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Clay sculpture within an object relational therapy : a phenomenological-hermeneutic case studies /

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Thesis submitted in partial fulfilment of the requirements for the Master of Arts degree in Clinical Psychology. Thesis (M.A. (Psychology)) - Rhodes University, 2005.
CLAY SCULPTURE WITHIN AN OBJECT RELATIONAL
THERAPY:
A PHENOMENOLOGICAL-HERMENEUTIC CASE STUDY.
Thesis submitted in partial fulfillment of the requirements for the Master of
Arts degree in Clinical Psychology
by
CARIN-LEE MASTERS
Supervisor:
PROF. DAVID EDWARDS
Department of Psychology
Rhodes University
Grahamstown
March 2005
ABSTRACT
The overall aim of this thesis is to explore the process of working with the Edwards claywork
method with a psychotherapy client who had significant relational difficulties and feared being
exposed as defective.
Within this there are particular aims: Firstly, to investigate whether the distancing that art therapy
can create, can help the client with relational difficulties to tolerate unexpressed disavowed
feelings, in particular her sense of shame about being exposed as defective; and secondly, to
examine whether material evoked through the claywork process can assist in furthering the
psychological formulation of this kind of client. The research was a phenomenological-
hermeneutic case study of a psychotherapy client, called Kim. Kim’s experience of therapy,
including two claywork sessions, was documented. This comprises a thematic narrative of her
therapy process prior to the claywork process, as well as a thematic narrative focusing on the
two claywork sessions. Her clay sculpture was photographed and alphabetically labeled
according to the chronological order in which she made the eight pieces comprising her
sculpture. A hermeneutic reading of the narratives was conducted using theoretical perspectives
including object relations, Adlerian psychology and art therapy.
It was concluded that, firstly, the distancing that art therapy can create does help the client, who
is afraid of being exposed as defective, to tolerate previously disavowed and unexpressed
feelings; and secondly, art therapy such as the Edwards claywork method, does deepen
psychological formulation of the client’s affective and relational difficulties. However, although
the image may graphically symbolize unconscious aspects of a client’s psyche, the present
study illustrates that a client may not always be able to enter into a relationship with the image or
dialogue between conscious and unconscious states. In this respect, the present study focuses
on aspects of art therapy of which there is limited literature.
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ACKNOWLEDGEMENTS
I would like to thank the following people who were instrumental in this process:
My supervisor, Prof. David Edwards, for his incisive guidance, enthusiasm and encouragement.
Thank you for being such a great and ‘soulful’ teacher.
The participant, Kim, in appreciation of her courage to take part in this research as well as
trusting and allowing me to journey with her on her claywork and healing experience.
Mike Earl-Taylor for his generosity and proof reading.
Those friends and family members close to my heart who supported me throughout this process.
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CONTENTS
ABSTRACT I
ACKNOWLEDGEMENTS II
CONTENTS III
INTRODUCTION 1
CHAPTER ONE: DEVELOPMENT OF THE SELF 4
1.1 INTRODUCTION 4
1.2 A CASE OF SELF-PATHOLOGY 4
1.3 PSYCHE, SELF AND EGO 5
1.4 BIRTH OF THE SELF IN RELATION TO CAREGIVERS 7
1.5 THE HOLDING ‘GOOD-ENOUGH’ MOTHER 8
1.6 THE NAISSANCE OF THE SELF AND THE PROTECTION OF THE ‘KERNEL’ 9
1.6.1 The “unthinkable anxiety” experienced 10
1.7 THE ORIGINS OF A NARCISSISTIC SELF-STRUCTURE 11
1.7.1 Protecting by protesting 13
1.7.2 Self-pathology and attachment 14
1.7.3 Adaptive strategies against the threat of exposure 15
CHAPTER TWO: THE ART OF PSYCHOTHERAPY AND ART AS THERAPY 19
2.1 INTRODUCTION 19
2.2 PSYCHOTHERAPY AND THE IMPORTANCE OF THE RELATIONSHIP 19
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2.3 TOLERANCE AND HOLDING WITH A ‘DIFFICULT’ PATIENT 21
2.3.1 Therapy as creative interacting and meaning-making 23
2.4 ART AS THERAPY 24
2.4.1 AIMS OF ART THERAPY 25
2.4.1.a The image facilitates dialogue 25
2.4.1.b Concretized inner conflicts 26
2.4.1.c Safety in distancing 26
2.4.1.d Facilitating different possibilities 27
2.4.1.e The image mirroring the relationship 27
2.5 THE IMPORTANCE OF GRADING ART THERAPY TECHNIQUES 28
2.6 CLAYWORK AS A FORM OF ART THERAPY 29
2.6.1 Introduction 29
2.6.2 The value of clay 29
2.6.3 Literature on claywork 29
2.7 EDWARDS’ CLAYWORK METHOD 30
CHAPTER THREE: METHODOLOGY 32
3.1 INTRODUCTION 32
3.2 THE AIMS OF THE RESEARCH 32
3.3 THE PHENOMENOLOGICAL-HERMENEUTIC APPROACH 35
3.4 THE CASE STUDY RESEARCH METHOD 35
3.5 THE RESEARCH PROCEDURE 36
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3.5.1 The research participant 36
3.5.2 The research context 37
3.5.3 Data collection 39
3.5.4 Data reduction 39
3.5.5 Data interpretation 41
3.5.6 Evaluation of research aims 42
CHAPTER FOUR: CASE MATERIAL 43
4.1 INTRODUCTION 43
4.2 BIOGRAPHICAL DETAILS 43
4.3 KIM’S ‘SIGNS AND SYMPTOMS’ 44
4.4 THERAPY THEMES PRIOR TO CLAYWORK 46
4.4.1 Depression and feeling out of control 46
4.4.2 Perfectionism and self-criticism 46
4.4.3 Difficulties in intimate relationships 47
4.4.3.a Fear of sexual intimacy 48
4.4.4 Narcissistic tendencies 50
4.4.4.a Devaluation 51
4.4.4.b Attacking in response to having been ‘exposed’ 51
4.4.5 Ambivalence 52
4.4.6 Unsure of changing self 53
4.5 THERAPIST AFFECTS 53
4.6 KIM’S EXPERIENCE OF MAKING AND DISCUSSING THE CLAY SCULPTURE 55
4.6.1 Introduction 55
4.6.2 Making the sculpture 55
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4.6.3 Kims sculpture 56
4.6.4 Descriptive view of Kim's sculpture 57
4.6.4.1 The Perfect “thing” 57
4.6.4.2 The Mudpie and “the whole childhood thing” 57
4.6.4.3 Kim’s protective shell 58
4.6.4.4 Spirals of anger 58
4.6.4.5 Masking with the “huge abstract thing” 59
4.6.4.6 Letting go 59
4.6.4.7 The “pornographic” image 59
4.6.4.8 Squashed femininity 60
4.6.4.9 Control vs “Chaos” 60
4.7 THERAPY THEMES REVISITED IN CLAYWORK 61
4.7.1 Difficulty relating to the ‘other’ 61
4.7.2 Perfectionism and needing to get things “right” 62
4.7.3 Defensiveness, attacks and devaluation 62
4.7.4 Grandiosity and idealization 64
4.7.5 The “pornographic” image as metaphor for sexual difficulties 65
4.7.6 Boredom as a defense 66
4.7.7 Ambivalence 66
4.7.8 Lack of integration between conscious and unconscious aspects 67
4.8 THEMES FOCUSSING ON CLAYWORK 68
4.8.1 Owning disowned anger 68
4.8.2 Repulsion 68
4.8.3 The mudpie and the acknowledgment of loneliness 69
4.8.4 “Escaping” into safety of own world 69
4.8.5 The “chaos” of underlying feelings 70
4.8.6 Masculine over-identification vs feminine disconnection 71
4.9 CLAY VS TALK THERAPY 72
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CHAPTER FIVE: DISCUSSION 74
5.1 INTRODUCTION 74
5.2 THE THERAPY RELATIONSHIP PRIOR TO CLAYWORK 74
5.2.1 An object relations understanding of defenses in the therapy relationship 74
5.3 THEMATIC OVERVIEW OF CLAYWORK 78
5.3.1 Introduction 78
5.3.2 Self, Insecure attachment and Relational difficulties 79
5.3.3 Masculine Protection 82
5.3.4 Reflections on the “Pornographic” image 84
5.3.5 Control vs “Chaos” 86
5.4 Concluding thematic overview 90
5.5 POST-CLAYWORK EXPERIENCE 90
CHAPTER SIX: CONCLUSIONS 94
6.1 INTRODUCTION 94
6.2 THE VALUE OF CLAYWORK COMPARED TO INDIVIDUAL TALK THERAPY 94
6.3 RESEARCH LIMITATIONS AND SUGGESTIONS 97
6.4 RECOMMENDATIONS FOR CLINICAL PRACTICE 98
REFERENCES 100
APPENDIX A: Consent form
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INTRODUCTION
Essentially, the current study aims to investigate and document the process of clay
sculpture with a psychotherapy client who feared being exposed as defective, and
experienced significant relational problems. The theoretical paradigms of object relations,
specifically Summers (1999) and Teyber (2000), Adler (1912/1958) and art therapy
theory, were used as hermeneutic lenses to explore this client’s relational difficulties and
psychological defenses, their origins, and how these were re-enacted in her current
relationships including with the therapist as well as her clay sculpture.
Certain concepts used in this thesis such as the psyche and the Self are best understood
phenomenologically as referring to patterns of lived experience in the world and are not
to be viewed as ontological entities in a fixed psychological context (Brooke, 1991). The
psyche is an entity designed for movement, growth, change and transformation, thus a
degree of evolution toward Self-realization is therefore embedded in all psychic
processes (Samuels, 1985). This parallels Winnicott’s (1958) view of the true Self which,
beginning in childhood, is a natural maturational process toward Self-realization. This
Self is the true potential of an individual which becomes ‘buried’ as a result of
unsatisfying or assaultive experiences in childhood. A false self with various concomitant
defenses, develops which aims to protect the true Self from further psychological injury.
Although these defenses originally served a protective or compensatory function, in
adulthood, they give rise to maladaptive patterns of behaving and relating.
In this study, difficulties in relating to others and expressing authentic feelings are
phenomenologically explored in relation to the experiences of a female student in her
early twenties who experienced emotional deprivation and trauma in her childhood. The
student, whose name has been changed to Kim to protect her identity, was a
psychotherapy client of the researcher (then intern psychologist) at the time of initiating
the research. Kim had significant difficulty in expressing her feelings and relating to
others, including the therapist.
The offering of an empathic therapeutic relationship in which ‘attacks on linking’ (Bion,
1959) are tolerated may play a significant role in helping the client to trust the therapist
(Coen, 2002; Teyber, 2000; Winnicott, 1958). However, often clients may struggle to
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express their underlying conflicts and repressed feelings through verbal language, and
for this reason, an expressive form of therapy may be more useful. Art is viewed as a
valuable agent for therapeutic change and healing. Art may bypass the conscious mind’s
‘censor’ more easily than words, and tap into feelings and experiences that have been
hidden in the unconscious (Naumberg, 1966/1987). Artistic expression may facilitate
various potentially therapeutic processes such as, reflecting the individual’s repressed
and disavowed feelings, allowing psychological distance from unconscious material,
facilitating a dialogue between the conscious and unconscious aspects of the psyche,
containing of strong feelings, giving tangible form to unconscious material, as well as
mirroring the therapeutic relationship.
The question arose as to whether the above-mentioned qualities of the artistic image are
able to provide these to a client who struggles to engage with another, and whether, in
spite of her fear of being ‘exposed’, the art image would be able to engender a dialogue
between conscious and unconscious aspects of her psyche. This material, once made
conscious, could be more fully integrated into the individual’s psyche, with the potential to
lead to greater psychic wholeness and authenticity. The importance of ‘unearthing’
underlying feelings with the intention of engendering insight and, in the process, owning
one’s feelings and experiences, are a few of the fundamental aims of psychotherapy.
Furthermore, it was examined whether an art therapy technique, such as clay therapy,
could be a valuable medium in facilitating the expression of disavowed aspects of the self
through its ability to create distance from psychological material.
It is recognized that dysfunctional patterns of relating established in childhood with early
caregivers/objects would, more than likely, engender difficulties in relating to others in
adulthood (Bowlby, 1988; Liotti, 1991). These difficulties in affectively engaging in human
relationships may be found to be present in relationships with other ‘objects’ as well,
including the artistic image. Previous research has shown that clients benefit in a variety
of ways from the use of a more expressive form of therapy (Anderson, 1995; Atlas, 1992;
Diers, 1999; Elliot, 1993; Gothan, 1998; Nez, 1991; Smuts, 2003). However, not much
has been researched on clients who struggle to engage with, and fear being exposed by,
others, including the artistic image.
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This study starts with a theoretical exploration of the ‘development of the self’ from a
Jungian and object relations perspective (Chapter One). This chapter includes the
investigation of the psychological birth of the self in relation to early caregivers, as well as
the development of self-pathology and various concomitant defense mechanisms.
Chapter Two explores the role of psychotherapy and the value of the therapy
relationship. This chapter also includes an examination of the role of art therapy in
contributing toward healing, with specific reference to the Edwards claywork method. In
this chapter art therapy is discussed broadly in psychodynamic terms.
Chapter Three outlines the methodological approach which was undertaken in this
research study. Chapter Four follows with the presentation of case material, including two
case narratives. Firstly, a thematic narrative of Kim’s individual therapy process prior to
the claywork experience is presented, which is followed by a thematic narrative of the
claywork process. Chapter Five examines these narratives with a series of hermeneutic
questions. Finally, in Chapter Six, conclusions related to the findings of this research are
presented.
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CHAPTER ONE
DEVELOPMENT OF THE SELF
1.1 INTRODUCTION
This chapter will first briefly introduce the reader to the research participant and basic
difficulties she experienced which brought her into therapy. The material that arose from
therapy particularly lent itself to interpretations according to Summers’ (1999) view of the
narcissistically wounded individual, who fears being exposed as defective. Thereafter, I
will introduce the reader to key terms used in this thesis, including psyche, ego and self.
A Jungian framework is used in explaining these terms as this perspective lends itself to
a more holistic view of the individual. Subsequently, the development of the self and the
naissance of self-pathology will be discussed within an object relational framework.
1.2 A CASE OF SELF-PATHOLOGY
The participant of this research, whom I will name Kim, was an Asian female student in
her early twenties, who presented in therapy with moderate to severe depression as well
as with significant difficulty in her relationships with others. What was striking in Kim’s
self-presentation was her assumption of self-loathing, she believed she had no
commendable qualities except her appearance and her mastery of the English language.
Her deepest conviction about herself was that she was inadequate, believing everything
she did was somehow wrong: she could not get her studies and life ‘right’, she could not
feel happy about anything, she did not like herself socially, she despised her partners, felt
inferior to her friends and had ambivalent feelings toward her parents, on the one hand,
admiring them and on the other, abhorring them.
The basic idea of an underlying negative sense of self, and the development of a variety
of defense mechanisms in order to protect the self has been expounded by various
theorists including Freud (1923), Jung, (1928) Adler (1912), Winnicott, (1958) and more
recently, Summers (1999) and Teyber (2000). It is well known that when an individual
has experienced a childhood that lacked a warm, supportive and facilitating environment
and, instead, was exposed to various forms of neglect and abuse, the child would more
than likely be unable to develop his/her innate potential, and instead, needs to protect
him/herself from further psychological injury. Various psychological defenses and
compensatory mechanisms may be employed, not only to protect against further hurt, but
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also to navigate the interpersonal world. This will be elaborated upon later. It is widely
recognised that most forms of psychopathology arise from a traumatic childhood and, in
response, may manifest in various forms of clinical patterns including what is known as
personality disorders. The current research focuses on a client who presented with
symptoms which may be classified within Summer’s framework of a narcissistically
wounded individual, who experiences severe anxiety in relation to their sense of
defectiveness being ‘exposed’ to others.
Kim’s feeling of defectiveness was the root of her rapid mood swings, paralysing
depression and catastrophic anxiety. A variety of personality structures and clinical
pictures may emerge in response to this sense of defectiveness. However, the protection
of a stubborn, persistent feeling of diminished or non-existent self-worth was the
organising factor in her personality. Although many clients typically include in their list of
problems complaints such as “I do not like myself” or “I have a low self-esteem”, for
clients like Kim, anxiety about experiences ‘confirming’ their feelings of inadequacy
organises their interpersonal relationships. This anxiety manifested in all Kim’s
interpersonal relationships including the therapeutic relationship, therefore, Summers’
account of the narcissistically wounded individual was deemed as most fitting in terms of
furthering a deeper understanding of her difficulties. These issues will be elaborated on
later. I next discuss fundamental concepts which are utilized in this thesis to clarify ideas
about the self as well as the origins of self-pathology.
1.3 PSYCHE, SELF AND EGO
Throughout this thesis I will be referring to the individual ego as the self, with a lowercase
s, and the capitalised Self refers to Jung’s idea of an archetypal Self. The psyche, the
ego and the Self are best understood phenomenologically, as referring to patterns of
lived experience in the world instead of viewing them as ontological entities in a fixed
psychological context (Brooke, 1991). Jung refers to the term ‘psyche’ as the “totality of
all psychic processes, conscious as well as unconscious”, or the place of experience and
meaning (cited in Samuels, 1985, p. 13; Brooke, 1991). The psyche is an entity designed
for movement, growth, change and transformation, thus a degree of evolution toward
Self-realization is therefore embedded in all psychic processes (Samuels, 1985). This is
parallel to Winnicott’s (1958) view of the true Self which is prevented from growth as a
result of poor childhood environmental responses. This is further expounded by
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Summers in his argument that this Self is the true potential of an individual which
becomes ‘buried’ under psychological defenses as a result of unsatisfying caregiving
responses, and is protected by a false self.
Further, Jung’s sense of Self includes being true to the deepest calling of Being itself
which is at the centre of what he termed, individuation, and is a call to realise the
potentialities of the Self; calling the inauthentic self to become the authentic Self (Brooke,
1991). This process of individuation entails a working relationship between the conscious
and unconscious, the ego and the Self. Jung posited that this working relationship
between the ego and the Self leads to the development of a sense of one’s unique
individuality and also one’s connection to the larger experience of human existence,
enabling one to live more authentically and in a truly creative, symbolic and individual
way. This process of becoming one’s own individual, may be understood from its
etymology, that is, the process of becoming indivisible, or at one with oneself (Samuels,
1985). Often the defenses created by the ego are viewed as aspects of the self to be
done away with. However, according to Jung the ego and its conscious and unconscious
forces is not to be dismissed or gotten rid of, instead, its forces need to work in relation
with the Self and not be disconnected from the Self (Hopcke, 1989).
In summary, the Jungian Self is superordinate to the ego and contains the conscious and
unconscious, personal and collective aspects of the psyche. The psyche is an imaginal
space in which the individual lives and it incorporates and surrounds the person. Thus,
conscious and unconscious material represented by the Self include the potentials of the
person, both realised and unrealised, as well as the deeper more spirit-related aspects of
a person. This can be compared to Winnicott’s true Self which is argued by Summers to
be the buried potential, which underlies psychological defensive strategies designed to
protect the self from further injury. The protective and adaptive strategies of the
narcissistically wounded individual can be seen as one pattern of responses to
unsatisfying or neglectful caregivers in childhood. In order for there to be psychic health
there needs to be a working relationship between the ego and the Self which leads to a
process of individuation. However, as a result of an assaultive or neglectful childhood
environment this process of individuation or Self-realization may be undermined or
arrested. This is next elaborated upon.
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1.4 BIRTH OF THE SELF IN RELATION TO CAREGIVERS
The human child has a natural drive toward maturation and development of its potential
Self, however, when the child’s basic needs are not met and he/she has to, instead,
conform to the needs of the caregivers, an ‘arrest’ in development occurs. The true Self
goes into hiding and a false self emerges which serves to protect the former. This
developmental ‘arrest’ and the structuring of a false self include the formation of various
psychological defenses which serve to protect the true Self.
According to object relations theory the infant has inborn affective tendencies as well as
a need for relatedness which plays a “crucial role in personality formation” (Summers,
1999, p.38). These inborn capacities, such as aggression and love, are either facilitated
or impeded by the responses of the child’s early caregivers (Summers, 1999) which in
most cases is the mother (Cashdan, 1988). The child constructs meaning from the ways
in which his/her caregivers (objects) have responded to him/her, which in turn form
patterns of relating between self and objects (others), known as object relationships.
The significance of the objects (caregivers) lies in the psychological ‘functions’ they
contribute to the nascent Self. The responses of caregivers such as praise or the
induction of shame, for example, are “taken in” or internalized by the child, and are
experienced by the child as pride or guilt (Cashdan, 1988, p.21). The origins of these
psychological functions can be located in the concrete, observable communications that
make up caregiver-child interaction, as well as in the more subtle empathic forms of
interchanges between the child and caregiver. These empathic interchanges are highly
significant in the formation of the child’s burgeoning sense of Self as they constitute a
connection with other human beings, “and are uniquely and quintessentially human”
(Cashdan, 1988, p. 21). Consistent empathic interchanges from caregiver to child form
the basis for a psychic infrastructure that affects how the child relates to others as well as
to him/herself (Cashdan, 1988; Summers, 1999). The child is therefore born into a social
milieu, and relatedness with others form a basic requisite for psychological survival and
psychic health since the child needs adults from the very beginning, not only to fulfill
physical requirements, but also psychological needs. The most important of these, is the
provision of an environment that will “support its vague and undifferentiated sense of
Self” (Cashdan, 1988, p. 20) whilst going through a maturational process toward greater
Self-realization.
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As mentioned, human beings have an innate drive to realize the inborn capacities of the
Self, which is regarded as the need for Self-realization. However, this need may work in
concert with the need for relatedness or they may be in opposition, depending on the
responses from the caretakers (Summers, 1999). According to Winnicott (1958), the
infant has an inborn disposition to experience a maturational process that cannot be
altered but that can be facilitated or impeded by its environment. This inborn capacity
toward growth or maturational process Winnicott equated with the true Self, “the potential
to become the unique Self one most truly is” (cited in Summers, 1999, p.42). If this
healthy expression of affect and relatedness, including healthy narcissism, aggression,
affection, and the ability to play, is interfered with, the child is compelled to use defenses
to protect its Self from being injured. It thus focuses on ‘the shell’ to protect ‘the kernel’
(Winnicott, 1958). The psyche becomes split between the false self adaptation to a
hostile environment and the true Self of inborn potential which is buried beneath the
protective layers, arresting the natural process of healthy maturation (Winnicott, 1965 in
Scharff, 1996) and potential Self-actualization.
1.5 THE HOLDING ‘GOOD-ENOUGH’ MOTHER
What appears to be most important in the early relational ties of the child is the
mothering figure holding the infant, sometimes physically but largely figuratively or
psychologically (Summers, 1999; Winnicott, 1958). The infant’s spontaneous impulses,
gestures and needs are the potential or naissance of its true Self. Here, it is necessary to
examine the part played by the infant’s mothering figure or caregiver. The mother can be
responsive in a good-enough or not good-enough way. The ‘good-enough’ mother meets
the gestures and needs of the infant and, to some extent, makes sense of them,
repeatedly and consistently (Summers, 1999; Winnicott, 1958), and a true Self begins to
emerge. This happens through the recognition and strength given to the infant’s weak
ego by the mother’s adequate responsiveness to the infant’s expressions and needs.
Thus, the inborn potential of the true Self is only realized through the repeated successful
responses of the mother to adapt to the infant’s spontaneous gestures or needs (Cooper,
1986; Winnicott, 1965 in Scharff, 1996).
On the other hand, the mothering figure that is not ‘good-enough’ is not able to
implement the infant’s spontaneous gestures and affects, and as a result repeatedly fails
to meet the infant’s gestures and needs (Cooper, 1986; Winnicott, 1958). Instead, the
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mothering figure substitutes her/his own needs which is to be given sense by the
compliance of the infant, and this compliance or other forms of compensations of the
infant is the beginning stages of the false self (Summers, 1999; Winnicott, 1958).
Through this false self, the infant establishes relationships, and by means of it
conforming to the (m)other’s needs, may attain an appearance of being real so that
he/she may grow to become what the caregiver wants. The false self has one positive
and important function – to hide and protect the true Self, which it often does by
compliance to the demands of significant others and/or developing various other
compensations.
The defensive function of the false self, therefore, is to hide and protect the true Self, that
part of the psyche that has been injured is protected from re-experiencing this trauma.
Winnicott (1958) classifies one aspect of the false self organizations at one extreme,
where the false self presents as real and it is this that observers tend to think is the real
person. However, in intimate relationships, the false self begins to fail. In situations in
which it is more expected to be a whole person the false self has certain essentials
lacking. In this case the true Self is hidden.
1.6 THE NAISSANCE OF SELF-PATHOLOGY AND THE PROTECTION OF THE
‘KERNEL’
As mentioned earlier, the development of a false self serving as protection of the true
Self as well as concomitant psychological conflicts, are to be found in the failure of a
child’s environment to adapt to his/her absolute dependency needs. Certain forms of
psychopathology are viewed as disturbances of the Self, with severe disorders such as
personality disorders rooted in very early disturbances of the mother-child relationship
(Cashdan, 1988). In childhood, the primary caretaker of characterologically disturbed
clients was typically unable to provide a stable, positive, supportive relationship to the
client (Summers, 1999). These unresponsive patterns or traumas may include overt
physical and sexual abuse, emotional unavailability, abandonment, sadistic teasing,
sexual provocation, hostile rejection and chronic expressions of disapproval and criticism
(Summers, 1999). As a result, clients with self-pathology develop psychological conflicts,
which become organised as defenses against “the trauma of unthinkable anxiety and
hence as a way of relating that does not betray the Self” (Davis & Wallbridge, 1981,
p.48).
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This can be further elaborated by viewing this process of defense development as an
organization toward invulnerability. What is common in most psychological defenses
employed by individuals with self-pathology is the belief that the person “must never
again experience the unthinkable anxiety”, the exploitation of the true Self, that he/she
experienced when at a very vulnerable stage of dependence on environmental provision
to needs (Davis & Wallbridge, 1981, p. 49; Winnicott, 1958). Thus, clients with self-
pathology, who have developed certain psychological defenses to protect themselves,
are, according to Winnicott, expressing “the fear of a breakdown that has already been
experienced” (cited in Davis & Wallbridge, 1981, p. 50).
1.6.1 The “Unthinkable anxiety” experienced
Children are highly dependent on their caregivers and thus vulnerable to all forms of
neglect and abuse. Trauma that begins early in life interrupts developmental tasks and
subjects young children to overwhelming emotional and physiological stimuli before they
are able to understand what is happening, and before they have the verbal skills to
communicate their suffering. Their distress is heightened in proportion to the amount of
violence used and to the invasive nature of the assaults (sexual, physical or
psychological). Should abuse continue over long periods of time, children grow up under
conditions that are literally warlike. In addition to the normal strains of childhood, they
carry the heavy burdens of rage, shame, guilt, and humiliation – all borne in silence and
isolation (Everett & Gallop, 2001). Children who are abused or maltreated by a relative or
nonrelative in a position of trust (Browne & Finkelhor, 1986) suffer the further insult of a
fundamental betrayal, since the healthy need for love and relatedness has been violated
(Marshall & Herman, 1998). The very people who are supposed to love and protect the
child become the sources of harm and danger. Familial perpetrators are rarely
consistently abusive and can intersperse terrorizing assaults with weeping apologies and
protestations of love (Everett & Gallop, 2001). Under these assaultive conditions children
learn that the world is completely unpredictable, that all adults are to be feared and that
nowhere is safe.
Childhood trauma can lead to a variety of overwhelming emotions, such as anger,
sadness, guilt, and shame. In order to avoid these intense feelings, children may take
refuge in various forms of protective mechanisms, such as dissociation (splitting of
consciousness), denial, amnesia, or numbing of bodily senses (Briere, 1992; Draucker,
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2000; Everett & Gallop, 2001; Herman, 1995). Although these responses are at first an
adaptive way to survive the traumatic experiences, they can become overgeneralised
and maladaptive over time, more specifically in adulthood. Repeated trauma in
childhood, including emotional and sexual abuse, “forms and deforms the personality”
(Herman, 1992, p. 96). Kolb (1989) in his argument that Posttraumatic Stress Disorder
(PTSD) may mimic every personality disorder, posits that “it is those threatened over
longer periods of time who suffer the long-standing severe personality disorganization”
(cited in Herman, 1995, p. 88). Indeed, psychopathology related to repeated ongoing
traumas in the past may be veiled in characterological problems that are manifest only in
disturbed object relationships and attitudes toward the self, others, and work. The child
trapped in an assaultive or abusive environment is faced with formidable tasks of
adaptation. Though the abused child may perceive him/herself as abandoned to a power
without mercy, he/she must find a way to preserve a sense of self, hope and meaning
with the alternative being “utter despair, something no child can bear” (Herman, 1992,
p.101) since the child is totally dependent on caregivers. Unable to care for or protect
him/herself, the child must compensate for the failures of adult care and protection with
the only means at his/her disposal, “an immature system of psychological defenses”
(Herman, 1992, p.96). Most of the abused individual’s psychological adaptations serve
the fundamental purpose of preserving primary attachment to his/her parents in the face
of evidence of their malice, helplessness or indifference. I next explore the origins of the
development of the narcissistic self-structure and certain concomitant defenses.
1.7 THE ORIGINS OF A NARCISSISTIC SELF-STRUCTURE
A variety of personality structures may emerge in response to environmental responses
or lack of it as mentioned above, with the following symptom pattern being only one such
outcome. In seeking the genesis of one form of pathological self-structure, that is, the
narcissistically wounded individual, a closer examination of the child’s first object
relationships need to be highlighted. As mentioned earlier, at this largely dependent
stage the child/infant is completely vulnerable and dependent on the caregiver to provide
for its needs including psychological needs, which include experiencing its authentic
affects. For these affective states to become internalized into the self-structure they must
be responded to and facilitated by early caretakers (Summers, 1999). Kohut (1986)
points out that the birth of the Self is facilitated by the parents’ treatment of the baby as
though it were a Self, with the child finding him/herself in the mother/caregiver’s
11
recognition. Competence and trust in the affective states are requirements for the
development of a stable positive sense of Self. Bowlby’s (1988) attachment studies
suggest that competence is facilitated by a caregiver who provides an optimal zone of
affective engagement, which includes allowing the child to experience negative affective
states, with the caregiver being responsive enough to help the child cope with it (in
Scharff, 1996). In this way the child learns to trust his/her affects and is capable of
dealing with difficult experiences and feelings. Similarly, if a caregiver facilitates,
encourages and enhances a child’s positive affects, such as enjoyment and interest, the
child will come to believe that his/her positive feelings and excitement are worthy of
other’s interest and thus that he/she is interesting.
On the other hand, a child who receives insufficient help with negative affects are
overwhelmed by them and does not develop the confidence to manage negative feelings
and experiences. In addition, if the child’s interests and enjoyment are ignored or
discouraged, he/she will likely believe that his/her naturally arising positive states are
unacceptable and not worthy of others’ attention. He/she is likely to conclude that his/her
authentic affects are ‘defective’, as though he/she were fundamentally lacking what
others find valuable (Summers, 1999). In this way the child cannot trust that he/she can
form and sustain relationships by acting on his/her spontaneous affects and interests
(Liotti, 1991; Teyber, 2000). Not being able to trust in the value of his/her authentically
experienced affects, he/she perceives his/her affects as unreliable and dangerous. As a
result, instead of relationships being based on genuine affects, they become organized
around protecting a sense of inadequacy that has now formed the core of their subjective
experience of self. Others become objects of gratification, by helping to protect against
awareness of a sense of defectiveness, or objects of mistrust if they threaten to ‘expose’
this perceived inadequacy (Summers, 1999). Anxiety driven affective states lack
authenticity, and any feelings that emerge without such threatening motivation could be
regarded as authentic including feelings such as sadness, frustration and anger.
Most narcissistically wounded clients report childhood experiences of having been
ignored, not responded to, or overly devalued by significant early figures, or, alternatively,
they were over-attended to the point that they had little opportunity to have their own
individual experiences (Summers, 1999). Individuals who have a narcissistic self-
structure did not learn to develop faith in their spontaneous feelings and experiences, did
12
not develop the capacity to regulate negative feelings and thus feel helpless in managing
them, lack faith that their affective states could be utilized as guides to action and thus
feel that their core is inadequate. Having buried their authentic affects they develop a
false self which operates in the world but is disconnected from their true Self and genuine
feelings.
1.7.1 Protecting by protesting
Adler’s (1912) perspective of a ‘masculine protest’ contributes toward furthering the
understanding of an individual’s need to compensate for feeling vulnerable and
inadequate. The individual compensates for this by identifying with socially sanctioned
masculine qualities. Adler posits that the starting point for this is a feeling of “weakness”
in the child (male or female) in the face of adults (in Ansbacher & Ansbacher, 1958, p.
47). According to Adler, the child’s need for affection and support is denied and so called
feminine qualities such as love, gentleness and compassion are hidden, and
overcompensated for, by masculine qualities such as over-reliance on rationality,
ambitiousness, aggression, control, dominance and so on. This can be likened to Jung’s
perspective on the archetype of Logos which he links to behaving in socially sanctioned
masculine ways which “hinders and cripples the individual through one-sidedness”
(Hopcke, 1989, p. 46). These principles of Adler and Jung are to be seen as abstract;
patterns of human behaviour not intrinsically allied with anatomical gender. The
‘masculine protest’ can be seen as serving a protective and compensatory function as a
result of the child having been made to feel “weak” in the face of parental responses.
Further, Adler posits that when the ‘masculine protest’ in women is “increased” it may
lead to various forms of neurotic reactions expressed through her body such as
“dysmennorrhea, vaginism and frigidity” (Ansbacher & Ansbacher, 1958, p.49). Women
with this difficulty also tend to have problems related to reproductive issues such as their
menstruation, pregnancy and childbirth.
The individual, who has experienced severe trauma as a child, not only develops
psychological defenses and compensatory mechanisms, but also tends to have difficulty
in relationships. I next deal with the origins of the narcissistically wounded client’s
relational problems.
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1.7.2 Self-pathology and Attachment
Work by Bowlby (1973/1988) and Ainsworth (1985), in what is generally referred to as
“attachment” literature, suggest that early childhood experience has a significant impact
on later emotional and interpersonal development (in Scharff, 1996). It is posited that
early parental support, nurturance, consistency and responsiveness produce secure
attachment between parent and child, such that the child is able to “approach the world
with confidence [and enhanced self-esteem], and when faced with potentially alarming
situations, is likely to tackle them effectively or seek help in doing so” (Bowlby, 1973 cited
in Briere, 1992, p. 32). In contrast, early parental neglect, ambivalence, inconsistency or
frank maltreatment is likely to disrupt or prevent optimal parent-child connection, leading
the child to distrust or fear parental contact, and yet often feel abandoned without it. Such
infants develop insecure modes of attachment, one of which is regarded as ambivalent
(Bowlby, 1988 in Scharff, 1996; Liotti, 1991).
The child is ambivalent in the attachment relationship if he/she, when distressed, strongly
searches for the caregiver’s comfort but is not easily calmed down when he/she receives
this. The caregivers of these children are usually unpredictably available, intrusive or
over-controlling (Liotti, 1991). If no corrective experience of attachment intervenes during
the life span between childhood and adulthood, these individuals are likely to construct
an interpersonal schema in which the self, when distressed, is perceived as at risk of
being misunderstood and the potentially helpful other is perceived as both unpredictable
and intrusive. The self-other relationship is governed by a schema which implies
excessive intensity and duration of requests of help, whilst expecting the
untrustworthiness of the other’s responses, and also fearing the intrusiveness of the help
of the other (Liotti, 1991). Most child abuse or neglect occurs in the context of
relationships or intimacy. As a result, it is not uncommon for abused children to fear,
distrust or experience ambivalence about interpersonal closeness. For example, sexual
abuse survivors often report difficulties in forming and sustaining intimate relationships,
as do many other adults with histories of other forms of childhood maltreatment (Briere,
1992). In a climate of disrupted relationships the child faces a formidable developmental
task of finding a way to form primary attachments to caregivers who are either negligent
or, from his/her perspective, dangerous (Herman, 1992). The child must develop a
capacity for intimacy out of an environment where most or all intimate relationships were
corrupt. He/she finds creative, but often, later, destructive ways to cope with an
14
unsupportive and assaultive environment. As mentioned earlier, unable to care for or
protect her/himself, the child compensates for parental failures with the only means at
their disposal, the development of immature psychological defenses aimed to protect the
self.
1.7.3 Adaptive strategies against the threat of exposure
Human experience appears in such rich assortment of adaptations and personality
structures that attempts to classify them into types are difficult and at times, arbitrary. Our
classifications are based on our observations which are usually informed by our
theoretical assumptions. However, some categorizing is necessary for two reasons: One
is that some ordering is necessary for us to cope with or retain the vast variety of human
experiences and personalities and its associated psychological phenomenon, and
secondly, classification enables us to relate one set of observations to another and to
apply to a new situation the knowledge gained from a former one (Lowen, 1988).
I continue to focus on Summers’ (1999) view of the narcissistic self-structure as it is most
fitting for the current case as well as selected certain psychological defenses for the
same reason. Although the narcissistic ‘defect’ has a tendency to be characterized by
different clients in similar ways, such as low self-esteem, the problem may manifest in a
variety of symptoms and relational patterns. The particular clinical constellation in each
case is a product of the defenses and adaptations used to protect against awareness and
exposure of defectiveness while providing such self-esteem and relating as the client is
capable of achieving. As mentioned previously, these psychological maneuvers are not
only defenses but also attempts to navigate the interpersonal world. However, the
constellation of strategies designed to avoid shame, or exposure of defect, is the
narcissistic character structure (Summers, 1999).
An individual with a narcissistic self-structure usually presents clinically with various
combinations of intense ambitiousness, grandiose fantasies, feelings of inferiority and
over-reliance on external admiration and acclaim. Also characteristic is “chronic
uncertainty and dissatisfaction about themselves, conscious or unconscious
exploitiveness and ruthlessness toward others” (Kernberg cited in Lowen, 1983, p.6). In
addition, there is an absence of self-restraint in their responses to people and situations
and a tendency to minimize their feelings, with the aim to be “cool” (Lowen, 1983, p.10).
15
Summers (1999) mentions certain psychological adaptations created to defend against a
sense of defectiveness via the construction of object relationships that include
compliance, grandiosity, devaluation, idealization and clinging attachment. I briefly
discuss these five defensive strategies:
Compliance with expectations of others is a strategy that tends to be used by clients
whose early caregivers required specific behaviour from the individual that fulfilled
narcissistic needs of the caregivers. These clients are trapped in a narrow cycle of
expectation to obtain parental attention. Because the parental need is often for a high
degree of success, such clients are often driven to succeed in achieving lofty goals. Their
desperation to achieve ambitious goals reflects not an inflated perception of themselves
but a need to hide their sense of defectiveness through the fulfillment of parental
ambitions
Grandiosity is an organizing defense for many narcissistic clients. When self-esteem
sinks to the point of desperation, and little parental approbation is forthcoming,
grandiosity is often an effective defense against the sense of defectiveness. Usually,
caregivers, in this case, have been totally unresponsive and expect little or nothing, with
the result that the child has been totally rejected and devalued by caregivers. This can
threaten complete self-esteem collapse and in response, the individual may have created
an inflated image of him/herself in a desperate effort to disavow a sense of defect.
However, to continue to believe in this grandiose image it needs to be bolstered by
others, which results in a personality organized around the desperate need to sustain the
feeling of self-inflation. Responses from others, other than approval or admiration,
threaten the grandiose defense with awareness of inadequacy. In this case, the drive for
achievement and perfectionism represent desperate efforts to alleviate the anxiety of
exposing a sense of defectiveness.
Devaluation is a strategy which is employed to ward off the sense of defectiveness and
boost the person’s sense of value in relation to that of others. To convince him/herself
that he/she is not inadequate, the individual obsessively attacks people close to them.
Each attack serves to allay the immediate anxiety of coming across as inadequate,
however, when the effects wear off there is a need to find new flaws in others in order to
gain reassurance that he/she is not inadequate.
16
Idealization is the opposite of devaluation but also serves as a defense against
defectiveness. Some individuals attempt to obliterate a sense of inadequacy by seeking
out and attaching to others whom they believe to possess exaggeratedly positive virtues
such as leadership, intelligence, skill, competence and beauty. Identification with these
‘exceptional’ people boosts their sense of value and thereby, temporarily, mitigates
anxiety over the feeling of inadequacy. Being acceptable to others regarded as having
high status and fitting in so as to be beyond reproach, wards off their sense of
defectiveness. This defense often bears the message: “I am terrified of being with
anyone [who is not flawless], for fear that their deficiencies will reflect on me! I must keep
my image spotless…” (Summers, 1999, p. 189).
Clinging Attachment refers to clients who are motivated by terror of object loss which
reflects the power to the tie of the original objects (caregivers). These individuals’ feelings
of defectiveness are manifested in anxiety-driven, clinging attachments. The tie to the
other is motivated not by the value of the other, but by the fear that, without the other, the
sense of defectiveness would be unbearable. These clients cling desperately to the
person who they believe will be there for them without threat of abandonment and who
will provide the approval and admiration they need in order to hide awareness of defect.
The object of their idealized romantic fantasy is often considered either actually or
potentially available and, therefore, of uncertain value to ‘repair’ the defect. The chosen
object must have sufficiently positive qualities that his/her admiration matters, however,
beyond that, the most important attributes are perceived availability, the possibility of a
secure attachment, and the object’s willingness to admire the client. The seeking is for a
potentially transformational object, an other, who possesses the power to magically
change the sense of defectiveness to a feeling of wholeness.
As just described there are five major adaptive strategies designed to protect against an
awareness of a sense of defectiveness according to Summers (1999). A thread that runs
through all these defenses and seems to be most striking about the narcissistically
vulnerable client is the protection of a stubborn, persistent feeling of diminished or non-
existent self-worth which organizes their personality. “The protection of this deep
conviction about one’s self, which may be called a narcissistic defect is the basic
motivating principle of the narcissistic personality…the anxiety of this defect exposed
may be called a narcissistic tension state…because exposure of this defect would be
17
experienced as shame, narcissistic tension entails the constant fear of a shame
experience” (Summers, 1999, p. 175). Thus, the narcissistically vulnerable client has two
apparently contradictory needs: On the one hand, he/she insists on maintaining a
persistently negative view of themselves; yet on the other, he/she works hard to prevent
the recognition of this ‘defect’ by others. Remaining continually vigilant regarding this
possibility puts enormous strain on relationships and interactions with others, resulting in
a life of chronic narcissistic tension. When this tension becomes unbearable, insignificant
events can threaten exposure and precipitate a rageful reaction, with the latter being the
‘final straw’ defense against shame. The state of persistent and continual narcissistic
tension clarifies why apparently minor events can provoke uncontrollable explosions of
anger (Summers, 1999, p. 176).
To summarize, the child makes meaning of the interactions between caregiver and child
and these created meanings are the object relationships consisting of the affective
connection between the Self and others. This provides structure to the Self and guides
the person’s ways of being and relating in the world. When there has been unloving,
hostile and inconsistent responses to the infant the true Self goes into hiding and, in
response, it protects itself from further assault by developing a false protective self. In
addition, as a result of inconsistent or intrusive parental responses the individual
develops an ambivalent interpersonal schema and expects unsatisfying responses from
others. In addition, various adaptive strategies are employed to protect against further
injury. The narcissistically wounded individual may evidence a variety of defenses
including compliance, grandiosity devaluation, idealization and clinging attachment.
These individuals lack faith in their spontaneous affects, perceive themselves as
defective and have relationships organized around protecting this defect from being
exposed. The fear of being discovered by others as defective is a thread that runs
through all of their defenses.
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CHAPTER TWO
THE ART OF PSYCHOTHERAPY and ART AS THERAPY
2.1 INTRODUCTION
Psychological defenses and compensations become stumbling blocks to further
psychological and spiritual development and restrict interpersonal relationships. The true
Self is buried under the adaptations which serve to protect from further psychological
injury. This chapter aims to elucidate the contributions that psychotherapy can make in
‘unearthing’ the buried potential. In addition, the role of art therapy will be examined with
a specific focus on clay therapy, in contributing towards providing a space for the
individual to give expression to their emotional pain and hidden capacities for growth.
2.2 PSYCHOTHERAPY AND THE IMPORTANCE OF THE RELATIONSHIP
Generally, the goal of psychoanalysis is the uncovering of the buried potential of the Self,
which is the experience of authentic affects, strivings and living (Summers, 1999).
Psychopathology and its concomitant symptoms can be seen as indirect communications
of potential ways of being and relating that have been unable to find direct avenues of
expression. Psychotherapy can therefore be a way of ‘deciphering veiled expressions’
and of providing the client with an opportunity for a ‘developmental second chance’
(Summers, 1999; Cashdan, 1988), once insight related to their symptoms has been
gained. This insight is best brought about within a therapeutic relationship. It is widely
known that the establishment of an attachment of the client to the therapist is one of the
key elements of successful therapy (Malan, 1979; Naumberg, 1966; Saketopoulou, 1999;
Wadeson, 1987). Within object relations therapy, the therapy relationship can be used
as a staging ground for the emergence of the client’s relational pathology and as a result,
the therapist-client relationship is seen as a special and unique object relation. What
makes this relationship special is that one of the participants in the relationship, the
therapist, knows that the client will reenact their relationship difficulties within the
therapeutic relationship (Cashdan, 1988; Summers, 1999; Teyber, 2000). Rogers (1951)
was one of the first to propose that the client-therapist relationship is in itself therapeutic
“and psychic change is contingent upon the therapist’s displaying a warm, understanding
and empathic stance toward the client” (cited in Saketopoulou, 1999, p. 331). There is
controversy about whether a therapeutic bond is dependent on the intrapsychic nature of
the client, that is, whether it is primarily dependent on the client’s capacity for
19
relatedness. If this is the case then the alliance would be largely predetermined since it
would be reflected in the ability of the client to relate in a meaningful way to others
(Saketopoulou, 1999). However, others have proposed that the healing ability of the
therapeutic relationship is in its capacity to provide a corrective emotional experience,
which is posited as a natural occurrence in the context of ‘good-enough’ therapy. Yet
other qualities related to the therapeutic relationship also facilitates its development.
Therapy entails the working through of problems that can often be very painful, and the
client’s motivation to remain in therapy and endure frustration and emotional pain can be
mediated by his/her perception of the therapist as helpful or committed to offer help. This
may create a stronger alliance and thus in the process encourage the client to stay in
therapy long enough to allow for other therapeutic interventions, such as interpretations,
to take effect (Saketopoulou, 1999). However, client qualities, such as their level of
motivation, ability to tolerate emotional pain and their ability to establish and maintain
relationships generally, will have an impact on the therapeutic relationship. Intimacy and
trust are significant aspects of the therapeutic relationship, and if the client had poor early
relationships with their caregivers it is more than likely that they would have significant
difficulty in establishing a relationship with others, including the therapist.
Individuals with poor early relationships often come into therapy with evident maladaptive
patterns of relating and behaving, however, as much as it may be easy for an astute
therapist to comment on this it is more judicious, especially in the initial stages of therapy,
not to try and make “clever interpretations” which will “spoil the process” but instead to
form an empathic bond with the client (Cashdan, 1988; Winnicott, 1958, p. 252). It is the
therapist’s responsibility to engage the client instead of trying to make interpretations or
suggestions for which the client is ill prepared (Malan 1979; Winnicott, 1969 cited in
Scharff, 1996). Engaging the client is clinical work and forms a significant part of the
therapeutic process including helping the client to tolerate the subsequent, and often
more challenging, aspects that will emerge in therapy. An important way to engage the
client, and which is a fundamental aspect of therapeutic healing, especially with a
‘difficult’ client, is for the therapist to tolerate their painful feelings and transferences, that
is, what they experienced in their early relationships with their caregivers (see section
1.7) they tend to transfer to the relationship with the therapist.
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2.3 TOLERANCE AND HOLDING WITH A ‘DIFFICULT’ CLIENT
It can take considerable work to remain patient and tolerant with ‘difficult’ clients who
seem unable to tolerate painful feelings and take ownership of their own inner conflicts.
Many clients with self-pathology are indeed unable to bear the pain and responsibility for
their emotional pain, and it is the “clinician’s task to help them eventually achieve such
tolerance” (Coen, 2002, p.xvii). These clients often oscillate in and out of emotional
contact with the clinician over prolonged periods and during which time they seem
incapable of collaborative exploration of their inner struggles.
Coen (2002) recommends that the therapist needs to persist with these challenging
clients even when there seem to be very little ‘evidence’ of change or progress. Some
clients for example may have an extraordinary need for control over, and participation in,
the therapy process and may have had multiple prior failed treatments where it was
believed that they were ‘untreatable’. However, working in therapy may be their only
hope for changing severely dysfunctional patterns of behaving and relating. As a result of
desperately needing to be in control in relationships many clients, such as the
narcissistically wounded individual, find it difficult to give up control in the therapeutic
relationship. No fundamental change in inner conflicts or personality can occur if the
client is in constant control of his/her feelings and/or therapy. Most of these kinds of
individuals are terrified of surrendering control as they have significant difficulty in trusting
the therapist, and given their early life experiences, this is understandable (Lowen, 1988).
Although many of these clients may show a veneer of self-confidence and assurance that
they do not need the therapist (Modell, 1986), the sensitive therapist should know that
this is simply a protective mechanism. However, the client will not let go of this protection
unless he/she sees something in the relationship that signals to him/her that the therapist
is on his/her side.
Winnicott (1969) posits that a therapist has to display all the patience and tolerance and
reliability of a ‘good-enough’ mother devoted to her baby, has to recognize the client’s
often seemingly ‘irrational’ wishes as needs, has to put aside other interests in order to
be available to the client and “has to seem to give what is really only given because of
the client’s needs” (cited in Scharff, 1996, p.193). The therapist needs to make a “good-
enough adaptation” to the needs of the client and which will be gradually perceived by
the client as “something that raises a hope that the true Self may at last be able to take
21
the risks involved in its starting to experience living” (Winnicott, 1958, p. 298). In
accordance with this, Cashdan (1988) recommends that the therapist should be able to
engage the client through “emotional linking” (p. 87) by conveying genuine understanding
and communicating that the client’s feelings are shared and appreciated. In addition,
what is most helpful for these clients is the therapist’s ability to gauge what they can or
cannot tolerate and how the therapist can enhance clients’ ability to bear what seems
unbearable for them (Coen, 2002). Some clients cannot tolerate intense psychoanalytic
interpretations and this needs to be respected. The therapist needs to focus on what
he/she can do to help these clients further, and often “doing” includes acceptance,
containment, silence, following their lead and so on. An important aspect of this is the
provision of a corrective emotional experience, by being empathic to their need to protect
themselves and to sustain a period of understanding during which the client uses the
therapist as a ‘selfobject’ experience (Summers, 1999) that is, transfers their past unmet
relational needs into the present relationship with the therapist, before the therapist
makes interpretations (Coen, 2002; Kohut & Wolf 1986; Summers, 1999; Winnicott,
1958). The therapist expects and accepts that the client transfers the past painful
experiences and concomitant feelings that they had with their early caregivers onto the
present experience with the therapist (Malan, 1979; Summers, 1999; Teyber, 2000).
Instead of the therapist ‘expecting’ emotional engagement with clients who struggle with
this, it serves the client best to expect the therapeutic engagement to include long
periods when the therapist cannot be sure that the client is involved in a constructive
treatment. Coen (2002) advocates that the path toward facing, resolving, and integrating
disavowed inner conflicts should involve tolerance and acceptance of “repeated detours
through avoidance and riddance” (p. 52). The client needs to do this for his/her own self-
preservation and the therapist can but wait until the client is ready to engage again. At
these times, the therapist has to feel and bear for these clients the terror of being
vulnerable in needing the therapist.
Similarly, Bion (1957) refers to the client’s inability to accept the therapist’s help and
emotional linking as ‘attacks on linking’ since there is a “hatred of emotion” (p.311) which
is felt too powerful to be contained by the client’s psyche. The client is opposed to “all
links whatsoever” (Bion, 1957, p. 314). In this case, the emotions related to establishing a
bond with the therapist would be too overwhelming for them and therefore there is a need
22
to dismiss or disavow it. However, as much as this may cause the therapist to feel
uncomfortable and perhaps unappreciated or wanting to retaliate, the client benefits most
when he/she sees that the therapist was able to ‘survive’ his/her attacks. Winnicott
(1969) posits that the “destruction plays a part in making the reality” since especially for
the characterologically wounded client, and more especially in the initial stages of
therapy, they depend not as much on interpretative work as they “depend on the
analyst’s survival of the attacks” (cited in Scharff, 1996, p. 252). Although the therapist
may feel like interpreting this, Winnicott argues that this response will “spoil the process
and for the client can seem like a kind of self-defence…the analyst parrying the client’s
attack” (cited in Scharff, 1996, p. 252). The therapist holds more value to the client when
he/she is able to survive the client’s attacks (Summers, 1999; Winnicott, 1969).
What seems to be most important is not so much that the therapist is able to make
insightful interpretations, although this does have its value, but that the therapist is able
to engage the client and be able to tolerate, hold and make meaning of their needs the
way a ‘good enough’ mother interacts with her baby.
2.4 THERAPY AS CREATIVE INTERACTING AND MEANING-MAKING
Winnicott (1971) posits that psychotherapy “has been developed as a highly specialized
form of playing in the service of communication with oneself and others” (cited in Scharff,
1996, p.257). The word ‘play’, according to Winnicott, extends beyond its meaning for
childhood play and includes creative interaction between people at any age, and the back
and forth of emotional engagement, between inside and outside and between one person
and another (Scharff, 1996). Psychotherapy takes place in the overlap of two areas of
‘playing’, that of the client and that of the therapist, and comprises two people interacting
together in a space of creative meaning-making. Winnicott calls this ‘a potential space’
(also known as a transitional space), where the client is able to use external objects,
including the therapist, in the service of an inner or psychic reality and puts out a ‘sample
of dream potential’. In creative interacting, the client is able to invest external phenomena
with symbolic meaning and feeling. However, when a client cannot interact creatively, the
therapist must attend to this significant symptom before interpreting any behaviour
(Winnicott, 1971 in Scharff, 1996). A way to possibly facilitate creative engagement for
clients who struggle with this, and help them to make meaning out of their experiences is
to incorporate other ways of engaging beside verbal language, such as art therapy.
23
2.5 ART AS THERAPY
Art therapy has drawn its foundations extensively from psychoanalysis. Its theories and
methods of practice are therefore based primarily in that particular paradigm founded by
Freud in the 1900’s. As Western culture is predominantly verbal, from the inception of
psychoanalysis, practitioners have used the spoken language as the primary medium of
therapeutic communication and expression (Wadeson, 1987). However, there has been
an opening in psychotherapeutic practice to explore more widely differing forms of
emotional expression, such as psychodrama, poetry, dance and art therapy (Dalley,
1984). In this manner, expressive art furthers the range of human experience by
providing symbols which contain the power to evoke authentic emotions (Diers, 1999).
The process of art therapy is based on the discovery that our most fundamental thoughts
and feelings are derived from the unconscious and reach its fullest expression in images
rather than words (Dally, 1984; Rubin, 1987). The ability and need to communicate is
essential to being human, and when verbal expression is problematic, art can be used as
a form of symbolic communication from the psyche.
Freud was one of the first to propound that the ‘talking cure’ has its limitations since we
have to rely on translating images into words (cited in Diers, 1999). Fundamental
thoughts, feelings fantasies, fears and childhood memories are stored and derived from
the unconscious (Naumberg, 1966) and often reach expression in images rather than
words (Naumberg, 1987; Rubin, 1987). A trauma or difficult early relationships may lead
to memories invested with a high level of emotional arousal. At the time of the trauma or
early deprivation, the authentic affects and needs could not be expressed and became
repressed into the unconscious (section 1.6). The memory and concomitant emotional
response could not find expression and often reappears in the form of psychological
symptoms and defenses. Therefore, the source of psychopathology is the repression of
authentic feelings in the unconscious leading to a variety of neurotic symptoms and
defenses (section 1.6).
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2.5.1 Aims of Art Therapy
Psychotherapy has two main goals which were referred to earlier: Firstly, uncovering
repressed unconscious material, and secondly, helping the client to gain insight into
his/her maladaptive behavioural patterns and defenses in relation to this unconscious
material (Rubin, 1987; Summers, 1999). The process of dynamically-oriented art therapy
assumes that an individual’s unexpressed feelings and inner conflicts are held within the
unconscious (Naumberg, 1987) and can be expressed via the art image. Dalley (1984)
defines the process of art activity as providing “a concrete rather than verbal medium
through which a person can achieve both conscious and unconscious expression, and
can be used as a valuable agent for therapeutic change” (p. xii). Art is the place in which
beings come to show themselves as what they are; it is the “‘setting-into-work of truth”’
(Levine, 1999, p. 29). As an essential manifestation of truth, art has the potential to give
meaning and direction to human existence and experience. Art is seen to be a very
powerful form of expression and can facilitate healing in a variety of ways, including the
image being able to facilitate dialogue, concretizing inner conflicts, creating psychological
distance, allowing for different interpretations and associations, as well as mirroring the
therapeutic relationship.
2.5.1 a) The image facilitates dialogue
Symbolic images created in art can facilitate the translation of unconscious material into
consciousness by circumventing the difficulty of speech (Naumberg, 1987). Siegelman
(1990) posits that the therapist who brings in a heightened consciousness and
involvement with the symbol or image will find that it unleashes buried affect, buried
insight, and a way of making the past, present and the unconscious, conscious. Through
the artistic image the unconscious is set into dialogue with the conscious state (Jung,
1961/1954; Siegelman, 1990). This may also allow for a dialogue to be initiated between
the client and the therapist. Through making these two forms of dialoguing (between
conscious and unconscious and client and therapist) possible, the art image can be seen
as highly curative (Rubin, 1987). The idea of art being one of the means to integrate the
conscious and unconscious aspects of the psyche and in the process facilitate healing
has inspired McNiff (1992) to call this process ‘art as medicine’. When the image is
formed, such as in painting or clay sculpture, the image that constitute the being of the
creation are experienced as wholly other, but there is a knowing that it also represents
aspects of the self (Edwards, 1987; McNiff, 1992). However, it is through others that we
25
discover who we are, when we learn to step aside and watch ourselves, the other
becomes the agent of transformation. In this way, dialoguing with images is a method of
expanding the conscious mind’s narrow vision of the self (McNiff, 1992). On entering the
world of the created image the client is able to become aware of the many who speak
through him/her, not simply the created figures but also the varied aspects of the psyche,
both conscious and unconscious. Thus the image allows for the creator to enter into a
relationship with it (Edwards, 1987) and open up the possibility of a dialogue between
participants, image and artist, both saying something to the other. Art is an area in which
experiences can be chosen and repeated at will, provides a latent capacity where things
can be re-experienced, resolved and integrated through setting up a dialogue within the
self. Art as therapy creates for the possibility of the image to expand communication and
offer insight outside of the reasoning mind.
2.5.1. b Concretized inner conflicts
Art therapy encourages a method of symbolic communication between client and
therapist, with the knowledge that every individual has an innate capacity to project
his/her inner conflict into visual form (McMurray & Schwartz-Mirman, 2001; Naumberg,
1987). Art can greatly enhance the psychotherapeutic experience of insight because art
not only uncovers the unconscious but, is also concrete and visual (Robbins, 1987;
Rubin, 1987). According to Naumberg (1987), in art therapy the client is faced with
evidence of a concretized image of his/her internal conflicts released from the
unconscious by his/her artwork. Through the use of graphic or other similar forms of
expression “those who originally blocked in speech often begin to verbalize in order to
explain their art productions”, frequently expressing more directly in pictures or sculptures
than in words (Naumberg, 1966, p.1) their, often painful, truth. Aspects of unconscious
material have been put into tangible form and the client can no longer disavow or deny it.
As a therapeutic tool, the art creation, unique to the individual, provides the focus for
discussion, analysis and self-evaluation, and since it is “concrete it acts as a record of
this activity which cannot be denied, erased or forgotten” (Dally, 1984, p. xiv).
2.5.1. c Safety in Distancing
The practice and process of the arts as creating rituals of expression in the form of
different media such as painting, sculpturing, dancing and writing, “is always a safe
container, a secure vessel to meet existential themes, pathos and mystery” (Levine,
26
1999, p. 45). The value of art therapy lies in its ability to be a very powerful and
immediate way of communicating repressed feelings and experiences while
simultaneously being less threatening (Dalley, 1984) because the client is able to put it
‘out there’ and engage with it in an ‘as if’ way (McNiff, 1992). This facilitates a process of
being able to identify with, while simultaneously allowing distance from, potentially
threatening material. As the image-making process develops the client is able to view the
image as a separate object and allows him/her to stare at, and step back from, it
(Edwards, 1987). The completed image, however incomplete, primitive or alien, is a new
factor in the therapeutic space; it is both a statement about, and a personification of, what
was formerly an inner experience as well as a reminder to the client and the therapist that
it has an existence independent of its creator (Edwards, 1987). The essence of art
therapy lies in the therapeutic outcome of having created something whether the client is
able to talk about it or not. This new ‘object’ created, in itself, gives voice to various
aspects of being, more specifically those aspects that have been disavowed and yet
unknown.
2.5.1. d Facilitating different possibilities
The image that becomes an actual object confronts its maker with a variety of
possibilities. If the originating impulse has arisen from the unconscious, then its
expression will be a unique configuration of forms and associated feelings (Edwards,
1987). It is thus most important that the image be regarded, by both the client and
therapist, in a variety of ways and from different perspectives. Associations may be
elicited by both client and therapist in a hermeneutic style of interpretation and meaning-
making. The image is related to as if it were an extended part of the maker, which, in a
metaphoric sense, it is. However, the perception of the image as independent and being
semi-autonomous must also be preserved, to allow for its personified aspects.
2.5.1. e The image mirroring the relationship
As argued earlier, the dynamics of the client’s early relationships are played out in their
current relationships including the therapeutic relationship. In this context, art can be a
container or organizer that mirrors aspects of the client’s relational conflicts related to
their past. The art therapy relationship offers a safe framework within which to explore
and experience past object relations. The image becomes the mirror for the relationship
the client has with him/herself, others and the therapist.
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As with traditional therapy, the attitude of the therapist toward the creator and the image
created is fundamental. In art therapy, analysis and reason may make significant
contributions to the ‘meditation’ on the artistic image but they do not dominate. Since
every aspect of the artistic creation process contributes to healing, it should not be
assumed that some expressions heal and others do not. Although therapists may bear
witness and may make their contributions, the healing agent is the art itself which
releases and contains the psyche’s therapeutic forces (Robbins, 1987). The healing or
‘medicine’ offered by processing art is an infusion of unconscious and conscious rather
than getting to a specific answer. Artistic images encourage the individual to look at them
and reflect upon their nature, both physical and psychological, therefore, rather than
labeling the image from our frames of reference, interpretation should enter the world of
the image and respond to its nature. Therapists have to meet the image and the
creator/client where they are and not impose their ideas and theories (Wadeson, 1987).
In the creative act, the various representations of the client’s intrapersonal and
interpersonal world are shaped and reflected through the artistic image (Robbins, 1987).
What is given artistic form can either mirror or complement what is going on within the
therapeutic relationship.
2.6 THE IMPORTANCE OF GRADING ART THERAPY TECHNIQUES
According to Lefevre (2004) it is important to grade artistic experiences to ensure that the
client, especially those who are very emotionally wounded, is not overwhelmed. The
grading helps to gradually increase the client’s “confidence that painful experiences could
be contained through imagery/artistic work, the relationship and the therapeutic frame”
(p.142). Similarly, others argue that certain severely emotionally wounded clients
including narcissistically vulnerable clients, may not be suitable for ‘unstructured’ art
therapy as they, for example, may not be able to draw on internal images, are unable to
mobilize emotional interest in the creative activity and thus the encounter with the
material may face them with feelings of overwhelm, or boredom, emptiness and
helplessness (McMurray, Schwartz-Mirman & Maizel, 2000). However, these authors
also argue that ‘unstructured’ art therapy would especially benefit clients “who tend to
mobilize their verbal talents in the service of especially inflexible defensive mechanisms
such as rationalization and intellectualization” (p. 195).
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2.7 CLAYWORK AS A FORM OF ART THERAPY
2.7.1 Introduction
There are many different forms of art therapy which employ different media that facilitate
expression and communication through imagery. Some of these include painting,
drawing, collages, drama, poetry and movement. This research will focus on clay as a
medium of expression in therapy. The properties of clay which include its pliability and
eventual tangible three-dimensional image, makes it highly suitable for expression of
feelings and experiences.
2.7.2 The Value of Clay
It is posited that specific properties of clay such as its pliability naturally invite the
expression of feelings. Clay is regarded as a very ‘forgiving’ medium. It is subject to
endless change. Clay’s plasticity makes it a particularly apt material for evolving a
process and experiencing change. Wadeson (1987) proposes that more than any other
medium, clay invites the person to play, to feel, to shape and reshape without necessarily
producing a finished object. Its tactile qualities can provoke expression of feeling through
pounding, pulling, slapping, breaking and so forth (Henley, 2002; Wadeson, 1987). Clay
allows for the expression of strong feelings such as anger and discharge of aggression.
According to Henley (2002), clay has the ability to bind things together including the inner
conflicts that clients may have. Henley talks about how clay is formed by the earth
through a long process of disintegration, re-integration and “melded together, awaiting
the sculptor’s hands” (Henley, 2002, p. 22). Clay has a dynamic, poetic quality to it and
lends itself to emotional expression and is therefore therapeutic.
2.7.3 Literature on Claywork
Clay as a medium of expression in art therapy has been employed in different ways by
various art therapists and psychotherapists. Nez (1991) made use of clay in order to
facilitate healing for clients who had difficulties related to childhood abuse. This included
an exploration into the cathartic and integrating potential of clay therapy, as well as
further elucidating the power of communicating unconscious parts of the self in a non-
verbal and less threatening manner. Nez found that clay encouraged a more
spontaneous and less controlled expression than other art media, and that the “act of
forming the clay seemed to put [the participant] in touch with primitive and intimate
29
physical sensations and emotions” (p. 125). Atlas, Smith and Sessoms (1992) posit that
the concretization of feelings in clay form might serve the function of exorcism or
abreaction. In his work with adolescents he discovered that clay as an expressive
medium helped them to externalize their concerns and regain focus in their daily lives.
Herrmann (1995) found that clay lends itself to the projection of anger as it can be poked,
manipulated and handled forcefully. In contrast to this, Gerity (1997) highlighted the
‘soothing tactile’ quality of clay. Anderson (1995) described a clay art therapy group
process with adult female survivors of incest. A structured programme with specific
methods was introduced and followed. It was reported that all the participants
experienced the process as helpful, and it had a positive effect on their lives and self-
esteem. As a result, claywork is viewed as a highly curative and expressive medium of
art.
2.8 EDWARDS’ CLAYWORK METHOD
In the current study the focus is on a particular method of claywork in therapy developed
by Edwards (Diers, 1998; Elliot, 1993). This method involves participants being given a
four kilogram block of clay and a piece of hardboard to work on, with instructions that
encourage free, playful molding of the clay without planning the end result. Participants
are encouraged to “let their hands do the talking” and to refrain from judging their
sculptures according to artistic standards. The next step is to reflect on the experience of
working with the clay. The aim is to "facilitate a dialogue" between the sculptor and
sculpture and to allow meaning to emerge freely in the subject’s own words, with
emphasis on the participant's emotions and physical sensations in relation to the
sculpture (Diers, 1998, p. 50). Edwards found that clay sculptures produced in this way
may contain projections of different aspects of the sculptor’s self-experience.
Several research studies explored the therapeutic benefits of claywork employing the
Edwards method. The majority of these are case studies. Franke (1992) investigated the
potential of claywork to facilitate deep emotional shifts through focusing on the ‘bodily felt
sense’ evoked by the sculpture. Elliot (1993) explored the clay sculpture's ability to
access the inner world of the sculptor by acting as a mediator or bridge between
conscious and unconscious parts of the self. Elliot discovered that the individual is
confronted with ‘hidden truths’ about the self through the medium of clay which facilitates
30
a journey of self-discovery. Gothan (1998) investigated the principles of effective
facilitation that would enable the individual to explore and discover meaning in the clay
sculpture. Diers (1999) investigated different hermeneutic perspectives in art therapy with
clay sculpture in terms of how well they open up and do justice to the experience of the
sculptor and the nature of the overall process. Smuts (2003) explored the potential of
claywork in therapy to facilitate the integration of feared and hated aspects of the self
with an adult survivor of childhood trauma.
In summary, research broadly suggests different ways in which therapeutic claywork may
facilitate healing and self-discovery through the use of clay therapy. However, research
on claywork does not specifically explore ways in which this medium may or may not be
useful with clients who experience significant difficulty in ‘exposing’ their sense of
inadequacy in relation to others, such as the narcissistically wounded individual.
Therefore, more research is needed to explore and describe how claywork may facilitate
healing for narcissistically wounded clients. This research is specifically called for within
the context of individuals who struggle to express themselves verbally and who fear
‘exposing’ themselves to others, including the therapist.
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CHAPTER THREE
METHODOLOGY
3.1 INTRODUCTION
This study is a phenomenological-hermeneutic single case study exploring the value of
clay sculpture with a narcissistically wounded client as part of her process of
psychotherapy. The study focuses on the experiences of a female student in her early
twenties, who will be referred to as Kim. Her experiences of interacting with her sculpture
as well as how this process furthered deeper therapeutic understanding will be
highlighted. This chapter provides a description of the aims, approach and procedure of
the research.
3.2 THE AIMS OF THE RESEARCH
The literature review illustrated that art therapy, and specifically clay sculpture as a form
of art therapy, has the potential to facilitate making unconscious material conscious,
which may lead to greater wholeness and integration of the Self. However, this
phenomenon needs more investigation specifically in the context of narcissistically
wounded clients and their specific psychological defenses including their anxiety about
being exposed as defective. The aims of this research are:
1. To investigate the process of working with the Edwards claywork method with a
narcissistically wounded client.
2. To investigate whether the distancing element that art therapy can create can help
the narcissistically wounded client to tolerate unexpressed disavowed feelings,
and in particular feelings of shame about exposing a sense of defectiveness.
3. To investigate whether material evoked through the claywork process can assist in
deepening the psychological formulation of the narcissistically wounded client.
3.3 THE PHENOMENOLOGICAL-HERMENEUTIC APPROACH
Phenomenological psychological research focuses on the qualitative exploration of
human experience and meaning. In contrast to a more positivistic approach,
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phenomenology entails an investigation of things as they appear, away from
preconceived theories about them (Giorgi & Giorgi, 2003; Smith & Osborne, 2003). This
implies a description of phenomena as they are, before theories and hypotheses about
them are formed. The phenomenological researcher seeks the psychological meanings
that constitute phenomenon through investigating and analyzing lived examples of the
phenomenon within the context of the participants’ lives and experiences (Giorgi &
Giorgi, 2003).
Phenomenology seeks to understand the lived experience of individuals, and seeks to
answer the question, “What is it like to have a certain experience?” (Miller & Crabtree,
1992, p. 25). This approach is characterized by an attitude of “open-endedness” so that
genuine discoveries may ensue (Giorgi, 1985, p. 13). This attitude of openness as a
central principle of phenomenology is captured in Husserl’s dictum, “back to the ‘things
themselves’” (Giorgi, 1985, p. 8). The phenomenological approach is regarded as the
most appropriate approach for this study, as it allows the researcher to enter Kim’s
experience of clay sculpting and stay open to whatever emerges during the image
making process. In this way, the study aims to stay as close as possible to the
participant’s clay sculpture experience which may be seen as “symbolic speech” in itself
(Rubin, 1987, p.12). The attempt is made not only to understand the meaning of Kim’s
verbalizations connected to her sculpture, but also to understand the way she interacted
with her sculpture and the therapist. As posited by Addison (1992), “meaning is not only
that which is verbalized; meaning is expressed in action and practices” (p. 111).
Hermeneutics moves beyond phenomenology in that the goal is to use interpretation of
lived experience to create a better understanding of this experience. Hermeneutics
therefore refers to the “business of interpretation” and looks at the meaning of human
activity within a specific context (Packer & Addison, 1989, p.1). According to these
authors, the use of phenomenological descriptions in itself does not always provide
adequate insight into a participant's experiences. The capacity to live through, or respond
to, events and experiences often “greatly exceed the capacity to know exactly what we
do or why we do what we do” (Giorgi & Giorgi, 2003, p. 27). Therefore, an important
assumption of a hermeneutic approach is that “interpretation is necessary to understand
human action” (Addison, 1992, p. 112). However, although an analysis and well-
grounded interpretation of lived meanings is necessary, as a researcher, it is important to
33
remain aware that whilst making interpretations, it is never possible to achieve an
objective, value-free stance. The researcher’s values and choice of paradigm are always
embedded in the research itself. Interpretation always starts in, and is an articulation, of
the interpreter’s understanding of what is going on. When the researcher makes an
interpretation of an action, he/she is bringing a “development” of his/her understanding of
that action (Packer, 1989, p. 97). These kinds of approaches, therefore, place a special
emphasis on self-reflection in the research process whereby the researcher uses
intensive inner searching and empathic immersion in participants’ experiences (Miller &
Crabtree, 1992, p. 26) which is sometimes referred to as a heuristic approach.
Hermeneutic analysis is by necessity a circular procedure (Addison, 1992), that is, an
iterative method. As a result, a central aspect of the hermeneutic approach is that the
researcher enters “an interpretive circle of intentional action” (Miller & Crabtree, 1992, p.
25) by moving back and forth between, for example, the participant’s experience and
assumptions and interpretations based on existing theories.
The hermeneutic approach, therefore, provides an additional dimension in that it moves
beyond mere description of phenomena to an interpretative dialogue between
phenomenological description and existing theoretical frameworks (Packer & Addison,
1989). The hermeneutic interpretative process entails the employment of existing
literature as ‘lenses’ through which experiences may be viewed and which can provide
access to the deeper dimensions of the data (Edwards, 1998). Literature provides “a way
of reading, a preliminary initial accessibility, a stance or perspective that opens up the
field being investigated” (Packer & Addison, 1989, p. 277). In this study, literature on the
development of the Self from a Winnicott and object relations perspective, the
experiences of narcissistically wounded clients within Summers’ view, an Adlerian
perspective of protecting the self, and art therapy are used as hermeneutic lenses
through which a deeper understanding of Kim’s clay sculpture experience is sought.
Apart from promoting a thorough understanding of the phenomenon in the current
investigation, the hermeneutic interpretative process also provides opportunities for the
further development of existing theory (Edwards, 1998). This may happen in that the
existing literature, which serves as a hermeneutic lens, in turn, also becomes evaluated
and modified through dialogue with the case material (Packer & Addison, 1989). Knight
(1997) describes this interaction between case material and existing theory as a
34
hermeneutic-dialogue. In this study the hermeneutic dialogue between literature including
object relations theories on the development of the Self, theories about the
narcissistically wounded individual, defensive and compensatory mechanisms, and art
therapy may be refined and tested for usefulness as conceptual lenses (Edwards, 1998).
3.4 THE CASE STUDY RESEARCH METHOD
Case study research involves the systematic and in-depth examination of one or more
cases of a phenomenon of interest with the aim of gaining an understanding of the
phenomenon, and developing or extending a theoretical framework (Edwards, 1998).
Case study research starts with an accurate and detailed description of a limited number
of units (often only one), such as an individual or a small group. These descriptions are
then used to conceptualize general principles pertaining to the phenomenon under
investigation. Therefore, from a single case study, general principles can be generated
through an inductive process (Knight, 1997; Smith, 1997). The present study is a single
case study, implying that the experience of one participant is under investigation.
Although research based on only one participant has been criticized, especially within
discourses favouring quantitative methods based on the positivist scientific paradigm, the
single case study method has been recognised as an important research tool within the
discipline of psychology (Edwards, 1998; Smith, 1997). Edwards (1998) posits that the
careful observation, description and discussion of individual cases have proven to be the
foundation of the development of clinical knowledge. Although of a more informal nature,
case studies involve a systematic research process providing rich data in which the latter
are contextualized. This means that a sufficient range of qualitative data is collected to
enable meaningful relationships to be examined within a single case. Another important
assumption in case-based research is that the participant’s experience is encountered
respectfully and these accounts of themselves call for exploration and understanding.
Accordingly, this kind of research calls upon the researcher to “err on the side of fidelity
to the phenomenon” (Giorgi & Giorgi, 2003, p. 49) and one way in which to ensure this is
to “enter the hermeneutic circle” by immersing oneself in the data and moving back and
forth between collecting, analysing, reflecting and writing (Addison, 1989/1992, p. 116).
This process will be elaborated on in the next section. An important aspect of immersion
in the current research, is the researcher’s commitment to remaining as close as possible
to Kim’s experience, including being committed to humanistic aims such as congruence,
35
acceptance and being person-centred (Lefevre, 2004). The researcher, therefore, makes
use of the first person approach employing the more personal term ‘I’ interchangeably,
with the more academic terms, such as ‘the researcher’ or ‘the therapist,’ where
appropriate or more fitting. The first person approach as opposed to the third person
method allows for a deeper and richer connection to the participant’s experience.
Case studies involve different phases of the research process, which can be seen as
existing on a continuum from description through to theory testing (Edwards, 1998;
Knight, 1997). The present case study firstly involves a phase of phenomenological
description, where the aim is to stay as close as possible to the data throughout
processes of data collection, reduction and extraction of themes. These methodological
procedures are discussed later. This study is also concerned with the development or
extension of existing theory regarding clay sculpture and therefore involves a theoretical-
heuristic phase. Case-based approaches represent the production of progressive
conceptual refinement because knowledge from a series of cases is continually refined to
generate general principles. In the current research the phase of theory testing will
involve the evaluation of the application of art therapy in previous cases as described
literature review. When a case provides an example of the successful application of
existing theory, the case serves to validate that theory. However, if the material of the
case requires that a new phenomenon be recognised, new distinctions be made, or a
different relationship between phenomena be seen, it provides a basis for extending or
developing theory (Edwards, 1998).
3.5 THE RESEARCH PROCEDURE
3.5.1 The research participant
The research participant, Kim, is a female student in her early twenties who experienced
traumatic losses in her childhood. She is of Asian descent and had been completing a
degree in business studies and law at the time of conducting the research.
The present research was undertaken with Kim whose progress in therapy seemed to be
blocked to some extent by difficulties in getting in touch with her feelings and related
unconscious material. From the outset of therapy Kim was particularly guarded,
defensive and had significant difficulty expressing and connecting with her feelings. She
would often resist interpretations and feared coming across as vulnerable or
36
incompetent. As a result, most of our initial sessions focused on me making explicit to
her that I will not force her to explore any parts of herself that she felt she was not ready
to deal with yet. Kim gradually began to trust me, however, she still had significant
difficulty expressing her feelings or gaining insight into the source of her difficulties.
Although after 26 sessions she had made significant strides in acknowledging certain
difficulties in her life, such as feeling inadequate and considering the reality that her
parents were not as available to her as a child as she had previously believed, Kim
continued to struggle to connect with her feelings and it appeared that therapy had
reached a significant impasse. It was hoped that a more expressive form of therapy,
such as clay sculpture, would enable her to access her disavowed and unexpressed
feelings. I suggested to Kim that we could explore her feelings and experiences through
clay therapy and permission was asked for her case to be used for research purposes.
The impact, both positive and negative, of the research on the course of therapy was
discussed with Kim, as well as other implications of being a research participant. Kim
gave verbal and written informed consent for her case as well as the photograph of her
clay sculpture to be used for research. She also gave written permission for her claywork
sessions with me to be video-taped and transcribed (see consent form in Appendix A).
As it implied a dual relationship, the fact that Kim was in therapy with me introduced
some ethical considerations. For this reason I endeavoured to conduct the research in
such a way as to cause minimal disruption of the normal therapist-client relationship. As
far as possible, I refrained from directing the post-claywork therapy process according to
my research interests.
3.5.2 The research context
In the current study the Edwards method of claywork was employed. Prior to conducting
the claywork process with the participant the researcher read up extensively on Edwards’
method. According to this method, the researcher endeavoured to ensure certain
conditions which would contribute toward optimal research data collecting. This included
the provision of an uninterrupted space and time within which the claywork process could
be undertaken, and orientating the participant to the process by attempting to portray the
message of ‘playing’ with the clay and not trying to make an image that others would
‘admire’. In order to ease the participant into the process I demonstrated the
technicalities of the clay such as using water while allowing her hands to shape the clay
37
into any form that emerges. I informed her to ‘turn off’ any criticism and to allow herself to
‘connect with the clay’. I communicated to her that each piece should find its natural
place on the board and pieces should preferably not be destroyed. After this
demonstration the participant was given a block of potter’s clay, water and a 40cm x
60cm hardboard to work on. The researcher played ambient background music, gave the
participant privacy and checked in on her every half an hour. The participant took 1½
hours of the first clay therapy session to create her sculpture. For the final hour of the first
session and the full 2 ½ hours of the following session the therapist explored the making
of Kim’s sculpture and associated sensations, feelings and images that emerged. This
entailed the implementation of an open-ended interviewing style that allowed for the
participant to describe her experience in her own words, in order to obtain her subjective
experience (Kvale, 1996; Taylor & Bogdan, 1998). Validity of data collection in all phases
was ensured by avoiding bias and selection effects as far as possible (Barker, Pistrang &
Elliot, 1994). The Edwards method is complementary to qualitative methods of inquiry.
Following the Edwards method, the researcher facilitated two phases of exploration of
the participant’s sculpture. The first phase is a less intense exploration, and the second is
a deeper mode of exploration which included the researcher’s interpretations. The first
explorative phase included the following aspects:
a) the description of how she made her sculpture.
b) the exploration of her kinesthetic sense of making the sculpture including encouraging
her to talk about getting her hands into the clay.
c) exploring the evolution of her sculpture in terms of what pieces came first, whether she
had changed or destroyed any pieces and whether she had struggled with any particular
pieces.
d) obtaining a detailed account of the participant’s imagery, feelings, impulses and
behaviour whilst working with the clay.
e) following non-verbal cues such as the participant touching a specific piece while
talking about another piece. According to Edwards this is significant as it might indicate a
connection between the different pieces.
In the second phase the researcher facilitated a deeper exploration of each piece while
continuing to ask open-ended questions and therefore obtaining the participant’s own
meaning and interpretation. The researcher would reflect and clarify only what had come
from the participant and did not attempt to lead her. This ensured the quality of the data
38
being collected. Toward the end of the last claywork session the researcher attempted to
interpret aspects of the participant’s sculpture and clay process, however, these
interpretations remained as close as possible to the participant’s own experiences and
verbalizations.
3.5.3 Data collection
The following three data sources were utilised:
1) Assessment and therapy notes made by the researcher/therapist prior to the
clay sculpture experience. These consist of thorough assessment notes
including Kim’s biographical details and personal history as well as notes
regarding the therapy process prior to the claywork experience.
2) Video-recording of the making of the sculpture and of the exploration of Kim’s
sculpture with the researcher/therapist. This included the video-recording of
two 90 minute sessions in which Kim’s experience of the sculpture was
explored with the researcher/therapist. An open-ended, unstructured
interviewing style was followed, allowing Kim to describe her experience of the
claywork in her own words (Smith & Osborne, 2003). Her reflections were
transcribed verbatim so as to ensure “fidelity to the phenomenon” (Giorgi &
Giorgi, 2003, p. 49).
3) Written therapy notes on the three sessions following the claywork
experience, other than those focusing on the claywork itself. Sections of these
sessions that provide additional information, which had relevance to the
claywork process, was identified and transcribed verbatim.
3.5.4 Data reduction
Vast amounts of data were reduced into concise, yet comprehensive and manageable
forms. According to Edwards (1993) three points should be kept in mind when reducing
vast amounts of qualitative data: Firstly, the method should be useful in advancing the
researcher toward achieving the research goal; secondly, methodological rigour must be
maintained so that the researcher remains faithful to the participant’s claywork
experience; and lastly, the data reduction process must be free from selection bias which
could involve the omission of aspects of the material which might be problematic for
39
theory, – this could significantly decrease the validity of the research. I next describe the
four ways in which data was reduced in the current research.
a) Case History: Data from assessment and therapy notes made by the
researcher/therapist prior to the clay sculpture experience, were reduced in order
to provide a historical context for the claywork experience. Relevant biographical
details were extracted and organised into a concise summary (section 4.2).
Careful consideration was taken to omit data which could potentially harm the
confidentiality of the participant.
b) Thematic narrative of therapy process prior to claywork: Vast amounts of data
obtained from the therapy process prior to the claywork experience were reduced
following methods described by Smith and Osborn (2003) and Taylor and Bogdan
(1998). The first step entailed reading through therapy notes a number of times in
order to become as familiar as possible with the data, while bearing in mind the
researcher’s experience of Kim during the therapy process prior to the claywork,
especially her guardedness and difficulty engaging in the therapeutic relationship.
The next step was to summarise the data into a thematic narrative by identifying
and selecting certain themes that richly illustrated Kim’s experience in therapy.
The researcher moved back and forth between different parts of the therapy
process material focussing on similarities, differences and contradictions within
the data while making preliminary interpretations about these. This was repeated
several times until six broad themes emerged which seemed to have bearing on
the clay sculpture experience (see section 4.4).
c) Sculpture photographs and map: Two photographs of Kim’s sculpture highlighting
all the main components have been included. Each piece in her sculpture has
been mapped and labelled alphabetically according to the order in which she
made them.
d) Thematic narrative of sculpture process: Significant amounts of data obtained
from the claywork experience were reduced following approximately the same
methodological process as executed with the therapy material mentioned above.
However, this time the researcher initially wrote up a chronological narrative
40
synopsis of the participant’s claywork experience and subsequently undertook a
more “analytical ordering” (Smith & Osborn, 2003. p. 71) into preliminary themes
which most richly described the participant’s experience of the claywork process.
The researcher aimed to omit repetitions when generating themes. In addition
certain key words and phrases were selected which supported related preliminary
themes. This led to the compiling of a thematic narrative. Throughout this process
the researcher moved between reading the data and interpreting them in a
circular manner which allowed for richer engagement with the data and for the
researcher to remain faithful to the participant’s experience. This was repeated
several times until broader themes emerged. An important aspect of getting to
unifying her experiences into themes was to look for contradictions,
inconsistencies, gaps and ambiguities (Addison, 1992) which further contributed
toward the deepening of themes. These themes were given titles, which
highlighted and captured most strongly Kim’s experience of the clay sculpture.
Eight themes emerged which were linked to themes that emerged from the
therapy process prior to the claywork process (section 4.7), and six themes were
identified that appeared to be more specifically related to the claywork process
itself (section 4.8). These were further reduced to four superordinate themes,
presented in section 5.3.
3.5.5 Data interpretation
Such a rich body of data lends itself to interpretation within a large number of possible
frameworks. Because of the limited scale of this project, only a few of these frameworks
were selected. These included object relational theories, specifically Summers (1999)
and Teyber (2000), related to the development of the Self, self-pathology and relational
difficulties, an Adlerian (1912/1958) perspective on compensatory mechanisms, as well
as literature on art therapy. These theories were used as ‘hermeneutic lenses’ to assist
in gaining insight into Kim’s clay sculpture experience. This was done by selecting
relevant sections from the theory as ways of reading the data and thereby developing a
deeper understanding of preliminary themes. From the themes that emerged in therapy
as well as the various preliminary themes related to the claywork process certain central
organising themes emerged which most richly described and illustrated Kim’s difficulties.
As these themes began to cluster together more closely, broader themes began to
emerge. These developed into four superordinate themes (section 5.3) and include:
41
1) Self, Insecure attachment and Relational difficulties
2) Masculine Protection
3) Reflections on the “Pornographic” image
4) Control vs Chaos
3.5.6 Evaluation of research aims
This stage specifically addresses the research aims in the light of the preceding
methodological steps. This includes investigating whether certain claims made within the
literature, such as the distancing effect suggested by art therapy theory, can help a client
who struggles to engage relationally and fears being exposed, to open up and explore
their disavowed feelings. Some authors suggest that only those clients who are able to
articulate their experience, are psychologically-minded and are able to engage with the
clay sculpture would benefit from this kind of process (Diers, 1999). Others argue that
the claywork process is able to open up a ‘dialogue’ between the conscious and
unconscious aspects of the client’s psyche (Edwards, 1987; Smuts, 2004). This research
provides the opportunity to investigate the extent to which certain narcissistically
wounded clients may be guarded against the potential of claywork to access
unconscious material as a result of feelings of shame about being exposed as defective,
and may not be able to engage with the clay and enter into a ‘dialogue’ with it. It is hoped
that this research might illustrate that although the client/participant may not be able to
enter into a ‘dialogue’ with the sculpture or between the conscious and unconscious
aspects of the psyche as some authors have suggested, they may still be able to benefit
by processing previously disavowed and unexpressed feelings in the claywork
experience. Secondly, although the client may not necessarily be emotionally articulate
and ‘psychologically-minded’ with regards to the sculpture, he/she would more than likely
benefit from the furthering of psychological formulation as a result of the material evoked
through the claywork process. Hence, the degree to which the findings of this research
supports, contradicts or expands existing theories was used to determine the validity of
these theories. This was done in order to establish ways in which insights developed
from this study might contribute toward further theory development.
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CHAPTER FOUR
CASE MATERIAL
4.1 INTRODUCTION
This chapter entails a phenomenological description of the participant’s case. The first
section of the chapter provides a historical context for participant’s case by presenting
relevant biographical details. The second section is a thematic narrative of the main
themes that emerged during the participant’s 26 individual therapy sessions with the
researcher/therapist, prior to the claywork experience. Finally, a thematic narrative of the
claywork experience is presented.
4.2 BIOGRAPHICAL DETAILS
The participant of this research, whom I will name Kim, was a postgraduate student in her
early twenties. She was of Asian descent and lived with her family until she began
studying. She had been studying away from home at Rhodes University for a few years
and was living in digs. The researcher had been seeing Kim for psychotherapy for
approximately 12 months before commencing the clay sculpture process with her.
Kim recalled having a close relationship with her mother until she was four years old. At
this point her mother gave birth to her twin sisters and experienced post-partum
depression. Kim was forbidden to enter her parents’ room while her mother was
recovering from depression. During this time Kim would play by herself and felt isolated
from others. She reported feeling “irritated” about not being able to be with her mother.
When she was a child she felt that she was neglected, emotionally abused and unloved,
more specifically by her mother. While she was growing up, her mother was also highly
critical, punitive and aggressive toward her. Kim described her mother as a “neat freak”,
tidy, organised and controlling. Kim felt that although her mother was “good” she was
“nothing else to me”. She described her mother as “boring, weak and unidimensional”. In
spite of this, Kim believed that this was “a pretty normal childhood”. Her relationship with
her mother remained cold and distant for most of Kim’s life until recently, when Kim
began to perceive her mother as “weak” as she could openly challenge her mother about
various issues.
Kim’s father, although he provided her with material resources, consistently failed to
recognise her emotional needs. However, she felt closer to him than to her mother since
43
he met some of her needs, albeit only material. Her father was generally emotionally
unavailable. She both admired her father for his hard work and perseverance, and
resented him for not being interested in her except academically. She believed she was
his “favourite”, the “apple of his eye” and was able to criticize and manipulate him,
however, she reported feeling ‘bad’ about this. When Kim was about 11 years old she
lived with her grandmother because her parents had moved to a different town. She
recalled that her father would visit her regularly, however, her mother had only paid her
one visit while she stayed with her grandmother. During this time and into her teens, she
stated that she would “escape into her fantasy world” by isolating herself from others,
including her family, and did a lot of things that “were kind of escapism”. She read and
wrote stories which was a way for her to deal with her problems. For example, she wrote
about how she wished her life could have been and created characters that she wanted
to be and who led a perfect life. In addition, Kim felt that she might have been sexually
abused when she was five years old. Although she had no cognitive memories of this she
had an intuitive sense, and in addition, experienced significant difficulty in her adult
sexual relationships.
As Kim was growing up, her parents did not take much interest in her social and
academic development. However, when she entered tertiary education her father placed
a lot of emphasis on, and took great pride in, her academic achievements. Kim felt that
he pressurised her to excel academically but very rarely showed interest in how she was
feeling. She had also gained more status in the family due to her higher level of
education, but this had only made her feel more resentful toward them. She felt that she
had no value in her family unless she produced outstanding academic results. In
addition, when she experienced depression or felt that she was not coping with life, her
father required a medical explanation for this. Kim would expect similar explanations for
her emotional difficulties, and a medical doctor would be her first port of call while
psychotherapy was the last.
4.3 KIM’S ‘SIGNS AND SYMPTOMS’
Kim had approached the Psychology Clinic in March 2002 because she had been
struggling to stay focused on her studies, and had felt depressed and unmotivated for a
few months. A major precipitating factor at the time was that, at the beginning of 2002,
she had gone to see a movie in which a girl was sexually violated by a number of young
44
men which she found significantly disturbing. Soon after this, in March 2002, she entered
a process of psychotherapy with another therapist who focused on issues related to
depression, “unhappiness”, difficulties recognizing her individuality, and parental
problems. Although Kim had told this therapist that she suspected that she was sexually
abused as a child, she did not allow this to be explored in therapy. She prematurely
terminated therapy in May 2002 because she believed that although therapy helped her
somewhat she expected more of a ‘miracle cure’ and not the exploration of her
childhood. In February 2003 she experienced an episode of debilitating depression and,
as a result, sought help at the Psychology Clinic again, at which point she was assessed
by the researcher (then intern psychologist). Kim’s eye contact in the clinical setting was
judged as poor. She appeared defensive and reticent to share information that might be
emotionally upsetting. Her discussions, therefore, were often quite superficial. She
showed stunted affect, and often attempted to minimize her psychological suffering. Her
mood was judged as depressed. She came across as intelligent, however, her emotional
insight was judged as impaired. She seemed somewhat motivated to address her
difficulties at the time.
Signs and symptoms of Major Depressive Disorder, Dysthymic Disorder (Axis I) and
Narcissistic Personality Disorder (Axis II) were evident and diagnosed as such. The
former included a depressed mood all day nearly every day, a loss of interest and
pleasure in most activities, psychomotor agitation, hypersomnia nearly every day, a
sense of worthlessness and a diminished ability to concentrate and make decisions. She
also appeared to have experienced symptoms of dysthymia for a significant part of her
life. The Axis II diagnosis included symptoms such as a grandiose sense of self-
importance, a need to be seen as ‘special’ with the idea that the only people who could
understand her, or she should associate with, are other special people or people with a
high status, she was preoccupied with fantasies of ideal love, she evidenced arrogant
and haughty attitudes and behaviours, and required excessive admiration. After this initial
assessment Kim entered into a therapy process with me, which, altogether, comprised 26
sessions of 50 minutes each, prior to the clay therapy process that was undertaken.
Initially, as a result of the severity of her depression and suicidal behaviour I saw Kim
twice a week for the first six weeks until she had stabilized. The following themes were
prominent during her therapy process with me.
45
4.4 THERAPY THEMES PRIOR TO CLAYWORK
4.4.1 Depression and feeling out of control
During the initial part of therapy, Kim frequently mentioned how she felt compelled to
”sabotage” everything she undertook and experienced periods of severe depression,
which, she believed, was beyond her control. For example, she tried to injure herself by
attempting to cut her lower arms with a steak knife a few times before a major exam. She
reported a sense of not being present when she attempted to cut herself and only when
she felt the pain did she realise what she was doing, and was ashamed that she felt a
sense of relief and exhilaration as a result of the pain. She felt afraid that she was able to
hurt herself and her belief that she had no control over it increased her sense of anxiety.
She described her behaviour as “weird” and called herself “psycho”. Kim would also
become immobilised by depression and not study for her exams, nor be able write final
papers. She described her depressed mood as feeling “stagnant”. Her worst feeling was
her perception that other people, such as her friends, were making progress in their lives
but she “had done nothing”. She began to find her studies boring and she felt hopeless.
She reported she was generally a lazy person and enjoyed sleeping but she felt that her
sleeping was not by choice any longer. She also experienced extreme mood swings, but
added that she was never completely happy in her life. She would tell herself to enjoy
something good when it was happening because it would inevitably end. She drank
alcohol excessively the year before, more specifically over weekends and would be
“plastered” almost every second weekend for the entire weekend. She felt that she did
not know her limits with alcohol. The following year she experienced “memory blocks”
when she was intoxicated although she reported not drinking any more than the year
before. She could not remember what had happened the night before. She experienced
no memory lapses in other situations. In addition, Kim envied her friends as she was of
the opinion that they had progressed academically, and were not “sleeping their lives
away” as she was. She believed that her friends’ lives were more exciting and that they
accomplished more than she did. As a result of this she felt she had nothing to contribute
in conversations.
4.4.2 Perfectionism and self-criticism
Kim experienced difficulties with chronic procrastination, more specifically in relation to
her studies. She stated that she was an “extremist” and would either put into place a rigid
work schedule or no scheduling at all. She stated that she was afraid that if she changed
46
her procrastination she would become “super-efficient”, which she believed was “not her
style”. She particularly worried about her inability to make decisions as well as chronically
doubting herself which were influenced by a fear of repeating previous mistakes that she
had made. She was significantly afraid of making mistakes and, therefore, when she
failed to do something perfectly she would not do it at all. She believed that unless
something was perfect it had no value.
Kim often expressed feelings of failure in many areas of her life, including in therapy.
She felt like a failure when she could not get things “right”. For example she felt she had
failed in therapy when she could not accomplish a therapy homework assignment that
the therapist had invited her to do. She stated that if she was not perfect in everything
she was a total failure. She believed that she had high expectations of herself as her
mother did, who “scrutinized” whatever she would do when she was a child. Kim also
believed that there was a “perfect” partner out there for her who qualified for this by being
attractive and wealthy.
Later in therapy, Kim hesitantly revealed that she had always had a struggle with self-
esteem in social situations and very rarely made conversation with others unless she had
something “gripping” to speak about. She did not want to appear “stupid” to others and
therefore, unless she had something “gripping” to say, she chose not to say anything at
all.
4.4.3 Difficulties in intimate relationships
Kim expressed deep frustration in relation to her friends, whom she had known for over
three years, and felt she could not be around them anymore because it “freaked” her out.
She said she used to enjoy being with them, but, began to view conversations with her
friends as inane and boring. She felt more comfortable with people who did not know her
very well, such as her digs-mates, since “nothing was too in depth” with them. Her friends
knew about “everything” that had happened in her life, they “questioned her more and
this irritated” her. Kim would ward off emotional contact in her interpersonal relationships
and when she did this she would experience a sense of boredom. She regularly
complained of boredom, or situations boring her. She would often become bored in
relationships including in therapy. An example in therapy was after a very difficult session
Kim would return the next week stating that she was bored with everything. When asked
47
whether she was also bored in therapy, she agreed and stated that she had nothing
meaningful to talk about anymore, that the things she may have to talk about are either
too painful or too trivial and, as a result, therapy had become “boring”. She linked this
sense of boredom to feeling “claustrophobic”, and would feel this way when people knew
too much about her and this irritated her.
Kim could not tolerate intimacy since it required that others got to know her on a deeper
level, which frightened her. As a result, whenever others got too close to her she would
withdraw out of fear that they would see beyond her façade of perfection and ‘expose’
her sense of inadequacy. She would isolate herself from others to defend against this
exposure. Kim also withdrew from others, including her family, when she was a child and
mentioned that she would dream about a “perfect world” where the characters in her
fantasies were “perfect”, led perfect lives and were always happy.
Kim also felt that she was “self-destructive” in sexually intimate relationships and
emphasised that she repeatedly got into “bad situations” with men. She vacillated
between being extremely mistrustful of all men to trusting men who could not commit to
her. In addition, she reported that she would play “mind games” with men who respected
her. She stated that, “when a good thing comes along I sabotage it”. She would “test”
these men to see how much they really wanted to be with her, or she would “use” them
as “personal punching bags”. She was ambivalent in her relationships with these men
and stated that although she wants “his love…[she does] not want him”. She believed
that men who respected her were “way too nice” for her and that her “life is destined for
more than being with a man who was crazy about” her. She wanted “better”, and
believed there was a better man “out there”. Kim also often expected potential partners to
commit to her prematurely and constantly wanted them to reassure her and make her
feel special.
4.4.3.a Fear of sexual intimacy
At the time of the initial interviews Kim was still a virgin and practised sexual petting, and
stated she practiced “everything” except penetrative sex. However, she did not enjoy
sexual experiences and reported feeling “dirty” and “cheap” afterwards. Kim entered into
these experiences mainly when she was under the influence of alcohol and would often
want to avoid these men after these experiences. She stated that she did not feel
48
emotionally satisfied in her sexual relationships. However, she added that she could not
be sexual with a man that she felt emotionally connected to, and could not be emotional
with a man with whom she was sexual. For example, she did not enjoy sexual intimacy
with a boyfriend whom she had been seeing at the time and who wanted to commit to
her. She felt that he was not sexually controlling enough and felt that he knew as little as
she did about sex and therefore she felt contempt toward him. She stated that she
needed a man who was strong and aggressive sexually, like one of her previous
boyfriends, and not a “wimp”. This points to her difficulty with closeness since the former
relationship required deeper emotional intimacy from her whereas her ex-boyfriend who
could not commit to her was less demanding for her to invest emotionally in their
relationship. Kim could enter into playful sex but not deeper sexual intimacy which
required an emotional investment from her.
What appears to be related to this theme is a dream Kim had. In the dream she was
having sex with an attractive and popular ex-partner with whom she previously enjoyed
sexual play but who was emotionally unavailable to her, subsequently she was suddenly
pulled away from him and found herself having sex with another ex-partner who was not
very popular and attractive and with whom she did not enjoy sexual experiences, both in
the dream and in reality. Kim’s relational template was that of significant others being
emotionally unavailable. She would block the experience and expression of her own
emotional needs by eliciting the same unsatisfying response from others in current
relationships. Accordingly, she either selected a partner who was emotionally unavailable
or when she did meet a partner who was able to respond to her emotionally, she rejected
him because his response aroused the pain related to the original emotional deprivation.
Kim also had a need to be surrounded by people whom she regarded as popular and
special: the first ex-boyfriend in the dream was someone who she viewed as special,
popular, attractive and with whom she yearned for a relationship in spite of his emotional
unavailability; and the second person in the dream was an ex-boyfriend who was very
interested in a committed relationship with her but whom she did not regard as popular
and attractive, and with whom she soon terminated the relationship. To believe in the
reality of a grandiose image, narcissistically wounded clients like Kim must have it
confirmed by others whom they regard as special. This is elaborated upon in Chapter
Five.
49
4.4.4 Narcissistic tendencies
Kim reported that she had a tendency to be impatient with others. If people lashed out at
her, she would not pay attention to them even if it would hurt her. She stated she was too
proud to show that she was hurt. She viewed this as a “power-struggle”, in that the other
person must “break first”. She did not like others to think that she was “the weaker one”
by crying or admitting to “defeat” first. She also reported that several of her friends had
accused her of being selfish and wanting things her way. Kim made enormous effort to
look good in public and come across as “perfect” in her appearance and speech. She
spoke with pride of how others admired the way she looked as she always dressed very
fashionably. She perceived herself as spoilt, mean, sarcastic, materialistic and shallow,
however, she believed that she was interesting when people took time to get to know her.
In addition, Kim could not tolerate silences in therapy and other situations because it
made her “social skills show up negatively”. In social situations she was often the centre
of attraction and she regarded herself as playing the role of the “ditsy party animal”.
Kim took pride in her mastery of the English language as well as her general knowledge,
and recalled that when she was a child her father had bought a collection of
encyclopaedias and insisted that she read these every day. She also added that her
father never really noticed that she was a bright child. As an adult she would pride herself
on her knowledge of the English language and, for example, would often correct the
therapist’s grammatical errors. When I brought the latter to her awareness Kim stated
that she often criticized others as a means to deflect from her struggles with feelings of
inadequacy.
Kim stated that she would cry when she wanted to manipulate her parents or to get
attention from others such as her friends. She often feared being exposed by others and
would be easily embarrassed in social situations. For example just before her 21st
birthday at which her friends were to meet her family for the first time, she was deeply
concerned that both her parents and her friends would expose an aspect of her that she
was ashamed of, such as her drinking and partying as well as unmasking her low self-
esteem.
Kim often expressed feeling different to, and better than, her extended family members
as well as other people from her cultural group. With contempt, she intimated that they
50
were inferior to, and less sophisticated, than her and therefore did not want to socialise
with “them” at university or at home.
4.4.4.a Devaluation
Kim would often complain that therapy was not working for her or that she expected
quicker results, “miracle cures” and expected to be symptom-free within a significantly
shorter period. Kim believed that medication was more effective than psychotherapy and
would emphatically state this to the therapist. At other times she would test the
effectiveness of therapy, for example she believed that her coping with her final exams
would be the “ultimate test” as to whether therapy had been effective. Kim would find
evidence to undermine her therapy process. For example, she recounted that she had
been to a psychology lecture in which it was stated that criminals often come from
“messed up” childhood backgrounds. She stated that since she had had this kind of
childhood, she would more than likely become a criminal. She added that the lecturer
also stated that therapy does not really work. She said that she did not want to change
and that maybe she should simply accept that she was “messed up”. Kim often doubted
the effectiveness of therapy and, for a significant part of therapy, did not expect to benefit
from it.
4.4.4.b Attacking in response to having been ‘exposed’
Especially initially, and often during difficult therapy sessions, Kim would often verbally
‘attack’ me after I would make an interpretation. At these times she would respond with
strong expressions of rage or seemed visibly ashamed when I made the ‘correct’
interpretation. Her mixture of anger and shame was so intense at times that she wanted
to run out of the therapy room. I would encourage her to stay with the feeling and talk
about it but at these times she would become very demanding for me to make her feel
better and take her pain away, and if I could not do this, ‘what was the point of therapy?’.
Especially after more difficult sessions in which Kim felt particularly vulnerable or
emotionally painful material had been processed, Kim would not return for therapy the
next week. When she did return, and I would bring up the difficulty of her previous
session she would deny it or state that she had “moved on”.
51
4.4.5 Ambivalence
Throughout the first few months of therapy Kim would vacillate between devaluing and
attacking others, including the therapist, and complete withdrawal. As therapy
progressed, she would attack me less but would vacillate between viewing therapy as
helpful and “better than talking to her friends” to devaluing it and seeing it as worthless or
not meeting her needs. For example she said she felt safer in therapy than “in the world”,
stating that I was able to give her more insight into her difficulties than her friends. Yet,
soon hereafter she was unsure of the effectiveness of therapy since she felt that it was
not addressing her current issues and instead focused on her childhood, which,
according to her, was irrelevant.
Kim would also vacillate between denying that her parents had failed to meet her needs
as a child, and acknowledging this. She repeatedly claimed that her childhood
experiences had nothing to do with her current emotional difficulties and that this was the
main reason why she terminated therapy previously. She claimed that she was “over” her
childhood issues. At different points in therapy, when attempts were made at connecting
her current problems with her experiences as a child, Kim would angrily protest that she
was to “blame” for her problems and that her parents had “nothing to do with this”. She
protested that she is “sick and tired” of looking at childhood issues and linking this to her
current behaviour and felt “tired of blaming others” for her problems which she felt she
needed to take responsibility for. She added that although she may have acknowledged
some of her difficulties in therapy she had “gotten over” her childhood issues. Still later in
therapy she acknowledged that she did not want to lose the bond she had with her
parents and for this reason she struggled to express negative feelings about them.
Soon hereafter, she began to doubt her belief that her father was perfect after he had
undermined her therapy process. At a later point in therapy Kim became tearful after
exploring her mother’s punitive parental style, however, she stated that it was “silly” to be
angry at her parents for things that happened ten years ago. After the therapist reflected
her difficulty in honoring her experiences, she spontaneously acknowledged that she
constantly attempted to protect her parents from her painful feelings. After approximately
12 months of therapy Kim returned from a vacation and said she had realised that she
had placed her father “on a pedestal” which she believed he did not deserve. However, in
spite of these significant steps toward acknowledging the roots of her emotional and
52
relational difficulties, Kim continued to vacillate between denial and acknowledgement of
her parents’ failure to meet her childhood needs.
Similarly, Kim vacillated between denying that she had been sexually abused and
acknowledging it. A clear example of this was when she attacked the therapist when a
link was made between Kim’s admiration for her friend who had been sexually abused as
a child and was healing in a therapeutic process and Kim’s related experiences. She
responded to this with anger and stated that this was the same problem she experienced
in previous therapy, angrily protesting that “everything is not about sexual abuse!”.
Seconds later she shifted to calmly stating that she often thought about the abuse and
does have a “gut feeling about it although its not definite”.
Kim often denied that she was feeling sad or any other evidently difficult emotions. For
example, at times when we touched on difficult material and it was evident that she was
feeling sad the therapist would attempt to explore this, however, Kim would fervently
deny that she was unhappy or would state that she had no reason to be unhappy, past or
present, because her “life was wonderful”.
4.4.6 Unsure of changing self
As therapy progressed and Kim became less afraid of being ‘exposed’ as inadequate in
the therapy room, and was more able to tolerate therapeutic interventions including
interpretations, she began to experience changes in herself and the way she related to
others beyond the therapeutic relationship. She felt less of a need to impress others, be
the “ditsy party-animal” and felt more comfortable within herself. However, she felt as
though she was going through an “identity crisis” and stated, “I know what I don’t want to
be but I do not yet know what I want to be”. At times, she appreciated that she was able
to be by herself and did no longer needed to be the centre of attraction, however, at other
times she felt that she was becoming “boring” because she had become less impulsive
and would “think things through” before she acted.
4.5 THERAPIST AFFECTS
Kim’s ambivalence, boredom in, and devaluation of, therapy often engendered a sense of
inadequacy and ineffectiveness in my ability as a therapist. Her continual attacks elicited
in me a sense that whatever I did would never be ‘good enough’ for her. I believe her
53
awareness that I was a therapist-in-training gave her more ‘ammunition’ to discount the
effectiveness of therapy. As I was in training, I was naturally still unsure of the most
effective techniques in dealing with clients’ psychological difficulties, more specifically a
client who would present with the kinds of difficulties that Kim did. As a result, I often felt
anxious before Kim’s arrival and exhausted when she left, feelings, which I rarely
experienced with other clients. However, I later realized that these feelings that arose in
me were not only related to my ‘insufficient’ experience and nascent confidence as a
therapist, but that Kim contributed significantly toward my sense inadequacy as a result
of her tendency to devalue and attack the therapeutic process and our relationship. This
kind of response in the therapist is common when dealing with a narcissistically wounded
client. It was challenging for me, and there were times when I doubted whether any
change was possible for her. The rare times when she did respond to, and accept,
therapeutic ‘gifts’ offered to her, including our relationship, gave me hope that there was
a part of her that wanted to heal, albeit very vague. Moreover, that she returned for
therapy most of the time generated a greater sense of hopefulness and I realised that I
needed to tolerate her attacks and defenses, although this significantly challenged my
developing confidence as a therapist. This kind of mistrust of the therapist’s ability to help
and attacks are common amongst more ‘difficult’ traumatized individuals. Whether I
showed her compassion through tolerance and/or whether I made an interpretation, most
of my responses were unsatisfying for her. Because Kim’s symptoms express indirectly
the feeling of inadequacy, inquiry into their origin evokes anxiety of exposure. Thus, the
responses mentioned above are typical of clients who attempt to protect a feeling of
defectiveness. Probing into motivation and maladaptive behaviours elicits anxiety about
being shamed, a defense, which is manifested interpersonally as narcissistic sensitivity.
In summary, although Kim had entered therapy and shared aspects of her early losses
and traumas as well as her current intrapersonal and interpersonal struggles, she still
remained highly defensive and resistant to forming a therapeutic alliance with me. It was
necessary for me to tolerate her defenses in therapy, however, it was also important for
her maladaptive behavioural patterns to be challenged and interpreted to prevent the
development of an impasse in therapy. I decided to move between these two approaches
depending on what was most beneficial for Kim and what she could tolerate at any
particular point in therapy. This approach seemed to have generated in Kim a deeper
trust toward me. I will deal with this issue in more detail in the next chapter. In spite of
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developing a degree of trust in me, Kim continued to struggle to verbally express her
feelings and experiences in therapy.
After 12 months of individual talk therapy I felt that introducing Kim to a more expressive
form of therapy, that is, clay therapy, might enable her to express suppressed feelings
and experiences which she struggled to express verbally. In addition, I was embarking on
my research project for my Master’s degree in Clinical Psychology and explored with Kim
whether she would allow me to use her claywork process as part of my research project.
4.6 KIM’S EXPERIENCE OF MAKING AND DISCUSSING THE CLAY SCLUPTURE
4.6.1 INTRODUCTION
After 26 therapy sessions I felt that Kim trusted me enough to explore her feelings and
experiences through the means of clay sculpture which I felt would facilitate greater
expression of her underlying conflicts. I discussed this with Kim and she was interested in
exploring clay sculpturing as a therapeutic tool. After consulting with her, a formal
decision was made that she would become a participant in this research.
4.6.2 MAKING THE SCULPTURE
The claywork process was undertaken in my consulting room where Kim usually came for
therapy. It was not a strange environment for her and it was assumed that she would be
most comfortable there. Cushions were placed on the floor and ambient background
music was played in order to create an atmosphere of serenity. I introduced Kim to the
process of claywork and demonstrated the playful manner in which she could interact
with the clay. This included instructing her to allow her hands to form whatever emerged
without any preconceived ideas on how the sculpture should materialize or without
concern for aesthetic perfection or beauty. Kim was given privacy so as to prevent any
concerns about being judged by another. I checked up on her every 20-30 minutes to
ensure that she felt comfortable and did not need anything. She took approximately 1½
hours to complete her sculpture.
After Kim indicated that she had completed her sculpture I joined her on the cushions in
front of her sculpture. She appeared very uncomfortable and irritated stating that she did
not enjoy her hands being covered in the “dirtiness” of the clay and adding that she was
not a “play in the dirt kind of person”. She repeatedly tried to scrape the clay from her
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hands and wipe the tiny dust particles from her clothes. She said she looked like a
“farmer person with all this mess” covering her and averted making eye contact with both
her sculpture and the therapist. When I asked her how the clay sculpture experience had
been for her she stated that it was “okay” but that she had gotten bored easily. She
wanted to create “something with meaning” and wanted it to be aesthetically attractive
but “just could not get it right” and thus became bored. She felt “probed” and became
very defensive when I asked her any questions related to her sculpture. With the second
claywork session, Kim entered the therapy room asking whether we were going to look at
her “horrible sculptures again”. According to her, the pieces of clay sculpture she had
made were “not pretty” because they were “not structured or normal like a real object”.
She stated that she had done sculpture and pottery as part of art classes in secondary
school, and if her art teacher were to see these images, “she would have had a heart
attack”. Kim seemed completely detached from, and uninterested in, the sculpture. She
would look above and over her sculpture and intermittently would glance at it in a hostile
manner. She was very reticent in her responses to the researcher’s explorations. Each
time I attempted to explore her images on a deeper level she would look at me in an
angry or hostile manner, or would become very anxious and dust herself off vigorously as
well as avoid any eye contact with me. When asked how she felt about looking at her
sculpture she said that she felt like she did not put much effort into it even though the
instructions given to her was that she does not focus on the aesthetic beauty of what her
hands were sculpting.
Kim initially tried working with large pieces of clay “but ended up making little things”.
What was particularly hard for her was that she felt she was “not really a creative
person”. She first thought the experience would be fascinating then felt it was not and
subsequently, she felt that she had no intention of doing more to the sculpture. She
wondered what she would say about the different images she had made and “did not
know what was going through [her] head”. While making the sculpture she felt that she
needed to “add a fascinating story” to each image. She thought this was just a “big
waste” of my time because she had “nothing interesting to say”.
4.6.3 KIM’S SCULPTURE
A photograph of Kim’s sculpture is presented on the next page which will help the reader
to follow the discussion of her sculpture and the claywork process. Kim’s sculpture can
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be seen as 8 separate pieces (A to H) placed in relation to each other. I will briefly
mention each one as a way to introduce them to the reader, using the phenomenological
method of staying as close as possible to Kim’s lived experience of the claywork process,
since this approach lies at the core of the current research. Besides the two clay pieces
which Kim named, that is, The Mudpie and The Pornographic piece, I have named the
rest of her pieces whilst also attempting to remain as close as possible to her experience
of each piece. Subsequently, I present a thematic narrative which embodies a more
object relational perspective, mostly that of Summers (1999), with relevant psychological
concepts. Firstly, I look at themes which emerged both in individual talk therapy and the
claywork process, and secondly, I highlight new themes which mainly emerged from the
claywork process.
4.6.4 DESCRIPTIVE VIEW OF KIM’S SCULPTURE
4.6.4.1 The Perfect “Thing” (Piece A)
With Kim’s first piece (A in photograph), which I have named The Perfect “Thing”, she
said she was unsure of what to make and simply played with the clay. She initially said
she felt “nothing” when she made it but later stated that it was the first “thing” she made
and had put a great amount of effort into making it look artistic and creative. She said she
was just starting “this whole exercise thing…and that’s why it looks more artistic than the
rest of the stuff…what time and effort ” it took her to make it. She felt that every aspect of
her creativity went into this piece and “it didn’t go into anything else”. I explored what
creativity entails for her and she stated that it “means being able to create something that
is beautiful”. This piece as well as a few of the others brought up themes related to her
need for perfection and control.
4.6.4.2 The mudpie and “the whole child thing” (Piece B)
Kim named the second piece that she had molded a mudpie, which she made by
breaking off a small piece of clay that she felt was more manageable for her. She said
the “whole child thing came up” while she was making this. While forming it she asked
herself what she used to make with mud “the rare times I did play with mud as a child”.
Kim appeared to become more uncomfortable the deeper the exploration became and, at
this point, she physically moved away from her sculptures and began vigorously dusting
herself off. However, she stated that it felt much better to make this piece since it was
something familiar that she could name unlike the rest of her pieces. Initially she could
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not remember what it felt like to make mudpies as a child. Later she recalled a familiar
feeling of holding the mudpie in her hand which reminded her of the time when she would
go on fishing trips with her father when she was about 8 years old. While he was fishing
she would entertain herself by making mudpies. She later revealed that during this time
she felt very lonely in spite of being with her father. On further exploration she repeatedly
stated that she “hated” fishing and did not know why her father took her along because
she ended up “chilling on the beach [by herself], playing with the sand and making
mudpies”. This piece stirred up feelings of loneliness and isolation from significant others.
4.6.4.3 Kim’s protective shell (Piece C)
Kim said she felt “good” when she made piece C (shell-shaped piece) because she was
still “into the whole novelty idea”. She did a lot of smoothing of the clay and created a
pattern on this piece. She felt this was “very artistic” compared to the rest of her pieces.
The smoothing action felt like something she was doing that was “positive and yet it
required very little effort and thinking”. This included a feeling “contrary to trying to make
a thing a lot prettier than it is…[it became] a lot softer”. The smoothing out action was
initially an attempt to make her pieces “pretty” but later she realised that when she did
this, it was very calming. When I explored the letter ‘K’ on this piece, she became very
defensive and said it symbolized her name and “nothing else!”. I asked more about the
feelings associated with creating this piece and she said “I have no idea what to tell
about that…just molded it in my hands and was playing with it for a while…that’s what
happened”. She said it was much nicer to play with the clay than to try and mold it on the
board. Kim could not engage with this piece at all in spite of having said that this was a
very artistic piece. Her ambivalence and defensiveness were evident in this account.
4.6.4.4 Spirals of anger (Piece D)
This piece started off with Kim rolling the clay out into a long snake-like piece which she
curled into a spiral shape. She enjoyed the initial “squeeshing” of this piece. She stated
that this was the only thing she really does with clay-dough and that she was “not one of
those people who sit there and create things”, so her hands will just do a squeeshing
action. She said this was also a way to vent her frustrations and added that she could
“never do this softly and instead it needs to be hard” as if she was “killing the life out of
it”. She compared this to a “terrible terrible habit” of doing the same with Prestik,
“squeeshing it really hard until it dies and loses all its consistency!”. She viewed it as a
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“nervous type of thing”. Kim’s underlying anger and frustration began to emerge at this
point although she continued to attempt to suppress and hide these feelings.
4.6.4.5 Masking with the “huge abstract thing” (Piece E)
With this piece Kim stated that she “did not make it into any shape” but thought if she
placed it in a particular position it would “appear” as if she had “put a lot of effort into it”.
When the therapist explored whether there was a sense not wanting to do this Kim
denied this and stated that she struggled, and was preoccupied, with not knowing
whether she was doing it right. With this particular piece she told herself that she was not
getting it right so she would pretend that she was creating “this huge thing” that she
hoped would “appear very abstract”. She could not say how it felt to make this piece. I
noticed little indentations in this image, which looked like a face or a mask and explored
these. Kim stated that she was going to “squeesh them out and make something
interesting but it wasn’t happening” and she got frustrated that she got mud under her
nails. She became anxious and furiously cleaned herself. This piece more specifically
highlighted Kim’s need to hide behind a façade.
4.6.4.6 Letting go (Piece F)
Kim stated that this was “just a big gunk” and she “was not making anything of this”. She
said she struggled with this piece and tried very hard to create something “meaningful”
but after a while it “began to feel like a job”, something that she needed to do which at
this point she “did not feel like doing” anymore. She was “really frustrated” with this piece
since she could not find anything meaningful to make with it and she “just clumped it”
because she was “not getting anywhere” with it. She said she “just gave up” on this piece
of clay. Because this piece did not “come into any specific pattern”, she lost interest and
asked herself “what’s the point of this whole exercise”. Kim’s attempts to control the
outcome and keep up her need for perfection began to fail her at this point and she
therefore “gave up”. However, her having given up was also an entry point into more
unconscious material as this was the first pieces which fell under the images that she
labeled as “chaotic”, and where she began to relinquish rational control.
4.6.4.7 The “pornographic” image (Piece G)
Kim began shaping this piece by placing a ball of clay in the center of the board and
began “stretching” it upward just to see “how high it would go before it collapsed”. She
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said it was “fun to do this as it did not feel like a job”. Kim was very embarrassed when
speaking about this piece and stated that it took a lot of “self-control not to destroy it”
before the therapist returned, since she was concerned that I would judge her for making
a “giant penis”. She wanted to destroy it because it looked “pornographic”. She said she
did not intend to make a phallic image and only realized this once she had completed the
piece and looked at it. Kim stated that she did not know why she made this and more
especially why she kept it since, had she destroyed this piece, we would not have been
discussing it. When the researcher attempted to explore this piece further Kim became
more defensive and stated that there is “nothing behind it”. She also said it looked like
the “Sorting Hat in Harry Potter”, which is a wizard’s hat that sorts the different trainee
magicians into their specific locations. Various themes arose from the exploration of this
piece including her difficulty with sexual intimacy, her isolation from others and her over-
identification with socially sanctioned masculine qualities, such as needing to rationally
process her experiences, controlling her emotions, and needing to dominate in
relationships.
4.6.4.8 Squashed femininity (Piece H)
With this piece Kim said she did not know what to do anymore and she just “squeeshed”,
squashed and prodded the clay which felt like a “job” to her as she continued to have a
sense of needing to create something, and said she did “not have the energy to sit and
break off little pieces and try and find something creative to work on”. She had prodded
and shoved her fingers into the clay which caused painful sensations in her fingers. This
action also created crevices and holes in the clay which she wanted to smooth out and
which she said she “cannot deal with them being there and needed to get rid of them”.
While making this piece she said she was very preoccupied with “some really serious
thoughts” related to her most recent relationship that had failed and her need to pursue
an ex-boyfriend who had been emotionally unavailable to her. This piece evoked
significant anger at herself and the pattern of dysfunctional relationships she
experienced. What had emerged strongly with this image was her rejection of her
femininity and her need to protect herself by assuming more masculine characteristics.
4.6.4.9 Control vs “Chaos”
There is also a general division within Kim’s sculpture: on the right side (pieces A to E)
her images reflect her need to keep up an appearance of perfection and need for
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conscious control, However, on the left side (pieces F to H) of her sculpture, she “gave
up” control and more unconscious material was able to emerge. Kim called the left side
of her sculpture “chaotic” and did not like these pieces, however, they brought up
previously disavowed feelings that she was eventually able to talk about in the clay
process.
4.7 THERAPY THEMES REVISITED IN CLAYWORK
4.7.1 Difficulty relating to an ‘other’
For the most part of both claywork sessions, Kim seemed completely detached and
disengaged from her sculpture, often referring to it as “horrible”. For her, the clay images
she had made were not pretty and needed to be “normal like a real object”. Initially she
avoided making eye contact with her sculpture and at times she would physically move
away from it. For her it was a “thing” separate and alien from her. Kim also made very
little eye contact with me during discussion of her sculpture or would respond with
piercing looks when I attempted to explore deeper into the meaning of her sculpture.
When I asked her about her sculpture and how she experienced it, she said “I still can’t
identify with anything…I am trying to but they are really so random…I can’t think of how I
can place myself…with connection to them”. Kim interacted with her sculpture the way
she interacted in her interpersonal relationships. She distanced herself emotionally, and
struggled to enter into a relationship with it. Similarly, Kim did not want others to get to
know her and if anyone attempted to do this she would withdraw or attack. She held up a
façade of perfection and control and did not want others to see her deeper sense of
defectiveness. It was also evident that the three-dimensional physical presence of the
sculpture made her feel very uncomfortable because it was an object that evoked
feelings of imperfection and shame for her.
Compared to individual therapy, the clay process revealed more clearly how Kim
struggled to engage in relationships with others, including with the therapist. She would
withdraw when others got to know her more intimately and feared that they knew too
much about her. Similarly, in the clay process, Kim was afraid of the therapist seeing her
sense of defectiveness and she defended strongly against the possible exposure of this.
Kim experienced significant problems in relating to others as a result of not trusting her
authentic affects as well as her anxiety of being shamed. As a result of her dysfunctional
relational template she also appeared to elicit certain responses from others in that she
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pursued men who were rejecting, like her parents, and rejected men who were able to
respond to her needs.
4.7.2 Perfectionism and needing to get things “right”
Kim disliked her sculpture because it did not hold any meaning for her, was not
aesthetically beautiful and for her, revealed her inability to “get it right”. Although she was
aware that she did not have to make anything particular she felt that she wanted to “add
a fascinating story” to her sculptures. She continually felt frustrated because she felt
compelled to make something that had structure and could be labeled. She therefore felt
that she was “not a creative person”. She felt that every aspect of her creativity went into
piece A and “it took a lot of effort to make” this piece. She tried being “creative” with piece
B as well but then stopped herself “from making it perfect”. With piece E she told herself
that she was not getting it right so she will just pretend that she was creating “this huge
thing” that she hoped would appear very abstract. She stated that she did not make it into
any shape but thought if she placed it in a particular position it would appear as if she
had put a lot of effort into it. Kim said throughout the making of her sculpture she was
preoccupied with wanting to do get it right. She also wanted to smooth out all the
crevices on her sculpture since she could “not deal with them being there” and wanted to
“get rid of them”. Kim was terrified of imperfection and when she could not “get it right”
she felt like a total failure. Because of her need for perfection, her fear of being seen as
inadequate and her need to protect against the exposure of this, she felt anxious that the
clay sculpture would expose her sense of inadequacy.
4.7.3 Defensiveness, attacks and devaluation
Each time I attempted to explore Kim’s sculpture on a deeper level she would look at me
in an angry or hostile manner or would become very anxious. Often, when I asked more
about the feelings associated with creating many of her images she would say “I have no
idea what to tell about that…I just played with it in my hands…that’s what happened”. At
different times during the claywork exploration Kim would appear sad but would deny it
when I reflected this feeling. When I explored her need to have been understood by her
ex-boyfriend after she had disclosed to him that she had been sexually abused as a child
she roared that she expected him to “say nothing!” nor ask stupid questions because “I
don’t need to give [him] any explanation for why I don’t talk about it…it’s my thing!”. Kim
was significantly out of touch with her feelings and wanted to prevent any knowledge of
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her underlying feelings. She also stated later that she “has no problems with the way she
is”, evidencing her need to defend against the knowledge of her vulnerability and
exploration of her feelings and experiences. Kim understandably felt threatened by my
inquiring as much as she wanted to understand why she experienced emotional
difficulties.
In accordance with Summers’ (1999) view, her defensive responses reflect indirectly
Kim’s sense of inadequacy and any inquiry into their origin evoked the anxiety of
exposure. Probing into underlying unconscious material and motivation elicits anxiety
about being seen as inadequate, the defense of which is manifested interpersonally as
acute sensitivity. Every client, to some degree, opposes the insights she/he consciously
seeks, but the narcissistic client reacts to this awareness with a special form of anxiety,
the dread of having his/her ‘defect’ uncovered.
Kim would sometimes question the value of the claywork, was cynical about it, or mocked
her sculpture and therapy in general. She also devalued her ex-partners, Asian men and
others in her life. For example, in the clay process she stated that in her past
relationships she had made it her duty to “sort out” her boyfriends because according to
her “they just could not get their lives together”. She hoped that there would be one
person out there who will be good enough for her but her ex-boyfriend was not since “he
will ruin my life and I will make his life a living hell!”. She believed that he had a lot of
problems and was not “at that point in his life to deal with it and every time we’re together
I am always telling him about how he needs to face responsibility, get his life into gear
and sort himself out”.
Devaluation is also a means to ward off her sense of defectiveness since, when she does
this, she boosts her value in relation to others. Her devaluation in the therapy process,
including the claywork, was as a result of therapy threatening awareness of her
limitations and such awareness in turn would lead to feeling inadequate. When she
devalues others it bolsters her self-esteem, which in turn, minimizes her sense of
defectiveness.
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4.7.4 Grandiosity and idealization
While processing issues related to piece G and H, Kim stated that she should have
“scored” with somebody else instead of her ex-boyfriend on the night of her birthday as
she looked “pretty enough”. Kim placed significant emphasis on her sense of fashion and
physical appearance. She also stated that each time she would go home for vacations
she would “score” with one of the men back home. However, she wanted to stop
“chasing after people” but instead would like someone to chase after her. She stated that
she would pursue men she was interested in, but that “most of the time I get it wrong
because I am so judgmental…especially the [Asian] guys all the time…and maybe I am
letting a few good ones go…”.
Kim spoke with disdain about her cultural group and stated that she had broken away
from “them” a long time ago and added “its quite sad…its just that I have no identification
with anything when I go back home”. Although she apparently accepted being Asian,
enjoyed her family, and enjoyed partying when she went home she felt that she could not
form any meaningful relationships with “them”. She detested Asian men as she found
them childish and “a waste of time”. When an Asian man approached her she would
ridicule, insult and reject him. She felt that she did not fit into the “stereotype” of the
typical Asian woman which was to be respectable and to behave like a “lady”. She
proudly stated that she “was the opposite of this…was loud and brash”, smoked, drank
alcohol and “committed the cardinal sin”. She also “freaked” her family out because all
her friends were white. Kim felt very proud that she had a circle of friends who were all
white and mostly foreigners.
In response to her unresponsive childhood environment Kim created an inflated image of
herself in a desperate effort to disavow her sense of defect. To continue believing in the
reality of this grandiose image, she needed to have it confirmed and boosted by others
with the result that most of her choices and relationships were designed to sustain the
feeling of self-inflation. Her perfectionism, drive to achieve the best, taking charge,
appearing seemingly better than others and mixing with people whom she regarded as
special were effective, but maladaptive, defenses against her sense of defectiveness.
In addition, Kim wished that she could find the “perfect” man who would love and adore
her. She felt that even if her ex-boyfriend was everything she ever wanted she would be
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“settling for something that is not good enough” for her. Her search for the ideal man was
a symptom of a character structure designed to ward off her sense of inadequacy by
identifying herself with ‘objects’ that she regarded as “perfect”.
4.7.5 The “pornographic” image as metaphor for sexual difficulties
The “Pornographic” image (piece G) symbolizes various aspects of, and meanings
related to, Kim’s difficulties, with the current theme representing one of them. Kim was
very embarrassed when speaking about this image and stated that it took a lot of self-
control not to destroy it before the researcher returned since she was concerned that I
would judge her for making a “giant penis”. She further said it looked “pornographic” and
a “bit phallic”. Kim was initially particularly defensive and withholding whilst exploring this
piece. She felt it was “creepy, ridiculous and odd-shaped” and a “weird…a big long thing
just chilling there”.
Kim associated a man’s penis with “not good sexuality” because it symbolized painful
sexual experiences for her and therefore it was not her “favourite part of the body”. She
was “not too happy” about not being able to enjoy sex and added that she “closes [her]
self up to the idea…emotionally”. Kim felt that this was “subconscious
choice…somewhere deeper I have just formed in my mind that it was going to be
painful”. She would “freak out just having the idea” that a penis was going to penetrate
her. She stated that if someone had to ask her “what does it feel like to have a penis
inside me, I wouldn’t be able to tell them because I have no idea…I can’t feel anything
other than pain!”. Kim also had an aversion to her own genitals and could not tolerate
anything related to a woman’s vagina. On inquiry she exclaimed that she “can’t deal with
it!…could not even watch the Vagina Monologues…I just have no connection with that
part of my body”. She stated that she “can’t even hear people talk about sex, giving birth,
abortions…” and would feel faint. However, she said she was “thankful” that she was
“this way” because it protected, and prevented, her from being promiscuous and having
sex with men she did not really want to be with and therefore “for once I am happy I have
this defense mechanism”.
As mentioned, this image symbolizes various aspects of Kim’s life and relational
difficulties including the reality of her sexual difficulties. A significant aspect of this
symbolization may be related to Kim’s sense of having been sexually abused as a child
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and her natural response to protect herself from experiencing this kind of violation again.
Kim experienced vaginismus which prevented penetrative sex. She felt frustrated about
this but also believed that it served as a “defense mechanism” which protected her from
sexual promiscuity. Except for when she was participating in sexual play that was
aggressive, Kim felt numb and emotionally withdrawn during sexual experiences. She
also felt a strong sense of shame after sexual encounters. These are some of the
common effects of sexual abuse. In addition, the sexual experience is a strongly affective
experience and entails a deeper sharing of the self as well as making oneself vulnerable
to another. However, Kim’s need to protect against being as vulnerable as she was as a
child as well as her fear of exposing her sense of inadequacy prevented her from giving
up control and surrendering to the experience of sexual bliss.
4.7.6 Boredom as a defense
Kim became bored very early in her sculpture-making process. This feeling would arise
whenever she felt that she could not get something “right” and it was not perfect the way
she wanted it to be. She also would evidence boredom when I explored issues that were
very painful for her such as her loneliness as a child or her current underlying and
suppressed sadness. At these times she would yawn in response to me and look around
the room as if to indicate that she was “bored” and not interested in the claywork process.
When material and reflections resonated with, and was too unbearable for Kim, she
would become bored as a way to defend against feeling. Kim’s boredom protected her
from connecting with painful feelings but also prevented her from forming emotional
connections with others. In effect, she would get bored in experiences because it lacked
her affective input and, as a result, everything felt meaningless and empty for her.
4.7.7 Ambivalence
Kim was often ambivalent in her responses to me and I mention various ways in which
this manifested. She vacillated between finding the clay process fascinating and finding it
tedious and frustrating. She would vacillate between stating that her sculpture was
horrible and she made no effort to be creative to stating that she had put some creativity
into it and enjoyed aspects of making it. At other times during the claywork process she
would acknowledge that her parents had contributed significantly to her emotional
difficulties and soon after she would deny this stating that she was “parent-bashing”.
Toward the end of the clay process, Kim stated that she no longer rejects the knowledge
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that she had a difficult childhood and thinks about it more lately. However, she felt guilty
soon after acknowledging this and stated that her mother’s voice will haunt her one day
when she has children and added, “nothing you ever do in your life is gonna be good
enough for your kids”.
Kim stated that she would like to have a more meaningful romantic relationship where
she would feel safe enough to share about her past and feel the person loved and cared
about her, however, soon there after she said she would just like to be in a relationship
even if it was a “destructive relationship as long as I feel that I mattered to someone”.
When I explored her initial feelings of anger toward her ex-boyfriend she said, “it wasn’t
anything like anger toward him”. She later acknowledged that she might have been
“unconsciously angry” at him. When I explored this anger she said that she was not
angry at him but that she was frustrated because she could not get him to be the person
she wanted him to be, “but there is also a kind of ambivalence about this because in
some way I am relieved when he is not the person I want him to be”.
I explored whether the pieces of her sculpture that are so separate from each other could
relate to her life. She stated that it could because there is different aspects of herself that
she chooses to show in different contexts but “not that there is a lot…I am not really
schizo or anything”. She first stated that she could be herself more in the company of her
friends than her family then later stated she could be herself more with her family.
This kind of vacillating is a common response of the narcissistically wounded individual
and appears to be part of the fear of having a shame experience or being ‘exposed’ as
defective. It also seems to be part expressions of Kim’s authentic feelings, however, she
would feel anxious and guilty about not complying with parental demands. She needed to
protect them from her authentic feelings, and she attempted to ward off this anxiety and
guilt by slipping back into denial.
4.7.8 Lack of integration between conscious and unconscious aspects
Kim’s pattern of lacking integration between the conscious and unconscious aspects of
her psyche was evident in individual therapy, but was particularly highlighted, and given
tangible form, in her sculpture. The first five images (pieces A to E) symbolize the rational
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conscious aspects of her psyche, and reflect her need to rationalize and control the
outcome of each image. Kim made a significant “effort” to make her images aesthetically
attractive and give them a “label”. However, she then “gave up hope” with the last three
images (pieces F to H) and decided to make “no effort” to be “creative” or to make her
images “beautiful”. She referred to the latter three pieces as “chaotic”. These appear to
be more clear expressions of unconscious repressed material. Kim preferred the first five
sculpture images which symbolized the rationally controlled conscious aspects of her
psyche, but was repulsed by her last three images, which seem to be manifestations of
deeper unconscious emotional conflicts. This evidences the lack of integration between
the conscious and unconscious aspects of her psyche.
4.8 THEMES FOCUSSING ON CLAYWORK
4.8.1 Owning disowned anger
Kim said she enjoyed the “squeeshing” of piece D. She stated that this was a way to
vent her frustrations. She said that she could not do this softly and instead it needed to
be “hard” as if she was “killing the life out of it”. She compared this to a “terrible habit” that
she had with Prestik, “squeeshing it really hard until it dies”. She viewed this as a
“nervous type of thing”. Kim also shoved and dug her fingers into the clay while making
piece H and stated that doing this was physically painful for her because she pushed so
hard into the clay that it caused her fingers to bend. It was clear that this was a way to
express strong feelings of anger. Kim had difficulty acknowledging that she was angry,
however, the clay became a medium of containment of her intense anger and rage. After
significant time during the clay process she was able to acknowledge and, therefore,
partly own her anger. I believe a very important contributing factor was my willingness to
tolerate Kim’s defensiveness for a significant period during the claywork process. In
addition, Kim was able to acknowledge her anger as a result of the clay process allowing
for more time to process her experience. She particularly pointed out that much anger
had gone into the “Squashed Femininity” piece (which was the last image she made), but
attempted to minimize this by stating that “a little part” of her felt angry. Although she
minimized the intensity of her anger this was a significant step for Kim as she had mostly
denied these kinds of feelings in therapy.
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4.8.2 Repulsion
Kim seemed completely detached from, and uninterested in, the sculpture and was very
reticent in her responses to my explorations of her experience of her sculpture. She felt
that she had put no effort into her sculpture. For her, the images she had made were
repulsive, “horrible” and “ugly things” which were alien to her. In particular, Kim wanted to
“destroy the pornographic looking” piece which “stood out” in the middle of her sculpture.
She was very embarrassed about this piece and often tried to avoid any exploration of it.
This is further evidence of Kim’s repulsion and rejection of aspects of herself, more
specifically difficult feelings and past painful experiences she had attempted to disavow.
4.8.3 The mudpie and the acknowledgement of loneliness
Kim preferred making piece B because it was something familiar that she could name
unlike the rest of her pieces and called it a mudpie. With hesitation she stated that it
stirred up “the whole childhood thing”. She recalled a familiar feeling of holding the disc in
her hand which reminded her of when she went fishing with her father as a child. While
he was fishing she would “entertain” herself by making mudpies. She later revealed that
during this time she felt very lonely in spite of being with her father. She stated that he
was “always preoccupied with his own interests” and paid very little attention to her. On
further exploration she repeatedly stated that she hated fishing and did not know why her
father took her along because she ended up feeling lonely. She said, “it never really felt
like quality time with my dad because he was always fishing…and I was just doing
something else…I was on the beach chilling by myself”. Kim acknowledged that she was
very isolated and lonely as a child and stated that in her childhood she never spoke to
her family and never spent much time with her parents. Kim responded to her loneliness
by what she termed “escapism” and it appears she had various methods of ‘escaping’
from difficult experiences. This leads us onto the next theme.
4.8.4 “Escaping” into safety of own world
While exploring Kim’s sculpture, at times it seemed as though she was not emotionally
present in the room with me, particularly after very painful material was stirred up or a
difficult memory emerged. For example, at one point I reflected her deep sense of
loneliness in relation to her family and even her current relationships. This was evidently
very painful material and seemed to evoke strong feelings of sadness for her. Upon
reflecting her sadness, the most she managed to do was to nod, which was significant for
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her because she usually responded with denial to this kind of exploration. Immediately
after this, it seemed as though she was not emotionally present in the room for a while.
She was startled out of this state when I spoke again. I asked her whether she had a
sense of not being in the room for a while and she confirmed this. She said that this
would happen “once in a while”. I explored when in particular this would occur, she was
unsure and I wondered aloud whether it occurred when her feelings were too
overwhelming or frightening. She confirmed this hesitantly and looked around, appearing
distracted and disinterested. At another time, and after exploring issues related to the
“pornographic” image, Kim was silent for a long time and stared blankly at her sculptures,
after which she suddenly broke out into laughter and stated that it was about nothing. I
gently encouraged her to talk about what was coming up for her and suggested that she
could write what she was feeling if it was hard to speak about it. She did not accept this
offer and instead roared that she is not able to do creative writing as she could before
because she was afraid of what she may reveal. Evidently, Kim struggled to dialogue
about difficult feelings and her ‘escaping’ was a way in which she defended against the
awareness of the depth of her emotional pain.
4.8.5 The “chaos” of underlying feelings
As previously indicated, Kim completely disliked her last three images (F,G and H)
because “they are very chaotic” compared to the first five images she created which,
according to her, were “far less chaotic”. Except for image E, she said she had molded
the first five images in her hands. I reflected that for the first five images she still had a
strong sense of wanting to control the outcome and making them aesthetically attractive.
She agreed. Kim was less inclined to want to control the outcome with the last three
images and stated that she made less effort with these. She said, “it was just creating for
its [own] sake”. Kim agreed that on the one side of her board there appears to be a sense
of wanting to keep things controlled, structured and aesthetically appealing, and on the
other, a sense of not wanting to control, little effort and, for her, this represented “chaos”.
Kim related this to the “control thing because I try to be in control a lot…more in control of
my emotions”. She stated that prior to therapy she was emotionally out of control since
she would “cry at the drop of a hat”. But more recently she tried to control her feelings.
Kim stated that she feared being out of control emotionally and said that there used to be
“a chaos in my life that I don’t want to identify with anymore”. She said that she was
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aware that going into this other extreme of wanting to control her emotions so strongly
was “not healthy either but I’m trying to find the middle ground”.
Kim wanted to disavow the “chaotic” side adding “I don’t know if it represents something
currently in my life…trying not to think of anything in my life that is chaotic”. She wanted
to be in control emotionally and wanted to disavow her emotions to the extent of not
wanting to allow any expression of it out of fear of being overwhelmed. Kim stated that
she went from being emotionally “out of control” to being emotionally controlled and
added “…I do sometimes have a sense that things are not going that well and are going
to come undone”. Toward the end of the claywork sessions she realized that
psychological healing “involves a lot more than identifying problems and dealing with
it…it involves for people to accept a lot of things and feel a lot of things”. She stated that
she entered therapy and regained control of her life “without actually having to feel
anything which I am scared is just going to unfrazzle me”. She felt that although therapy
helped her to gain control over her life again, she did not allow herself to process things
emotionally but instead would try to work things out rationally. Kim was amazed to see
the sculpture taking metaphorical form and making sense for her at the end and stated,
“It makes it a lot more obvious when you staring at them now…Ja, I never thought about
it when I was making it”. She agreed that she tried to suppress her feelings for a long
time and realized that this was not helpful for her, however, she was afraid to “lose the in-
control part” of her. Although she feared giving up control, she also expressed a need to
acknowledge her feelings, and stated, “I need to start feelings things again”.
4.8.6 Masculine over-identification vs Feminine disconnection
As mentioned earlier, the “Pornographic” image (piece G) appears to symbolize various
aspects of, and meanings related to, Kim’s difficulties including the theme currently under
discussion. This image stands out, is a strong presence and clearly holds a central
position in Kim’s sculpture. Kim’s tendency to be “brash and loud”, her apparent
arrogance and confidence, cynicism and rational approach are aspects of an over-
identification with her masculine energy. Thus, it appears that she attempts to disown her
feminine qualities such as compassion and sensitivity symbolized by the ‘Squashed
Femininity’ image (piece H) and unconsciously identifies with socially sanctioned male
characteristics. She agreed that she had assumed a more masculine role in her life by
“just being a little bit stronger and in control”.
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Although Kim presented a veneer of femininity such as wearing the most avant-garde
female fashions, this was a way of compensating for the poverty of psychic feminine
energy. As she said “Ja, okay…I don’t really cry…I think that’s a big aspect of femininity
that I have let go of”. She also had very little compassion for herself and other people and
would often frown upon and speak disparagingly about her own and other people’s
emotional difficulties. She said that although she felt she was making progress in therapy
she tried to do this without feeling. She stated “its not the same [without feelings]…its not
the point…”. At the end of the session Kim stated that she realized that she was trying to
deal with her difficulties by “being in control” and that she needed to “let go a little and
face things more and properly this time…just listening or feeling stuff…instead of just
putting a logical solution on it…I learnt about my masculine and feminine side”. I explored
whether this actually did resonate with her, she stated that it made sense to her in that
“my behaviour…cutting off my feelings and being very in control…cutting off from my
femininity”. She was able to recognize that she tried to deal with her emotional difficulties
by employing defense mechanisms, such as rationalization and intellectualization.
Kim identified with masculine characteristics, such as being in control and aggressive, as
a way of ensuring invulnerability. At the same time she perceived feminine qualities such
as expressing feelings and being compassionate as indicative of inferiority and
weakness. She pursued men she felt attracted to, did the “scoring”, and would reject men
who were “too nice” to her, treating them with disdain and contempt. Kim became the
abuser in certain relationships in which she would continually mistreat and devalue the
men who respected her. This is common amongst individuals who were abused as
children. There is tendency to identify with the qualities of the abuser as a means to
ensure invulnerability.
4.9 CLAY VS TALK THERAPY
As previous research on clay therapy has shown (section 2.6.3) the clay sculpture
allowed for the projection of Kim’s unconscious and repressed material. This relates to
the themes that more richly emerged from, and were strongly illustrated in, the claywork
process compared to individual talk therapy. These include the projection of intense
anger, the depth and intensity of her struggles with sexual and other intimate
relationships, her fear of being emotional overwhelmed as well as re-enacting narcissistic
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defenses such as devaluation and attacking to ward off feelings of shame. Many of these
themes relate to her sense of defectiveness and her need to defend against this being
exposed to others, including the therapist. The clay process also highlighted her sense of
inferiority and her need to compensate for this by over-identification with male qualities
and the disavowing of feminine characteristics. The manner in which she related to the
clay sculpture by disengaging and not being able to enter into a dialogue with it as well
as the therapist, provided further material regarding her struggles with emotional
intimacy, trusting and relating to others.
In conclusion, the discussion of the case material illustrates that the claywork process
allowed for continued processing of Kim’s difficulties which emerged in individual talk
therapy. However, the claywork process also allowed for deeper expression and
exploration of issues which Kim strongly disavowed and denied in individual therapy.
These include her anger, her sense of loneliness, anxiety about being overwhelmed by
her feelings. What seemed particularly illustrated and highlighted in the clay process
were her tendency for perfection and control, her dysfunctional relationships with others,
her sexual difficulties and her tendency to over-identify with masculine qualities whilst
disavowing feminine characteristics. Some of these themes will be hermeneutically
interpreted in the next chapter.
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CHAPTER FIVE
DISCUSSION
5.1 INTRODUCTION
The current research has outlined ways in which to better understand Kim’s experience
of an expressive form of therapy, namely clay therapy. The essential research aims need
to be kept in focus: To investigate the process of working with the Edwards claywork
method with a narcissistically wounded client who feared being exposed as inadequate
and struggled to relate to others; to investigate whether the distancing that art therapy
can create can help this kind of client to tolerate unexpressed disavowed feelings, and in
particular feelings of shame regarding her sense of inadequacy; to examine whether
material evoked through the claywork process can assist in deepening the psychological
formulation of the this kind of client. I firstly explore aspects of the process of individual
therapy prior to the claywork process which contributed toward Kim trusting me more,
and subsequently I use an object relational perspective, with specific focus on Summers’
(1999) and Teyber (2000), to hermeneutically understand Kim’s relational difficulties
including her relationship to her sculpture. I further employ the perspective of Adler
(1912/1958) to understand Kim’s over-identification with socially sanctioned masculine
qualities.
5.2 THE THERAPY RELATIONSHIP PRIOR TO THE CLAYWORK
In this section I will explore various aspects of the therapeutic relationship using object
relations theory as a hermeneutic lens. I specifically focus on the view of Summers
(1999) with regards to the conceptualization and analysis of the narcissistically wounded
client. The aim is to engender further understanding of Kim’s difficulties, especially her
struggles to engage in a relationship.
5.2.1 An object relations understanding of defenses in the therapy relationship
Kim’s struggle to engage, tendencies to attack and devalue therapy, as well as her
ambivalence made the task of therapy challenging for me (section 4.5). Especially
initially, as well as at different times during the therapy process, my affective response
was to feel ineffective and inadequate in dealing with her and, at times, I felt a strong
urge to protect myself and to retaliate. However, I reminded myself that Kim’s behaviour
was part of her generic conflict and as a result, any retaliation on my part would be a re-
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enactment of her childhood experience of rejection and criticism (Coen, 2002; Gabbard,
1998; Ogden, 1992). Every analytic client, to some degree, opposes the insights he/she
consciously seeks. But narcissistically wounded clients, like Kim, react to this awareness
with a special form of anxiety: the dread of having her defects revealed or uncovered,
which can be understood as the threat of having an experience which would elicit intense
feelings of shame (Morrison, 1989).
Throughout most of the initial stages of therapy Kim would vacillate between devaluing
and attacking others, including me, and complete withdrawal. Her mixture of anger and
shame was so intense at times that she wanted to leave the room. At these times she
would become very demanding for me to make her feel better and take her pain away,
and if I could not do this, ‘what was the point of therapy?’. It seemed that all Kim’s efforts
would go into defeating me, into making therapy a “meaningless game”, into
systematically destroying whatever she experienced as good and valuable in me
(Kernberg, 1986, p. 230) which is characteristic of certain narcissistically wounded
clients. Kim’s resistance was a defense which served to ward off potential feelings of
shame should therapy ‘expose’ her as well as prevented her from entering into greater
intimacy with me. To illustrate this, often when Kim would speak it felt as though she was
not talking to me, and that I was excluded from her awareness. Whenever she spoke
about her difficulties I perceived a feeling of deficiency in genuine emotional expression,
which is typical of the narcissistically wounded client (Kernberg, 1986). As Modell (1986)
posits, the client is turned off emotionally, she does not communicate feelings, for to do
so would strengthen the relational tie (section 1.7.2). Any attempt at forming a
relationship with Kim was denied and blocked by her.
In addition, for approximately the first 12 sessions of individual therapy Kim desperately
attempted to hold on to an idealized image of her parents that did not match the reality of
her childhood experience. The more I pointed out the failures of her parents and the
impact this had on her, the more Kim resisted this and protected them, and the more I
interpreted her defensive manoeuvres the more she defended against this awareness.
Kim was significantly anxious about being ‘exposed’ in therapy and strongly defended
against this. An integral aspect of the therapeutic process is to tactfully interpret the
client’s underlying conflicts, however, because the narcissistically wounded client’s
symptoms express indirectly a deep sense of inadequacy, inquiry into their origins evoke
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extreme anxiety of ‘exposure’ (section 2.3). As a result, the therapist is left with a
conundrum – to interpret or not to interpret? For narcissistically wounded clients, like Kim,
the threat of being exposed makes them particularly anxious of therapeutic interpretation.
I intuited that I needed to work with her defenses in a supportive and understanding way
before making any interpretations.
Although I felt drained after most sessions with Kim, I remained hopeful that with
patience on my part, she would be able to allow herself to trust me more and feel safe
enough to risk being vulnerable in the therapeutic relationship. I followed the
recommendation that the therapist sustain a period of understanding during which the
client uses the therapist as a ‘selfobject’ experience, before explanation or interpretation
begins (section 2.3). This meant that Kim would be better served by empathic resonance,
than by the imposition of truths she was not ready to hear, even if for prolonged periods
this involved just listening to her, without any new information being provided by me. I
decided that I needed to follow her along for a while, while offering her opportunities to
reveal more about herself when she was ready (Teyber, 2000). I repeatedly and
consistently gave her permission to disclose or proceed at her own pace, and reminded
her that I cannot take her where she does not want to go. I ‘colluded’ with Kim for a while
and allowed her to feel that she was ‘in control’, something which, I believe, she needed
in order to feel safe enough to open to her painful inner conflicts.
Although I became more aware of Kim’s anxiety about being exposed and allowed her to
‘use’ me as a ‘selfobject’ (section 2.3), I was also aware that she needed to get in touch
with, and express her unexpressed needs and feelings that were deeply buried beneath
her apparent assertiveness, “guarded by a wall of shame” (Kohut & Wolf, 1986, p. 193). I
was concerned that at some point I would have to point out her defenses as well as the
underlying feelings (Malan, 1979). There is always the possibility of the therapist
supporting the client’s defenses at the expense of resolving the issues underlying them
and Kernberg (1986) cautions against this. However, with narcissistically wounded clients
the therapist has to be vigilant regarding the danger of exposing their sense of
defectiveness in a way that they will find humiliating and possibly arresting the process
on the one hand, and on the other, of being too careful not to injure the client to the point
that therapy never gets past the client’s defenses and becomes unproductive (Summers,
1999).
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I realised that neither interpretations nor empathic resonance by themselves would
benefit Kim, and I attempted to take the middle road with her which appeared to bear
fruit. Sensing her needs session by session, I decided to follow her and my intuition in
terms of, either, mirroring her needs sufficiently and/or pointing out and interpreting the
themes that played out in her relationships, including in therapy. These included carefully
exploring her vacillating ambivalence, devaluation, and fear of emotional intimacy, and
linking this to her unfulfilled childhood needs. I attempted to show to her the helplessness
and hopelessness that lie beneath her anger, depression and grandiosity, explaining the
protective functions these defenses served, but that they were no longer adaptive and
were in fact engendering more problems in her life and relationships. I knew that hidden
beneath her narcissistic defenses was not only a feeling of defect but also a potential Self
that had not been allowed direct expression in the world (Summers, 1999), a potential
that Kim could not consciously conceive of as yet.
Gradually, albeit guardedly, Kim began to trust me more and internalise my
interpretations and have more empathy for herself (Kohut & Wolf, 1986) as a child whose
needs were not responded to, and as an adult, suffering from the consequences of these
unmet needs. She began to take minute risks in making herself vulnerable in, and
dependent on, the therapeutic relationship and allowed herself to feel her sadness and to
cry in front of me for the first time after approximately six months of therapy. Although,
the first time she cried, she responded with shame and tried to hide her tears, Kim was
able to see that her feelings were understood and accepted by me, and that she was in
fact not going to be judged or criticised. A few sessions later, to my surprise and without
therapeutic encouragement, Kim began to make links between her present problems and
her parental failures, something which I initially thought she was too defended against to
be able to do. However, at times she continued to attempt to protect her parents and
deny painful feelings.
As she began to allow herself to experience her authentic feelings and needs in the
therapeutic relationship, this began to generalise to other situations in her interpersonal
relationships (section 4.4.6). For example, she began to set boundaries in her
relationships with certain men who usually used her for their sexual needs, began to re-
evaluate her friendships and her identity in relation to her interpersonal relationships, and
began to experience more authentic self-awareness. In one of our later sessions Kim
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stated how she does not feel the need to be the “ditsy air-head” who entertains others
any longer, however, she was feeling as if she was going through an “identity crisis” and
said, “I know what I don’t want to be but I do not yet know what I want to be”. I regarded
this as a positive indication that Kim’s authentic Self was beginning to emerge. I began to
make more interpretations which Kim was able to accept and process, both inside and
outside the therapy room.
The journey inward for Kim had begun, as she was more willing to risk exposing her
sense of ‘defectiveness’ in therapy and allowed herself to feel the sadness of the losses
she experienced as a child. Kim began to evidence a relative degree of dependency on
me and expressed that she “feels better in therapy than in the world”, and I was excited
that a shift had begun for her. I realised these were giant steps for Kim and
acknowledged her courage in allowing herself to be vulnerable in therapy. However, I
understood that it would still take us a while before Kim would be able to fully explore her
childhood traumas and for her to integrate the ‘bad’ with the ‘good’ within herself and in
her relationships. Kim indicated in our last session before a big break that she was
disappointed that this break was occurring because she had just started to “get
somewhere”. I reflected her disappointment and sadness but encouraged her that there
are aspects of therapy that she has taken into herself, which she will always be able to
draw on when she needed to, and reminded her that we will meet in the new year again.
Kim had not only developed trust in me, but she began to trust in her authentic affects
more and I realised that patience and faith in the process of therapy had reaped great
rewards. Although Kim had begun to trust in the therapeutic relationship, she continued
to struggle to express her feelings verbally. I felt that Kim could benefit from a more
expressive form of therapy, since she had begun to trust me more, and appeared less
anxious about being shamed in the therapeutic relationship.
5.3 THEMATIC OVERVIEW OF CLAYWORK
5.3.1 Introduction
Although various themes emerged from the case narrative of the claywork process, it
would be cumbersome to present them in their entirety. Since the aim was to relate the
claywork process to Kim’s difficulties in general, I selected 4 superordinate themes which
permeated the data and encapsulated the most essential aspects related to Kim’s
experience of the claywork process as well as engendered a richer understanding of her
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difficulties. I use art therapy theory together with object relational and Adlerian theories
as hermeneutic lenses to deepen this understanding.
5.3.2 Self, Insecure attachment and Relational difficulties
One of the interesting aspects of this research is that Kim’s dysfunctional relational
pattern was particularly highlighted in the claywork process. Kim was disengaged from,
and lacked complete interest in her sculpture for a significant part of the claywork
process. She tried to avoid any form of contact, including eye contact, with her sculpture
and stated that she could not “connect” with it. She evidently struggled to enter into a
relationship with it. It is posited that art therapy such as claywork allows the individual to
enter into relationship with the image and stimulates a dialogue between the conscious
and unconscious (section 2.4.1.a). It also creates a space and form that distances the
individual from his/her, often painful, unconscious material (section 2.4.1.c). However,
and more initially, Kim was unable to enter into a relationship with her sculpture in spite
of the potential distancing factor, and defended against dialoguing with it as well as with
the therapist. Especially in the initial stages of the claywork process, Kim was extremely
anxious and defensive, protecting herself against the possible exposure of her sense of
inadequacy through the claywork process. This was made clear by her need to make a
“perfect” sculpture and when she “could not get it right” she felt frustrated and inadequate
stating that she was not “a creative person”. Kim’s pursuit of perfection was motivated by
her terror of failure and fear of being perceived as inadequate (Summers, 1999).
Kim associated the Mudpie (piece B) with feelings of loneliness as a child in relation to
her father and acknowledged her father’s emotional absence in spite of his physical
presence (section 4.8.3). It appears after her mother had wholly rejected her from the
age of four years, she turned to her father for comfort, protection and emotional support,
however, he also failed to meet these healthy attachment needs. Her mother was also
intrusive, punitive and over-controlling and her father’s availability was unpredictable.
This generated an ambivalent mode of insecure attachment to others, which was re-
enacted in her adult relationships (section 1.7.2) including in the therapeutic relationship.
As a result of her parents’ unsatisfying responses, Kim constructed an interpersonal
schema in which, when she was distressed or frightened she felt at risk of being
misunderstood, and expected others to be both unpredictable and intrusive, as her
parents were (Liotti, 1991). Similarly, in her relationship with me during individual therapy
as well as during the claywork process, Kim construed me as she did her parents, as a
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significant ‘other’ whom she expected would not understand her needs and would be
unpredictable and intrusive. During the discussion of piece G and H, certain relational
themes arose such as her need to “isolate” herself from others when they got too close to
her, as well as her ambivalence in intimate relationships. As a result of her ambivalent
mode of attachment Kim expected interpersonal consequences similar to those provided
by her early caregivers (Teyber, 2000).
The “Squashed Femininity” image (piece H) evoked discussion around Kim’s intimate
relationship difficulties and she acknowledged that she would pursue men who could not
commit to her and who were largely emotionally unavailable to her, as her father had
been. What also emerged during this exploration was her tendency to emotionally
withdraw from intimate partners when the relationship offered her the possibility of
greater intimacy. As Teyber (2000) posits, the possibility of having a benevolent
response to the old unmet need arouses shame or anxiety since the other’s affection is
likely to arouse the pain of the original deprivation. It appears that Kim’s tendency to
reject benevolent responses and her pursuing of unavailable partners was a way for her
to avoid the anxiety related to her unmet needs. Kim would elicit the same unsatisfying
responses from others in current relationships similar to the responses she received from
her parents.
Kim was constantly anxious about being discovered as flawed or defective. During the
exploration of certain images (G and H) in the claywork process, Kim mentioned that she
often isolated herself from her friends and would feel anxious when they got to know her
more intimately. Similarly, during individual therapy she mentioned preferring to socialise
with people who did not know her very well. It appears that her withdrawal acted as a
means to ward off the anxiety of being discovered as flawed. Similarly, Kim experienced
the sculpture as threatening to expose her and, in response, devalued or attacked it as a
way to ward off her sense of defectiveness (section 4.7.3). She called it “horrible” and
saw it as separate and alien from her. She was not able to accept her creations as
expressions of aspects of herself, and, as a result, rejected them. This could be related to
the quality of “otherness” often associated with artistic creations (Edwards, 1987, p. 101).
As discussed in the literature review, when an image is made the creator may realise that
although the image belongs to him/herself and is symbolic of inner experiences, it also
seems to have an identity of its own (section 2.4.1.c). According to Edwards (1987), this
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quality of ‘otherness’ has the function of helping the creator become separate from
his/her symbolised inner experiences, seeing them as both part of, and separate from,
the self. It appeared Kim wanted to disavow the rejected aspects of herself that her
sculpture symbolised, however, she unconsciously manifested her dysfunctional
relational pattern by disengaging from her sculpture (an ‘other’) and attacking it out of
fear that it would expose her imperfections. Kim, therefore, responded to her sculpture
the way she responded to others. In the claywork process, she also verbally attacked and
devalued others with whom she had formed relationships. She particularly did this in
relation to those who expected greater emotional intimacy from her because of her fear
that they would become aware of her deep sense of inadequacy. Kim had not
internalised a secure and loving interpersonal schema and therefore each time she
entered a potentially intimate relationship it would activate her ambivalent relational
response (Liotti, 1991). As much as she yearned for intimacy, her way of relating to
others protected her from being vulnerable but also prevented emotional engaging with
others, and therefore she experienced feelings of emptiness and boredom, as she had
throughout most of the claywork process.
To conclude this section, Kim could not enter into relationship with her sculpture and a
dialogue was not stimulated between the conscious and unconscious of her psyche.
However, it did create a space and form that psychologically distanced her from her
painful unconscious material. And although she feared being exposed by the sculpture,
this quality of the image allowed her to feel safe enough to talk about experiences and
feelings that she had previously disavowed. In spite of Kim’s need to defend against the
possibility of the sculpture ‘exposing’ her sense of inadequacy, her persistent attempts to
“get it right”, was evident of her need to ward off the anxiety of being seen as defective.
Thus the claywork process, specifically her relationship with the sculpture, mirrored Kim’s
relational difficulties in relation to her fear of others seeing her as inadequate. Based on
her interpersonal history as well as the data that emerged from the claywork process,
Kim’s fear of exposure and her ambivalent mode of attachment created significant
interpersonal anxiety for her, more specifically, in situations that required deeper intimacy
such as with intimate partners and in therapy.
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5.3.3 Masculine Protection
An important theme that emerged from the claywork process was Kim’s tendency to over-
identify with socially sanctioned masculine qualities and the rejection of her feminine
qualities, such as the expression of feelings and having compassion for herself and
others (section 4.8.6). This was symbolized and expressed in the “Pornographic” image
(piece G) and the “Squashed Femininity” image (piece H) respectively. These were the
two largest images, with the former taking a central position amongst her eight images,
evidencing the significance of this theme in her life. These two images also engendered
the strongest emotional response from her, partly because she felt ashamed of making a
“giant penis”, and more than likely because she had strongly disavowed the feelings
associated with these two images.
Adler’s (1912) perspective of a ‘masculine protest’ allows for a deeper understanding of
Kim’s tendency to compensate for feeling vulnerable and inadequate by over-identifying
with socially sanctioned masculine qualities, which was graphically portrayed in her
sculpture (sections 2.4.1.b and 4.8.6). During the discussion of the “pornographic” image
she spoke about her tendency to be “brash and loud” and her need to be “stronger and in
control”. She also pursued men she was attracted to or she would ridicule and verbally
attack men whom she regarded as inferior to her. In addition, her apparent confidence,
arrogance, cynicism and preference for “rational solutions” further points to what Adler
conceptualized as a ‘masculine protest’ (section 1.7.1). He posits that the starting point
for this is a feeling of “weakness” in the child (male or female) in the face of adults (in
Ansbacher & Ansbacher, 1958, p. 47). According to Adler, the child’s need for affection
and support is denied and so called feminine qualities such as love, gentleness and
compassion are hidden, and overcompensated for, by masculine qualities such as over-
reliance on rationality, ambitiousness, aggression, control, dominance and so on. This
can be compared to Jung’s perspective on the archetype of Logos which he links to
behaving in socially sanctioned masculine ways which “hinders and cripples the
individual through one-sidedness” (Hopcke, 1989, p. 46). These theories of Adler and
Jung are to be viewed as abstract; patterns of human behaviour not intrinsically allied
with anatomical gender.
In accordance with Adler’s view, it appears that Kim over-identified with certain masculine
qualities as a need to protect herself from being as vulnerable as she had been as a
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child. Throughout her childhood there was a need for her to protect herself against the
onslaught of others, such as her parents as well as the perpetrator who may have
violated her sexually. Her mother’s punitive and critical parenting style and her father’s
emotional absence prevented her from trusting in her authentic affects, such as the
expression of love and sadness as well as a need for relatedness. Instead, her authentic
feelings and needs were not met and aroused anxiety, which as a child, she was not able
to cope with and needed to be suppressed. These unexpressed feelings and needs,
when later re-evoked, would signal danger for her and a sense of “chaos” (section 4.8.5).
Kim’s aggressive and attacking demeanor appears to be another way in which she
compensates for, and protects herself against, feeling vulnerable. In addition, Kim
appears to have identified with her father as she often spoke about how much she
admired him for his hard work and ambitiousness (section 4.2). She appreciated his more
“rational” approach compared to her mother, who she regarded as “weak” and irrational,
and who she spoke of with disdain. Her father met some of her needs, albeit material
rather than emotional, and therefore she valued him more as a role-model and caregiver.
This may have contributed toward needing to identify with masculine qualities. Kim
appears to have constructed a ‘masculine protest’ as a means of establishing a sense of
connection, albeit superficial, with a significant caregiver as well as to cope with feelings
of vulnerability and fear of further violation. She had been emotionally, and more than
likely, sexually, violated as a child, and her need to protect herself from further violation is
a strong motivating factor for establishing this protective defense. She adopted a hostile
and abusive stance toward others as a means to protect herself and to ensure that she
would never again be as vulnerable as she was as a child (Davis & Wallbridge, 1981;
Winnicott, 1965).
In summary, the graphic centrality and prominence of the “pornographic” image (piece G)
in relation to Kim’s sculpture as a whole, and my experience of her as being generally
very hostile, cynical and aggressive in her approach toward others, points to the essential
nature of this theme in her life. Adler’s concept of a ‘masculine protest’ is helpful in
generating a deeper understanding of this behaviour. It appears that Kim over-identified
with certain masculine qualities such as relying on rationality, aggression and cynicism
and rejected her feminine qualities, such as compassion and expression of feelings. This
seems to be related to having been made to feel ‘weak’ as a child in the face of her
parents having not met her needs for the healthy expression of feelings and relatedness.
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In order to compensate for this, she developed a ‘masculine protest’ which protected her
from feeling vulnerable, helped her to maintain a sense of connection with a significant
caregiver, as well as prevented her from experiencing situations that would elicit the
suppressed feelings underlying this compensatory response.
5.3.4 Reflections on the “pornographic” image
It is known that a particular image can bring out and symbolize different aspects of an
individual’s psychological life (section 2.4.1.d). The “pornographic” image (piece G)
seems to have various important meanings including symbolizing Kim’s sexual difficulties
and related physiological responses which served to protect her from being vulnerable
psychologically and physically. This image appears to represent her own fears of being
penetrated and, for her, the sense of being violated, by a sexual partner.
While discussing Kim’s sculpture with her, she wanted to “destroy” and “get rid of”
unwanted aspects of it and found it repulsive, more specifically, the “pornographic” image
(piece G). In spite of her initial defensiveness during the claywork exploration, the
presence of this image facilitated an opening up about her sexual difficulties and the
emotional and physical pain she experienced with penetrative sex. This was unlike
individual therapy where she resisted exploration of these issues and often minimized
them. As posited by Dally (1984), the art creation provides focus for discussion, analysis
and self-evaluation and since it is concrete it cannot be denied, erased or forgotten. After
denying that the “pornographic” image had any meaning for her, Kim revealed that she
was repulsed by a man’s penis and would experience severe discomfort with penetrative
sex. During the exploration of this image Kim also revealed that she felt disconnected
from, and repulsed by, her genitals. She added that she “can’t deal with it [her vagina]…I
have no connection with that part of my body”. It appears that Kim’s genitals were a part
of her that she wanted to “get rid of” as it was associated with possibly having been
sexually violated as a child and was also a significant source of her pain in relation to a
significant ‘other’. Furthermore, it appears to be an aspect of herself that she was not
able to control thus denial of it’s existence gave her some sense of control over her
sexuality. On further exploration of the “pornographic” image, Kim revealed that she
would avoid anything related to the ‘penetration’ of a woman’s genitals such as
pregnancy, childbirth, the use of tampons and other related matters. This increasingly
points to the likelihood that Kim suffered from vaginismus, although, we were not able to
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explore and treat this therapeutically. These are some of the common symptoms that are
experienced by victims (or survivors) of sexual abuse in childhood (section 1.6.1).
The strong presence and graphic centrality of the phallic image (piece G) and her disgust
at it as well as her own genitals, are evident of Kim’s deep inner conflicts regarding sex
and her sexuality, which is a common response of sexual abuse victims. Often, the
younger the child was when the abuse took place and the closer their relationship to the
perpetrator, the more there is a tendency for the victim to repress the experience as a
result of having been betrayed by someone they trusted (section 1.6.1). Although Kim
had no cognitive memories of having been sexually abused, she experienced various
symptoms (mentioned above) and had a ‘felt-sense’ of it, which are equally significant. It
is posited that memories of traumatic experiences defined as overwhelming and outside
of the realm of normal experiences are encoded, stored and retrieved differently than
ordinary memories. Because memories related to trauma, such as sexual abuse, do not
fit existing cognitive schemas, they may not be integrated with ordinary verbal
autobiographical memory or incorporated into conscious self-representation (Draucker,
2000; Herman, 1992). Traumatic memory loss is best understood as one type of
defensive disconnectedness (dissociation), that is, a defense against overwhelming
affect. Although Kim had no cognitive memories of having been sexually abuse, she
experienced symptoms that are typically related to this kind of traumatic experience.
Another way to interpret the meaning of the “pornographic” image in relation to Kim’s
vaginismus, is according to Adler’s view of the masculine protest “increased”. Recall
Kim’s disgust and disconnection from her genitals as well as her avoidance of anything
related to a woman’s vagina. She also experienced significant difficulty with her
menstruation which included severe pre-menstrual tension as well as “mood swings” and
spoke about this contemptuously. As mentioned earlier, the ‘masculine protest’ serves a
protective and compensatory function as a result of the child having been made to feel
“weak” in the face of parental responses (section 1.7.1). Adler posits that when the
‘masculine protest’ in women is taken a step further, it may lead to various forms of
neurotic reactions expressed through the body such as “dysmennorrhea, vaginism and
frigidity” (Ansbacher & Ansbacher, 1958, p.49). There may also be a tendency to have
problems related to reproductive issues, such as menstruation, pregnancy and childbirth.
Based on this perspective, Kim seemed to want to reject aspects of herself which
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represented her femininity and its sexual expression as, for her, it seemed to indicate
‘weakness’ and vulnerability. Deep emotional and sexual intimacy also requires making
oneself vulnerable in relation to an other. However, Kim perceived vulnerability as
dangerous and indicative of “weakness” which appears to be further evidence of her
need to protect herself from being vulnerable and powerless in relation to others, as she
had been as a child.
In summary, although Kim initially attempted to deny psychological conflicts related to her
sexuality, as she had done in individual therapy, she was able to open up about these in
the claywork process. It appears that the three-dimensional concrete presence of her
sculpture and, more specifically, the prominence of the phallic image prevented her from
further disavowal as it could not be forgotten or denied. Two apparently contradictory
meanings related to her sexual difficulties and associated physiological responses
emerged in relation to this image. On the one hand, it could be related to Kim’s fears of
being sexually penetrated and aggressed as a result of possibly having been sexually
abused as a child, and therefore, as an adult, she may be protecting herself from further
sexual violation through a variety of psychological and physiological defenses. On the
other hand, following Adler’s view, the centrality of the phallic image may equally be
expressive of Kim’s aggressive and hostile stance in her life, which may also serve a
compensatory function of preventing further vulnerability.
5.3.5 Control vs “Chaos”
Another broad theme that arose from the claywork process was Kim’s need for control
and perfection which manifested in the way she handled, and related to, her sculpture. It
appears there are two ways in which to understand this experience. I firstly discuss Kim’s
need for perfection and control in relation to Summers view on certain (mal)adaptive
strategies employed by the narcissistically wounded client in order to maintain a
relationship with the original caregivers. Thereafter, I apply an object relations
perspective in discussing Kim’s need stay in control in order to avoid dealing with painful
feelings related to her childhood experiences.
From the outset of making her sculpture Kim attempted to construct images that were
“perfect” and aesthetically attractive. She attempted to remain in conscious control of
what she created and wanted to ensure that her images would be impressive. The more
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she attempted to do this, the more frustrated she became at not being able to “get it
right”. On examination of her sculpture, her need to control and make something “perfect”
was clearly illustrated in the way she handled pieces A to E. She attempted to give each
one of these pieces a shape that was “recognizable” and to which she could add a
“fascinating story”. When she could not make a “perfect” object she would then “give up”
completely (illustrated by piece E), and on completion, attempted to reject and disown the
“horrible” images she made.
In individual therapy, Kim mentioned her tendency toward needing to do things perfectly
and if something she undertook, like her studies, was not of an exceptionally high
standard, she believed she was a complete “failure” (sections 4.4.1 and 4.4.2). In
addition, during the individual therapy process Kim experienced periods of chronic
procrastination and believed she was an “extremist” as she would either set up a rigid
work schedule or would not schedule anything at all. She believed that the latter, not
scheduling, was part of the way she “sabotaged” herself. Likewise, in her relationships
with others Kim felt compelled to impress others and to say things that were “gripping” or
“fascinating”, if not, she would not engage with, and speak to, others in social situations.
Similarly, in her relationship with me, Kim was mostly guarded and afraid to reveal herself
and would say as little as possible about her experiences. At one point in individual
therapy when I explored this she stated that her issues were too “trivial” and if she had
nothing “gripping” to say to me she preferred to say nothing.
It appeared that Kim’s parents valued her only insofar as she could produce, amongst
other things, academic results that they could be proud of. This need to deliver ‘results’
was evident in Kim’s approach to the things she undertook in her life, including her
studies and therapy. This was also apparent in the making of her sculpture. As
mentioned previously, Kim attempted to create images that were “perfect”, aesthetically
attractive and “fascinating”. Her desperation to achieve ambitious goals and her
perfectionism not only reflected a need to hide her sense of inadequacy, but was also
attempts to fulfill parental wishes, a typical response in narcissistically wounded clients
who adopt the adaptive strategy of compliance (section 1.7.3). As mentioned in the
literature review, if the caretaker is unresponsive to the child’s needs, the child will
attempt to form the relationship according to the needs of the caretaker (section 1.6).
Because attachment is necessary for survival the child typically searches for a way in
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which to maintain some type of connection, albeit with defensive protection (Liotti, 1991;
Summers, 1999). Throughout individual therapy as well as the claywork process, Kim
would protect her parents out of fear that she would say something that felt like a betrayal
of them. During the claywork process she would, at times, accept my interpretations
related to her parents but would subsequently experience this as “parent-bashing”. This
need to protect them prevented her from dealing with her authentic affects. Kim felt
trapped in the fulfillment of parental wishes and at the same time feared living a more
authentic life, which would include expressing her suppressed needs and authentic
feelings. She often protected her parents in individual therapy as she did in the claywork
process and was ambivalent in her recognition of the ways in which they failed to meet
her emotional needs. This leads us onto the next point which relates to Kim’s fear of the
“chaos” of her feelings which emerged in the claywork.
It appears after having made her first five images in which she attempted to control the
outcome and expression of her feelings, Kim began to “let go” and started “creating for its
[own] sake”. She stated that she had made less of an “effort” to form her last three
images (pieces F to H) into images that would be impressive and aesthetically attractive.
It appears that with more time, Kim was able to allow herself to “mess” with the clay. One
component of art activity, such as clay, is that it offers an opportunity for “relaxing
controls and letting go” (Dally, 1984, p. 33). Kim’s ‘letting go’ in relation to her last three
images seems to be more expressive of her inner conflicts (section 2.4.1.b). She agreed
that with these three images she experienced less of a sense of wanting to control the
outcome but also felt intense aversion toward them. It appears that unconscious and
disowned material was given expression and concretely illustrated in her last three
pieces. Kim initially struggled to acknowledge that these were aspects of herself and
continued to disown them for a significant part of the claywork process. I believe that the
need to disown these reflect their intensity in Kim’s psyche. The intensity of Kim’s
repressed feelings was particularly given form in her last three images (F to H), which
can be seen as a form of “symbolic speech” (Rubin, 1987, p. 12) about intense feelings
such as her sadness and anger which she had been afraid to acknowledge.
Kim’s suppressed feelings, symbolized by the “chaos” of her three last images, can be
associated with her intense emotional responses to the rejection and hostility of her
parents. Recall that Kim entered therapy to find solutions to her overwhelming
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depression and anxiety about losing control. Kim also had a poor relationship history and
struggled with emotional intimacy. These can be understood as symptoms related to
having been rejected by her mother as well as neither having received emotional
nurturance from her father. In addition, the experience of possibly having been sexually
abused would engender intense feelings by itself. These were all unresolved issues and
associated feelings which Kim was, understandably, afraid to acknowledge and own.
The importance of unveiling underlying repressed affects and owning them is one of the
fundamental goals of psychotherapy (section 2.2). This unveiling of hidden expressions
including repressed inner conflicts and gaining insight into the meaning of behaviours is
best lived through in a relationship charged with affective and cognitive meaning (the
transference) (Rubin, 1987). Kim had begun to show trust in me after a significant period
in individual therapy and after she realized that I was able to survive her attacks (sections
2.3 and 5.2.1). After significant time in the claywork process and through my careful and
respectful inquiry, Kim was able to acknowledge that she had a tendency to want to
control her feelings and experiences. In the claywork process, she acknowledged that
through therapy she regained control over her life but tried to do this “without actually
having to feel anything which I am scared is just going to unfrazzle me”. Later on in the
claywork process, she realized that psychological healing required “more than identifying
problems…it involves accepting a lot of things and feeling a lot of things”. Kim was able
to acknowledge that not owning her feelings was creating difficulties in her life and
relationships.
To summarize, Kim’s tendency toward perfection and control was a theme in her life
which was more clearly highlighted and graphically illustrated in the claywork process
compared to individual talk therapy. Despite her need to suppress and control the
expression of her feelings, Kim’s sculpture reflected the deep emotional conflicts within
her psyche. The need to control her underlying affects can be understood as, on the one
hand, an adaptive strategy to comply with the wishes of her parents in order to maintain a
relationship with them, and on the other, a defense against acknowledging and dealing
with intense feelings related to her experience of hostility and rejection by her parents
when she was a child, as well as possibly having been sexually abused. The intensity of
Kim’s suppressed emotions was particularly highlighted and given form in her last three
images. As a result of the sculpture as well as my support and unconditional presence,
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Kim was eventually able to use her sculpture as valuable information about herself
(Rubin, 1987).
5.4 Concluding thematic overview
The broad themes that emerged from the clay sculpture gave vital information and
deepened my understanding with regard to Kim’s difficulties including her relational
struggles. Although some of these themes arose in individual therapy such as her sexual
difficulties and her aggressive and ‘masculine’ stance, they were more clearly illustrated
and highlighted in the claywork process. This facilitated a deeper understanding of Kim’s
struggles as well as allowed her to own some of the aspects of herself that she had
previously disavowed or denied.
5.5 POST-CLAYWORK EXPERIENCE
Although Kim terminated therapy after three post-claywork sessions, she appeared
different in her approach to therapy and our relationship. I next explore these sessions
and my experience of her subsequent to the claywork process.
Kim returned for three sessions after the claywork process, but avoided talking directly
about this experience. I decided I would not impose an agenda of wanting to talk about
the experience and followed her, trusting that what needed to be dealt with would
emerge. For two of these sessions she raised issues around returning to her hometown
and fearing that she would “lose” the person she had become while studying away from
home. The latter was a major concern for her since, from the time she commenced
therapy, she often spoke about the significance of how much she had changed since
coming to Grahamstown. It appears that individual therapy, as well as the claywork
process contributed significantly toward this shift as she had begun to let go of her belief
that her parents were “perfect” and that she had a “wonderful” childhood. In the post-
claywork sessions Kim mentioned her disappointment in her father and that he had
changed for her. Although the claywork process itself was not directly discussed in the
sessions that followed this process, some of the issues explored were indirectly
connected to important themes that emerged from the claywork process. In the post-
claywork sessions, it appeared Kim was more able to take ownership of previously
disavowed feelings and experiences, was more emotionally engaged in the therapeutic
relationship and seemed more open to my interpretations.
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However, Kim failed to return for therapy after the third post-claywork session in spite of
having seemed to be less defensive and more able to accept my interpretations. I
wondered whether she might have been overwhelmed by, or was anxious about
exploring issues that were highlighted in the claywork experience, which might have
contributed toward premature termination. However, Kim’s premature termination might
have been more related to various external factors including practical issues, such as my
change of intern placement from a university clinic setting to a psychiatric hospital. This
required that Kim needed to come for therapy at a psychiatric institution, which might
have elicited her fears of losing control and being “psycho” as she had once stated. Also,
Kim did not have her own means of transportation and since the hospital was a distance
away from her university residence, it required that she find transport to bring her to
therapy each week. In addition, the reality of needing to return to her hometown and the
eventual termination of our therapeutic relationship may have also been anxiety-
provoking for her, more especially since she appeared more emotionally connected in the
therapeutic relationship after the claywork process.
It is important to consider the possibility that although the claywork process was able to
facilitate the expression of aspects of Kim’s difficulties, it may have flooded her. Aspects
of Kim’s fears and defensiveness related to participating in the claywork experience were
understandable, since there is a “danger as well as a reward” in opening to the
unconscious (Jung in Wallace, 1987). Although many clients who work with art therapy
may also sense this ‘danger’ (cf Smuts, 2003) for a narcissistically wounded client this
danger elicits the fear of possibly being exposed with resultant feelings of shame and
humiliation, and therefore such deep inquiry, for this kind of client, needs to be carefully
considered. The three-dimensional presence of her sculpture and the acknowledgement
of disowned aspects of herself in the claywork process might have been too frightening
for Kim as much as she wanted to “start feeling things again”.
It is argued that the therapist who uses expressive art in therapy should grade artistic
experiences to ensure that the client with certain kinds of self-pathology is not
overwhelmed (section 2.5). The grading helps to gradually increase the client’s
confidence that painful experiences could be contained through imagery/artistic work.
Similarly, others argue that certain severely emotionally dysfunctional clients may not be
suitable for ‘unstructured’ art therapy (section 2.5). However, these authors also argue
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that ‘unstructured’ art therapy would especially benefit clients who tend to use their verbal
talents in the service of especially inflexible defensive mechanisms such as
rationalization and intellectualization. I am of the opinion that Kim’s decision to terminate
therapy soon after the claywork process was not as a result of it having been an
overwhelming experience. It seems that her use of certain defenses, such as her
rationalizing, prevented her from experiencing it as overwhelming. Part of what may have
further contributed toward Kim not being overwhelmed, was my humanistic approach of
being sensitive and respecting of her needs as well as the psychological distance offered
by the sculpture.
Furthermore, previous research such as that conducted by Elliot (1993), Diers (1999),
Smuts (2003), demonstrated that the client was able to engage with the clay and for them
to gain significantly deeper meaning and psychological healing as a result of this (section
2.6.3). However, Kim was not able to engage with her sculpture in this manner and there
was no apparent ‘dialogue’ between the conscious and unconscious aspects of her
psyche. The question this raises is whether this makes the claywork process less
valuable. Kim’s inability to enter into a relationship with her sculpture was a reflection of
her struggles to relate to others (and herself) and this in itself was useful and furthered
therapeutic understanding of her emotional and relational difficulties.
Finally, an important aspect that needs highlighting is the amount of clay invested in the
“chaotic” images (F to H) in Kim’s sculpture. It is apparent that the amount of clay used to
form these images represented the amount of psychic energy in the processes related to
these images. This suggests that there was significant psychic energy invested in both
her underlying feelings and her need to hide these, as well as issues related to sexuality
and the need to protect herself. This can be compared to her need to present to the world
a perfect and aesthetically attractive veneer.
In summary, Kim appeared more able to emotionally connect in the therapy relationship,
seemed to take greater ownership of previously disavowed feelings and experiences and
was more open to my interpretations after the claywork process. Although she terminated
therapy soon after the claywork process, this appears to be more related to practical
external factors than her having been overwhelmed by this process. However, bearing in
mind the fear of being exposed as defective experienced by the narcissistically wounded
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client, it is important to consider the possibility that the claywork experience could have
been overwhelming for Kim. If this was the case then it would have been important for
me to grade the expressive art material presented to Kim, before embarking on an
unstructured claywork experience. However, it is more likely that Kim was not
overwhelmed by the experience judging by the fact that she returned for therapy as well
as was more emotionally engaged and receptive to my interpretations.
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CHAPTER SIX
CONCLUSIONS
6.1 INTRODUCTION
Following a phenomenological-hermeneutic approach, the research took the form of a
case study. A single participant’s experience of modelling and exploring her sculpture
was undertaken with specific focus on how she related to her sculpture. In the current
research the possibility of art therapy to contribute toward the emotional expression of a
narcissistically wounded client, who struggled to express her feelings and experiences in
individual talk therapy, was explored. The theoretical paradigms of object relational
theory, specifically Summers (1999) and Teyber (2000), Adler (1912/1958) and art
therapy, were used as hermeneutic lenses to explore the participant’s emotional
difficulties and psychological defenses, and how these were re-enacted in her current
relationships including in her relationship with the therapist as well as her sculpture.
The research was guided by three aims: Firstly, to investigate the process of working with
the Edwards claywork method with a client who struggled to engage relationally;
secondly, to explore whether the distancing that art therapy can create can help this kind
of client to tolerate unexpressed disavowed feelings, and in particular, a sense of shame
about being exposed as defective; and thirdly, to examine whether material evoked
through the claywork process can assist in deepening the psychological formulation of
this kind of client.
6.2 THE VALUE OF CLAYWORK COMPARED TO INDIVIDUAL TALK THERAPY
Before the claywork process the participant, Kim, had significant difficulty expressing her
feelings and experiences in individual therapy. She was persistently guarded and
defensive, and struggled to engage in the therapeutic relationship. These were aspects
of her difficulties which were typical of narcissistically wounded clients. Kim’s specific
constellation of presenting symptoms included a persistent feeling of inadequacy. A
variety of personality structures may emerge in response to this sense of inadequacy or
defectiveness. However, the protection of a stubborn, persistent feeling of diminished or
non-existent self-worth was the organizing factor in her personality. Concomitantly,
certain psychological defenses, which served to protect against the feeling of
inadequacy, motivated her personality to be organised around the ever-present threat of
exposure (Summers, 1999). Kim employed certain narcissistic defenses including
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grandiosity, attacking and devaluation, perfectionism and control, which together with the
fear of being exposed, were re-enacted in the claywork process toward both her
sculpture and myself.
During the claywork process Kim was able acknowledge certain aspects of herself which
she had previously disowned, but which had occasionally emerged in individual therapy,
such as her need for perfection as well as her tendency to control her emotions. It
appears what had facilitated this was the history of my offering of an empathic
relationship (section 2.2) to her in which her ‘attacks on linking’ were tolerated (section
2.3), as well as the psychological distance from rejected parts of herself facilitated by the
clay sculpture (section 2.4.1.c). As mentioned in the literature review the quality of the art
image allows the individual to experience psychological distance from psychological
material and as a result, renders it less overwhelming (Edwards, 1987; McNiff, 1992).
Although Kim initially remained defensive and in control in the claywork process as she
had been in therapy and other relationships, with time, she became less defensive and
her inner “chaos” was revealed. The distancing that the art image offers allowed her to
tolerate previously disavowed and unexpressed feelings.
The claywork process allowed for the concrete expression and, as a result, exploration of
certain themes which Kim would avoid in individual therapy. Some of these themes
appear to symbolize different and contradictory aspects of Kim’s experiences. However,
together, they were expressions of Kim’s need to protect herself from being vulnerable.
These include the graphic expression of underlying conflicts related to the “pornographic”
image, such as her difficulties with sexual intimacy, and her over-identification with
masculine qualities which served a compensatory function and protected her from feeling
vulnerable (section 5.3.3). On an unconscious level, Kim strongly identified with these
qualities which had a negative impact on her intrapersonal and interpersonal
relationships. Concomitantly, she disavowed her feminine qualities since she perceived
these as indicating weakness and vulnerability. Kim’s disconnection from her sexuality
and genitals may be a response to possibly having been sexually abused as a child.
However, it may also symbolise what Adler terms the ‘masculine protest’ taken a step
further which engenders neurotic reactions such as vaginismus and frigidity in women
(section 5.3.4).
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It is argued that art as therapy allows for the working with symbolic images arising from
the unconscious and setting them into dialogue with the conscious state (section 2.4.1.a).
However, although Kim’s sculpture graphically symbolised unconscious aspects of her
psyche, she was not able to open up to a dialogue with her sculpture and neither
between the conscious and unconscious aspects of her psyche. Instead, the sculpture
was able to reflect the intensity of her relational difficulties, including the therapeutic
relationship. As stated by Robbins (1987), art can mirror what is already going on in the
therapy relationship (2.4.1.e). Although art therapy such as claywork may provide an
opportunity to reflect on what arises from the unconscious and may give form to it, certain
individuals may not be able to engage with this material on a conscious level. However,
in spite of Kim’s inability to consciously and emotionally engage with her sculpture, the
therapeutic exploration of it allowed for the highlighting of her relational problems as well
as providing an opportunity to work with previously disavowed and unexpressed feelings
that were symbolically expressed in her sculpture.
Although Kim was significantly disconnected from and denied intense feelings such as
anger, more especially in the initial stages of the claywork process, she projected this
onto the clay. The self-expressive qualities of clay and its ability to be a container for
strong emotions also allow the client to regress in the safety of this form of expression
(Henley, 2002). Henley mentions that one of the most outstanding qualities of clay is its
propensity for being a vehicle for the discharge of strong emotions such as anger and
anxiety. Despite Kim’s defensiveness, the intensity of her suppressed feelings were
clearly illustrated in her sculpture, more specifically the images she called “chaotic”
(section 4.8.5). Kim was able to project and, in so doing, express her intense but
unconscious psychic material onto the clay sculpture. The unconscious was given
tangible form in the image, serving as a record for previously disavowed psychic material
(section 2.4.1.b). This material, once made conscious could be more fully integrated into
Kim’s psyche, with the potential to lead to greater psychic wholeness and authenticity.
Through respectful inquiry and interpretation, Kim was able to recognise how her
defenses such as wanting to control and block her feelings were causing difficulties in her
relating to herself and others. The importance of recognizing and owning one’s feelings
and experiences is one of the fundamental aims of psychotherapy. The claywork process
facilitated Kim’s ‘owning’ of some of her previously disavowed feelings and experiences.
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The participant’s experience suggests that clay therapy can be a valuable medium to
facilitate the expression of disavowed aspects of the self. However, it needs to be
considered that certain narcissistically wounded individuals, who may have difficulty
engaging with an ‘other’ generally, may be significantly anxious about being exposed,
and certain forms of art therapy may be too confrontative for them. Previous research has
shown that many clients benefit from the use of a more expressive form of therapy
(sections 2.7.2 and 2.8). However, not much has been researched on narcissistically
wounded clients who struggle to engage in relationships including that with the artistic
image. This research shows that for certain clients who are highly guarded against being
exposed as defective and as a result, have difficulty verbally expressing their inner
conflicts, clay therapy may be helpful in highlighting certain difficulties which they have
been unable to express verbally. In addition, the psychological distance from disavowed
inner conflicts that art therapy can create can help the narcissistically wounded client to
tolerate previously unexpressed and painful feelings as well as tolerate their sense of
shame about being perceived as defective. However, it is important to consider that for
certain narcissistically wounded clients, grading of art therapy material may be necessary
to prevent the possibility of being overwhelmed emotionally.
What seemed to have played a significant role in the current participant not being
overwhelmed by the unconscious material symbolised in her sculpture, was the offering
of a supportive empathic relationship by the therapist, the ability of the clay image to
create psychological distance from Kim’s disowned emotional conflicts as well as the
participant’s use of certain defenses such as rationalization.
6.3 RESEARCH LIMITATIONS AND SUGGESTIONS
Although much research has been conducted using clay as a form of expression in
therapy (section 2.6.3), there appears to be very little literature on clay therapy with
clients who fear being exposed as defective as well as experience severe relational
difficulties. For this reason it is difficult to draw conclusions from this one case. In other
instances where the benefits of art therapy was discussed with regards to ‘difficult’
clients, these authors merely commented about the value of art therapy with this kind of
client but did not conduct actual research with them. Therefore, a significant limitation is
that this research has only one case on which to base its findings. The suggestion is
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made that future research needs to be conducted with more cases specifically focusing
on clients who struggle to engage relationally as well as fear being exposed as defective.
6.4 RECOMMENDATIONS FOR CLINICAL PRACTICE
Based on an important aspect that emerged from this research, that is, the narcissistically
wounded client’s fear of being exposed as defective and the ability of art therapy to tap
into repressed unconscious material, it is recommended that careful consideration is
necessary in the light of these particular difficulties prior to attempting a more expressive
form of therapy with this kind of client. Although the client may develop deeper trust in the
therapist as well as may agree to undertake this kind of process, this may not be
sufficient reason for judging this kind of process as appropriate.
Further, the clay sculpture was made in two sessions with the intention of exploring the
material that emerged from it over the course of Kim’s individual therapy. However, there
was a four-week break after the two clay sessions which may have been counter-
productive in terms of Kim integrating the material within a safe environment. It is
therefore recommended that regular therapy sessions should occur immediately after an
expressive process such as clay therapy. Although claywork sessions by themselves
may lead to meaningful insights, this research illustrates that it would be more beneficial
if the claywork process is immediately followed by regular sessions, which would facilitate
working through the issues raised in the claywork process.
Certain factors limited this study and include my moving over to a different institution as a
result of changing internship placements. This may have impacted on the participant’s
decision to terminate therapy which prevented further appraisal regarding the long-term
effects of the claywork process. It is possible that my lack of experience as a therapist
may have further limited the outcomes of the claywork process as well as the current
research.
Finally, some recommendations for clinical practice are made. Firstly, it is recommended
that for clients who are narcissistically wounded, the therapist may provide a graded
experience of expressive art therapy to ensure they are not flooded with overwhelming
material. Secondly, for this kind of client, the claywork process is most beneficial when
immediately followed by regular sessions in which material evoked in the claywork can be
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processed in a safe and containing environment. It is also important to ensure that the
client feels safe enough with the therapist as a result of having sufficiently experienced
the therapist as being ‘on his/her side’, that is, as non-judgmental, tolerant and empathic.
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Addison, R. B. (1989). Grounded interpretive research: An investigation of physician
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investigation in psychology (pp. 39-58). New York: Sta