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Between water and words: Reflective self-awareness and symbol formation in art therapy


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This article explores the development of symbols in art therapy. It is particularly interested in the moment when art materials are lifted up from their concrete materiality and acquire symbolic significance in the context of the therapeutic relationship. This investigation into symbol formation is explored by comparing two individuals' different uses of water. The first is based on Helen Keller's encounter with water as described in her autobiography The Story of My Life (1903). This account is then compared to the use of water by an adolescent boy with profound autism, in an art therapy session. The theoretical perspectives of art therapy theory and developmental psychology are used to examine the particular interpersonal and intrapersonal conditions that may be required for the development of reflective self-awareness and the emergence of symbol formation. Some implications for practice are explored towards the end of the article.
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International Journal of Art Therapy
Formerly Inscape
ISSN: 1745-4832 (Print) 1745-4840 (Online) Journal homepage:
Between water and words: Reflective self-
awareness and symbol formation in art therapy
Jonathan Isserow
To cite this article: Jonathan Isserow (2013) Between water and words: Reflective self-
awareness and symbol formation in art therapy, International Journal of Art Therapy, 18:3,
122-131, DOI: 10.1080/17454832.2013.786107
To link to this article:
Published online: 12 Jun 2013.
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Between water and words: Reflective self-awareness and symbol
formation in art therapy
This article explores the development of symbols in art therapy. It is particularly interested in the moment when art materials
are lifted up from their concrete materiality and acquire symbolic significance in the context of the therapeutic relationship.
This investigation into symbol formation is explored by comparing two individuals’ different uses of water. The first is based
on Helen Keller’s encounter with water as described in her autobiography The Story of My Life (1903). This account is then
compared to the use of water by an adolescent boy with profound autism, in an art therapy session. The theoretical
perspectives of art therapy theory and developmental psychology are used to examine the particular interpersonal and
intrapersonal conditions that may be required for the development of reflective self-awareness and the emergence of
symbol formation. Some implications for practice are explored towards the end of the article.
Keywords: Helen Keller, symbol formation, reflective self-awareness, visual joint attention, autistic spectrum
disorder, theory of mind
This article explores how symbols are formed
within art therapy. It is particularly interested in
the moment when art materials are lifted up from
their concrete materiality and acquire symbolic
significance. This moment of transformation is
examined by contrasting two individuals’ very
different use of water. The first is based on a
historical and literary account of an encounter
with water as described by Helen Keller in her
autobiography The Story of My Life (1903). This
is contrasted with a profoundly autistic
adolescent boy’s use of water in an art therapy
session. Both individuals’ experience of water,
together with their respective capacity to develop
symbols, is examined through the theoretical
lenses of art therapy theory, developmental
psychology and psychoanalytic theory. Through
making the comparison, this article aims to
highlight the importance of the interpersonal
relationship out of which symbols may emerge
and be given shape in images and words. It will
explore the primary*although not exclusive*
role that visual joint attention plays in the
development of reflective self-awareness and its
relationship to symbol formation. This, it will be
argued, is of central importance to art therapy,
which is interested in the emergence and
possible emotional meaning of symbols within
the therapeutic relationship, the structure of
(Damarell, 1999; Isserow, 2008).
The importance of symbols
It is difficult to imagine a world devoid of symbols.
The richness, complexity and expressive potential
contained in symbols are a distinguishing feature
of what it means to be human. Symbol formation
lies at the very heart of humanity enabling both
inter and intra-personal communication.
Disturbances or inhibitions in symbol formation,
either for developmental or pathogenic reasons,
often result in a substantially curtailed experience
of life. As such, the therapeutic endeavour to
enable and promote symbol formation has been
an early preoccupation of psychoanalysis (Freud,
2011; Klein, 1988; Segal, 1957,1991) as well as
in the relatively more recent field of art
psychotherapy (Case, 2005; Dalley et al., 1987;
Dubowski, 1990; Killick, 1996; Killick &
Schaverien, 1997). In my work as an art therapist
in a profound and multiple learning difficulty
(PMLD) residential school for young people, I
have been interested in the moment when art
materials are transformed from being used
concretely (Segal, 1957) to being lifted up and
used in a more symbolic manner. Although often
momentary, this significant change has led me to
wonder what the psychological and relational
conditions might be that enable this to occur.
This shift from the absence to the acquisition of
symbol formation has nowhere been more
dramatically documented than in Helen Keller’s
autobiography The Story of My Life (Keller, 1903).
It is a description of moving from one kind of world
into another and pertinently informs some of my
International Journal of Art Therapy, 2013
Vol. 18, No. 3, 122131,
#2013 British Association of Art Therapists
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clinical concerns. Before turning to that
remarkable*if now mythologised*dawning of
symbolic thinking, it is useful to briefly return to
Helen Keller’s life to set the moment in context.
Helen Keller revisited
The name Helen Keller is intimately linked with
the image of an individual overcoming the
isolation of blindness and deafness to become ‘a
symbol of the indomitable human spirit’
(Herrmann, 1998, p. 9). Keller was born in
Tuscumbia, Alabama, on 27 June 1880. Keller
was not congenitally blind and deaf but lost the
use of her sight and hearing following an acute
illness at 19 months of age. The doctors at the
time described it as ‘an acute congestion of the
stomach and the brain’ (Keller, 1903, p. 3),
although the illness is now thought to be
meningitis (Herrmann, 1998, p. 9). In 1886, her
mother Kate Keller was inspired by an account in
Charles Dickens’s American Notes’ (Dickens,
1842) of the successful education of another deaf-
blind child, Laura Bridgman, and travelled to a
specialist doctor in Baltimore for advice. He put
her in touch with local expert Alexander Graham
Bell who was working with deaf children at the
time. Bell advised the couple to contact the
Perkins Institute of the Blind, the school where
Bridgman had been educated, then located in
Boston Massachusetts. The school delegated a
teacher and former student, Annie Sullivan,
herself visually impaired and then only 20 years
old, to become Helen’s teacher. The meeting of
Annie Sullivan and Helen Keller marked the
beginning of a 49-year-long relationship between
teacher and pupil and one that brought them both
international acclaim (Herrmann, 1998, p. 43).
See Figure 1: Helen with her teacher.
Figure 1. Helen Keller and her teacher Annie Sullivan
Reflective self-awareness and symbol formation in art therapy 123
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From the start of their meeting, Annie began
spelling names of objects that she and Helen
encountered, using the manual finger alphabet
Annie had learned to communicate with Bridgman
at the Perkins Institute. At the time Helen had no
language, seemed profoundly unreachable and
feral. With steely determination Annie worked in
this manner with the highly spirited Helen as they
began to forge their relationship. This work in turn
laid the ground for the birth of thought, the
‘miracle’ as the amazed Victorians referred to it
(Herrmann, 1998, p. 45), which occurred a month
after Annie’s arrival at the Keller’s homestead. In
her autobiography, Keller provides a moving
account of this moment:
We walked down the path to the well-house,
attracted by the fragrances of the honeysuckle
with which it was covered. Someone was drawing
water and my teacher placed my hand under the
spout. As the cool stream gushed over one hand
she spelled into the other the word water, first
slowly, then rapidly. I stood still, my whole
attention fixed upon the motion of her fingers.
Suddenly I felt a misty consciousness as of
something forgotten*a thrill of returning thought;
and somehow the mystery of language was
revealed to me. I knew then that ‘w-a-t-e-r’ meant
the wonderful cool something that was flowing
over my hand. That living word awakened my
soul, gave it light, hope, joy, set it free! There were
barriers still, it is true, but barriers that could in
time be swept away. (Keller, 1903,p.12)
Keller’s dramatic ‘revelation’, and the return of
her capacity to think symbolically, suggests a
transformation from experiencing the world as
two-dimensional and body-dominated into a
three-dimensional, psychologically alive
permeated space. Explicit in her account is the
realisation that one thing can represent another:
the shapes of the finger-letters ‘w-a-t-e-r’ spelled
into her hand can represent the cool liquid
flowing into the other. Implicit in this realisation, it
may be argued, is the awareness that this
symbol can be shared with another mind, that
being her teacher’s. This awareness of having a
mind in relation to other minds is a profoundly
human experience, enabling what Martin Buber
(2004) calls ‘IThou’ relating, that is, an
awareness of self as a person in relation to other
Hobson (2004) argues that genuine
communication is based on a background of
sharing between minds, where feelings link one
person to another and where the intention to
communicate is apprehended and attended to by
the other. In the above example, it may be
speculated that Keller made the quantum leap
into something that may be close to mentalisation
(Fonagy, Gergely, Jurist, & Target, 2002), that is,
the capacity to ascertain and infer others’
intentionality and mental states. Keller’s sudden
capacity to comprehend the nature of symbols
seems to be born out of her awareness of her
teacher’s passionate intention to communicate
and share the world with her and the self-
realisation that she too had a mind that could
receive such a communication. In this sense, it
can be argued that Keller’s development of
symbols was concurrently formed alongside and
dependent on her capacity for reflective self-
awareness. It is to this development in infancy
that the article now turns.
Joint attention, reflective self-awareness and
symbol formation
Keller provides a very dramatic account of the
emergence of a seemingly fully formed capacity
for symbol formation. However, in ordinary
development this is based on a far slower and
accumulative process within the infant dependent
on a range of developmental milestones marked
by two distinct ways of relating to the world.
Trevarthen’s (1993) concepts of primary and
secondary intersubjectivity respectively
encapsulate these two distinct periods of
development, which can be considered to lay the
ground for the emergence of symbol formation.
Primary intersubjectivity refers to an early
period of infant development between birth and
the second part of the first year of life. In its
simplest terms, it is characterised by the
experience of shared emotional states between
the mother
and the infant in mutual face-to-face
engagement (Trevarthen, 1993). Diagrammatically
this can be represented by axis IM as seen in
Figure 2. The experience of sharing states of
affect between mother and infant is enabled
through a range of behaviours including affect
attunement (Stern, 1985), reciprocity (Brazelton,
Koslowski, & Main, 1974) and turn-taking
between mother and infant as well as mother’s
(I)nfant (W)orld
Figure 2. From Hobson, 2004, p. 272
124 J. Isserow
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contiguous mirroring (Fonagy & Target, 2007)of
the infant’s state of mind. Importantly, it also
allows for periods of rest where the infant is given
a chance to look away and self-regulate before re-
engaging with mother (Stern, 1977). In his more
recent book, Stern (2010, p. 43) argues that this
experience of intersubjectivity and the sharing of
emotional experience is the ‘foundation for future
mental and emotional life’. It can be argued that
experience of primary intersubjectivity or ‘mind-
mindedness’ (Meins et al., 2002) is of profound
importance for later life and that the quality and
consistency of the care has far-reaching
implications. Within a psychoanalytic paradigm,
Winnicott’s (1971) idea of ‘primary maternal
preoccupation’ (1956) also captures this quality of
mother’s concern with her infant and their shared
emotional experience during this vital early
developmental period. One of the main
behaviours characteristics of primary
intersubjectivity in this period is that the infant is
only able to attend to one object at a time. The
infant may interact with mother or with an object
but never does he attend to both in a coordinated
way (Bakeman & Adamson, 1984) (axis IWin
Figure 2), even when mother is looking at the
same object (axis MW).
Secondary intersubjectivity
At around nine months of age the infant’s
behaviour increasingly demonstrates ‘a growing
awareness of how other persons work as
psychological beings’ (Tomasello, 1993, p. 33).
A new type of behaviour begins to emerge and
includes the sharing of attentional focus and affect
around a common object or event (Scaife &
Bruner, 1975). This new form of cooperative
intersubjectivity (person-person-object
awareness) is called secondary intersubjectivity
(Trevarthen, 1993). At this period, there is a
dawning awareness of mother having her own
mental and emotional state and the toddler
becomes as interested in her mental state as
much as the object or event itself. This secondary
intersubjectivity underpins joint attention
behaviours and not only includes the sharing of
interest but also includes the monitoring and
directing of the other’s attention around an object.
This is often achieved through the use of pointing,
gesture and referential eye contact. Sharing of
attention with a significant care-giver around a
third object or event is often accompanied and
reinforced by tremendous positive affect and
shared enjoyment.
Vision plays a central but not exclusive role in
enabling the infant to ‘locate’ the object or event,
targeting the domain for the shared experience.
The infant (and joint attention partner) has to be
able to follow the line of sight indicated by the
pointed finger or directional eye movement.
Doherty (2009) has explored how the unique
morphology of the human eye enables gaze
direction to be detected. Humans are the only
primate species with extensively visible white
sclera (see Figure 3). As a result, Doherty (2009,
p. 106) argues, gaze direction is easier to detect,
enabling humans to signal with gaze. The eyes,
with their capacity to focus direction of interest
and communicate affectual states, play a
significant role in shaping and locating both the
infant’s and the carer’s shared attentional field. In
the absence of vision, carers need to find
alternative sensory routes to ensure the infant
finds a way to another mind and the shared world
beyond their relationship (Frith, 2003; Hobson,
2004; Isserow, 2008).
This kind of directional gazing and declarative
(Leung & Rheingold, 1981) shapes the
attentional focus of the other so that an object or
event that may have been in the background is
now brought to the foreground of attention. For a
toddler to follow the direction in which another is
looking or pointing strongly suggests that the
infant has an awareness of the other as a
psychological agent with its own affect and mental
states. This opens up the potential to ascertain
and apprehend different psychological states of
mind in others, laying the ground and being a
‘critical precursor’ to the development of a theory
of mind (Baron-Cohen, 2000).
At this point in his development, the toddler not
only expands his repertoire for social interaction,
but he is also able to explore the world, discerning
its potential meaning which is always socio-
contextually dependent. The prime example of
this is the visual cliff experiment (Sorce, Emde,
Campos, & Klinnert, 1985) where the toddler uses
social referencing to determine the meaning of a
visually ambiguous situation. The child is placed
on a platform that halfway along turns into a visual
cliff. The child’s mother is placed at the far end of
the platform encouraging him to crawl over. At this
point the toddler needs to be able to share
mother’s attention to the visual cliff*to step into
her shoes*and to understand mother’s facial
communication, whether she is frowning or
smiling, to determine if the situation before him is
one of danger or one of play. What is of primary
importance here is the toddler’s capacity to take
on another’s perspective and to realise the
‘meaning conferring’ (Hobson, 1993) nature of
other minds. ‘Seeing’ the world from another’s
point of view implies an awareness and self-
Reflective self-awareness and symbol formation in art therapy 125
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reflection that the infant too has a mind that can
be informed by another’s perspective or, put
another way, it means looking from the outside to
see the self from the inside. From here the
connection to the development of symbolic
thinking and reflective self-awareness becomes
more possible to understand and can be
diagrammatically represented as shown in
Figure 4.
Hobson’s (2004, p. 272) relatedness triangle
(Figure 4) provides a useful conceptual
scaffolding to understand how the capacity for
joint attention may develop and be intimately
linked to the related events of reflective self-
awareness and symbol formation. While clearly
symbol formation might be understood from
various perspectives, remaining a mysterious
process, the following is an attempt to provide a
possible account of its development.
In returning to the moment of symbol formation
with Keller described above, it is possible to
speculate that somewhere in her mind Helen
realised that her teacher too had a mind and that
this mind had its own interest and attention. It is
feasible to suggest that Helen ‘stepped into’ her
teacher’s shoes ‘as if’ seeing the world from her
perspective (represented in Figure 4 by the
movement ‘A’). From this position, she could
apprehend her teacher’s ‘meaning conferring
nature of her mind’ (Hobson, 1993, p. 49),
realising that her teacher could attribute the finger
configuration ‘w-a-t-e-r’ to represent the cool liquid
substance flowing through her hands
(represented in Figure 4 by the axis MW). From
here Helen could have a realisation that she too
had a mind that could take on a new perspective
of the water and that she could share in conferring
meaning onto the liquid by the finger alphabet
spelled out in her hand and to use the figure
configuration to represent water. This new view
can be represented in Figure 4 by the movement
‘B’. She realised, as Hobson says, that she could
‘intend to symbolise and make one thing stand for
Figure 4. Triangle of relatedness (Hobson, 2004, p. 272)
Figure 3. Primate vs. human eyes
Clockwise from top left: the eyes of two marmosets, a gorilla, a chimpanzee and two humans. Note that only the humans have visible
sclera. (Photos: marmosets, Hannah Buchanan-Smith; gorilla, copyright Michelle Klailova; chimpanzee, Louise Lock; humans, Martin
126 J. Isserow
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something else’ (1993, p. 255). What is interesting
about Helen and her teacher’s communication is
that they were able to locate the shared field of
experience through the tactile domain of the finger
alphabet. As mentioned earlier, it is vision and
directional eye movement in the sighted infant
that facilitates the capacity to target and locate the
object or event that can be shared and
experienced together.
The development described above places the
symbol in a triangular relationship to what it
signifies. In addition, the finger-shaped-letters
‘w-a-t-e-r’ do not resemble the thing itself. Rather
it is through a shared convention that meaning
has been inferred onto the finger shapes so that it
now stands as a sign (Sobchack, 1992). Similarly,
the arbitrary sounds of language and written
squiggles on a page become the shared signifiers
to their signified. While a semiotic investigation
into the complexity and difference between the
signs of symbol, icon and index is beyond the
scope of this article, it is important to note that
symbol here is used within the Peircean tradition
(Peirce, 1972) where the signifier does not
resemble the signified. Their relationship is
fundamentally arbitrary and must be acquired
through the use of another’s mind. As such, the
use of symbols is dependent on the capacity to
both share an experience with and retain a degree
of separateness from the other.
It is this triadic relationship described above
that initially develops externally to the toddler and
later becomes internalised as a function of the
mind (Hobson, 1993), through repeated
experiences. It is this capacity that can be
understood as the development of symbol
formation. However, it is important to note that far
from being a cognitive capacity, the development
of symbol formation has deep emotional roots. It
requires that the toddler is able to separate from,
while at the same time be able to identify with its
primary care-giver. The toddler’s emotional
struggle for separation can be seen in Winnicott’s
notion of the ‘transitional object’ (Winnicott, 1971)
which may be considered to exist in between the
developmental stages of primary and secondary
intersubjectivity (Trevarthen, 1993). Its role attests
to the emotional challenge of separation required
to perceive objects as separate, objective and
outside the self. This places emphasis on the
importance of the earliest relationship out of which
symbol formation may develop. After all, as it is
possible to speculate, it is Helen’s experience of
being held in mind by another mind that became
the precursory step towards being able to think
about her own mental activity and internalise the
experience of secondary intersubjectivity
(Trevarthen, 1993), as described above.
Reflective self-awareness and symbol formation
in an art therapy session
Having explored Keller’s use of water along with
the possible dynamics involved in the formation of
symbols from a developmental perspective, the
article now turns to look at the capacity for symbol
formation of a profoundly autistic adolescent boy
within an art therapy session. These sessions
form part of a treatment programme in a school
that works with young people with PMLD, in the
south east of England. The examination of
reflective self-awareness and symbol formation is
embedded in a detailed vignette, written up
immediately following the session. All personal
details of the adolescent have been changed to
preserve confidentiality and consent to use
anonymous case material has been given.
Tom is a lively, physically robust 14-year-old boy
of average height and weight, who has a
diagnosis of being on the severe end of the
autistic disorder spectrum. He has a likeable face
with bright blue eyes that constantly dart around
and a very expressive mouth which is often
scrunched up, giving him an appearance of a
perpetual smirk or grimace. He has been at the
school for nearly three years and has attended art
therapy for just under a year. He is an only child of
a Mediterranean couple and is one of the few
children at the school who has contact with his
parents. His parents have had an acrimonious
separation but, interestingly, still live in the same
house. His father occupies the lower portion of the
house while his mother lives in the upper section.
It is unknown which part of the house he sleeps in
when he returns home, which he may do around
one weekend every month. All correspondence
from the school to his parents needs to be sent to
each parent independent of the other, despite
being sent to the same address. Tom was referred
to art therapy as part of a care programme to help
him with his extreme mood swings of becoming
too ‘high’ or too ‘low’. This split in mood suggests
a direct correlation to the split within the parental
The following extract takes place 10 minutes
into an art therapy session. The session is in a
bright dedicated art room, which has several
tables pushed together in the middle of the room
with a variety of art materials and paints laid out in
a palette and brushes on one of the tables. To the
Reflective self-awareness and symbol formation in art therapy 127
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right of the room is a large aluminium sink
serviced by hot and cold water taps with one
spout. The hot water is connected to a gas boiler.
The water in the boiler becomes very hot, but once
empty it cools down, before heating up again. At
this point Tom had been attending therapy for
eight months and was quite familiar with the room.
With elated energy and a maniacal smile, Tom
takes the small coiled up piece of string from the
table and dips it into the yellow and orange paint
in the palette. Holding the paint-drenched string in
his hand he wildly moves to the basins opposite
the table and takes down several bowls from a
shelf above the sink. He places a large bowl into
the sink, drops the string into the bowl and quickly
turns on the hot and cold-water taps. All this
seems to be done at lightning speed and I move to
stand near Tom by the sink. I remind Tom that the
water in the tap can become very hot and that we
need to make sure that it does not become too hot
and risk getting hurt. The water gushes into the
container in the sink and Tom seems mesmerised
as he watches the now pale yellow water first fill
and then spill over the sides. The knot of string
floats at the edge of the bowl firmly holding Tom’s
attention. In an attempt to both physically and
psychologically contain Tom, I turn down the
excessively fast running taps managing both the
temperature of the water as well its flow rate. Tom
then turns the taps higher as I encourage him to
try to keep the water luke-warm. I occasionally
gauge the temperature of the water with my hand
and turn down the hot water or increase the cold.
In a devouring way he takes the string into his
mouth, fills his mouth up with water and spits out
several strong squirts of water against the splash-
back tiles behind the taps. Occasionally he takes
the string out of his mouth and rests it in the bowl.
He then drinks some of the water either directly
from the tap or from the bowl only to regurgitate it
back into the bowl. At other times he keeps the
water in his mouth and then spits it out against the
tiles in a long stream. He then flaps his hands
together in an excited way. He then takes the
string back into his mouth and plays with it in his
mouth for a while, sucking, pulling and licking at it
between his teeth and tongue.
The hot water becomes very hot and I remind Tom
to be careful and try to keep the water just warm. I
turn on the cold water, regulating the temperature
and our hands do a kind of dance around the taps
both satisfying Tom’s desire for strength of water
flow as well as making sure that it is safe to use. It
is a complicated dance as I have to both avoid his
occasional jets of squirted water directed at the
tap and avoid him pushing my ‘thermometer-
finger’ out of the stream. After reminding him
several times that the water is hot, Tom says ‘Hoh’
and almost points to the water. I say ‘Yes the
water is hot’. I then ask him if we could work
together to make warm water by mixing both the
cold and the hot together. He ignores me as the
water flows continually and fills up the overflowing
container. Drinking from the bowl, Tom then
manages with a greater capacity to regulate the
temperature of the water himself. Tom continues
to play with the string in his mouth and lap up
some water before squirting it out again.
In this report, Tom can be seen to have an
appropriate awareness of the different materials
and their physical properties, which possibly
suggests that Tom has been able to achieve a
degree of differentiation of self from other. Tom’s
preoccupation with the string is suggestive of an
infant’s pre-natal interest in their umbilical cord,
bringing to mind Piontelli’s work (1986)of
observing pre-natal and neo-natal life. I felt at this
point that it was unclear from Tom’s use of string
how differentiated or how fused Tom was with me.
In his paper on string, Winnicott (1960) suggests
that the young boy’s obsessional use of string is
used to restore a previous state of connectedness
to his mother. I felt that Tom’s use of string placed
him somewhere on the spectrum between a
completely fused relationship and a more
differentiated one with myself, and it seemed to be
actively blurring any gaps between us.
Tom uses water in a reckless manner, letting it
endlessly fill up and spill over the sides of the
container. Similarly, I think, Tom uses the water to
fill up and spill over the container of his mouth. In
doing so he blurs all distinctions between an
inside and an outside. The difference of his mouth
to the water is further confused when Tom mixes
the water with his saliva, as well as using water to
continuously create a drinking-spitting cycle.
Perhaps the creation of jets of water from his
mouth is connected to an earlier feeding situation
where Tom may have experienced the feeding
object (breast or bottle) as a sensual jet of fluid in
his mouth. Through maintaining a degree of non-
differentiation, he is able to avoid distinguishing
whether this fluid came from a spring inside his
mouth or from a source external to him. His use of
string both inside his mouth and inside the
container which is full of running water suggests
to me that when the string is in his mouth he
concretely equates the endless running tap to his
mouth (Segal, 1957). Through using water in this
way he seems to be recreating this blurred
experience in his mouth, bypassing or obfuscating
any recognition of any separate person, possibly
128 J. Isserow
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defending himself from any knowledge and
dependency on a separate source.
From previous sessions of actually seeing and
smelling Tom regurgitate water, it is possible to
speculate from his body posture that here too he
may have been regurgitating the water from his
stomach to his mouth. This can be considered to
be indicative of a state of mind, which completely
denies the dependency on any outside source, as
here his own stomach is made to feed his mouth.
The self-generating sensation of the liquid coming
from within him also suggests that he may, in
primitive phantasy, feel as if his mouth is the tap
and that he has ownership of the feeding breast
inside him.
Despite his overwhelming interest in the water
and the string, Tom does not generate in me the
mind-numbing feelings that my work with other
children on the autistic spectrum can generate.
With Tom I felt able to persist in my attempts to
regulate the water temperature and try to reach
his mind by describing his actions and behaviour
to him, alerting him to the presence of the two taps
which could be used to enable both of us to safely
work together. His insistence on using
predominantly one tap despite the two taps being
attached to the same spout is suggestive of
Tustin’s (1981) idea of basic un-integration
between hot and cold, male and female. Similarly,
it is hard not to link his extreme and un-integrated
mood swings to the concrete, geographical
location of his parents within the same house as
mentioned above.
I am aware I experience Tom’s almost exclusive
preoccupation with the hot water as being
rejecting, making me feel left out in the ‘cold’. I
have noticed at times that Tom can leave me
feeling deeply frustrated and exasperated as he
quickly moves around the room, often avoiding
my presence. This makes me wonder if Tom’s
more manic behaviour conceals a deeper anxiety
of a deathly and lifeless state brought about by an
awareness of a separate object. His at times
manic denial of the other seems to function as a
way of keeping these depressing and catastrophic
feelings in abeyance. When he is very quiet and
withdrawn, do these more deathly feelings of loss
My persistent attempts to help him regulate
both the intensity of the flow and temperature of
the water, for his benefit as well as my own, can
be seen as an attempt to regulate Tom’s feelings
on both a material and psychological level. There
are faint echoes here of the scene described by
Keller above, for like Keller and her teacher, we
both have our fingers in the water together, and it
enables Tom to briefly think and be aware of the
hotness of the water. He is able to respond to this
awareness by saying ‘hoh’ and almost points to
the tap with his fist. It is possible to speculate that
at this moment he has a greater capacity to be in
relation to my mind and that he can experience
me not just being in competition for control of the
taps, but as an accommodating person who could
take into account both his feelings and desire for
an interface with the water, as well as the physical
and potentially dangerous qualities of the hot
His use of the word ‘hoh’ and pointing gesture,
following my use of the word ‘hot’, joins up our
attention to a shared experience. It is a fleeting
moment of joint attention and brings the work to
life. At that moment Tom seemed to ‘step into my
shoes’ and take on my perspective. In doing so he
could be in relation to another mind and have an
awareness of his own mind that too could pay
attention to the quality of the water being
described to him. It is these fleeting moments
when Tom manages to be in relation to, and
identification with, a human mind that the sensory
materiality of the water is lifted up to be used in a
symbolic manner. As a corollary to this, the denial
of another mind in the room seems to leave Tom
in a sensory-dominated world. Although there
must be some identification with another mind for
Tom to be able to produce the word ‘hoh’, it seems
as if this is only partial, retaining a somewhat
unclear and incomplete recognition, as he leaves
off the last consonant, which would otherwise
form a boundary.
Tom is greatly attracted to water, using it in
very ritualistic and repetitive ways. What may
have been problematic in his development may
be understood in part to reside to his
identifications, not with a person but rather with a
non-human object. It is at these moments when
he is able to be in relation to, and identified with,
a human mind that he can realise the meaning-
conferring nature of minds including his own,
which enables a greater symbolic relationship to
emerge. From a psychoanalytic view, his use of
water can be seen to move from more
transitional space (Winnicott, 1971) towards
increased triangular space (Britton, 1998)as
symbol formation begins to develop.
Implications for art therapy
The momentary engagement with Tom and our
shared attention seems vital to sustain the
liveliness of the work together. It hopefully
suggests that efforts to engage can be built on
and sustained. Even an incremental development
in Tom’s capacity to engage in relationships is
Reflective self-awareness and symbol formation in art therapy 129
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significant. The vitality of the water completely
captivates Tom, leaving him hard to reach.
However, the water can potentially also be used
as a point of shared connection to begin to
engage him in interpersonal mind-to-mind
relating. Although the importance of joint attention
and its connection to reflective self-awareness
have been explored here in relation to an
adolescent on the autistic spectrum, I would argue
that its value can be generalised to other clinical
areas. Within any art therapy session it may be
useful to consider if and when the client is
predominantly engaged either with the art
material/art object or with the therapist, as well as
moments when the client can be in relation to all
components of the art therapeutic relationship
and in a more secondary intersubjective state of
mind (Damarell, personal communication).
Clearly the client’s early attachment patterns
(Fonagy and Target, 2007) will have a significant
impact on the quality of joint attention in art
therapy. However, the therapeutic relationship
provides an opportunity for reworking this early
experience along with the potential for new
development. Also, it is important to note that the
art-making process in art therapy has periods of
rest and self-regulation built in when the client
may move towards and away from art making
and/or the therapist in the relational dynamic.
In addition, the development of reflective self-
awareness and symbol formation is by no means
exclusive to the art therapeutic relationship. It
can be argued that making art in the presence of
a mindful other may also have significant
benefits. However, in the end it is the client’s
shared experience and capacity to take on
another point of view that may enable therapeutic
change to occur. Importantly, it is the particular
sensitivity and skill of the art therapist to know
when to make space for the client to have a more
primary intersubjective experience and when to
encourage a greater sense of secondary
intersubjectivity and attuned joint attention
(Stern, 1985). Clearly this capacity is developed
as part of the art therapists’ training, which
includes the development of a sensitivity to the
vitality affects (Evans & Dubowski, 2000)
embedded in the use of art materials, along with
the capacity to tolerate not-knowing for extended
periods; the capacity to attune to a depth of
feeling and consideration for unconscious
dynamics between all elements in the art
therapeutic triangular relationship; a depth of
understanding of the particular difficulties and
care context of a specific client group; practising
within a safe, ethical and therapeutic framework;
and a capacity to articulate and self-reflect on
practice privately and in supervision. It is this that
makes art therapy a relational environment par
excellence to facilitate the mutually enabling
processes of reflective self-awareness and
symbol formation.
See Herzog’s documentary ‘Land of Silence and Darkness’
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Biographical details
Jonathan Isserow is a state registered art therapist
who has worked extensively within child, adolescent
and family psychiatry. He has an MA in
Psychoanalytic Observational Studies from the
Tavistock Clinic and is currently a PhD candidate at
UCL. He is the Programme Convenor for the MA Art
Psychotherapy Programme at University of
Roehampton, London.
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... Winnicott (1971) has suggested that play is a means of reaching the authentic, creative, less defended part of a person's personality, what he calls the true self. In the therapeutic relationship the art material can be raised from its concrete materiality and obtain a symbolic meaning in an image, which can be explored and understood (Isserow, 2013). Exploration implies looking together, which is more or less a matter of course in art therapy (Isserow, 2008). ...
... Widening perspectives is possible in art therapy by creating an image and then changing it, which can give clients the opportunity to look at the reality from different perspectives and accept a more adaptive point of view (Czamanski-Cohen & Weihs, 2016). However, Isserow (2013) underlines the fact that in the end, it is the client s ability to take another standpoint that enables therapeutic changes to occur. ...
Full-text available
In order to provide clinical utility for research of how art therapists perceive clients’ inner change, the authors created a structured observational framework. This note taking and assessment consist of five themes and sub-themes: Therapeutic Alliance, Creating, Affect-Awareness, Self Awareness, and Ego-Strength. The framework was designed to be clinically-friendly, adaptable to various settings, and assist communication with both patients and relevant healthcare professionals.
... Building on Schaverien's work, Bragg and Fenner (2009) develop the triangle into an interactive square, and Springham et al (2014) place the triangular relationship into attachment theory frameworks to reveal at its heart two humans and a material object. Isserow (2008Isserow ( , 2013 points out that the two people present in the triangle look together at the art object to try and share the feeling or meaning it holds. His work focuses on joint attention in early development, and its links to joined up triadic relating and symbol formation. ...
... Isserow usefully brings together different frameworks: developmental psychology 'theory of mind' (Baron- Cohen, 2004), which describes the ability to acknowledge that another person also has a thinking mind with another point of view; and psychoanalytic theory, which emphasises the benefits of more sophisticated triadic, as opposed to early dyadic, relating patterns (amongst others Britton, 1989, Burhouse 2000. Isserow (2013) suggests triadic encounters with art in the presence of 'a mindful other', art therapist or not, will facilitate joint attention, encouraging joined up triadic relating, reflective self-awareness and symbol formation (P130). ...
Full-text available
This paper looks at whether we can bring art psychotherapy theory to understanding the role of art in a new context; the medical pain consultation, as part of an experimental arts in health research project. The project studied the introduction of a set of art images into chronic pain consultations, to help patients and doctors communicate complex experiences of pain. The paper draws on different theoretical approaches from art psychotherapy, to provide ways to understand the meanings of an art object introduced between two people. Triangular relating, symbolisation and transactional uses of the image are explored (Isserow 2008, 2013, Schaverien 1991,1995, 2000). The image is also considered within a social frame and from an intersubjective viewpoint (Tipple 2003, 2011, Skaife 2008). The images were artistic depictions of pain, previously co-created by other pain patients with an artist as a communication resource. Videos of consultations where doctors and patients used these images were studied. The paper takes case examples of features observed in a thematic analysis and uses art psychotherapy theories to explore them further. Suggested implications are that using images in this setting may allow negotiation of unconscious dynamics between clinician and patient and have potential to aid communication and empower patients, suggesting avenues for future research. The potentials and limitations of bringing theory to this context are considered. The research took place within a multidisciplinary team. Keywords: chronic pain; triangular relationship; transactional objects; multidisciplinary research; art psychotherapy theory; arts in health.
... More recently, the role of joint visual attention in art psychotherapy has been given greater attention. Damarell (1999) and Isserow (2008Isserow ( , 2013, have begun to make links between joint visual attention skills and art psychotherapy noting how triadic practices of relating in art psychotherapy are predicated on, and also promote the experience of looking together. This alternating gaze between participatory partner and the art object -as described above -actively establishes the opportunity for the service user to apprehend the mind of the therapist in relation to their own mind. ...
Full-text available
This paper compares two strikingly different uses of water. The first by an adolescent young man on the autistic spectrum, in an art psychotherapy session; the second, by an ordinary developing toddler, observed at home. It uses insights gleaned from psychoanalytic infant observation to illuminate the seemingly enigmatic behaviours found in clinical practice. In doing so, it delineates the centrality of joint visual attention in the development of symbol formation. Understanding is advanced by making evident that water may be used to either enable or inhibit this process. As such, it argues that the phenomenon of liquidity be given greater consideration. Further, it critically champions for the inclusion of infant observation in art psychotherapy training.
... The process of creating with art materials may enable symbolization and the creation of a transitional space (Huss, 2015;Winnicott, 1971). The artwork may reflect the primary and internalized relationships of the client (Isserow, 2013), and thus expand her/his self-consciousness (Gavron & Mayseless, 2018;Huss, 2015;Schaverien, 1992Schaverien, , 2011. The study of Haeyen, Van Hooren & Hutschemaekers (2015) reveals that AT provides some clients direct access to feelings that are less accessible through verbal processing. ...
This pilot study examines fluctuations in the strengths of the art therapy working alliance and the therapeutic working alliance over time in simulated art therapy sessions. Participants were 53 female graduate students of art therapy (Age range 23-57), who assumed the role of creators/clients in simulated art therapy sessions, and filled out the two questionnaires (n = 44 at time 1, n = 29 at time 2, n = 36 at time 3). Repeated measures of the two alliances were obtained in three time points during the simulation from only 19 participants. Findings revealed a distinct difference in the patterns of change between the two alliances: while the strength of the therapeutic alliance increased linearly during the course of the simulation, the strength of the art therapy working alliance decreased in the middle of the simulation and increased at its end. The main factor that was found as significantly decreasing at time point 2 was the Art Task factor. Significant associations between the two alliances were found at each of the three time points. Results shed light on the complex nature of art therapy, in which the ‘simulated client’ may experience fluctuations in her/his trust levels in the art medium during the art therapy simulation process, while the collaborative relationship with the ‘simulated therapist’ may get stronger. Results, implications and limitations are discussed.
... We see here what seems to be 'reflective self-awareness'. 17 The psychologist relates how the 'patient's voice becomes softer as she describes 'a portrait of a person'. We can see that a meaningful emotional connection appears to have been made, and the patient seems to reference this human connection by drawing attention to the 'humanness' of the image. ...
Full-text available
The challenge for those treating or witnessing pain is to find a way of crossing the chasm of meaning between them and the person living with pain. This paper proposes that images can strengthen agency in the person with pain, particularly but not only in the clinical setting, and can create a shared space within which to negotiate meaning. It draws on multidisciplinary analyses of unique material resulting from two fine art/medical collaborations in London, UK, in which the invisible experience of pain was made visible in the form of co-created photographic images, which were then made available to other patients as a resource to use in specialist consultations. In parallel with the pain encounters it describes, the paper weaves together the insights of specialists from a range of disciplines whose methodologies and priorities sometimes conflict and sometimes intersect to make sense of each other’s findings. A short section of video footage where images were used in a pain consultation is examined in fine detail from the perspective of each discipline. The analysis shows how the images function as ‘transactional objects’ and how their use coincides with an increase in the amount of talk and emotional disclosure on the part of the patient and greater non-verbal affiliative behaviour on the part of the doctor. These findings are interpreted from the different disciplinary perspectives, to build a complex picture of the multifaceted, contradictory and paradoxical nature of pain experience, the drive to communicate it and the potential role of visual images in clinical settings.
... At no point did any art therapist direct attention through an object-directed statement, such as simply telling the group to look at the artwork. The action in this conceptual category matches descriptions of the concept of joint attention in art therapy where the service user is asked to not just focus on the artwork, but also on the art therapist's mind as it attends to that artwork (Isserow, 2008(Isserow, , 2013. Facilitating joint attention is at the heart of MBT (Bateman, 2007). ...
This article describes video-based observation of three mentalization-based treatment (MBT) art therapy groups in services for people who have received a diagnosis of personality disorder. Four focus groups (service user researchers, MBT trained psychologists, MBT trained art therapists, and the three art therapists who submitted videos) developed descriptions of the practice they observed on video. A grounded theory method was used to develop a proposition that if the art therapist uses art to demonstrate their attention, this tends to help potentially chaotic and dismissive groups to cooperate, whereas if the art therapist gives the appearance of passivity, it tends to increase the problematic interactions in the group.
Full-text available
(KOR)본 연구는 영국에서 축적된 미술치료학 연구의 지적구조를 규명함으로써 영국 미술치료 학의 연구영역과 세부내용을 파악하고, 국내 연구에의 시사점을 도출하는 데에 그 목적이 있다. 연구대상은 영국미술치료사협회에서 출간하는 「International journal of art therapy: inscape」의 1권 1호부터 23권 3호(1996-2018) 사이에 게재된 논문 202편이다. 연구도구는 Excel, SEMI, COOC, WNET, NodeXL 프로그램을 사용하였으며 연구대상 논문에서 추출 한 144개 단어의 개별출현빈도와 동시출현빈도를 바탕으로 유사도 계수를 산출하고, 네트워 크를 시각화한 뒤에, 연구영역별로 연관된 논문의 내용을 정리하는 방법으로 지적구조를 파 악하였다. 본 연구의 결과는 다음과 같다. 첫째, 주요 연구주제를 군집화한 결과, 7개의 상 위 군집 안에 41개의 하위군집이 분포된 것으로 나타났다. 둘째, 위의 결과로 17개의 의미 있는 연구영역을 구분할 수 있었으며 지적구조의 세부내용을 살펴본 결과, 조현병, 학습장 애, 자폐 스펙트럼 장애, 외상 후 스트레스 장애, 경계선 성격장애에 대한 연구를 다수 찾아 볼 수 있었다. 그리고 아동화와 이미지를 탐구하거나 새로운 미술치료 이론을 고찰한 연구 도 다수 찾아볼 수 있었다. 이러한 결과를 바탕으로 국내 미술치료학 발전을 위한 시사점을 논의하였다. (ENG)This study aims to identify research domains and detailed contents of art therapeutics in the United Kingdom by investigating the intellectual structure, and deriving implications for research in South Korea. The research targets were 202 original papers published in the “International Journal of Art Therapy: Inscape” from volume 1, number 1 to volume 23, number 3 (1996-2018). This journal is published by the British Association of Art Therapists. Excel, SEMI, COOC, WNET, and NodeXL programs were used as research tools. Based on the individual appearance frequency and simultaneous appearance frequency of 144 words extracted from the targeted research papers, the similarity coefficient was calculated. After visualizing the network, the intellectual structure was identified by the organizing contents of the papers related to each research domain. The results of this study are as follows. First, after grouping major research subjects, it was revealed that 41 subgroups were distributed in seven high-level groups. Second, 17 significant research domains were classified. After examining the detailed contents of intellectual structure, many studies on schizophrenia, learning disability, autism spectrum disorder, post-traumatic stress disorder and borderline personality disorder were found. Moreover, many studies had researched children’s drawings and images, and investigated new art therapy theories. Based on these results, implications were discussed for the advancement of art therapeutics in South Korea.
Two studies present the development and validation of the Art Therapy Working Alliance Inventory measure, based on Bordin’s [1979. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252–260] conceptualisation of the therapeutic working alliance. The measure captures unique aspects of the art therapy working alliance that take into account the client’s relation to the art medium in the presence of the art therapist. The measure’s reliability and validity were examined. In Study 1, 40 art therapy students, who participated in art therapeutic simulations as clients during their training programme, rated the measure in its development phase; in Study 2, 104 art therapy students completed the final questionnaire and the Working Alliance Inventory in regard to therapeutic simulations. Exploratory factor analysis revealed three main factors: perceiving the art medium as an effective therapeutic tool (Art Task); the affective and explorative experience during art-making (Art Experience); and, acceptance of the art therapist’s interventions in the art medium (Art Therapist Acceptance). Associations were found between Art Task and Art Therapist Acceptance with each of the working alliance components, as well as between Art Experience with the Bond component. Implications for practice and research are discussed. Plain-language summary In verbal psychotherapy, a strong therapeutic alliance between client and therapist is necessary to achieve therapeutic goals. In art therapy, this alliance includes a third object: the art medium, comprised of art materials, artmaking and artworks. In this study, we developed and tested a new questionnaire for art therapy service users which measures the client-art medium alliance formed in art therapy. The new questionnaire is based on the Working Alliance Inventory, a well-known measure used in psychotherapy (Horvath & Greenberg, 1989) and is called the Art Therapy-Working Alliance Inventory. In order to measure the alliance between the client and the art medium, the Art Therapy-Working Alliance Inventory asks about three main areas: the client’s perception of the art medium as a therapeutic tool (Art-Task), the client’s affective experience of his/her artwork (Art Experience), and the client’s acceptance/rejection of the art-therapist’s interventions in the art medium (Art Therapist Acceptance). We asked 104 art therapy students to assume the role of clients in simulated art therapy sessions and then fill out the questionnaire at the end. We found a strong association between the two alliance scores; in other words, the stronger the alliance between the client and the art therapist, the stronger the alliance between the client and the art medium. Thus, we concluded that the Art Therapy-Working Alliance Inventory can serve as a useful tool in the research of art therapy practice.
Vitality takes on many dynamic forms and permeates daily life, psychology, psychotherapy and the arts, yet what is vitality? We know that it is a manifestation of life, of being alive. We are very alert to its feel in ourselves and its expression in others. Life shows itself in so many different forms of vitality. But just how can we study this phenomenon? This title is divided into three parts. Part I is an introduction and background to vitality. Part II suggests a neuroscientific underpinning for forms of vitality, and shows how the time-based arts require and use these forms. Part III concerns the implications of forms of vitality for developmental and clinical work. This inquiry aims to further identify and explore this realm of dynamic forms of vitality, and to illustrate the breadth of its scope. This title may be helpful in approaching the dynamic dimension from psychological, neuroscientific, and phenomenological perspectives, and may be useful in reorienting some notions of emotion theory, memory structure, and social communication, as well as psychotherapeutic theory and practice.
Most of us are continually aware that others have thoughts and feelings - but are children? When? This book is a concise and readable review of the extensive research into children's understanding of what other people think and feel, a central topic in developmental psychology known as "Theory of Mind". The understanding of belief is central to this text, which explains in simple terms what representational theory of mind is all about, and shows how researchers have demonstrated this understanding in 4-year-olds. The book considers what leads to this understanding, including the role of pretend play, understanding of attention and eye direction, and other precursors to representational understanding of mind. The general relevance of theory of mind is demonstrated through coverage of the development of other mental state concepts, and the relationship between understanding mental representation and other representational media. The author also carefully summarizes current research on the relationship between theory of mind and concurrent developments in executive functioning, and the understanding of language. The book closes by considering autism. A major achievement of theory of mind research is the light it has helped throw on this puzzling developmental disorder. Providing a comprehensive overview of 25 years of research into theory of mind, the book will be of great interest to both students and researchers in psychology, philosophy and the cognitive sciences.
Imagining Animals explores the making of animal images in art therapy and child psychotherapy. It examines two contrasting primitive states of mind: the investing of the world about us with life through animism and participation mystique, and the lifeless world of autistic states of mind encountered in children who are hard to reach.