Art and Healing: Criteria for Healing Art in a Therapeutic Context.
In 2001, I have already dealt with the relationship between free and therapeutic art. One of my conclusions at that time was that art keeps us in reality, that it teaches us that we have both, body and soul. In the following text I develop this idea further and determine guiding criteria for an art that can be healing in the therapeutic context, an art that complements conventional medicine with what it unfortunately often lacks: A holistic view of man.
"I was confused about health as a child. My parents had to ask a stranger if I was healthy.
I was confused about health because the stranger said I was healthy and then gave me an injection.
No one ever asked me if I felt healthy."(1)
In the above quote two worlds collide: Who actually determines that health is achieved? The orthodox physician? The person affected?
Depending on one’s point of view, there are different perspectives on health and healing. Is health an objectively measurable or rather a subjectively perceived event? How can healing be achieved? Exclusively through the empirically founded, heroic path of Western orthodox medicine? Or possibly also in the form of inter-subjective communication, for example within the framework of a supervised artistic process?
Art has found its way into the health care sector a long time ago, but its current position can best be compared to that of a maid carrying her mistress's train.
Of course, it is appealing to weigh up strengths and weaknesses of the various approaches towards health and ultimately choose a winner. But health and healing are very special and serious fields, well-being and woe of real people are at stake. Therefore, any intellectual dispute is to be ruled out right from the beginning. And this is why the present work is not intended to discuss which approach towards health is the right one. Rather, it is intended to discuss how deficits and weaknesses in different approaches can be balanced out and their strengths combined - so that art and medicine join hands for the good of mankind.
UUndoubtedly, we owe much to the achievements of orthodox medicine. And every day our medical knowledge increases, more diseases can be diagnosed, treated and cured. At the same time, the number of sick people remains alarmingly high. Why is that? What is missing in our orthodox medical concept of disease? What is healing anyway?
Let us start this investigation the way philosophers usually do: by clarifying terms. So what exactly is health and disease, what is healing?
Health and disease are complex concepts. To see one merely as the absence of the other is not enough. This fact also becomes evident in the considerable variety of terms applied by the various scientific disciplines, sector-specific definitions that are at times narrow, at times broad. Health can, for example, encompass the physical and mental well-being of a person in its entirety - or merely describe the function and performance of a single physical and mental system. Also the subjective experience of health varies greatly, and objectively measurable and subjectively experienced states can differ greatly.(2) (3)
Our modern Western medicine is highly influenced by a mechanical-physical approach towards life: "A completely atomistic view, an examination of smallest individual parts"(4) which has its roots in Virchow's discoveries(5) and is currently reflected in the strong emphasis on molecular-biological and genetic research(6).
Thus the Western trained physician's point of view is clear: It is limited to the mechanical-physical perspective and consequently somatic, i.e. related to the body, and causal-analytic.(7) The orthodox physician examines the empirically verifiable causes of illness, which can be traced down by materially verifiable findings in organs, blood, etc.
"The diagnosis' aim is to determine pathological changes and their causes, and to eliminate or compensate such causes as far as possible. If this is achieved before the patient's body has been permanently and irreversibly damaged, it is referred to as healing."(8)
In conventional medicine, the term healing refers to physical recovery, more specifically: recovery to the condition before the disease, which was impaired by pathogens or injury. In a second meaning, healing refers to overcoming a disability, restoring functionality, measured against a norm or ideal condition.(9)
Therefore, from a strictly orthodox medical point of view healing presupposes knowledge of a scientific body of rules, including defined norms, and requires application of sanctioned methods(10). However, this approach is problematic in several respects. For example, it disregards other, non-physical causes in the process of disease and accepts the questionable assumption of a homogeneous substrate, i.e. the complete similarity of organs etc., which in fact is not given.(11) The difficulties that exist in the evaluation of drug and therapy effects(12) (13), support this criticism, as do the millions of patients who do not find healing by conventional means or who have undergone therapy but are still suffering. Weizsäcker's definition of the presence of a disease - namely that a physician acknowledges this disease(14) – is symptomatic of how the effects of a deficient medical theory are currently handled: by "presenting large groups of patients as simulators"(15).(16) Furthermore, the conventional medical approach is based on an incomplete conception of the human being because it reduces him to physical functions and negates his individuality.(17) However, the fact that human beings have a life of their own that eventually denies access to orthodox medicine becomes disturbingly apparent in inadequate compliance(18) and patients sabotaging(19) orthodox medical treatment.
Perhaps at this point a certain fuzziness of German language becomes apparent: the German verb heilen can be used transitively and intransitively. However, its translation into English results in two expressions: to cure, which is to be used transitively and roughly describes the process in which orthodox medicine eliminates objectified diseases; and to heal, which can be used both transitively and intransitively. When the latter, to heal, is being used intransitively it encompasses the entire human being and his desire to become whole again.(20)
The achievements of medical science are undeniable. At the same time, however, there are anomalies(21), that can neither be explained nor satisfactorily remedied within the framework of conventional medical theory. Strictly speaking, the entire structure of the established orthodox medical theories based on a concept of dead matter(22) is currently challenged, for the radical changes that resulted from quantum theory have so far received little or no attention in the physical concepts that serve as the theoretical basis of orthodox medicine.(23)
Today, the World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"(24) and thus explicitly includes the social dimension of health. Antonovsky's concept of Salutogenesis, which sees health and disease as a continuum and, in addition to physical and psychological aspects takes social and ecological dimensions into account, points in a similar direction.(25)
Antonovsky's concept is interesting for yet another reason: It represents a contrast to conventional medicine and takes a completely different perspective. While the scientifically trained physician searches for pathogenic factors, Antonovsky's search focus are factors that promote health. While the physician searches for the stressor and tries to isolate and eliminate it, the salutogenetic approach wants to strengthen the factors that promote health – eventually including even the stressor, to which Antonovsky attributes not only destructive, but (also) promoting, activating influences.
"The authors state correctly: 'The ability to exercise control over the stressor thus completely prevented immunosuppression'[(26)]. In my opinion, this highly exciting result is not taken into account in the discussion. Obviously, a shock as a stressor can have a healthy impact on the organism, provided one can flee it. If, however, one only considers the pathogenic consequences, the perspective opened up by this finding is missed."(27)
Antonovsky considers the sense of coherence that as the "main determinant for both, the position one gets on the health-disease continuum, as well as for one's orientation towards the healthy pole"(28). For this disposition which he defines as "a global orientation which expresses the extent to which one has a penetrating, enduring and yet dynamic sense of trust"(29) Antonovsky identifies three components: Comprehensibility, manageability and significance. He defines these determinants as follows:
Comprehensibility "refers to the extent to which one perceives internal and external stimuli as cognitively meaningful, as ordered, consistent, structured and of clear information"(30).
Manageability is defined "as the extent to which one perceives that one has appropriate resources available to meet the demands emanating from the stimuli with which one is confronted"(31), whereby these resources may also be provided by third parties.(32)
Meaningfulness is the motivational element. It refers to "how important it is to be involved 'as a participant in the processes that make up one's own destiny and everyday experience'."(33)
One of Antonovsky’s surprising findings is that it suffices if a person's sense of coherence is linked to a purely subjectively significant area of his life, however unrepresentative it may be in the face of the world as a whole, in order to have positive salutogenetic effect.(34)
Taking into account that the orthodox medicine’s research question "What makes us sick?" cannot completely satisfy us in our efforts to heal, and considering the arguments mentioned in the previous chapter, Antonovsky's research question "What makes us healthy?" represents an inspiring change of perspective that even encompasses death(35).In contrast to alternative medical healing systems, the salutogenetic paradigm does not represent a theory that directly competes with orthodox medicine and causes it to reflexively draw the line(36). A co-operating coexistence seems possible.
Yet it also leaves open questions: "A salutogenetic orientation makes no suggestions for a good life in the moral sense"(37). What kind of good/healthy life do we want to strive for? And who defines what is good/healthy?
What are we looking for when searching for a procedure that ideally complements orthodox medical treatment? To put it pointedly, one could say: For a maid who does not put her mistress under competitive pressure while self-confidently avoiding staged discussions on the question if she is carrying the train after or the torch ahead. A maid who, if necessary, is able to do both: with her torch show deficits and blind spots in orthodox medicine and – for the patient’s benefit – compensate them without comment. A maid who stands outside the medical system, yet is firmly rooted and familiar to the people.
In the following section we will discuss which criteria could be used to determine healing art in a therapeutic context.
We have seen above that the German verb heilen can be used both transitively and intransitively and that the transitive use - which in English corresponds to to cure - is the domain of orthodox medicine. One of the much lamented shortcomings of orthodox medicine is that, by splitting the human being into individual, independently treatable objects, it loses sight of the human being as a whole. To cure, however, necessarily requires an object, thus for orthodox medicine the whole person is neither tangible nor treatable.
From these considerations, intransitivity results as a determining criterion for the healing art we are looking for. But what exactly does this mean?
Man is a being that understands expressions(38), and yet he is more than that: Man is a being that makes sounds, gestures, a being that expresses himself, his self, of which he is conscious, in expressions.
Now, his expression can be addressed to a thou - or not. If man does the former and with his utterance addresses a counterpart, a doctor for example, then this happens with the intention that the thou reacts to his expression. And the counterpart's reaction will be all the more satisfying for the person expressing himself, the better the thou understands it, the more the sender has attuned himself in his expression to the needs and expectations of his counterpart.
This way the expression will inevitably change: Its significance moves away from the one who sends it out and towards the one for whom it is intended.
The suffering person expresses himself through an expression, in lamentation, in exclamations of pain. And his expression has an intention: "Help me!", he shouts out to the doctor, to the therapist in the language the recipient will understand. He is the person in need and he addresses the thou with his expression.
However, expressions, pain-driven exclamations that do not reach anyone, are pointless. Perhaps the person who is not perceived in his need will eventually stop expressing himself. Eventually his unheard expression will become manifest, will coagulate into an empirically measurable disease, and it is the disease itself that becomes the expression(39)
Yet eventually this persons saves himself and heals himself by his own power. And becomes one who gives expression without having the recipient in mind: a free human being. An artist.(40)
The person who makes an expression can address this expression to a recipient. But he can also make an expression which is an expression of his inner being and which at the same time is directed exclusively at himself, his inner self. This form of expression, an expression that is not directed to any object, to any recipient, to any thou, that does not address a doctor for help – an expression that is, in short, intransitive -, is supposedly one criterion for determining healing art.
Answers to the question of what art is fill libraries, and feature articles regularly declare art to be in crisis. Much of art's crisis has to do with the fact that it has to prove itself within a market, i.e. that it is directed at a thou that evaluates, rewards and manipulates it.
If we take a step back, leave the market and go back to the production sites of art, to the studio, to the rehearsal room, in other words, shut out the thou who evaluates, then art returns to its originality: to the expression of what is inside, independently of any thou.(41)
In order to understand what art is, the reflections of Benedetto Croce prove to be helpful. For Croce cognition is sensations that can be expressed:
"In practice, they [cognition and expression; KUS] coincide, because cognition occurs in expression: only at the moment of expression cognition is attained, so that from the absence of expression one can conclude with absolute certainty that there is no cognition."(42)
Consequently, for Croce any human expression is art. However, what distinguishes the professional artist from the ordinary person is the depth of his sensibility and expressiveness, which goes beyond the usual and penetrates areas beyond immediate personal concern.(43) Psychologically speaking, one could say that any person can access and express himself, but the professional artist does not content himself with the limits of his own self and instead is able and willing to go beyond them.
So, every person who makes a mark is an artist, just as Beuys claimed? Croce, in part, agrees, just as Beuys he expands the concept of art: "Everything that man produces is practically art, insofar as it is an expression of his intellectual activity. All art is expression and all expression is art."(44) By defining art as a cognitive activity comprehensible to all, Croce denies it any elitist position.(45)
Is therefore every person equally an artist? Yes - and no. Every human being has the fundamental ability to express himself and thus also to give expression to his self in artistic form. To what extent he actually does remains open and results in an individual positioning on the continuum of expression and silence. Nevertheless, Croce defines a quality criterion that applies equally to all. It is "to grasp and express something with precision."(46)
Human insight is reflected in the quality of its expression. And every human expression that is the result of a mental activity is art. The quality criterion that should determine healing art is therefore: precision in perception and expression and thus precision in cognition.(47)
One of the most striking features of orthodox medicine is that it reduces the human being to his physicality and treats him almost exclusively on this level.
"It is an amazing yet undeniable fact that contemporary medicine does not have its own doctrine of the sick person. It teaches phenomena of being ill, differentiation of causes, consequences, cures of diseases, but it does not teach the sick person."(48)
"A second point where this shortcoming becomes obvious is with the emphasis sick person. Because for pathological science this human being has only specificity with respect to the animal, with respect to the living, with respect to nature in general: he is an object among objects."(49)
But the human being - especially the suffering human being - is more than his objective body. When he comes to see the doctor and asks him for help, he asks as a whole person. But the doctor who works in orthodox medicine usually addresses the body alone.
In a case study on a farmer suffering from abdominal pain, the patient's actual concern is described as follows:
"The doctor has to find a name for it, but it must be the right one. Where a thing has not yet found its right name, it wanders through the world, restlessly, until it finds it. [...] Therefore the urge for knowledge was stronger than that for medicine or scalpel.."(50)
Disease and suffering are thus more than a need in itself; being ill also has to do with being cut off from truth or knowledge.(51) Treatment with conventional medicine alone cannot bridge this gap(52); in the above-mentioned story the farmer's illness continues to progress during orthodox medical treatment despite temporary phases of relief, and the knowledge gap deepens.(53)
"We must approach him [the sick person] as quietly, observantly, receptively, acceptingly as no other profession would request us to, and we must act experientially, empirically, in an even more eminent sense than any other science could ever do."(54), writes Weizsäcker in his concluding analysis of the case. The sick person and the physician must become companions(55), "the boundaries of medicine should be shifted so that they also include the field of the [patient's] actual medical history"(56), because "it is not enough to describe the task of the physician negatively as a fight against the disease."(57): "Disease is [...] the offering of a knowledge of truth."(58)
However, the reality of today's medical interventions is different:
"The crisis of medical intervention manifests in an increasing restriction of the freedom of medical intervention, but also in an increasing inability to perform it. Whereas in the past, for example, there was the great medical or clinical diagnostician who made diagnoses with great certainty and reliability [...] from all his professional, practical experience [...], today's physician is essentially the 'collector of diagnostic data'"(59)
The dilemma of the attending physician is thus that, on the one hand, he should cure the sick person, but he should do so exclusively with the means that scientific medicine provides(60)
Deciphering the story behind the symptom, as it was called for in the above example, cannot be done by doctors, at least not with any of the tools provided by their science. Anyway, their self-image as physicians is characterized rather by an active, transitive activity directed towards a clearly defined object in the sense of to cure. Today the passive, serving, listening role of the companion finds expression most likely in the sophisticated and sensitive diagnostic apparatuses, which, however, are of little help when it comes to deciphering the story behind the symptom.
But who actually holds in his hands the key to the story behind the symptom? If the physician is only to play a passive, serving, listening role, then who must actively take possession of that key? In his reflections on the psychotherapeutic process, Rogers comes to the conclusion "that the client is the one who knows where the shoe pinches, which direction to take, which problems are crucial, which experiences have been deeply buried. Slowly I realized that [...] I would be better off relying on the client for directing the process."(65b)
So it is the patient/client who holds the key to the story behind the symptom - even though this knowledge may have temporarily eluded his consciousness. Healing art should therefore be a path to the truth, as in artistic expression knowledge reveals itself as precise knowledge.
So if the patient himself holds the key to the story behind the symptom, what does he need a therapeutic companion for? The patient could follow the path of healing art entirely on his own: by becoming aware of his own feelings, by expressing them precisely without regard to a possible recipient, until he finally finds the key that reveals the truth. What difference does a possible companion/observer make in this process?
We know from quantum physics that the observer plays a decisive role in determining the outcome of the experiment(61)and Weizsäcker already indicated in which mental attitude the therapeutic companion should support the patient/client in his search for the story behind the symptom: "quietly, observantly, receptively, acceptingly [...], experientially, empirically"(62), all those descriptions that have little in common with the active medical practices associated with to cure.
Rogers has studied the client-therapist relationship very closely in his research on client-centered psychotherapy. For this relationship, but also for all other relationships - with students, colleagues, family(63) – he makes the following observations:
"I have formulated a hypothesis that means a lot to me now[. …] I have indicated that the research available to us supports this hypothesis[. …] If I can establish a relationship that is characterized on my side as: Authenticity and transparency, I show myself with my real feelings; Warm acceptance and appreciation of the other as an independent individual; Empathy, the ability to see the other person and his world through his eyes; then the other person in that relationship: Will experience and understand aspects of himself that he has suppressed up to now; Find that he is more integrated and more able to act effectively; […] Will be able to cope with life's problems more appropriately and easily."(64)
From the client's point of view, he describes the Situation as follows:
"that the client experiences being accepted uncompromisingly[, ...] no matter what feelings he has [...], how he expresses himself[, ...] how he assesses himself at that moment[...:] the client feels that he is psychologically recognized by the therapist, just as he is. This expression includes the concept of empathic understanding and the concept of acceptance."(65)
What Rogers expresses here, his conclusion from many years of working as a therapist and scientist, is that it is above all the attitude of the therapist - and not any kind of therapeutic intervention - that causes a development to take place in the client. Therefore the therapist's attitude must be characterized by authenticity, acceptance and empathy.
It is the patient who holds the key to the story behind the symptom, and he is free to go in search of it all by himself. But eventually he embarks on that journey, path of healing art, with a companion. Not that his companion will do the work in his place and discover the key. But because the companion, like a catalyst, is able to support the patient's search through an appreciative, non-judgmental attitude.
In the previous section we developed three guiding criteria to characterize healing art:
- Intransitive expression: The person who makes an expression in the sense of healing art addresses exclusively himself in this expression, not any counterpart.
- Precise cognition: The goal of the process of a healing art is precision in perception and expression and thus precision in cognition.
- The observer as catalyst: The companion on the path of healing art works exclusively through his appreciative, non-judgmental attitude.
In the last section of this work, we will now examine the extent to which the aforementioned criteria, which can be applied in all artistic fields, have already been realized in an existing practice.
Arno Stern began his research in the 1940s in a children's orphanage. He wanted to create a place where children and adults could express their innermost being artistically, away from the public: the Closlieu was created. Today, there are numerous Closlieus with Closlieu Servants trained by Stern.(66) (67)
The aim of the following sections is not so much a comprehensive presentation of Stern's concept, but rather a brief analysis of the extent to which Stern's Closlieu meets the aforementioned criteria for healing art.
The person who makes an expression in the sense of healing art addresses exclusively himself in this expression, not any counterpart.
At the Closlieu mixed-age groups do not produce art in the conventional sense, since art in Stern's understanding always addresses a recipient's expectations which then in turn leads to the alienation of expression. Instead, the Formulation, not intended for the eyes of others, is supposed to flow out, a trace that is not even picked up by the author himself. Stern expressedly distances himself from any art therapeutic intention - which is in Stern's understanding as well oriented towards a recipient. During sessions participants are allowed to talk, but not about the works that are being created or have been created; all paintings remain at the Closlieu and are archived there; there are no exhibitions.(68)
The goal of the process of a healing art is precision in perception and expression and thus precision in cognition.
Stern’s intellectual departure point is his theory of Formulation, an original language of drawing that expresses the speechless experience in the womb. In an attitude of relaxed seriousness, in unresisting, pre-reflexive devotion, the participants are invited to follow this trace and allow the organic memory to flow out while they grasp it as clearly as possible in a pictorial expression of whatever kind.
The companion on the path of healing art works exclusively through his appreciative, non-judgmental attitude.
Of particular importance to Stern are the Closlieu Servants, for who he offers a training, which is a prerequisite for licensing further Closlieus. It is their task to observe the Closlieu rules and rituals: formal rules concerning the location; rules of communication (no marvel, no judgment, no interpretation; no competition; no teaching); archiving; serving support of the (technical) painting process. These rules and rituals are intended to enable the painting process as a process of unintentional painting.
The way work is done at the Closlieu fulfills the guiding criteria for healing art developed above to a high degree.
The aim of the present work was to find and define guiding criteria for healing art in a therapeutic context. The respective justification of the criteria took place in quite different ways:
Pathogenetic, i.e. based on the deficits of orthodox medicine: Orthodox medicine breaks the individual into standardized single objects of observation, it neglects to heal in favor of to cure and replaces the compassionate, communicating doctor with the apparatus.
Salutogenetic, because healing art creates a manageable area of subjective importance: the patient's problem, however complex, becomes manageable in an artistic intervention that strives for precise knowledge.
Primeval, because there is yet a third way of looking at healing art. One that is so basic that it is easily overlooked: There is someone who empathizes, who overcomes his own ego borders, who compassionately observes the suffering thou, someone who remains silen(69) and supports this suffering person with sympathy: the companion.
There is yet another word for what he does. A simple word, one that normally wouldn't even come to mind in this context, but which describes exactly what is happening: