Integrative Arts Psychotherapy in a medium secure unit

1. Integrative Arts Psychotherapy in a medium secure unit Sandrine Maurer The Eric Shepherd Unit Hertfordshire Partnership Trust This presentation is an attempt to Explore the adaptation of this model to this particular field of forensic Some of my colleagues have presented the unit In brief:…..This presentation is an attempt to Explore the adaptation of this model to this particular field of forensic Some of my colleagues have presented the unit In brief:…..

2. Context The Eric Shepherd Unit is a regional medium secure unit providing forensic services to people with learning disabilities detained under a section of the Mental Health Act, 1983. The unit offers a comprehensive assessment and treatment programme. ……….……….

3. Client group The client group consists of adult males who present complex needs including learning disabilities, personality disorders, often with mental health problems and a forensic history. As you are already aware………As you are already aware………

4. Presenting issue The patients generally demonstrate little conscious control over their impulses and often have little insight into their complex psychological processes and motivations. So how does creative arts psychotherapy specifically address those two problem? So how does creative arts psychotherapy specifically address those two problem?

5. Integrative Art Psychotherapy An integrative model A humanistic psychotherapy A multi-arts modality . It integrates various models : psychoanalytical psychotherapy, objects relations, humanistic psychotherapy, attachment theory etc and is Basically a humanistic psychotherapy Focus on what it means to be human, an embodied person in a world with others .Traditionally known as a talking cure, but patients can find it difficult to talk And it can be difficult to know if it is: - unconscious repression, - bloody mindedness, - or an incapacity due to the learning difficulties Arts can help reveal what may not be so easy to say or hidden (though it has to be noted that because of that it can also make it a difficult process by itself) ….. It integrates various models : psychoanalytical psychotherapy, objects relations, humanistic psychotherapy, attachment theory etc and is Basically a humanistic psychotherapy Focus on what it means to be human, an embodied person in a world with others .Traditionally known as a talking cure, but patients can find it difficult to talk And it can be difficult to know if it is: - unconscious repression, - bloody mindedness, - or an incapacity due to the learning difficulties Arts can help reveal what may not be so easy to say or hidden (though it has to be noted that because of that it can also make it a difficult process by itself) ….

6. Integrative Art Psychotherapy Patients are able to express themselves in ways other than speech Use of creativity for exploration Sessions as part of a whole process involving a multi-disciplinary team It provides Different vocabulary/ language. The use creative imagination and metaphor offers many avenues for exploration: Different sense - different human experiences (list) sand tray Explore behaviour and relationship, feelings Provides out let/ arena for understanding/ making sense of .an other element of adapting this model to a forensic unit is MDT, review, case conference etc / confidentiality Having to balance a beginning, middle and end and to help with transition from session to unit. To communicate with nursing staff I will use an example as an illustration, you will appreciate that in the time given, I will only give a very brief outline of the patient etc……. It provides Different vocabulary/ language. The use creative imagination and metaphor offers many avenues for exploration: Different sense - different human experiences (list) sand tray Explore behaviour and relationship, feelings Provides out let/ arena for understanding/ making sense of .an other element of adapting this model to a forensic unit is MDT, review, case conference etc / confidentiality Having to balance a beginning, middle and end and to help with transition from session to unit. To communicate with nursing staff I will use an example as an illustration, you will appreciate that in the time given, I will only give a very brief outline of the patient etc…….

7. Example Harry, 46 years old Detained under section 37/41 Has spent 5 years in the unit 1 year in psychotherapy Was referred from the prison service Brief history: Born prematurely, had delayed milestone, did not walk until he was 4 years old and as a mild to moderate learning disability Very disrupted childhood:…….. Was referred from the prison service Brief history: Born prematurely, had delayed milestone, did not walk until he was 4 years old and as a mild to moderate learning disability Very disrupted childhood:……..

8. Harry’s view of his family Father had alcohol problem; he was a violent man father hitting mother and very abusive to Harry and his brother Mother is described as pampering him to such an extend that he now feels this resulted in his inability to cope independently (she died age 74 in 97 about 8 years ago) Father died when he was 13, in a bike accident, Harry suffered injuries to arm and head (not know if it had any biological impact) He started drinking around age 17 Lived in council home with mum at first Hectic adult life with heavy drinking, living in B &B, hostels or homeless Initially had a couple of jobs, road sweeper and pot man in a pub Has a list of convictions for criminal damage, common assault, drunk and disorderly and indecent exposure which we will refer to later He now has no contact with brother or other family one Important aspect of his childhood ……..Father had alcohol problem; he was a violent man father hitting mother and very abusive to Harry and his brother Mother is described as pampering him to such an extend that he now feels this resulted in his inability to cope independently (she died age 74 in 97 about 8 years ago) Father died when he was 13, in a bike accident, Harry suffered injuries to arm and head (not know if it had any biological impact) He started drinking around age 17 Lived in council home with mum at first Hectic adult life with heavy drinking, living in B &B, hostels or homeless Initially had a couple of jobs, road sweeper and pot man in a pub Has a list of convictions for criminal damage, common assault, drunk and disorderly and indecent exposure which we will refer to later He now has no contact with brother or other family one Important aspect of his childhood ……..

9. Fear in the home Is the Presence of fear in his life - fear that still exist in the unit And this is how is came to me through Self referral for anxiety. Has already done many groups and individual work SOG Drug & Alcoh When he came to me, ……..he presented as very…….. Is the Presence of fear in his life - fear that still exist in the unit And this is how is came to me through Self referral for anxiety. Has already done many groups and individual work SOG Drug & Alcoh When he came to me, ……..he presented as very……..

10. Initial presentation Compliant and adaptive behaviour Self conscious, self vigilant Tries to keep in control Underlying anxiety Compliant and adaptive behaviour (need to belong, avoid rejection) Avoid painful feelings Vigilant Careful Tries to keep himself together, keep in control by using jokes Wants to be seen as a good person Underlying anxiety The treatment program therefore was………… Compliant and adaptive behaviour (need to belong, avoid rejection) Avoid painful feelings Vigilant Careful Tries to keep himself together, keep in control by using jokes Wants to be seen as a good person Underlying anxiety The treatment program therefore was…………

11. Treatment plan Gradually slow down his process Pause for reflection Focus on areas that provoke anxiety Explore dynamics of interaction with others .Slowing him down as he easily (deflect) change subject Also Impulsivity . Make him aware of it, help him observe more .Develop a capacity for thinking and for reflection . Focus on areas that provoke anxiety - What function does the anxiety serves and how he reacts to it .explore the dynamics of interaction with others - Explore relationships …. I will show you a very small snippets of how the use of metaphor helped him to become more aware of some of his ways of behaving…..Slowing him down as he easily (deflect) change subject Also Impulsivity . Make him aware of it, help him observe more .Develop a capacity for thinking and for reflection . Focus on areas that provoke anxiety - What function does the anxiety serves and how he reacts to it .explore the dynamics of interaction with others - Explore relationships …. I will show you a very small snippets of how the use of metaphor helped him to become more aware of some of his ways of behaving….

12. First Stage Developing a working alliance Uncovering defences: Happy colours Covering up Diverting, distracting Though I refer to stages the progress is not linear More like a spiral Initially developing a working relationship Using useful coping strategies and at the same time need to explore what is behind, under happy colours, jokes, compliance, keeping busyThough I refer to stages the progress is not linear More like a spiral Initially developing a working relationship Using useful coping strategies and at the same time need to explore what is behind, under happy colours, jokes, compliance, keeping busy

13. Second Stage Further exploration of initial presentation Exploring dynamics of interaction: Negative transference Unhealthy survival defences “Parallel offending” (Neil Gordon) As we uncover his healthy defenses and further explore his initial presentation, he becomes more uncomfortable and it starts triggering his anxiety and so he started to become suspicious of me seeing as a police woman – negative transference – how he perceives me drawing from his past experiences And this triggers his more unhealthy defense mechanism in an attempt to protect himself And he recreated his offence process in the room which Neil Gordon from Rampton hospital calls parallel offending and gave us the opportunity for exploration Over head I From his history we know that he has limited capacity for self soothing, his father modeled drunkenness and violence, the mother who was over protective could not actually protect him, there were no containment, no secure attachment (calm does not exist in his world) Ordinary feelings become overwhelming because of incapacity for self soothing there is a transition from anxiety to excitement (same physical signs heart beat etc) ? The excitement can bring sexual arousal which gets released through an act like flashing, this gives him a buzz and allows him to see the displaced bad feelings in the other he got rid of them Then there is a collapse of the excitement ? which leads to depression and ? back to the initial feeling stateAs we uncover his healthy defenses and further explore his initial presentation, he becomes more uncomfortable and it starts triggering his anxiety and so he started to become suspicious of me seeing as a police woman – negative transference – how he perceives me drawing from his past experiences And this triggers his more unhealthy defense mechanism in an attempt to protect himself And he recreated his offence process in the room which Neil Gordon from Rampton hospital calls parallel offending and gave us the opportunity for exploration Over head I From his history we know that he has limited capacity for self soothing, his father modeled drunkenness and violence, the mother who was over protective could not actually protect him, there were no containment, no secure attachment (calm does not exist in his world) Ordinary feelings become overwhelming because of incapacity for self soothing there is a transition from anxiety to excitement (same physical signs heart beat etc) ? The excitement can bring sexual arousal which gets released through an act like flashing, this gives him a buzz and allows him to see the displaced bad feelings in the other he got rid of them Then there is a collapse of the excitement ? which leads to depression and ? back to the initial feeling state

14. Third Stage Exploring sources of anxiety, thinking of initial feelings Making connections with the past .. one day as he was talking about fear, I invited him to put fear in the sand tray…. .. one day as he was talking about fear, I invited him to put fear in the sand tray….

15. Fear in the corner He picked an object that represented fear to him (since fear is not in the object but in the subject) Over head II – and he started to get in touch with feeling of loneliness and rejection which are at the source of his anxiety And he started to make some links with the past The little boy hiding in the corner, feeling shame and humiliation Now As this became to overwhelming, he added some characters to the sand tray….He picked an object that represented fear to him (since fear is not in the object but in the subject) Over head II – and he started to get in touch with feeling of loneliness and rejection which are at the source of his anxiety And he started to make some links with the past The little boy hiding in the corner, feeling shame and humiliation Now As this became to overwhelming, he added some characters to the sand tray….

16. Feeling lonely, rejected But this only enhances his feelings of difference, loneliness and rejection …But this only enhances his feelings of difference, loneliness and rejection …

17. They are scared The level of anxiety starts to rise and he starts to portray the others as scared too… everybody is scared his level of arousal starts to transit …The level of anxiety starts to rise and he starts to portray the others as scared too… everybody is scared his level of arousal starts to transit …

18. Seeing the fear, “getting a buzz” And he releases all this feelings by scaring them – flashing - Which gives him a buzz as he see the fear in them He can then walk away….And he releases all this feelings by scaring them – flashing - Which gives him a buzz as he see the fear in them He can then walk away….

19. Back to loneliness Feeling happy at first but soon finding himself back in his corner all alone and depressed In the mean time the others are starting to coupling up.. When all he wants is make friends but there are no other spider of his size. Tragic story of the hunch back of Notre Dame In the next image he shows his deep need for acceptance and belonging…. Feeling happy at first but soon finding himself back in his corner all alone and depressed In the mean time the others are starting to coupling up.. When all he wants is make friends but there are no other spider of his size. Tragic story of the hunch back of Notre Dame In the next image he shows his deep need for acceptance and belonging….

20. Deep longing for acceptance So is his dilemma being scared or being lonely Proximity induce danger so to decrease danger he needs to decrease proximity and become lonely Or he can be blunt with other people, with no real contact, no real intimacy He has a desire represented here, desire for intimacy But his methods don’t really work Through the use of creative imagination he can see in the sand tray… The work is to look in and out, using the space of the room for containment and the relationship - to support self soothing and communication with another. – to develop his sense that he can be in touch with difficult emotions without being overwhelmed and while being in contact with someone how does not reject him I A P helps the patient to take from the symbolic, to find a voice . through a range of activities that are not great and contacts that are unsatisfactory we can then use puppets as mediators bringing it more into the body in a safe way. From fantasies of domination and control often revisiting the event of their crime or prior abuse, fantasies that are perverse and narrowing to creativity that is fresh and new To internalize the good object and have a wider range of positive activities to help them move in the world safely.So is his dilemma being scared or being lonely Proximity induce danger so to decrease danger he needs to decrease proximity and become lonely Or he can be blunt with other people, with no real contact, no real intimacy He has a desire represented here, desire for intimacy But his methods don’t really work Through the use of creative imagination he can see in the sand tray… The work is to look in and out, using the space of the room for containment and the relationship - to support self soothing and communication with another. – to develop his sense that he can be in touch with difficult emotions without being overwhelmed and while being in contact with someone how does not reject him I A P helps the patient to take from the symbolic, to find a voice . through a range of activities that are not great and contacts that are unsatisfactory we can then use puppets as mediators bringing it more into the body in a safe way. From fantasies of domination and control often revisiting the event of their crime or prior abuse, fantasies that are perverse and narrowing to creativity that is fresh and new To internalize the good object and have a wider range of positive activities to help them move in the world safely.