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THE HOSPITAL AS AN ARTISTIC SPACE:
DYNAMICS OF THE THERAPEUTIC COMPLEX

Yoshihide Takaesu

IZUMI HOSPITAL
1150 Enobi,Gushikawa City,Okinawa,904-2205 Japan Phone:098-972-7788 Fax:098-972-7319


The Hospital as a Microcosm

     The hospital is a kind of microcosm, and the psychiatric hospital especially constitutes a microcosm unto itself. In this particular universe, there are the usual daily life problems of nourishing, clothing, and housing the patients, in addition to the various unique problems peculiar to the nature of a therapeutic community. We (the doctors and members of the general staff) are always asking therapists for the most appropriate and effective treatments for patients in our mental hospital.
     Within the context of therapy, we focus especially on the purpose of “the art space” and the particular hospital's facilities. Since the time of Dr. Maxwell Jones, the acknowledged creator of the concept of the therapeutic community, many theses have been dedicated to this idea. Forming part of this “therapeutic complex” is a group that uses art therapy to heal patients.      With regard to past treatment methods, there has been a tendency to highlight particular individual techniques and skills as the special art of the professional. At the same time, the therapeutic community and its various special characteristics, particularly that of “the therapeutic complex dynamic”, have received much less attention.
     As far as the modern hospital is concerned the era of psychotherapy and individual technique as the principal means of treatment is already coming to an end. Many therapeutic professionals, in cooperation with each other, are seeking appropriate methods for piecing together the most effective “therapeutic complex”.
     There exists in modern society at large, especially in the mass media and general medical population - a deeply rooted prejudice against the psychiatric hospital. Certainly, the general confusion of Japanese society after the end of World War II was reflected in the area of the kind of psychiatric treatment that existed 20 years ago.
     Also, psychotherapy and its associated activities, as well as the many interdisciplinary studies related to psychotherapy, are constantly achieving new gains in knowledge that are radically transforming the field in a positive manner. Of course regional differences play a significant role in these many pioneering achievements. My practice of psychiatric therapy has been developed in Okinawa, and I personally believe that the openness there toward trying new psychotherapeutic treatments is much greater than in other areas of Japan, although Okinawa is thought to be the most undeveloped region in Japan in the field of psychotherapy.
     For the mental hospitals in Okinawa, a new style of hospital operation that acknowledges the traditional Okinawan spiritual leader “shaman”, “yuta” (Takaesu, 1980) may prove to create, in a certain sense, a productive situation for everyone involved. In the future, the subject of dynamism within a therapeutic staff (i.e. the functions of the staff working together as a team) may become a major topic in our field.
     For many years, numerous studies that analyze the patients' families and the patients' personal interactions among themselves have been accumulating. However, studies dedicated to the therapeutic staff and their viewpoint have been quite few in number. Until today, there has been a great tendency to overemphasize the importance of the individual psychotherapist.
     For example, for one specific illness, there may be several quite different diagnoses of the ailment, depending on the specialty of the individual psychotherapist treating the patient. Such cases are not few in number.
     Given the current situation, we are asked to reconsider the particular elements of the patients' therapeutic environment and also to entertain second thoughts about the dynamics of the therapeutic staff working together to affect their patients' progress.
     The members of the therapeutic staff, working as integral parts of the therapeutic complex, may possibly become the catalysts in igniting a future revolution in the functioning methodology of the psychiatric hospital.

The Structure and Function of the Hospital

     My friends and professional colleagues recommended to me that I establish a facility that would incorporate my own philosophy and policy in the functioning of a hospital. I decided to go ahead with such a project. If I were to actually proceed with the building of my own hospital, I would establish a unique psychiatric hospital whose core activity would be artistic psychotherapy.
     I also gave great thought to the many existing kinds of psychotherapeutic techniques. In particular, I thought about establishing a structure and functional methodology in my hospital wherein I could incorporate each kind of art therapy into my practice.
     During the five years following the establishment of my hospital, we were able to bring the general therapeutic techniques of painting, music, and literary arts into the hospital environment. From then on, my focus was to maximize the therapeutic possibilities of “the art space therapeutic complex” in each section.
     For a mentally ill patient, each artistic technique may have a particular significant meaning. With respect to any particular mental illness, we always take note of the peculiar language distortions that may take place in the patient's daily conversations. We also carefully heed any changes in the patient's interactions with other members of the therapeutic complex.
     The patient's surroundings become even more significant when we give consideration to the optimum environment that will facilitate the verbal and non-verbal interactions of the mentally ill patients with the other members of the therapeutic complex.
     First of all, we had to consider the design of the building. What kind of structure were we to construct? We wanted equilibrium of straight and curved lines. What should be the size of the windows and their locations? What should be the direction of the light, and how much shade should there be? We also gave long thought to the subjects of ventilation, air circulation, and the placement of water use areas.
     In order for the hospital to fulfill its function as a healing establishment, careful attention was dedicated to selecting the most appropriate kinds of furniture, placement of chairs and desks, telephones, the vending machines, the color schemes in all the hospital facilities, equipment, etc. Thus, we focused on the problem of creating an environment where we could effectively provide various therapeutic treatments for our patients. This approach may be said to be and extension of the subtle know-how associated with psychotherapy.
     What type of paintings should be hung on the wall? What kind of background music should be played? These elements are very significant in helping outsiders to understand the basic concept of, and approach to treating our patients.
     I always gave careful consideration to the many elements constituting the hospital's environment. These elements included the lobby chairs and their placement, the kind of spacing between them, the coordination of design in the hallways with that of other hospital spaces, and the entrance areas and their proper correlation to the other hospital areas. The gardens involved ecological and traditional systems. Consideration was also given to the plants in the hospital's interior design and those in the exterior design, the parking lot areas, the walking trails, the art therapy area's entranceways, and the hospital's maintenance lot.
     Maintenance is especially important, especially in art therapy, because proper maintenance promotes the effective management of art therapy, its associated exhibitions, and the cleaning up afterwards. However I will not discuss this particular matter further because, in today's Japan, hospitals that have an ideal art therapy facility are almost nonexistent. In modern-day Japan, attention is most frequently focused on obtaining the newest and most expensive medical equipment, while the implementation of art therapy is normally put off to the side or given a lower priority. Despite the fact that the introduction of the technique of art therapy is comparatively easy and effective, it cannot yet be said that modern Japanese psychiatric treatment has reached a full understanding of art therapy's techniques and effectiveness.
     Let us consider art therapy from the perspective of both the Japanese medical insurance system and the hospital's functioning. Of course, I am not saying that in a treatment facility in which there are not any formal art therapy facilities, an art therapy treatment cannot be put into practice. With respect to any phase of a particular mental patient's illness, it is possible to achieve a suitable psychotherapy no matter what sort of facilities might be available to the psychotherapist involved. The problem would normally be the continuation and progression of a suitable and effective art therapy treatment protocol for individual patients.
     In an environment where there are not enough suitable treatment facilities a much greater degree of individual skill and enthusiasm is required from the therapist providing the treatment. Also, the burden on the psychotherapist increases, and critically important treatment teams become much more difficult to piece together.
     Furthermore, art therapy for the psychotherapeutic complex (or for the patient group treatment community) and proper environmental maintenance become much more difficult in a hospital lacking the normal appropriate treatment facilities.

Various Techniques of Art Therapy

     There is always the practical problem of being ready and able to provide the most appropriate treatment for a particular individual's illness; painting, music, literary arts, psychodramas, box gardens, ceramics, dance, etc. It is reasonable to think that the skill and sensitivity of the psychotherapist are limited and that the possible modes of expression of the mentally ill patient are limitless.
     Just how competent is the individual therapist at reading the endless variety of verbal and nonverbal messages communicated by the patient to the therapist? What sort of sensitivity does the therapist have to the endless stream of expression that comes from the patients in his care? The therapist must always continue to persevere in his efforts to deepen and attune his sensitivity to the unlimited range of expression of his patients (Takaesu, 1981).
     There have been times when the therapist, due to limited verbal expression, misunderstood the patient who was experiencing a delusion. There are also delusions that are not at all verbally communicated by the patient to the therapist. The delusions of the patient are expressed through his paintings via the sense of sight. In paintings, these same delusions are not changed or deformed into a dimension of words (Takaesu, 1979).
     Without this verbalization, the actual physical image of the delusion is expressed concretely in the painting - and with no verbal elaboration. This painted message is received by the therapist as a direct communication from his patient. When a therapist analyzes a patient's painting, it is difficult not to use words in the analysis, but it is indeed necessary to try to keep the analysis on a nonverbal basis.
     There are many possible interpretations of the sounds and gestures of the individual patient, but I want to deal with these communications just as they are. Keep in mind the need to be psychologically prepared to listen to the actual patient's breathing as it really is. Try to be “like-minded” when we think about the fundamental principle of exhibiting consideration for the other person.
     Putting together a staff and holding conferences and meetings are also important. In what manner might we liberate the one-on-one private psychotherapy sessions in the special room for the benefit of the psychotherapy team? The ideal therapy would be one in which two or more therapists might participate in the therapy session. The therapy would then be followed by a conference in which the therapists would subsequently exchange roles and their responsibilities in the subsequent therapy session. Since the early days of psychotherapy the general principal has been to have several psychotherapists participate in the therapy, whenever possible.
     As the number of psychotherapists increases the sensitivities and techniques brought to bear on the clinical problem multiply. The sharing of the various psychotherapeutic responsibilities also provides necessary training to the therapy team members in order to competently fulfill each responsibility of the task.
     A person seeks out the things that he individually lacks by looking within the hearts of others in his milieu. Also, the individual's personality may be rediscovered again through interaction with others in the therapy session. These phenomena (i.e. that of regaining self-discovery and the searching out in others those qualities that one lacks) are experienced through the interrelationships of the psychotherapist's group.
     The paintings are visual expressions. What is expressed in the small frame? One may approach the painting and attempt to understand its message through verbal expressions and explanations or through nonverbal expressions. There is also a third way of divining the revealed message in the painting and that third method is known as “clinical iconography” (Takaesu, Omori, Irie, and Miyamoto, 1981). In any case, the process of “reading paintings” is quite important.
     Music is an auditory expression and requires sensitivity to the tones of the various musical instruments. The most important thing is to train one's ear to be able to catch the changes in the tone of voice and the tone colorations of the individual's utterances as he speaks.
     In addition, the starting point for music therapy is developing in oneself sensitivity to surrounding circumstantial noise, human sounds, the sounds of swaying trees, the sounds of the wind, etc. And in each case the main theme is the improvisation made by the individual in his own music.
     Literary arts therapy was originally viewed as a verbal construction from the world of logos. At the same time, improvisational ability is still regarded as part of the world of pathos.
     When one considers art therapy as an art expression rather than simply as an art project, one is able to experience the unique elements that only art therapy can provide-such as an expressive ambiance that precedes the verbal and nonverbal metaphor. Therapeutic ambiance in which there are meanings and interpretations of a painting, a piece of music, or a piece of literature need not be translated into words (sometimes because of quite chaotic messages).
     Psychodrama already covers each aspect of art therapy. Looking at each particular art therapy project right from the start, one may consider every art work as an individual drama unto itself. Furthermore, psychotherapy can be thought of as a drama without a plot. Even more so in the process of psychotherapy, all the elements of the psychodrama are repeatedly put into question through improvisations. The elements of the psychodrama under constant improvisation include the role of the director, the main character, the various roles to be played, the supporting actors, and the people who will be the audience. How much space will there be on the stage, when will the next performance take place, and what are the basic assumptions of the psychodrama's scripts?
     Clay working therapy will help to develop sensitivity to one's surrounding space, to the image of the ceramic object, to the circuit between one's sense of touch and the movement necessary to produce a personal expressive skill.
     Dance therapy gives us a direct path to the thinking of the dancing world. More than anything else, there is the problem of proper breathing. Also required is cultivation in the dancer of sensitivity to proper posture, movements, and gestures.
     In the actual practice of art therapy, one keeps in mind the necessity of improvisation. Despite the therapy's script making certain assumptions, the unfolding of the actual story may diverge significantly from the original script. There will normally be some differences between the set psychotherapy script and the actual playing out of a psychotherapy session. Through these divergences from the basic script, the psychotherapist will gain new knowledge that enables him to become a more effective psychotherapist. There is no such thing as two identical psychotherapy methods; art therapy (psychiatric therapy) in the real and messy world we deal with can only be applied to one case at a time, and each case will be different from all others in many specific elements.
     It is important for the therapist to continually hold in the front of his mind the concepts of being “concerned” and being “like minded” for the welfare of the patient. The challenging aspect of a therapist's task is to maintain a high degree of spiritual sensitivity for those brief moments when there is a “catching or holding of breath”. The crux of the spiritual sensitivity problem for the therapist is to be able to perceive this kind of breathing during a single brief meeting with the patient.
     If the therapist is able to accomplish this, sensitivity heightens in reading another's thoughts and mind, and ultimately learning to open up one's heart to members of a group. In other words, this general sensitivity is a feeling for the “Ma-ai” (the Japanese concept of the interpersonal relationship) or interrelationships of the individuals within the therapeutic complex. Artistic expression is a communication technique that concerns the “Ma-ai” (Takaesu, 1975).

The Flow of Art Therapy

     1. Art therapy and the first patient meeting. No matter whoever the patient or what the particular problem might be, the imagination of the therapist starts generating ideas prior to the meeting with the patient. The patient as well as the therapist experience feelings such as the association of ideas prior to the first therapist/patient meeting, possible surprise or relief that may be felt upon entering the meeting room, and an initial distancing felt between therapist and patient that may change or resolve as the conversation progresses.
     2. Preparation and warm-up for the first meeting. As the number of communications between the patient and the therapist increases, a common meeting ground for their future relationship is formed. A sense of togetherness (co-ownership of the feelings within the relationship) fosters a feeling that elevates the conversations to a higher degree of free expression. This development allows the minds of the two parties to come closer together.
     3. The selection of the technique (The opening up of the mind). Choosing the proper therapy technique depends upon the particular characteristics of the patient as well as the particular treatment methods at which the patient's psychotherapist may be adept and those with which he has had less experience. In any case, the therapist must be open to all of the patient's expressed communications. The therapist works constantly to keep tuned in to the patient's ongoing messages and their real meanings.
     4. The therapeutic alliance for the revitalization of the healing process. Many interactions occur between the patient and the therapist in the surrounding environment of a general audience made up of the hospital staff, auxiliary hospital workers, and other members of the hospital environment (including the other patients). The actual site of the psychotherapy has a direct bearing on the psychotherapeutic relationships that develop during the therapy. In addition, this location also controls the degree to which the formation of the alliance among the psychotherapists may be achieved. Therefore, the therapeutic alliance changes as the art space moves about and the degree to which the complex group properly functions.
     5. Expression and background as turning points. Those expressions that appear at the climax of psychotherapy are directly related to the mind change of the patient, a sort of release in the healing process; being able to read these subtle changes in the expressions of the patient is then the work of the therapist. This therapeutic work should point the therapist in the direction of “playing”. Because of the existence of unbearable suffering and pathos on the part of the patient, the smiling face of the therapist becomes a symbolic life saver for the patient. Playing with the patient's paintings, or music, or whatever type of artistic expression employed by the patient becomes his psychotherapy.
     6. Using art therapy method as drama for a starting point. The first meeting and the actual beginning of psychotherapy are two distinct events. There is a receptive capacity or acceptance on the part of the therapist to the patient's existence in the midst of chaos. The therapist's being able to feel sympathy for the patient will soon give rise to various confrontations between them. The patient draws up in his own mind the image of his own ideal therapist and produces the climax of his own psychodrama play. Then comes the departure of the patient from the hospital and a parting from his therapist. The therapist is left behind in the hospital with the lingering sound of the departed patient, the aftertaste of whatever progress has been made with the therapy. Someone has left; the shade of the tree feels color (Japanese poem).
     7. The audience as an aspect of the psychotherapy, or the journey with others. The flow of each of these art therapies actually occurs within the hospital's therapy space, and in this sense, the hospital is an artistic space. The occurrence of each stage of the drama is individually taken in by the staff and other patients. Thus, it may be said that in the realm of psychotherapy, an audience is always present. Even if the psychotherapeutic experience itself is shielded from others because of the privacy of a special room, the patient may still think about others looking in. A human being cannot exist without the mutual gaze of love/concern/caring of other human beings. To be seen by others and to live with others allows one to become one's true self. There is a special significance to having an audience for the art therapy activity in a psychotherapeutic program.
     8. The “Ma-ai” concept for the therapeutic complex . Regarding modern hospital operational methods, there are numerous hospitals that use the attending doctor system. On the other hand, there are hospitals that employ combinations of the on-call physician system with regular staff doctors, outpatient staff physicians, and a doctor on permanent call. Patients are surrounded by overlapping layers of hospital staff such as the clinical psychologists (CP), psychiatric social workers (PSW), nursing staff (NS), occupational therapists (OT), physical therapists (PT), recreational supervisors, volunteer general staff, kitchen staff, dietitians, pharmacists, and medical technicians. The question then arises concerning the various perspectives of all these people.
     Are the psychotherapists especially aware of the existence of the other non-therapist staff working in the hospital environment? Are they aware of the existence of the patients, or are they indifferent to them? The old vision of the one-on-one psychotherapy (i.e. a single psychotherapist working individually with his subject patient) is now understood to be rather ineffective.
     The “Ma-ai” concept applied to the therapeutic complex is based on the interpersonal relationships with the three basic principles of space, time and spirit. The “Ma-ai” is a sharing space where patients face each other in an interpersonal relationship and have a dynamic distance between selfness an other. The “Ma-ai” is the background of the therapeutic community's nature. The “Ma-ai” between the rediscovery of the function of the hospital as a member of the therapeutic community and the therapeutic complex (in other words, the therapists group dynamic) gives one an understanding of the great changes taking place in today's hospitals (Takaesu, 1977).
     Art therapy is a journey that consists of trying to find oneself through gaining an insight into one's inner feelings. The ability to achieve this insight can come through the realization that the individual is living together with others and not completely alone unto himself.

References

     Takaesu, Y. (1975). A study of the human figure drawing of chronic schizophrenics in relation to their “Ma-ai” disturbance. Japanese Bulletin of Art Therapy , 6, 15-21. (In Japanese; English summary.)
     Takaesu, Y. (1977). Group art therapy of chronic schizophrenics from the “Ma-ai” aspect. Japanese Bulletin of Art Therapy, 8,7-15. (In Japanese; English summary.)
     Takaesu, Y. (1979). The application of art therapy to schizophrenic patients, especially from the viewpoint of their “Ma-ai” disturbance. Japanese Bulletin of Art Therapy, 10, 55-60. (In English.)
     Takaesu, Y. (1980). “Yuta” (shaman) belief in Okinawa. Social Psychiatry, 3, 33-39. (In Japanese.)
     Takaesu, Y. (1981). Schizophrenic experience in pictorial expressions through a young hebephrenic patient. In V. Andreoli (Ed.), The pathology of nonverbal communications (pp.317-322). Milan: Massion Italia Editori. (In English.)
     Takaesu, Y., Omori, K., Irie, S., and Miyamoto, T. (1981). Psychopathology and art therapy: Clinical iconography. In K. Omori, Y. Takaesu, and Y. Tokuda (Eds.), Lectures of Art Therapy, no. 3 (pp. 147-171). Tokyo: Seiwa Shoten.(In Japanese)