Provocative Art Therapy for the 21st Century

By Hephzibah Kaplan (2003)

The creative act cannot be underestimated as a healing force in its own right. When this creativity is structured within a therapeutic relationship the therapy can become more poignant and focussed. The terms of engagement however have been taken from many models. Whilst art therapy is slowly gaining confidence in becoming a discipline in and of itself, historically it has struggled with self-definition. Since it’s inception, art therapy has taken its developmental cues from contemporaneous psychotherapy disciplines. There is a continuum (some might consider a hierarchy) of art therapy approaches that have been informed by the four forces in psychology in the 20th Century: psychodynamic, behavioural/cognitive, humanistic/existential and transpersonal art therapy.

As practitioners we have always been open to learning from other disciplines and have incorporated this learning to enrich our profession and to benefit our clients. Art therapy in development has been a blank canvas inviting the group of art therapists to make their mark – however small or colourful. So I would like to share with the art therapy world some parallel personal development and to attempt to demonstrate how I have integrated it into my art therapy practice.

In 1997 I came across the work of Frank Farrelly, a psychiatric social worker from Madison, Wisconsin. In the 1960’s he worked with Carl Rogers at Mendota State Psychiatric Institute. In his 93rd interview with a schizophrenic patient, tired of incessant threats and delusions, Farrelly tried a provocative approach, using humour as a therapeutic tool. He documented and published this work and this was the beginning of the therapeutic discipline known as Provocative Therapy. (www.provocativetherapy.com)

Since discovering this way of communicating with clients, I have been attending training workshops with Farrelly, and with The British Institute of Provocative Therapy (www.provocativetherapy.co.uk). I have also been persuaded to be the video cameraman at these training workshops as all provocative therapy sessions are videoed for the clients to take home. Filming hours and hours of provocative therapy sessions has been a wonderful opportunity to learn more about this approach. Provocative Therapy training has shown me how to use my sense of humour in a therapeutically-directed and effective way, to help my art therapy clients.

I have spoken about this work enthusiastically, and sometimes evangelically, to my colleagues but the persuasive criteria has to be if the clients themselves have benefited from this approach. The answer is consistently yes.

In art therapy we provide our clients with a stimulus (the art materials), we establish the therapeutic space for the self-expression made tangible (the artwork or image) and we engage in a therapeutic conversation which includes debriefing, history-taking, sharing, exploration, discovery, understanding, as well as engendering feelings of trust, safety and relationship (the response). In the responsive discussion we try and gently nudge our clients to a place where they can be empowered to resolve general or specific problem areas in their lives.

Provocative therapy is essentially a therapeutic and humorous negotiation about how to live your life. Some colleagues tell me that they too feel comfortable enough to use their inherent sense of humour with clients. Provocative therapy is not only about using your sense of humour but it is also the careful and considered selection of a provocative strategy from the list of 39 main ways to provoke (there are even more). It is also the ability and absolute pre-requisite to provoke “with a twinkle in the eye and affection in the heart”.

On the goals of Provocative Therapy, Frank Farrelly writes:

“The client, then, is provoked by the therapist to:

1.Affirm his self-worth, both verbally and behaviorally.

2.Assert himself appropriately both in task performances and relationships.

3.Defend himself realistically.

4.Engage in psycho-social reality testing and learn the necessary discriminations to respond adaptively. Global perceptions lead to global, stereotyped responses; differentiated perceptions lead to adaptive responses.

5. Engage in risk-taking behaviors in personal relationships, especially communicating affection and vulnerability to significant others with immediacy as they are authentically experienced by the client. The most difficult words in relationships are often “I want you, I miss you, I care about you” — to commit oneself to others. “ (p.56 Provocative Therapy, Brandsma J, Farrelly F.)

Provocative therapists need to have a sense of humour as well as an ability to conjure up images. Without pre-conception every life story has a movie attached to it and if the practitioner can tune into the movie of that client’s life and see the inner joke, then they can describe, or satirise, or humour the behavioural patterns, as opposed to laughing at the client self. This can bring about healing. Art therapists usually have a strong visual modality and can be great at thinking of images, real or absurd, to bring into the therapeutic space.

One of the useful tools in provocative therapy is the use of reverse psychology. This short case history shows how provocative therapy is used responsively within the art therapy session.

Louisa, a 6 year old girl – depressed and confused

Louisa, a six year old girl, was referred to me for art therapy by her General Practitioner. She presented with emotional behavioural problems and was depressed. She did not allow her mother to leave the art therapy room, and spent much of her time, cuddled by her mother, as an infant-in-arms would be. She did not want to talk to me and the only adult she would talk to was her mother. I encouraged her to draw, to paint and to make up stories. She would use the art materials fairly confidently though was extremely reticent to talk about what was troubling her. Naturally I put no pressure on her to talk until she was ready to do so.

Her parents had recently split up but were pretending to be ‘happy families’ every weekend. Her parents’ relationship was confusing and Louisa was as unclear as they were, as to their confirmed separation, or not……

After 3 sessions, Louisa began to trust the art therapy process a bit more and would happily sit and paint, and draw out the pain……Meanwhile her mother began to dominate the silence with non-stop chatting about her life, and her family. It was hard for her to allow her daughter the space to express herself verbally. In spite of her mother’s interruptions, Louisa would not allow her to leave the room. I suggested to her mother that this was Louisa’s time and that she should be silent in the session. She genuinely tried not to talk but could not bear to be with the silence.

As a reaction against this, Louisa had begun intensely irritating her mother at home, and in the session, by talking in “Donald Duck Speak”. These were husky vocalisations (that I could not understand) and that her mother (an ex-actress) had taught her.

One session, as her mother began to tell me about her week, Louisa started ‘Duck talk’ and got louder and louder. It was certainly irritating me! It was time to make a therapeutic intervention. This was the first time that I considered an alternative approach to working with the transference processes. Should I invite Louisa to express some of this anger in her image-making, or to use a provocative therapy tool? I chose the latter.

Becoming all headmistressy, I insisted that Louisa was not allowed to talk any more English for the rest of the session and that she was only permitted to talk ‘duck language.’ Louisa continued to talk ‘duck’ until she was gasping for breath.

After 20 minutes non-stop ‘duck’ Louisa wanted to stop, and I said she wasn’t allowed to. She carried on for another 5 minutes, yapping away as she painted. She asked to stop again and this time, being about 8 minutes before the end of the session, I said she could return to English.

Louisa spent the last 8 minutes of the session talking to me in beautiful English, talking about her feelings of anger and her intense irritation with her mother. She was now relating to me in a communicative and self-healing way, while her mother listened on astonished.

Instead of asking Louisa to stop talking ‘duck’ I had asked her to “do more of the same”, a standard provocative therapy strategy. I had pushed her into a position where she had been invited to communicate incomprehensibly which had the reverse effect of allowing and empowering her real feelings to be verbalised. This was the pivotal moment in our therapy.

The following session, Louisa’s mother reported a remarkable improvement during the week, as well as a complete cessation of ‘duck talk’ at home.

But it can get far more provocative than this! When provocative therapy is used as a stimulus, as a parallel process to the stimulus of the art materials, the client experiences a deep awakening which can be transformative.

One of the central aims of Provocative Therapy is to pro-voke (pro-vocare/ to call forth) the client’s ‘inner voice’ – to encourage the emergence of that inner voice that knows best what to do. This is axiomatic to the work of the existential philosopher and psychotherapist Dr. Eric Ledermann who suggested that the purpose of therapy is to make ‘the unconscious conscience, conscious’.

In the following case history the client was interrupted, asked irrelevant questions and given absurd suggestions until the client was provoked to talk authentically.

The nature of a dialogue with a 16 year old ‘drop-out’ might come across as politically incorrect. The language is abrupt without frills. The questioning is unsubtle. This is client-centred work. With another client my language might be impeccable, or mumbling, or even contradictory. The provocative therapist aims to mirror the client to reflect back an absurd picture of aberrant behaviour. This is also provocative. However, it is necessary to repeat the maxim, this is always done ‘with a twinkle in the eye and affection in the heart.”

The responsibility of every practitioner is Primum non nocere: First do no harm. Therefore humour has to be further defined in order to eliminate the cruel or sadistic. The term neo-humour[1] has been developed to imply this usage. Provocative therapy uses neo-humour to facilitate healing.

Jake’s images, show how the direct, and sometimes crude, dialogue has enabled him to move from a state of fragmentation to one of integration.

Jake, age 16
Jake was referred to me for an art therapy assessment by his psychotherapist who had been seeing him for a couple of months. She informed me that Jake liked art and that perhaps the art therapy process would help him open up.
Jake arrived 10 minutes late. I phoned him on his mobile phone 5 minutes into the start time, to check he was coming, and he asked which number in Harley Street he should go to.

Jake came in looking dishelvelled and dirty, with holes in his clothes. He wore old jeans, black scuffed boots and a loose fitting long-sleeved shirt. His ginger hair was shoulder length, central parting, and greasy. He wore it like curtains over his face. The only aesthetic accessory were his very elegant and trendy glasses. A decent haircut would improve his overall look enormously. In short, he looked like a regular student-type!

After taking down some initial details (name, address, date of birth etc.) I asked him why he had come. He said “I need to express myself creatively”. I suggested he start painting using his non-dominant hand (his left hand) and without using any brushes, rollers or other tools. We carried on chatting throughout the hour-long session, while he simultaneously painted with his left hand.

I knew that my conversation with Jake would have to ‘cut to the chase’; that my provocative therapy training would help me find and share the comedic images that would enable Jake to be amused by his self-defeating predicament and behaviours, (rather than depressed and disempowered by them). I was not going to be mocking him, but I would be mocking and teasing his situation/lifestyle/attitudes. Provocative Therapy training has given me the confidence to humourously reflect the harsh truth of his situation, and deliver it with love, warmth, respect and congruence.

Thus I found myself working with a depressed 16 year-old ‘drop-out’ with a history of drug abuse (he started smoking marijuana at age 10). Jake was, in many ways, an ideal client for an art therapy process with a provocative therapy dialogue.

During our provocative therapy-type conversation I asked lots of questions, I sometimes interrupted him (but never when I heard his authentic voice), and I painted verbal pictures while Jake painted on the paper with his left hand. Jake never consciously illustrated what we were talking about, and yet each part of his image correlated with the content of our discussion. He was amazed and surprised when I pointed out the synchronicity of words and paint marks.

The last detail for consideration, before I describe elements of our conversation, was that Jake had started painting on one side of the large piece of A1 -sized paper, and as he filled up that area, he asked if could turn the paper round, which he did. Each time he ‘filled up’ the area, he turned the paper round, so that the painting’s evolutionary cycle mirrored the rotation of a clock. At the end of the session, I pointed this out to him and suggested that since he had turned the paper round clockwise, the prognosis was good! More importantly, the evolution of the paint marks followed a narrative progression from fragmentation to integration. This is the completed image. (To view the ‘clock rotation’ start at 12pm and end at 9pm)

1. On his Family

Parents divorced when he was 4. Has seen his father weekly since then. He lives mostly with his mother and step-father, and two younger half-brothers. His mother kicked him out of home 2 years ago. He understands her reasons for kicking him out but has not quite forgiven her. He has since made up with her and lives mostly at her house. He occasionally lives at his father’s house, and occasionally with friends, or in a squat.

Therapist: “So, do you still blame your parents for their divorce?”

Client: “A little”

Therapist: “Well that’s OK. You’re a teenager. You’re allowed to blame your parents, that’s what teenagers do. But only for another 4 years mind. You’ve got 4 years left to blame them and then you’ve got to let it go. You don’t want to be one of those grown-up adults that still blame their parents. You know those types…”

Therapist: “Do you go to school?”

Client: “No”

Therapist: “Oh, you’re one of those ‘drop outs’……..So what do you do all day?”

Client: “I sleep”

Therapist: “Where do you sleep? Do you have your own bedroom?”

Client: “I sleep on floorboards in the attic”

Therapist: “Is it one of those filthy attics with cobwebs and spiders and rats and mice and rubbish piled high?”

Client: “No, its not like that dirty…… I don’t have a light.”

Therapist: “Have you read Harry Potter?”

Client: “No…”

Therapist: “And how his wicked aunt and uncle kept him in a cupboard under the stairs with no light……before he escaped to school?”

Therapist: “Why did you drop-out of school? Was it the people, the course, the teachers, home life, sex life….”

Client: “The people”

He described how about 2 years ago he got ‘paranoid’ in social settings.

Therapist: “You thought they were out to get you?”

Jake smiled, and said he has been on and off anti-depressants that don’t really work.

Therapist: “Well psychiatric drugs aren’t so good”

Image detail 1: image of Jake,

 

within the cavern, feeling loony,

with purple wooden trees.

2. On Drugs

Has done (taken) everything; has taken heroin but not injected it. Mostly smokes weed.

Therapist: “So how do you get drugs? Do you have any money?”

Client: “Some”

(His mother had sent a cheque for our session)

Therapist: “Where do you get it from?”

Client: “My mother”

Therapist: “Where else?”

Client: “I don’t know”

Therapist: ” So, how do you get money? How do you support your habit? Do you steal?”

Client: “No, I don’t have a habit, I don’t do heroin anymore. I sometimes sell dope”

Therapist: “Come on! Sometimes?! How often? Once a month is sometimes. Once a week? Once a day? More?”

Client: “About once a week”

Therapist: “Have you been caught yet? Have you got a record?”

Client: “No… I’ve been cautioned twice”

Therapist: “So, you’re a criminal – who’s been lucky so far”

Image detail 2: Jake on drugs

3. On Friends

Therapist: “Do you have any friends, or mates?”

Client: “Yeh”

Therapist: “What do you do, where do you meet?”

Client: “Well there used to be 10 of us and we’d meet and then we grew to a group of 200 or so”

Therapist: “Where do 200 friends meet up? Parties? Raves?”

Client: “We’d meet at High Heath and ….” (other parks mentioned)

Therapist: “What do you do there?”

Client: “Drugs…..but its all shit”

Therapist: “So you can have 200 mates stoned, but can’t do real life relating?”

Client: “Yeh”

Therapist: “What about relationships, sex?”

Client: “Yeh, I got a girlfriend”

Therapist: “How did you meet her?”

Client: “She found me at one of the gatherings and I was thinking of suicide and she saved me”

Therapist: “What’s she doing now?”

Client: “She’s doing her GCSE exams, right now as we speak”

Image detail 3: talking about girlfriend and flirting with death. Painted the black sunset or sunrise (he couldn’t decide which); then painted the skull; followed by target and spiral (on talking about his mother and himself).
4. On Art

The only subject Jake said he enjoyed and was good at, at school, was art. ” I’m good at art.” He spoke very congruently about his abilities in this area and tried to describe the sort of technically detailed images that he used to draw. I let him speak without interruption when he described his art. I felt this to be the voice of inner purpose that I was seeking to provoke. He was almost ‘in trance’ describing these images, as he was reflecting congruent memories.

I went with this belief that this was one area that interested Jake, and the means to some recovery.

Therapist: “Why don’t you go to art school and sign up for a foundation year?”

Client: “Well that’s what I was kind of working towards in school”

Therapist: “You’d fit in very well. You can look like a slob, you don’t need to relate too much to other people. You’d enjoy the creative process.”

Client: “I’m scared to be creative.”

Therapist: “Do you ever try? Do you have a notebook for drawing in?”

Client: “Yeh, I’ve tried but I can’t do it”

Therapist: “What happens when you start”

Client: “I get blocked”

Therapist: “What kind of block?”

Client: “It’s a wall. I just come across a wall”

Therapist: “Well that’s quite simple, just draw a ladder…..”

Client: “Yeh, I like this idea”

On hearing how he warmed to this idea, I persisted in utilising one of the Farrelly Factors of providing insane solutions.

Therapist: “That’s the solution to the wall problem, keep drawing ladders. Everytime you have a block, or a wall, draw a ladder. Then turn over the page, and draw another ladder, and another one until you can get over that wall. And while you’re doing this, you can get really good at drawing ladders, flat ones, square ones, round ones…”

Client: “Yeh, I really like that idea. I think it will work”

Client: “Could you write it down for me please so I don’t forget…”

I tore out a large piece of A4 and handed him a pen, he wrote in the middle, ‘draw ladders’. Jake had chosen for himself some homework and had asked me, politely, to help him.

I pursued the idea that he could become an artist.

Therapist: “You can be an artist from the age of 16-90. It doesn’t matter when you start.”

Client: “But I think I’m too affected by the drugs to do anything. I can’t think anymore”

Therapist: ” Look, I don’t know, maybe you are fucked in the brain, maybe not, but you can still be an artist. Even if you have a psychiatric breakdown and you find yourself in the ‘loony bin’, you can be an artist in there. They always have an art group, or art therapy. And, at the other end of the spectrum, you could be an artist selling your artwork in the Cork Street Galleries. There’s a position for you somewhere as an artist in society. You can choose to position yourself wherever you like.”

Image detail 4: integrated head of an artist. I mentioned this reminded me of a portrait of Van Gogh, with one ear. Jake could not quite remember the image I referred to, but accepted this as a compliment.
5. On Recovery

Therapist: “It’s up to you. You have to stop blaming everyone and take responsibility yourself for getting better.”

Client: “I’m beginning to think that”

Therapist: “Well no-one else is going to do the work. The psychiatric drugs aren’t doing it for you. The recreational drugs aren’t doing it for you……I believe creativity is the only way forward. Creative work is the most healing thing to do. You can be an artist.”

Therapist: “There’s a new movie you should see. Do you go to the moves? It’s with Ed Harris and it’s about Jackson Pollock, who was also called Jack the Dripper. I don’t know what it’s like but it’s about an artist who I think you’d like. Why don’t you take your girlfriend?”

Client: “Maybe” (lightening up at the idea)

Therapist: “Why don’t you do something normal, and take your girlfriend to see this movie, as a reward for doing her exams?”

Client: “Maybe”

Therapist: “You could scrub up and go out on a date”

Client: “Yeh, maybe”

6. Final reflection and discussion on the image

Therapist: “Look how you have moved around the page……you’ve gone from being all over the place, being fragmented, through drugs, your girlfriend with the black sunrise or sunset (we never did decide what it was), to suicide and flirting with death (the skull), to your relationship with your mother (the circle and target, with the adjacent spiral), to finally an integrated beautiful head.”

Client: “Yeh….its amazing”

Therapist: “That looks a very together and angry red face……”

Client: “No, I don’t think red is an angry colour”

Therapist: “What is?”

Client: “More black”

Therapist: “How did you find the session?”

Client: “Interesting. I was able to talk more about things when doing the painting.”

Therapist: “Do you believe things are going to improve for you?”

Client: “Sometimes. Sometimes definitely not”

Before he goes out, Jake asks me a question. I was thinking about how during the course of one hour he had become more coherent and clearer. One of the aims of Provocative Therapy is to provoke psycho-social reality testing.

Client: “What month is it?”

Therapist: “May…… ” (Was he testing me, or was he needing to touch base with ‘reality’ ?)

Therapist: “What day of the week is it?”

Client: “um….Thursday?” ( whilst he seemed to genuinely not know the month, he seemed relieved to know that he had got the day of the week right!)

Jake came back to see me 6 weeks later. I was astonished by his new image. Clean and ironed t-shirt and decent jeans. I suggested he make an image about his name. He asked if he could do graffiti. As his name, as well as his ‘tag’ is the main feature of the image I cannot show it to protect his identity. It turns out the Jake is a keen graffiti artist in a big city and we had a long chat about criminality. He asked me about confidentiality (and I told him our professional guidelines) and then he told me about a plan to rob a sub-post office. As he graffittied and decorated on the art paper I spoke about how they, in the nick, would love his ass, and if he thought he was paranoid now, it would soon enough be real fear etc. etc. In fact, I suggested, he could by-pass the nick and go straight into adult psychiatry as no doubt his paranoia would be immense and justified by the time the job was done…….We talked, we laughed, Jake painted.

Jake also asked me about a portfolio for art school and which pieces would be deemed acceptable to take along.

I never saw Jake again. His weekly psychotherapist reported to me that Jake was doing exceptionally well suddenly. He had been accepted into art school and was looking forward to developing his creativity.

I hope this brief essay has introduced you to some of the ways that Provocative Therapy can be incorporated and modelled for art therapy. I believe that learning provocative therapy has enhanced my art therapy work without changing my identity as an art therapist.

Hephzibah Kaplan

July 2003


References

Brandsma, J. & Farrelly, F. Provocative Therapy Capitola: Meta publications 1974
Case, C. & Dalley, T. The handbook of art therapy Routledge 1992
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Danvers, J. The knowing body: art as an integrative system NSEAD 1995
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Kaplan, H. Art Therapy and Homeopathy www.drkaplan.co.uk 2001
Kaplan, H. Art Therapy and Whole Person Medicine www.wholepersonmedicine.co.uk 2001
Ledermann,E.K. Philosophy and Medicine Tavistock 1970
Malchiodi, C. ed. Medical Art Therapy with Adults Jessica Kingsley 1999
Malchiodi, C. ed. Medical Art Therapy with Children Jessica Kingsley 1999
Neighbour, R. The Inner Consultation, Petroc Press 1997
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Rhyne, J. (1990) Gestalt Psychology/Gestalt Therapy: Forms/Contexts The American Journal of Art Therapy Vol.29
Robbins, A. A multi-modal approach to art therapy Jessica Kingsley 1994
Rosenberg, M. Non-violent communication a language of compassion PuddleDancer Press 2001
Rubin, J. ed. Approaches to Art Therapy Bruner/Mazel 1987
Skaife, S. Sickness, health and the therapeutic relationship: thoughts arising from the literature on art therapy and physical illness Inscape Summer 1993
Silverstone, L. Art Therapy, the person-centered way Jessica Kingsley 1994
Yalom, I. Love’s Executioner and Other Tales of Psychotherapy. Penguin July 2003
Waller, D. Becoming a profession Routledge 1991.

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[1] The term neo-humour was first described by the Provocative Therapist and author, Dr. Brian Kaplan 2002.