The Benefits of Art Therapy in the Immigration Field

Summary

Presentation given at the 3 rd European Conference on Psychotherapy, AEP (Association of European Psychiatrists), Heidelberg , Germany , 2003.

This paper deals with the author's observations applying art therapy in the centre SAPPIR, Barcelona , and the advantages of this discipline in the immigartion field:

Art therapy reduces importance of verbalization, so the patient does not have to know well the therapist's or host country's language/s.

The patient can use his/her symbolization and choose his/her rhythm without having to adapt it to the therapist's or the host country's culture.

The artistic creation provides a safe focus to explore the positive and negative aspects of one's own or the host country's culture.

The artistic creation can support one's cultural identity especially in situations of conflict between the original and host country's culture.

Those patients who are from different cultures and not familiar with psychological treatment, might find art therapy more effortless and less frightening than conventional treatments.

In our centre we have observed that some patients have been able to show much progress with art therapy, mainly in socialization, managing the multiple losses involved in immigration and adapting better to their (very often) difficult actual situation, which means confronting and taking the initiative to chang, at least a little, their labour and living conditions.

Resumen:

Conferencia en el 3er Congreso Europeo de Psicoterapia; AEP
(Asociación de Psiquiatras Europeos), Heidelberg, Alemania, 2003.

El presente trabajo describe las observaciones efectuadas por la autora al realizar arteterapia en el centro SAPPIR, Barcelona, así como las ventajas que supone esta disciplina aplicada al campo de la inmigración:

La arteterapia resta importancia al aspecto verbal, por ello no es necesario que el/la paciente domine el/los idioma/s del/de la terapeuta o del país de acogida.

En nuestro centro hemos observado que algunos/as pacientes han podido progresar mucho con arteterapia, especialmente respecto a su socialización y al manejo del duelo múltiple migratorio. Han podido adaptarse un poco mejor a su (muchas veces) muy difícil situación actual, enfrentando y mejorando sus condiciones laborales, sociales y de vivienda.

My paper deals with my observations working as an art therapist in a centre which provides free mental health service for immigrants and refugees in Barcelona, Spain (the name of the centre is SAPPIR = Servicio de Atención Psicosocial y Psicopatológica a Inmigrantes y Refugiados).

My objective is to show the advantages of art therapy in the immigration field.

Usually the director of the centre, Dr. Joseba Achotegui, refers me patients who could not benefit from verbal therapy for linguistic, cultural or personal reasons, or because in general they have difficulty verbalizing their problems, feelings and emotions.

After I am introduced by Dr. Achotegui I usually explain to these patients what art therapy is.

Method : I apply art therapy according to the British model, which means based on Kleinian Psychotherapy and Winnicott's Potential space.

Concerning Melanie Klein , her texts The Psycho-Analytic Play Technique: its History and Significance (1955) and Contributions to ‘Symposium on Child Analysis' (1927) are of special interest for art therapy. One of her main ideas in these texts consists of equating the children's play with the verbal treatment of adults. Though she describes mainly her work with children, the main aspects of her play theory can be transferred to art therapy, even though it is with adults. For example, as much as children can express their aggression in their play, the art materials can offer safe means to express aggression or to hold feelings which are difficult to bear in an external space.

Anxieties, fantasies and guilty conscience can be transferred into the art work. Thus the process can already provide certain relief.

In general, the symbolic representation is less threatening than verbal communication. Symbolic or indirect representation can reduce anxiety and afterwards it is possible to start verbal expression. Klein considered the final verbal elaboration to be essential for relating with reality. Here, the question would be, if an improvement in the patient's condition can happen without verbalization and only by the creative process.

Klein's idea was to reduce anxiety by interpreting its causes. It is important to stay then with the symbolic language. Otherwise the therapist destroys the patient's symbolism. Some elements of the art work can acquire a special symbolic meaning for the patient.

In any case it is impossible to establish a simple translation of symbols. They always have to be considered in the context of the whole therapeutic situation. Klein preferred to interpret the material after it had been expressed several times.

Moreover, the process is always much more interesting than the result. Every detail and every change of behaviour, attitude, facial expression, breath during the process is important.

She underlines the importance of every child having his/her own drawer with its own play and art materials. In art therapy every patient must have his/her own folder where s/he can keep his art work. This makes the patient feel that his/her work is in a safe space and it symbolizes the safe holding of the therapeutic relationship. The patient might decide not to put his/her artwork in the folder, but to give it to someone (the therapist, a friend, a relative etc.) or to destroy it. In this case the disposal itself is very often worth interpreting.

Concerning Winnicott , art therapy is influenced by his theory of the “Potential Space“, described in Playing and Reality (1971). The potential space lies between the inner world and the actual or external world or reality. It is the only place where the child can develop his/her play, and the individual experiences creative living. Both the child and the adult can experiment through play this transitional space, which offers the interplay between “the personal psychic reality” and “the actual world”, the object objectively perceived.

Winnicott already pointed out the importance of this space for cultural experience, and Leon and Rebeca Grinberg transferred the potential space to the relation of the immigrants' original group and receptive group, between his past and his future ( Migración y Exilio , 1996). Exploitation of this space leads to a pathological condition and loss of the ability of symbolization and the necessity of using primitive defence mechanisms. This is the case if the host society offers a hostile and not receptive environment (L. and R. Grinberg, 1996). In this sense art therapy with its ludic character is a helpful technique to be offered to immigrants who have had little or no opportunity of experiencing this sense of trust and confidence in their environment (new culture).

The therapeutic holding is very important in the immigration field (independent from the therapeutic technique), especially when the immigrant has gone through a lot of rejection in the host society.

Art therapy in SAPPIR

My patients are mainly children and women from Morocco , Latinamerica and Pakistan . I see them once a week, usually for 45 minutes. The treatment can last from 3 months to 2 years and is very often determined by the social, labour or legal situation of the immigrant.

I start by explaining to them the art materials. Here it is important to consider that some of my patients have never had any contact with art, and art materials in Western terms, before. In these cases it is important not to introduce all the materials at once because that could lead to overstimulation. I usually start with wax crayons, pens and pencils, then continue in further sessions with chalk and later with ink, water colour and finally recycled materials for collage. After the bidimensional work one can proceed to the tridimensional artwork, which means to work with clay, recycled boxes, wire, etc. I usually show them how to use the different materials, so that they can have a wider range of possibilities. But I usually do not give them any subjects. The non-directive way of working in art therapy corresponds to the free association of verbal therapy. However, in cases of severe pathologies or when the anxiety is unbearable, in order to work non-directively, it is necessary to choose special subjects, at least during the first sessions.

Some patients like to comment their art work after finishing it. Some talk first about their problems and then start to paint, and others do not like to talk at all or only very little. Sometimes their Spanish is so poor that verbal communication is hardly possible.

The task of the therapist consists mainly in creating a safe setting and an empathic relation, so that the patient can feel safe enough in order to be able to begin a creative process.

All my patients in this centre continue with their psychiatric treatment as well.

There are several advantages of art therapy in the immigration field:

It reduces the importance of verbalization, so the patient does not have to know well the therapist's or host country's language/s. Art facilitates a communication without words, though it is possible to start a verbal process about the art work and related subjects, too. The inability to speak the language of the receiving society can be felt as a very painful experience that might even hinder the initial understanding of the new ways of life (Freire, 1991). Offering a non-verbal communication can already provide certain relief.

The patient can choose his/her rhythm and use his/her symbolization without having to adapt it to the therapist's or the host country's culture.

For example, the art work of two Moroccan female patients look like calligraphy or geometric ornamentation, respectively.

Because of the relative prohibition of the image in Islamic culture, layman's art, particularly handicrafts and applied arts acquired special importance. The same happens with calligraphy, which in the Islamic world is considered as an art which also takes on a religious and symbolic function. It is a source of values and estethic emotions (Hattstein, Delius, 2000).

Both women have never had any contact with Western art before, so it is not surprising that they have recovered the artistic origins of their culture. The patient whose art work mainly looks like calligraphy could work during the sessions her daily life problems caused by her illiteracy and indeed she took the decision to start another Spanish course. In her childhood her mother did not want her to study, because in her opinion studying was only a man's affair. In Barcelona she was expelled from one language course for illiterate foreigners because she was considered to be “too nervous“.

Here I also want to underline the regressive effect of art therapy. The calligraphy drawings brought her back to this childhood situation. The regression appeared also in her material choice: When I showed her the chalks, saying that this is what they use in school to draw on blackboards, she grasped it immediately. Her case is also a good example of the importance of the therapeutic holding described by Leon and Rebeca Grinberg (1996): At the initiation of treatment her behaviour and verbal communication was determined by primitive defence mechanism, mainly projecting. She improved very quickly, after only two months of treatment her verbal aggression decreased significantly.

The other patient chose from the very beginning to work with geometric ornamentation.

After half a year she told me (and she hardly talked ever) that as a reference she had the images in her mind which she remembered from her childhood when she used to do carpets and tapestries with her mother. Thus she could show images of her childhood and adolescence.

Although she had not been to school and has not had any contact with art in Western terms, she had a sophisticated tradition of handicrafts, as a lot of Moroccans do.

Interestingly, both women decided in their last sessions to create figurated motifs, one a landscape, the other a person swimming in a pool. The latter had to do with her preference for swimming, an activity she started during the treatment, a decision which was remarkable for her very strong inhibitions and her traditional Islamic dressing.

Concerning the patient's rhythm, in the case of this patient, besides the advantage to be able to use her symbolization, another crucial point was to be able to use her rhythm. The process was extremely slow. For some pictures she needed months, for the last geometric picture she needed eight and a half months (!). But towards the end, she did a bracelet in ten minutes, which was a complete change of material and duration. Having finished the process, I think it was important to let her work in such a slow way and to provide thus a safe place where nobody would pressure her. In daily life she experienced a lot of pressure by the social worker because of her living and labour situation. During the treatment she became more active, started to take initiatives, and could reduce her inhibitions in a considerable way.

She had been treated using verbal therapy before, but she had many difficulties in verbalizing her problems - not only because of her lack of knowledge in Spanish. I think the fact that art therapy gave her the opportunity of expressing herself in her specific cultural way and by doing so, to follow her own very slow rhythm, was decisive for her improvement. Another important point was that she could (re-) discover her creative potential. She started her own creative process besides our art therapy sessions, evidenced by the artwork she did at home and which she then brought to treatment to show me.

The artistic creation provides a safe focus to explore the positive and negative aspects of one's own, or the host country's culture (Cooper, 1999). This is of special importance for working in groups. When there are group members of different countries, they can exchange experience of their original countries, the host country and aspects and difficulties of acculturation. This exchange of cultural aspects can be of great value in mixed groups of natives and immigrants, for example in primary and secondary schools. Thus the participants can reflect on their prejudices and might be able to overcome them. Collective art work can also act as a liaison leading to bonding and empathic understanding with others with whom the experience is shared (Freire, 1991).

Also in individual sessions the patient can use the art work as a technique of association. For example a 30-year-old Latin-American woman, diagnosed as schizophrenic and clinically stable, started to paint after nine months of art therapy traditional elements of her country and of their National Holiday. Then she painted some historic events, the symbol of the local football club, where she used to go quite often, and a mountain of her original country. All these picture had their special meaning within the context in which they were created. But they all had in common that she could remember positive feelings of her past which until then did not appear in her discourse. She repeated several times: “I felt well there.“ This was especially surprising when she drew the mountains and explained that she saw them when she went with her father, sister and brother to see their mother, who then lived in Argentina with her second husband and common children and who had left the patient when she was four years old. Her version until then was always the one of a non-existing mother who, through this picture, turned into at least an intermittent mother.

Once again I want to stress the regressive character of art therapy which facilitates the expression of memories of the original country, culture, language, etc. Furthermore, art therapy has the advantage that people can experience these memories, if they want, in a non verbal way, which can lead to more security. This can be connected to Klein's observations that the symbolic representation causes less anxiety.

This regressive aspect of art therapy can facilitate the expression of memories of the original country, culture, language, etc. Thus the patient can work aspects of the multiple loss of immigration. One aspect of this multiple loss is the patient's physical well-being, which might have been affected by a very daring voyage, by poor housing, by labour exploitation or very risky work (i. e. in construction) or even by sexual abuse (Achotegui, 2000). Among those patients who have been doing figurative motifs, some drew independently from each other a boat on the sea. Besides the danger of their figurative voyage, I think that this repeating motif can be interpreted as a lack of support, stability and holding in the receiving society, like a boat lost in the Ocean. This can be related to another part of the migration loss, which is the loss of social status. Jobs below their qualification, a low acquisition potential, sometimes lead to situations in which the immigrants might have to accept poorer social conditions than in their original countries.

The artistic creation can support one's cultural identity, especially in situations of conflict between the original and host country's culture, and in situations when at least one part of this identity is vanishing (Dokter, 1998).

The creation of images can strengthen the sense of identity. In this sense, Tibbetts and Stone (1990) found out that short-term art therapy is especially effective with seriously emotionally disturbed adolescents. They proved that the treatment increased significantly the adolescents' sense of identity.

The art can also help to integrate bicultural elements of those who have been staying in the host country for some time (Freire, 1991) and/or of those who live in mixed families and/or of those who experience a very big cultural difference between their family life, where the values of the original culture might dominate, and their life in different social settings like at school, work etc.

Especially for children, art is a much easier way to express themselves than words. This is an advantage which is not only evident in the immigration field.

All people have got a creative potential inside them, although it might be inhibited. In this sense it does not matter from which country they come from, how old they are, etc.

Working with immigrants the art therapist has to know about different non-European art forms. The non verbal communication is not free from cultural values either. Sensory impressions are also received through cultural influences, as well as verbal interpretations (Dokter, 1998). It is essential that the art therapist does not only study the differences of beliefs and values, but also the symbols and images of non Western art forms. “...preferences regarding the use of line, colour and form may vary because every culture has its own approach to art.“ (Campanelli, 1991). On the other hand, one should also avoid the other extreme, which would be stereotyping the artistic traditions and simplifying the richness of these traditions which are composed of a lot of different facets.

Furthermore, the therapist should know about anthropology and the principles of transcultural therapy. Concerning the latter, the therapist has to be aware of the need to adjust the therapeutic limits to the transcultural context. Here the therapist must consider the importance of the outer world, which makes it impossible to concentrate on the inner world exclusively. Many of the immigrants' psychological problems originate in the outer world (Kareem/Littlewood, 1992; Fernando, 2002; Kirmayer/Minas, 2000).

Another point is the more distant relationship between therapist and patient, which in the transcultural context is usually extremely difficult to maintain, for people from different cultures might perceive this distance as threatening, or at least confusing (Kareem/Littlewood, 1992).

Finally, the therapist should always be aware of his/her cultural background, his/her beliefs and values and always consider that the patient does not necessarily share them. One should gain self-knowledge about one's attitudes, feelings and stereotypes and especially how they can influence the interaction and the countertransference with the patient (Dokter, 1998).

All these aspects have been very well described by Suman Fernando (2002),

Jafar Kareem and Roland Littlewood (1992) and Roland Littlewood and Maurice Lipsedge (1997), among others.

Results : In our centre we have observed that patients have been able to progress a lot with art therapy, especially those who could not benefit from verbal therapy. They have progressed mainly in socialization, managing the multiple loss of immigration and adapting better to their (very often) difficult actual situation, which means confronting and taking the initiative to change their labour, legal and living conditions.

Among many non-Western patients it is very surprising how easily they start a creative process, often faster than a verbal one. This can have to do with the habits of their original countries: On the one hand, in many cultures there is less tradition of verbal psychotherapy. On the other hand, especially on the country-side, they might have strong traditions in applied arts. Thus art therapy gives them the chance to express themselves in a way which is more acceptable for them.

Conclusion : Art therapy in general is especially indicated for people who have difficulties in verbalization because of physical, psychological, linguistic or cultural reasons. In the immigration field, the latter two are very common situations. That is the reason why art therapy should be introduced more frequently in multidisciplinary teams who provide mental health or educational service to immigrants and refugees, as is already the case in Great Britain (i. e. Bayswater Families Centre; InterCommunity Health Centre; Medical Foundation for the Care of Victims of Torture, all three in London; NHS psychiatry in Bradford and in many multicultural schools), USA (in many multicultural schools), Canada (i. e. Creative Alternatives, Montreal; The Juggling Cultures, Toronto), Israel (Ministry of Education), Northern Ireland (i. e. Family Trauma Centre; WAVE Trauma Centre, both in Belfast), Netherlands (i. e. Pharos Foundation), Germany (i. e. Behandlungszentrum, Berlin), Norway (i. e. Psychosocial Centre for Refugees, University of Oslo), Austria (i. e. Oase, Linz), Australia (i. e. STARTTS), etc.

References:

• Joseba Achotegui (2000). ‘Los duelos de la migración: una aproximación psicopatológica y psicosocial'. In: E. Perdiguero and J. M. Comelles (eds.) Medicina y cultura. Estudios entre la antroplogia y la medicina , Barcelona, Edicions Bellaterra.
• Michael Campanelli (1991). Art Therapy and Ethno-Cultural Issues, The American Journal of Art Therapy , vol. 30, pp. 34-35.
• Jenny Cooper (1999). ‘Thrown in at the Deep End'. In: Campbell, Liebmann, Brooks, Jones and Ward (eds.) Art Therapy, Race and Culture . London and Philadelphia , Jessica Kingsley Publishers.
• Ditty Dokter (ed.) (1998). Arts Therapists, Refugees and Migrants. Reaching Across Borders . London and Philadelphia , Jessica Kingsley Publishers.
• Suman Fernando (2002). Mental Health, Race and Culture . 2 nd ed., Basingstoke , Palgrave.
• M. Freire (1991). ‘Foreword'. In: Wanda Sawicki The Juggling Cultures . London and Ontario , London InterCommunity Health Centre.
• León and Rebeca Grinberg (1996). Migración y Exilio , Madrid, Biblioteca Nueva.
  (English version: L. and R. Grinberg (1989). Psychoanalytic Perspectives on Migration and Exile . New Haven , Yale University Press.)

• Markus Hattstein and Peter Delius (eds.) (2001). El Islam. Arte y Arquitectura , Cologne, Könemann.
• Jafar Kareem and Roland Littlewood (1992). Intercultural Therapy. Themes, Interpretations and Practice . London , Blackwell Science.
• Laurence Kirmayer and Harry Minas (2000). The Future of Cultural Psychiatry: An International Perspective. Canadian Journal of Psychiatry , Vol. 45 Issue 5, 438-447.
• Melanie Klein (1955). ‘The Psycho-Analytic Play Technique: its History and Significance'. In: New Directions in Psycho-Analysis , London , Tavistock.
• Melanie Klein (1927). Contribution to “Symposium on Child Analysis“. Int. J. Psycho-Anal. , 8.
• Roland Littlewood and Maurice Lipsedge (1982). Aliens and Alienists. Ethnic minorities and psychiatry , London and New York , Routledge.
• Terry Tibbetts and Beth Stone (1990). Short-term art therapy with seriously emotionally disturbed adolescents. The Arts in Psychotherapy , 17, 139-146.
• Donald W. Winnicott (1971). Playing and Reality . London and New York , Tavistock/Routledge.