Emotional Development and the Emergence of
Depressive Disorders. Cambridge: Cambridge university Press.
Bateson A. , Fonagy, A. (2006). Oxford : Oxford University Press.
Bee H., (1997). Psychologie du développement. Les âges de la vie. Bruxelles : De Boeck Université.
Bergeret J. (1996). La personnalité normale et pathologique. Paris : Dunod.
Bettelheim B. (1984). Kinder brauchen Märchen. München: dtv.
Cahn R. (1998). L'adolescent dans la psychanalyse. L'aventure de la subjectivation. Paris : PUF.
Canfield J.V. (1990). The Looking-Glass Self. An Examination of Self-Awareness. New York: Praeger.
Cooper M. (2003). Existential therapies. London : Sage.
Debesse M. (1966). L'adolescence,. Paris: PUF.
Donders J., Hunter S. (Eds). (2010) Principles and Practice of Lifespan Developmental
Neuropsychology. Cambridge: Cambridge University Press.
Emerson E., Einfeld S.L. (2011). Challenging Behaviour. Cambridge : Cambridge University Press.
Fonagy P., Gergely G., Jurist E.L., Target M. (2007). Affect Regulation, Mentalization and the
Development of the Self. London: Karnac.
Jung C.G. (1964). Man and his symbols. New York: Doubleday and Company.
Kapur N. (Ed ;) 2011). The Paradoxical Brain. Cambridge : Cambridge University Press.
Kohut H. (1991). Analyse et guérison. Paris: PUF.
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Marcelli D., Braconnier A. (1999). Psychopathologie de l’adolescent. Paris : Masson.
Mucchielli A. (1883). L’analyse phénoménologique et structurale en sciences humaines. Paris : PUF.
Neumeyer R.A., Raskin J.D. (Eds) (2000). Constructions of Disorder. Meaning–Making Frameworks
for Psychotherapy. Washington D.C: American Psychological Association.
Richard F. (2001). Le processus de subjectivation à l’adolescence. Paris: Dunod.
Rogers R. (1991). Self and Other: Object Relations in Literature and Psychoanalysis. New York: New
York University Press.
Schiltz L. (1999). Musique et élaboration imaginaire de l’agressivité à l’adolescence. Evaluation
d’une expérience thérapeutique. Thèse de doctorat en psychologie clinique. Paris: Université Paris-
V.
Schiltz L. (2004). La fonction du double à l’âge de la quête d’identité. La Revue française de
Psychiatrie et de Psychologie médicale, VII (80) ; 51-55.
Schiltz L. (2005). Dysfonctionnements cognitifs liés aux pathologies limites à l'adolescence. Etude
comparée de quelques tests projectifs. Neuropsychiatrie de l’Enfance et de l’Adolescence, 53 (3) ;
107-113.
Schiltz L. (2007). L’art thérapie en milieu scolaire : un outil de prévention tertiaire en
psychopathologie de l’adolescence. Revue Francophone du Stress et du Trauma, 7(3) ; 152-161.
Schiltz L. (2008). Histoires écrites sous induction musicale : Une contribution au psychodiagnostic, à
la psychopédagogie, à la psychothérapie et à la recherche. Courlay : Fuzeau
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Tome 1 : Domaine psychopédagogique et développemental
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Tome 2 : Domaine clinique et psycho-social

Silvermann W.K, Field A.P. (eds). (2011). Anxiety Disorders in Children and Adolescents. Cambridge:
Cambridge University Press.
Valabrega J.-P. (2001). Les mythes, conteurs de l’Inconscient. Paris : Payot & Rivages.

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Apollo, Venus and Pan:

Internal myth, object
relation, creation in an
art-psychotherapeutic relational
context and reality
Ruy de Carvalho
The function of the internal myths: their organization and evolution
While reflecting upon the emergence of psychic phenomena and their evolution based on
my patients’ processes in Art-Psychotherapy, with me, in particular, Group Analytic
Psychotherapy, I began to realize how internal configurations were organized and
expressed either by their creations or by the peculiar way they relate themselves in the
context of the sessions or how their relational experience developed in the daily life.
This fact has improved my thought in terms of integrating different dispersed knowledge,
and lead me to rethink about the function of the so-called internal myths.
There is a long history of references to myths in psychotherapy, in particular, dynamic

psychotherapy, starting with Freud with the Oedipus Complex and other allusions to Greek
myths such as Eros and Tanatos, and also Jung and his followers, who have tried to
associate different aspects of the unconscious psychic functioning with classic myths, but
they have also dedicated themselves to understand the contemporary social myths.
The role of the myths in terms of different cultures and societies is, undoubtedly,
unquestionable. The function of the myth at this level is to answer synthetically to the
imperative existential questions, to introduce order and social rule to the Chaos of the

108
relational experience and to calm down the anguish of the Great Doubt concerning the
sense of existence.
That is then, the essential quality of the myth. According to Pedro Barbosa (1915):
“The myth creates symbolic reading mechanisms of the reality… as a symbolic system of
the knowledge…”
(Barbosa, Pedro, In: “Metamorphoses of the Reality – Art, Imaginary and Aesthetic
Knowledge”- (Edições Afrontamento, Coleção “Grand’Argular/8, Porto, 1995).
Thus, it becomes a complex system of “modelling of the reality” within what it has in
common with the “logical” rational record, typical of the science, the one of the logic of
identity. But this one, in spite of its quality of linear logic, can also be mystified, as we can
see nowadays in many myths of the present society. Old myths have nowadays a scientific
approach in order to give credibility to extraterrestrial technology, biological energy fields
influenced by the universal quantum dimension, auras and extrasensory powers or parallel
dimensions where post-mortem life continues, among many others. Psychologists,
psychiatrists or psychotherapists know through their clinical experience, that patients with
schizoid characteristics need to adhere to such myths as a way of ensuring their psychic
homeostasis, where the existence of great references is necessary, so that they do not get
troubled due to the helplessness of the psychic chaos. In this way, the myth achieves
essential quality and validity and it is not our role to question an equilibrium based on
alternative premises as long as they are functional, shareable and promote meaningful
existence.
Now I would like to open a parenthesis and contextualize before I further develop my
presentation. When we refer to myths, we must distinguish among the classic, religious or
cultural myths and the internal myth. As far as the former are concerned, the classic or
religious myths, they always have their origin in fear and belief in unknown powers that
man attributed to beings different from themselves and superior to him. They translated
parallel human experiences. Their purpose was to order the world with the unknown
powers towards the man. Often, they do not establish a demarcation between the man,
the animal, the vegetal and the inorganic bodies. Sometimes, they are horrendous and
violent. The older the myth is the more it relies on magic-animist parameters. They have
markedly a religious character and a connection with the evolution of that feeling.
Under the technical point of view, the myth represents a synthesis between the rational
and the irrational. The cultural myth shares with the personal one, the fact of having been
created from a conflict, since it appears from someone, although there is later the share of
the collective. A certain number of facets of the individual is expressed by a certain
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number of characters. It is similar to the dream. As far as the ancestral myth is concerned,
the characters are imagined under its universal aspect.
A myth transmits necessarily a message. That message is created in a conscious way with
influences of the unconscious, by the creator of the myth. Thus, it depends not only on the
intuition of the individual but also on the historic context, which become overlapped.
Partly, the message escapes from the conceptualization assuming an analogical logic. A
myth is an argumentation, trying to fascinate. When it takes the form of a revelation, it
assumes or can assume an enhanced power in society. Fascination implies an
identification. The myth creates, necessarily, the hero, as much as the incarnation of the
archetype ideal of the individual and therefore, of the society.
A myth tries to gather or gathers a function of social nature at the psychological level. The
functioning of a society implies the acceptance of a myth or of a set of myths, but it is
always in evolution. Therefore, stable societies do not exist, as well as perennial myths do
not exist.
Under the ontological point of view, the myth is a mediation or attempt to provide an
answer to the existential chimeras, with a stabilizing effect in the psyche of the individuals
of a society.
“Without knowing and understanding the ideas and the images on which the modern or
the past consciences were based, it is not possible to understand our own time. Rites,
ceremonies, traditions and usages even completely laicized nowadays are often heritages
from beliefs and religions, persistent or extinct long time ago; however, philosophies,
literatures and arts from all epochs and from all countries near or far from ours are still
today impregnated with them”.
Another characteristic of the myth is to tend functionally to unity (towards the

reconciliation of the individual with the world). According to Aristotle, such unity
represents the natural place of the individual and is an expression of the inviolable. It is
out of the space-time. At the psychological level, a space-time is always associated with
the individual’s activity. Thus, the unity is of irrational nature. That unity is the normative
unity of the individual. It is of ideal nature. In this way a myth protects or tries to protect
the individual, and when doing so, it confirms it.
Generally, notions of justice or of taboo (the inviolable) are involved, which are
indissoluble from the notion of order. This order is of ontological nature and, in other
words, it can only be comprehended by the conscience of the individual in an incomplete
way (Korónlos, philosopher).

110
Concerning the personal myth, according to Feinstein and Krippner (1988) the designation
was coined by Ernest Kris, psychiatrist, in 1956, who used it to “describe certain elements
allusive to the human personality, which the psychoanalysts must take into account if they
want to obtain durable effects”.
According to James Hillman the “myths speak with the psyche in their own language; they
speak emotionally, dramatically, sensually and fantastically”.
For Feinstein and Krippner (1988) the myths, in opposition to Script, of attitudes or beliefs
“are able to access to the archetype dimension of the human mind, which transcends the
early conditioning and the cultural context”. They still add that regarding personal myths
“they are ways of organizing the experience, which can ultimately be considered as more
or less effective for the well-being and performance of an individual or a group”.
Feinstein, D. and Krippner, S. in: “Personal Mythology. The Psychology of your Evolving
Self. Using Ritual, Dreams and Imagination to Discover Your Inner Story”; Jeremy P.,
Tarcher, Inc. Los Angeles, 1988.
Later in this presentation I will refer again to the ideas of Feinstein and Krippner and will
add some personal reflection.
The psychic dimension of the personal myth is based on a “logic of analogy in the symbolic
thought” and on a kind of “the third included principle“ … where the “mythic-poetical”
creation while generating internal myths which allow the organization of the experience,
gains primacy. This has qualities of divergence, that is to say… «the explosion of the one in
the multiple» (Jean Chevalier), of extrapolation, of generalization, of resistance to
argumentation and to the reality test, offering itself as an alternative or a perspective of
reality. In a healthy way it will have a progressive quality with the possibility of
transforming itself. In the case of being pathologic, it will become fixed as it is proper to
mental disorders.
It occurs to me the evolution of the mythic record of a patient, where the personal and the
religious myths overlap. It is the case of a young lady, in her 30s, who have passed through
a frightening experience of a contact with a dimension of angels but also of demoniacal
figures. Early in her childhood she suffered sexual abuse. This fact distorted the relational
myths present in a healthy and well succeeded childhood. The reference of abuse while a
relational-existential perspective was present during her adolescence under the form of
non-belonging drama and she felt excluded and attacked by the peers. The beginning of
adulthood was painful with unsuccessful loving and professional experiences, where the
imminence of “attack” to narcissism existed while subjective perspective. Therefore the
possibility of transforming the myth early established from the experiences of abuse failed;
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furthermore, the autonomy necessary for an individuation providing psychic cohesion,

existential significance and relational satisfaction is frustrated.
After a suicide attempt, she told me about her survival: “It was a miracle”. Her need of
empathetic strengthening, lead me to answer to her, in spite of not sharing with her
religious beliefs: “Indeed, it was a miracle”. Afterwards, she devoted herself to a religion,
searching for a redemption myth which could be adopted by her. This provides her a
mystical investment, supporting existential pain and emptiness, empowering her to
believe in life again, as a possibility of sense, love and fulfilment. In this period she invests
again in art creation, where the gradient of good, beautiful and sublime provides her a
background of regulation and sustainability. We know from James S. Grotstein (1999)
(Grotstein, James. S. In: “O buraco negro” (The black hole) Climepsi Editors, Lisbon,
October 1999) that the “symbolic (and pre-symbolic) transformations of the cognitive and
emotional significance of the experiences constitute the object of the mind”… Therefore,
the mythpoiesis record of the artistic activity can be the supplier of the support that
enables the structure and the organization of the psychic life, since it provides organizing
creative psychic references, promoting an active intrapsychic symbolic interactionism.
This is one of the motifs pointed out regarding the creative compulsion of the psychotic
patient. When we work with this kind of patients, we must share, though temporarily, with
their present myths, while beliefs. If the antagonism between our own myths about reality
and those of the patients is very intense, then the possibility of an empathic and symbolic
intersubjectivity becomes difficult, and an obstacle to the patient´s understanding may
oppose a fruitful psychotherapeutic relationship. In turn, the synergism of the myths is also
an obstacle to help the patient within the analysis of the internal reality, since the
perspective of the “present reality” at the service of resistance is more intense, as “João
Azevedo e Silva” reminds us of.
Our task of extrapolating from classic myths is easier since we deal with myths which due
to the distance do not oppose our present myths. It will be more plausible to understand
the psychic processes put into action both metaphorically and metaphysically, when
looking to the old myths or to those which are culturally more distant, than to those which
are nearer or in which we are immersed, accepting them as present “reality”.
I dare to make some questions: “Who is Zeus or Jupiter for you?”
Or, “What is Zeus or Jupiter?”
Or still: “Do you believe in Jupiter as a God?”

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Facing such questions, none or little kerfuffle will be created. The most probable and
present answer will be that Zeus is the ancient Greek god who presided the Olympus and
Jupiter, his roman equivalent. Thus, he is a pagan god and therefore a false god, or a god
who lost his cultural context. So, it is not probable to believe in Jupiter as a God. The
question is pacifying and even viable for free associations.
Freud, a lover of the Greek classic culture, evidenced by the quantity of archaeological
artefacts belonging to his ancient art collection, based on the myth of Oedipus, Laius and
Jocasta, to refer to the universalization of the triangular theory of relationship which
culminates with the evolution of the internal construction of the object relation in the
child. According to him, the successful resolution of the complex is indispensable in order
to ensure the balanced interdependent autonomy of the individual, thus enabling a
satisfactory intimacy and to keep the psychic stability. Within this purpose it will be
necessary to overcome the libidinal fixation towards the progenitor of the opposite sex
and the hostile desire of aggression towards the parental figure of the same sex.
Since Freud, we have observed a race to the myths, with interpretations more or less
hermeneutic, more literary or less realistic, resorting to anthropopathy, to anthroposophy,
to the currents of psychology or of the Gnostic mysticism. Furthermore, some lines of the
psychological thought intend to reduce the comprehension of the human psychic
functioning to the extrapolation, through ancient or modern myths. It seems to me more
complex what occurs when we intend to reduce the internal experience or the
psychological suffering of patients to this or that myth. In fact, there are myths for all kinds
of taste. The Oedipus myth itself has been object of several attempts by authors to “steal”
it from Freud, with the purpose of offering other perspectives of it, through a brilliant
eclecticism, thus willing to share his glory, who only wanted to illustrate and indicate a
particular aspect of the psychic functioning. The interpretation of Paul Diel about the
Oedipus myth is an example of this.
The diversity of both religious and cultural myths is, in fact, so varied, that it is possible to
use them to reference or illustrate the most diverse aspects of people’s psyche.
Nevertheless, I must reconsider the risk of formatting and of reductionism of the
individual’s internal experience to a partial even adulterated comprehension of the total
mental functioning. It is even more complicated when the therapist intends to foist or to
prescribe ancient or cultural myths to the patients with the aim of signalling or better
understand their internal experience. However, it is perfectly viable that some myths
related with particular themes are in association with particular technical-artistic
resources in the planning of an Existential Art Therapy within a specific scope.

113
However, the myths may become important in order to unlock a self-absorbed, closed and
egocentric perspective, enabling to provide references of the universality of multiple
emotional experiences.
Several myths have been pointed out as allusions to aspects of the psychic life:
- Sisyphus, named by Camus, a symbol not only of the human perseverance facing its
existential drama, but also of the emotional intelligence;
- Antigone, daughter of Oedipus, personifying piety and filial dedication;
- Electra, as a reference to the Oedipus complex in the woman:
- Saturn, referenced in conflicts between parents and children;
- Abel and Cain, protagonists of the sibling rivalries;
- Ariadne, as illustration of love lost and female depression, but also of the love rescue
represented by the thread which helped Theseus to save himself from the labyrinth of the
Minotaur;
- The labyrinth of the Minotaur, as a metaphor for the sinuous road of life, where death
can happen at any time;
- Daedalus, who built the labyrinth of Crete, as a prototype of the wise and creative
elderly;
- Philemon and Baucis, representing the dependence links of the elderly and their inability
to face mourning when losing their companions.
- Icarus, symbolizing the impetuosity and the euphoric fascination of the young person,
but also the risks of omnipotence.
It would be even useful to remember the present Portuguese governments, of Troika

democracy, which with their measures of systematic cutbacks in the elderly pensions, run
the risk of making the legend of the Visigoths, ancestral people of our culture, come true;
according to this legend, the Visigoths would throw the elderly from a precipice when they
became disabled.
I could go on, signalling through the myths, almost all aspects of the psychic activity.
Afterall, the myths were created by people. When I began reflecting upon the present
114
theme, I imagined to which ancestral myths I could resort, in order to represent in

metaphors some of my ideas regarding the mythical gradient in which the Art-
Psychotherapy sessions, in particular, Group Analytic Psychotherapy, took place. Under
this point of view, I have been perhaps influenced by some of my favourite old myths.
Within a very free way we could say that in the imaginary space where the Art-
Psychotherapy session is performed, myths equivalent to Ancient Gods operate:
- Apollo, god of the day and of the light, and thus of the reason, as well as of the
combative aggressiveness, always victorious. His harmony is reflected on the equilibrium
of the desires, since he gathers in himself multiple oppositions, culminating in an ideal of
wisdom. In accordance with some theologies, he was first a god of the night, shining like
the Moon, with a silver bow which is also transformed in a harp. He is a god that vivifies the
living beings, heals the evils of the humanity, but also kills. Through the sibyls, he provides
the intuitive and revealing oracles. The power of “not to suppress the human impulses”
and lead them to an awareness or “progressive spiritualization thanks to the conscious
development” is attributed to him. (Jean Chevalier and Alain Gheerbrant, 1982)
We could associate with the Apollo primacy, the synthesis of the opposites proper to the
creative process put into action in the art making of the Art-Psychotherapy sessions,
providing the evolution of the significances, leading to the healing process.
- Aphrodite, goddess of the sublimation of the “wild love, integrating it in a really human
life” (Jean Chevalier and Alain Gheerbrant, 1982). Lunar par excellence, she can be
associated with the human passion, with connection to the animal of its nature, but also to
the propensity to the genital affect relationship, operating at a level nearer the
unconscious.
The influence would be carried out not only through the passionate pleasure involved in
the act of creation, but also through the propensity to configure an object and binding
relation between the patient/creator and the art-psychotherapist, which has a sublimated
purpose: the transformation or healing of the individual.
- Pan, a god of an obscure nature, with the connotation of god of All and thus containing
an essential genesis energy. He is a flute player, defender of the untouched nature,
promotes hoaxes, chaos or fate proper to life path and causing existential uncertainty. He
is associated with Dionysian cults and to the Echo myth leaving open his connection to
Narcissus. Some people see in him the incarnation of the universe itself. His sexual desire
is unending, insatiable and onanistic. He named the word panic, the terror which spreads
through the whole being. In Art-Psychotherapy, so I imagine, it would correspond to the
dimension of the unknown in the minds of both the patient and the art-psychotherapist,
where the intuition and the creation powers merge, in the search of completeness in a
115
psyche based on total object representations, providing a supported significance of all,

that is to say, of the existence, which if not achieved, lead the individual to the panic of
mind rupture. According to Fernando Pessoa, he is in his essence, a creator and a destroyer
god simultaneously. This poet dedicated him a beautiful hymn.
Hymn to Pan
(by Master Therion)
Thrill with lissome lust of the light,

O man! My man!
Come careering out of the night
Of Pan! Io Pan!
Io Pan! Io Pan! Come over the sea
From Sicily and from Arcady!
Roaming as Bacchus, with fauns and pards
And nymphs and satyrs for thy guards,
On a milk-white ass, come over the sea
To me, to me,
Come with Apollo in bridal dress
(Shepherdess and pythoness)
Come with Artemis, silken shod,
And wash thy white thigh, beautiful God,
In the moon of the woods, on the marble mount,
The dimpled dawn of the amber fount!
Dip the purple of passionate prayer
In the crimson shrine, the scarlet snare,
The soul that startles in eyes of blue
To watch thy wantonness weeping through
The tangled grove, the gnarled bole
Of the living tree that is spirit and soul
And body and brain – come over the sea,
(Io Pan! Io Pan!)
Devil or god, to me, to me,
My man! my man!
Come with trumpets sounding shrill
Over the hill!
Come with drums low muttering
From the spring!

116
Come with flute and come with pipe!

Am I not ripe?
I, who wait and writhe and wrestle
With air that hath no boughs to nestle
My body, weary of empty clasp,
Strong as a lion and sharp as an asp –
Come, O come!
I am numb
With the lonely lust of devildom.
Thrust the sword through the galling fetter,
All-devourer, all-begetter;
Give me the sign of the Open Eye,
And the token erect of thorny thigh,
And the word of madness and mystery,
O Pan! Io Pan!
Io Pan! Io Pan Pan! Pan Pan! Pan,
I am a man:
Do as thou wilt, as a great god can,
O Pan! Io Pan!
Io Pan! Io Pan Pan! I am awake
In the grip of the snake.
The eagle slashes with beak and claw;
The gods withdraw:
The great beasts come, Io Pan! I am borne
To death on the horn
Of the Unicorn.
I am Pan! Io Pan! Io Pan Pan! Pan!
I am thy mate, I am thy man,
Goat of thy flock, I am gold, I am god,
Flesh to thy bone, flower to thy rod.
With hoofs of steel I race on the rocks
Through solstice stubborn to equinox.
And I rave; and I rape and I rip and I rend
Everlasting, world without end,
Mannikin, maiden, Maenad, man,
In the might of Pan.
Io Pan! Io Pan Pan! Pan! Io Pan!

117
Rephrasing the question I have made a short while ago, if I ask:
- “Who is God?”
Or: - “What is God”?
Not to mention: - “Do you believe in God?”
Certainly, polemic and even animosity will arise now, with the actual dogma presented as
unquestionable, as an imperative reality. I would not dare, at this time, to use my
metaphoric and associative imagination in a free way as I did before with the ancient
myths I referred to, in spite of having on my mind, the challenging book of Françoise
Dolto, “The Psychoanalysis of the Gospels”. But this quality of unquestionable dimension
of the myth is of invaluable value for the human being and it is intimately rooted in the
emergence of a mind in itself, on the threshold of times when it started spreading
throughout the planet. Thus, intimately rooted in the flourishing of complex cultures in the
human groups, it was implicit the mythpoiesis mechanism, or automatic myth-making
proper of the human cerebral functioning, being inherent the processing of the external
reality perception and the production of a thought translatable in an effective behaviour
in managing survival and procreation. But from the moment that the individual develops a
capacity to question and to put in doubt, he is also exposed to the distressing horrors of
transitoriness, precariousness, the imminence of suffering, fragility and anticipation of
death, among other inevitabilities proper to malice of life, released when Epimetheus
opened the box in possession of Pandora, her wife, by order of Zeus.
Thus, the intra-psychic mythpoiesis capacity has, first of all, two essential functions:
- to complete the experience from which we only have a partial perspective, involving
complex cerebral mechanisms of processing perceived information with implications in
the psychological field;
- to protect the individual from the devastating and excessive experiences which can
disturb the mental functioning, like those I have mentioned before.
As for the psychic processing mechanisms that can be pointed out as involved in the
mythpoiesis, these have in general the purpose of completing the imprecise information. It
is known, for instance, that information transmitted by our eyes to the brain is not perfect
and is completed by the occipital lobe, among others, in order to enable a three-
dimensional vision and a reliable perception of movement. This is one of the brain innate
functions, related to fantasy, whose objective is precisely to complete the experience,
among others, involved in the production of imagetic thought by the brain, which is, for
118
some researchers, its main function. Vetting is another of the mechanisms involved that
can privilege movement perceptions, but also influence the movement perception where
it does not exist. In this way, sometimes the brain deceives or plays tricks on us. The role of
the mirror-neurons has been appointed concerning many phenomena of extrapolation of
the perceptive information.
The synesthesisa, though not very common, correspond to psycho-sensory phenomena, in

which a stimulus occurred by the perception of a sensory mode is transferred to another
one. According to Doron and Parot (2001), an example of this is the case of the composers
Scriabine and Messiaen, who have referred a “colour hearing” caused by music. Recent
studies with positron emission tomography revealed the increase of the cerebral blood
flow in the left inferior and right frontal postero-temporal areas, without involving the
areas of the primary visual cortex related with the report of vision of words associated with
colour. Another mechanism we can associate with this is the intermodal transference
through which a learning made through a sensory variant reflects over a learning of
another sensory modality.
Several laws regarding perceptual organization of Gestalt theories can also be mentioned
within a mythpoiesis field:
- “Law of proximity: the elements spatial or temporally near tend to be grouped in the
same configuration;
- Law of similarity: the similar elements belong to the same configuration;
- Law of symmetry: figures with one or several axis of symmetry are recognized as good
shapes in an easier way;
- Law of continuity: a configuration whose elements are oriented in the same direction is
recognized as a good shape;
- Law of closure: tendency to build configurations which do not present gap“.
(Doron, R. and Parot, F. in: “Dicionário de Psicologia” (Psychology Dictionary). Climepsi

Editors. 1st. Edition, Lisbon, October 2001).
We can still include in these laws, the law of isomorphism, which considers (roughly) that a
shape configured in the external reality corresponds always to a shape configured
internally.

119
Empirically, I can extrapolate that equivalent to these different mechanisms involved in

the processing of perceptions can also be implicated in the thought processing itself, and
therefore in the mythpoiesis mechanisms. Its reference is relatively familiar for the art
psychotherapists through the observation of the way their patients-creators retain their
creations and reflect upon them. Very often we observe, in particular, in group, the use of
syllogisms and absurd reasoning to build the significance of the creative product.
Levi-Strauss defined the myth as the “logical tool” in order to conciliate diachronically
(under an evolutionary point of view, in time) the semantic entities (the ritual considered
as a meaningful unit) which cannot overlap synchronously (under the purely describing
point of view, of the different rites which constitute the ritual)”. (Rodriguez, Jean and Troll,
Geoffrey, in: “L’Art-Thérapie-Pratiques, techniques et concepts. Manual Alphabétique.
Edition Ellébose, Paris, 1995).
The use of such mechanisms related to mythpoiesis seems to have a particular purpose:
enabling to deal with the incomplete experience, the one that causes uncertainty, doubt
and even fear, since the survival to the predators in the nature, depends on the fast
decision-making against the signs. If we infer that at the internal level, the psyche is
organized in a way similar to its predisposition to deal with the external reality, then a
sense must be attributed to everything causing uncertainty, doubt, anguish or fear, and it
must be configured in a way to become sustainable, keeping the psychic equilibrium. Thus,
there is a tendency to organize complex behaviour schemes, based on the learning
through experience, which can provide foresight and anticipation. This is true with regards
not only to the survival experience but also to the relational experience, which are related
in the human being.
The personal myth, (I prefer to call it the internal myth) has therefore an essential function
of making “objectified”, contextualized and sustainable all the experience involving a
threshold of uncertainty or unknown. It will be functional when enabling the affective
psychic homeostasis, and rational, and it can be modulated throughout the existence.
Nevertheless it becomes dysfunctional when facing a precocious devastating and
excessive experience, or an innate disability of the individual, the possible equilibrium
brought by the internal myths is precarious, rigid and related to the mental disorder. Even
so, it can be put at the service of a possible psychic equilibrium. In this way, the religious or
the cultural myth and the internal myth share a paramount vocation: to conjure the
devastating anguishes of the existence, such as the time, implying a transitory existence,
the existential pain and the death.

120
REFERENCES
Carvalho, R. Um amor do Coração: Arte-Terapia em Portugal – Uma perspetiva plurifacetada. In:

Arte Viva. Revista Portuguesa de Arte-Terapia. Nº3, 2013.
Carvalho, R. Criação Terapêutica nas Instituições – Teoria e Técnica. In: Arte Viva. Revista Portuguesa
de Arte-Terapia. Nº3, 2013.
Carvalho, R. Introdução à Arte-Terapia. In : Arte Viva. Revista Portuguesa de Arte-Terapia. Ano 2 nº2,
2011.
Carvalho, R. Os tabuleiros de areia e o jogo da areia e arte-psicoterapia integrativa. In : Arte Viva.
Revista Portuguesa de Arte-Terapia. Ano 2 nº2, 2011.
Carvalho, R. Princípios para ser feliz. In : Arte Viva. Revista Portuguesa de Arte-Terapia. Ano 2 nº2,
2011.
Tagarro, M., Catarino, S. & Carvalho, R., (2010). Arte-Terapia : Arte de Ser Criativo – Três Olhares
Complementares. Cidade Solitária, 23. 190-197.
Carvalho, R. Le « paradoxe de l’exclusion » Fonction intégratice de lArt. Exclusions et Art-Thérapies.
Sous la direction de Jean-Luc Sudres. L’Harmattan, Paris, 2010.
Carvalho, R. Art therapy/psychotherapy – the portuguese perspective : from instituitions to private
practice. In : Jubilé de la SIPE. From Yesterday to now/ D’ier à aujourd’hui. Publication de la Société
Internationale de Psychopathologie de l’expression et d’Art-thérapie (International Society for the
Psychopathology of Expression and Art-Therapy). Direction de Jean-Luc Sudres. Rencontres
Internationales SIPE-at/artesia, Castres, 2009.
Carvalho, R. A arte de sonhar ser. Fundamentos da Arte-Psicoterapia Analítica-Expressiva. Edições
ISPA. Lisboa, 2009.
Carvalho, R. Construindo pontes com a imaginação: Arte-Psicoterapia Analítica Grupal. In: Arte Viva.
Revista Portuguesa de Arte-Terapia. Ano 1. Nº 1. Lisboa, 2009.
Carvalho, R. Nuances techniques de l’évaluation en art-psychothérapie. In: Forestier, R. (Org.)
L’évaluation en art-thérapie. Pratiques internationales. Elsevier Masson. France, 2007.
Carvalho, R. O polimorfismo da arte de sonhar ser. In: Revista Científica de Arteterapia Cores da
Vida. Ano 2. Vol 3. Nº 3. Julho-Dezembro, 2006. Disponível em:
http://www.brasilcentralarteterapia.org
Carvalho, R. O drama da não pertença: paradoxo da exclusão, a função integradora da arte. In:
Coleção Imagens da Transformação: Rio de Janeiro, Nº 12, Volume 12, Clínica Pomar, 2006.
Carvalho, R. Arte-terapia: identidade e alteridade. Uma perspectiva polimórfica. In: Arte Terapia:
Reflexões: São Paulo, Nº 6, Sedes Sapientiae, 2006.
Carvalho, R. A arte de sonhar ser. In: Coleção Imagens da transformação: Rio de Janeiro, Nº 8,
Volume 8, Clínica Pomar, 2001.
Carvalho, R. Matizes da Vida. Edição Baldacci, 1997 (Livro de poesia).

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Art Therapy Portuguese Magazine

Nº4 . October 2014

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Art Therapy Portuguese Magazine

Art Therapy Portuguese Society

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Sociedade Portuguesa de Arte-Terapia

Propriety and Editor Collaborators

Legal Deposite 298498/09 Grafic Project

Periodicity Any kind of layback is forbidden without

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

In this international edition we have the participation of professionals with a broad

My contribution to International ARTE VIVA is an article presented in 2009 in Lisbon at the

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Jean Luc Sudres - Parallèlement à une formation en Psychomotricité, Jean-Luc Sudres, né

Actuellement, J.L. Sudres est Professeur de Psychologie à l'Université Toulouse-Jean

En 2009 J.L. Sudres a créé à l'Université Toulouse-Jean Jaurès un Diplôme Universitaire

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Lony Schiltz - PhD in Clinical Psychology, Habilitation to Direct Research,

Régis Bernadet - Doctor of psychopathology and psychologist, he write a doctoral thesis:

Ruy de Carvalho - Degree in medicine, Art Therapist/Psychotherapist. Founder and

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

La médiation théâtrale et l'obèse. Application et évaluation clinique

Lárt dáccompagner ládolescere

The Sad Look of Medusa - Mythology and Depression in Art Therapy

Therapeutic love. A Necessary Convergence

Art as Therapy in Times of Crisis

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Vanessa Roma***, Frédéric Sanguignol**** et Christian Prim*****

Dans la littérature, l’obèse souffre généralement d’alexithymie(Mariage, Cuynet, Godard

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

La prévalence des troubles du comportement alimentaire dans la population des patients

2. TROUBLE DU COMPORTEMENT ALIMENTAIRE (TCA) ET ART THÉRAPIE: UNE

2.1. La controverse classique et stérile ?

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

2.2. Ce que nous pouvons dire de la recherche actuelle

La revue de la littérature fait tout de même apparaître un certain nombre d’objectifs

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

2.3. Troubles du Comportement alimentaire et psychodrame

Le psychodrame, comme les autres formes de thérapies médiatisées, a aussi l’avantage de

2.4. Trouble du comportement alimentaire et dramathérapie

2.5. Obésité et Théâtre thérapeutique

En somme, l’étude des courants théâtraux et des différents dispositifs de théâtre

On comprend aisément la question provocatrice de Frisch & al (2006), l’art-thérapie avec

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

3. MISE EN PLACE D’UN DISPOSITIF DE THÉATRE THÉRAPEUTIQUE POUR LES PATIENTS

3.1. L’activité de théâtre thérapeutique

3.2. Les séances

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

- présentation du théâtre-thérapeute, de l'atelier, des règles intersubjectives et de la

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

corps/amure face à la stigmatisation (Rousseau 2004), il protège des relations

- retour sur les deux séances précédentes

- rappel des règles intersubjectives

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

Cette improvisation peut renvoyer le patient à ses difficultés de communication, pour

- chez le notaire, un héritage surprise «quasi ridicule » : L’improvisation se déroule chez le

Art Therapy Portuguese Magazine ARTE VIVA . nº 4 . October 2014

l'autre. Cette improvisation amène aussi à aborder la culpabilité que la non-

4.3. Les outils utilisés

- L'Echelle Toulousaine d'Estime de Soi (ETES) de S. Esparbès, F. Sordes-Ader, N. Oubrayrie

Vanessa Roma*, Frédéric Sanguignol et Christian Prim***