Introducing Art Therapy into the Christie HospitalManchester UK 2001–2002

K. Heywood*

200B Hayfield Road Birch Vale, High Peak, Derbyshire SK22 1DA, UK

Summary In September 2001, the author was invited by Dr. Wendy Makin (MacmillanConsultant in Palliative Care) and Andrea Sarginson (Volunteer Arts Worker) tointroduce art therapy to the Christie Hospital as part of a postgraduate trainingcourse at the University of Sheffield. The aim of this paper is to explore how theproject could help inpatients and outpatients to address their psychological needsand come to some understanding of their situation, following their diagnosis ofcancer.r 2003 Elsevier Science Ltd. All rights reserved.

KEYWORDS

Art therapy;

Christie Hospital;

Psychological needs;

Cancer

Art Therapy

Art Therapy is the use of art materials for self-expression and reflection in the presence of atrained art therapist. The main aim of the practi-tioner is to enable the patient to effect change andgrowth on a personal level, within a safe facilitat-ing environment.

In oncology, some concerns arising as a directresult of a person’s illness may require a humanisticapproach, focusing mainly on day to day strugglesand issues regarding their future. However, otheranxieties may emanate from deep-rooted pro-blems, for which a psychodynamic approach couldbe more appropriate. Overall, art therapy providesan effective way of helping the patient to workthrough their difficulties by way of exploring whathas been revealed in the image.

An art therapist holds a postgraduate qualifica-tion in Art Therapy, as well as being stateregistered with the Health Professions Council(HPC) and a member of the British Association ofArt Therapists (BAAT). There is a sub-group of thelatter, known as the Creative Response, whichspecialises in the area of palliative care.

Art Therapy training can either be full or parttime, requiring the student to have previouslyattained a degree or diploma in art, as well ashaving had a minimum of 1 year’s experience ofworking in the community. Wood1 explains that‘...(training) involves the consideration of differenttheories in psychology, psychotherapy, psychiatryand art therapy and a practical experience throughplacements in different therapy settings. Anawareness of inter-personal dynamics is gainedthrough experiential group-work and an increasingappreciation of the art process is developedthrough the continued experience of the trainee’sown art making’ (p. 6).

Knowledge of councelling and psychotherapeuticskills is therefore an important part of the arttherapist’s work, as is the pursuance of his or herown interest in creating images. The student isobliged to undertake personal therapy for theduration of the course, as a way of gaining furtherinsight into the psychodynamics of the therapeuticrelationship.

Development of Art Therapy

The term ‘Art Therapy’ was first used in Britainduring the post World War II rehabilitation

ARTICLE IN PRESS

*Tel.: +44-1663-74-34-89.

1353-6117/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.doi:10.1016/S1353-6117(03)00021-0

Complementary Therapies in Nursing & Midwifery (2003) 9, 125–132

movement in 1942. Two strands developed at thistime: Irene Champernowne was responsible forintroducing an aspect of psychotherapy throughart, which led to Art Therapy being widely used inthe area of mental health. Adrian Hill, on the otherhand, an artist recovering from tuberculosis, wenton to work with patients who were suffering fromthe same condition. Since then, more artists beganto use their skills in hospitals as a way of helpingpeople with physical illnesses.

In 1998, Camilla Connell2 pioneered the use ofArt Therapy in cancer care at the Royal MarsdenHospital from 1987. She writes: ‘Sufficient work hasnow taken place to begin to indicate that arttherapy has a valuable and for some an irreplace-able, part to play in meeting the psychologicalneeds of patients through the different stages oftheir illness.’ (The inclination to do my practicaltraining at the Christie Hospital was inspired byConnell’s work, in addition to my having hadpersonal experience of cancer.) Further evidenceof the value of Art Therapy in palliative care can befound in the wealth of literature on the subject (forexample3. It is worth mentioning here that Feld-man4 emphasises the importance of considering thephysical limitations of the patient, which maynecessitate flexibility with regard to the length ofsessions, and where these are held. He alsomentions using only new materials in situationswhere there may be a danger of cross-infection.

Benefits of Art Therapy

Some of the benefits of Art Therapy are mentionedthroughout this paper. With regard to the ChristieHospital, it seems that it can be helpful to people indifferent ways, depending on their circumstances.

Patients who are on the Adult Leukaemia Unit orthe Young Oncology Unit may be vulnerable tonegative or conflicting feelings, intensified byprolonged periods of isolation and sickness. In apilot study on ‘Adult Bone Marrow Transplants’,compiled by Gabriel, Bromberg, Vandenboven-kamp, Walka, Kornblinth and Luzzatto (2000), it issuggested that ‘ ythe non-verbal metaphoricalmodality of art therapy may be especially bene-ficial for patients who need to deal with emotionalconflicts, and with feelings about life and death, ina safe setting.’ The results of this study emphasisedthe effectiveness of Art Therapy as being stimulat-ing, flexible and non-threatening and fulfilling avariety of emotional needs (Psycho-Oncology, 00:00–00).

On the open wards, people are able to share theirthoughts with others in a similar position tothemselves. However, it seems that those whocould come to the art room appreciate a change ofscenery, in a safe, supportive and creativelystimulating environment. Art Therapy also providesa way of dealing with pain for these patients, who,in most cases, have just undergone major surgery.Thomas3 explains that people tend to feel morepain when suffering emotionally, due to their painthreshold being lower. She maintains that ArtTherapy can help a patient to release emotionsand anxieties, and thus work towards psychologicalrehabilitation and an improved sense of well-being.

I have found that Art Therapy particularlybenefits outpatients, who often express theirvulnerability at being away from the continual carewithin the hospital setting. It seems that theirfeelings become suppressed because of a reluc-tance to burden others with their problems. Theysometimes speak of a need to appear strong forrelatives and friends, for fear of increasing theirlevels of anxiety. I do not think much has beenwritten about outpatients who are suffering orrecovering from cancer, so I can only go from myown experience of working with this client group. Itappears that Art Therapy offers a safe way toexpress or release feelings which would otherwiseremain hidden. I found that the main areas ofdistress, tended to be around body image, otherpeoples’ attitude towards their cancer, and adapt-ing to life at home and in the community.

Whatever their situation, most people who werereferred to Art Therapy could think about makingchanges in their way of thinking and consequentlymove forwards.

Benefits of Art Therapy:

* addresses personal issues* increases autonomy and confidence* helps maintain a sense of identity* offers an active rather than a passive role* increases sense of well-being* addresses issues around body image* helps in the management of pain* helps in adjusting to diagnosis* facilitates release of emotion* offers a stimulating change of surroundings* fulfils a natural need to be creative* offers an opportunity to make changes* helps patients to move forwards* offers emotional support* offers an effective non-verbal way to commu-

nicate* helps to address feelings of isolation.

ARTICLE IN PRESS

126 K. Heywood

Introducing Art Therapy into the ChristieHospital UK

Initially, I acquainted myself with people in thehospital by producing leaflets, which explainedwhat Art Therapy was about, and visiting thevarious departments. Andrea Sarginson, acted asmy supervisor, and Dr. Makin contacted consultantsand ward managers asking if they would considerreferring their patients to me. The response wasvery positive, resulting in my working with peoplefrom Ward 1, Ward 8, the Adult Leukaemia Unit,Nathan House and the Young Oncology Unit. Out-patients were also referred. A number of casestudies from some of these units are presented inthis paper. For anonymity all names of patientshave been changed.

As Art Therapy became established at thehospital, patients who were mobile attendedsessions in the art room on Mondays and isolationwards were visited midweek. During the initialmeeting it was important to spend time assessingpatients’ needs and ensuring that Art Therapy wasright for them. For example, some people mayprefer to learn a skill rather than work therapeu-tically, whilst others may be feeling too ill, orwaiting to go home. Many had not painted sinceschooldays, and it was important to reassurepatients that they did not have to be ‘good atart’ but rather enjoy the process and use thematerials and colours as a form of spontaneous self-expression. My role was to support them andfacilitate an insight into their emotional well-being.

Patients who came to Art Therapy often spoke ofthe excellent quality of care they had received atthe Christie Hospital. Various emotional problemsappeared to be associated with having cancer.Common responses to this were feeling unable tocope, low self-esteem, or fear of their illnessreturning.

Often it seemed as if something needed nurturingwithin themselves. Guggenbul-Craig5 explains this:‘The sick man seeks an external healer, but at thesame time the intra-psychic healer is activated. Weoften refer to this intra-psychic healer in the ill asthe ‘‘healing factor’’. yThe physician within thepatient himself and its healing action is as great asthat of the doctor who appears on the sceneexternally. Neither wounds nor diseases can healwithout the curative action of the inner healer.’However, the art making process can also act as acatalyst, enabling people to realise their naturalinclination to be creative, which in itself offershealing attributes.

Tools needed to do the job

One of the first things to consider when setting upthe Art Therapy service was finding a suitable spacein which sessions could take place. Fortunately, theChristie Hospital had a large art room which wasalso used by volunteer art workers throughout theweek. It encompassed the necessary requirements,such as a sink, tables and chairs, plenty of light, akiln and adequate storage space. I was alsoprovided with a large lockable cupboard, moneyfor art materials and a file for the safe-keeping ofpaperwork.

Some art materials used in Art Therapy:

* Pastels* Oil pastels* Poster paints, acrylic paints* Watercolours* Brushes* Paper* Felt tip pens* Crayons* Pencils* PVA glue* Portfolios for storing artwork.* Clay

Patient referral

As mentioned earlier, senior staff from throughoutthe hospital began referring patients to me oncethey were aware that Art Therapy was availableand had become familiar with the basic referralcriteria.

Basic referral criteria:

* Patients who appear distant, uncommunicative,angry, weepy, obviously distressed or worried.

* Patients who seem to have pain or respiratorydistress associated with anxiety.

* Patients who need support in adapting tochanges in their life and adapting to theirdiagnosis.

* Patients who stress a need for creative self-expression.

* Patients who appear confused.

Some patients, however, found out about ArtTherapy through other sources, such as seeing anotice, or having read a leaflet. They may arrive atthe art room door, in which case I would briefly talkabout the psychotherapeutic aspects of the work,and ask them why they were interested, beforearranging a formal referral with the appropriatemember of staff.

ARTICLE IN PRESS

Introducing Art Therapy 127

Referral forms were addressed to me and sent tothe Rehabilitation Unit, where they were safelystored in a file ready for my collection. On theisolation wards, such as the Adult Leukaemia Unit,forms would be kept in the nurses’ office.

The next step would be to arrange an initialassessment where issues would be discussed such asconfidentiality, the length and number of sessions(bearing in mind the patient’s treatment, state ofhealth and visitors) and whether we should meet ona one-to-one basis or in a group situation.

A typical session

An image is usually made in the presence of an arttherapist, whose role is mainly that of a facilitatorand confidante rather than a teacher or artsworker. Sometimes artwork is produced outsidethe therapeutic environment, either at home or onthe ward, and presented at the next session. It isimportant that the creative process remains thefocus of the therapeutic relationship because itprovides a framework for holding powerful feelings,which can then be acknowledged and workedthrough. Art Therapy is a shared experience, inthat although the patient can find his or her ownmeaning in the image, the therapist will, asSchaverien6 notes,‘yassess the whole person inrelation to the pictures, and in relation to the arttherapist,’ (rather as a three-way reflective pro-cess), and thus respond intuitively to the patient’sdemeanour.

Patients are offered a wide range of materials, asafe environment, and undivided attention fromthe therapist, who must be empathetic andsensitive to everything that happens, without beingintrusive. If someone has difficulty in starting, itcould be suggested that they choose a colour ormaterial that appeals to them, then make a markand see what transpires. However, I have foundthat once a person settles down with a blank pieceof paper or a lump of clay, the creative process canoccur spontaneously, without any prompting fromme. As Winnicott7 elucidates: ‘What we do isarrange a professional setting made up of timeand space and behaviour, which frames a limitedarea of ycare experience, and see what happens.’I would add that an important part of thetherapist’s job is to ensure that the patient trustsin the process and feels secure, and in order to dothis, certain boundaries are established, such asconfidentiality and consistency.

Patients often express their surprise at what theyhave produced, and how much has been revealed intheir image. Sometimes, if the picture has been

used as a ‘scapegoat’ (i.e. a recipient for painfulfeelings), tears may begin to flow, perhaps provid-ing a healthy release of suppressed emotions. Thetherapist must know how to give full attention,listen with empathy, metaphorically ‘hold’ thepatient and stay with them. It is important thatthe therapist has access to appropriate supervisionwhere difficult emotions, often evoked through thetransference and counter-transference, can beaddressed. This is also an opportunity for the imageto be viewed in a fresh light.

Patients’ images are stored safely in the artroom, within a large portfolio. Models are kept in alocked cupboard. It would be recommended thatthe patient leave their artwork for the duration oftheir therapy treatment, in case a review isneeded. However, once the sessions have come toan end, the images are theirs’ to be used as theywish. Some people prefer to take artwork home,whilst others, who had perhaps used therapy as away of relieving stress, may want to leave itbehind. In the latter case, it is explained that itwould be available for them to collect, should theychange their minds. If the therapist needed to useimages for supervision or other purposes thepatient’s permission would be asked for, by wayof a signed consent form.

Case study 1

Ward 8

Ward 8 is where self-caring patients, who areundergoing radiotherapy treatment, can stay fromMonday to Friday.

MargaretMargaret, a lady from this ward, arrived at the artroom door one Monday enquiring about Art Ther-apy. I invited her in, and after explaining my roleasked why she was interested. She replied that shewas looking for a creative way to relieve stresscaused by the effects of her illness. The ward clerksubsequently authorised her referral and then asuitable time was arranged that would leastcoincide with treatment and visitors. Margaretcame for one session, which seemed to be all thatwas needed.

On a large sheet of coloured paper, Margaretused thick acrylic paint to produce a picturecomprising three poignant images, which I willproceed to describe individually (Fig. 1):

(a) At the top of the paper, a white cloudappeared, where Margaret said she would like

ARTICLE IN PRESS

128 K. Heywood

to be. To this, she added bright yellow whichshe described as ‘ythe colour of daffo-dilsFthey give you hope in the spring.’ Therewas silence for a while as she covered the cloudwith red ‘veins’. Suddenly, she called outaloud, in the realisation that this was hercancerous breast. At this point, I sensed herdistress and possible need of support.

(b) Black rain was falling, reflecting the dark,dismal day outside. Then a blue umbrella waspainted, which Margaret changed into a hatcrowning the outline of a sad face lookingdownwards. This image seemed to depress her,causing her to cry. She spoke of losing her hairthrough the chemotherapy, ‘showing theworld’ that she had cancer.

(c) This final image depicted the sea, whereMargaret apparently liked to go for solace.She described it as being representative of hermoods, and somewhere she could turn to. Shebegan to talk freely about personal problemsassociated with the effects of her illness,admitting to being very confused and frigh-tened, yet having to be strong for everyonearound her in order to protect herself andothers. In this one session, it seemed that arttherapy had served its purpose. Having usedthe image as a receptacle for her painfulfeelings, and thus confronted the reality ofher situation, Margaret could now move for-ward. Schaverien6 suggests that: ‘ythe artobject, like the scapegoat, becomes embo-died, overpowered, and is subsequently dis-posed of, and that this may result in aresolution of some inner conflict. This processeffects a change in the patient, and enables anew state or an altered sense of self toemerge.’ At her request, I referred Margareton to the hospital councillor.

Case study 2

The ALU

Patients are admitted to the ALU following theirdiagnosis of leukaemia and are cared for in isolatedrooms, which have to be kept sterilised due to thehigh risk of infection.

It was necessary to adopt a flexible approach onthis ward, mainly because patients were often tooill to participate, occasionally becoming tired ornauseous as a result of the chemotherapy treat-ment. I respected their needs, whilst taking care tomaintain continuity in the relationship, throughcommunication with staff or simply putting myhead round the door.

KathyThe following case study concerns a lady in her 30s,who was referred to me by a staff nurse as‘someone who may be interested in doing someartwork’. On my first visit, I perceived Kathy ashaving a calm and philosophical attitude towardsher illness, although she mentioned that she hadbeen traumatised by the diagnosis. After I ex-plained my role in some detail, she appeared keento start immediately. I showed her a selection of artmaterials, and was surprised when she chose a boxof pastels, which struck me as a particularly messymedium in contrast to her squeaky clean environ-ment. (Staff reassured me that pastels were safe touse.)

Kathy produced six pastel images over the samenumber of sessions, despite sometimes feelingunwell. The two images I would like to write aboutseem to have been most apparent in reflecting hersituation:

(a) Flowers or blood cells? (Fig. 2): Kathyproceeded to draw some flowers and buds in shadesof red and yellow, most of which contained a

ARTICLE IN PRESS

Fig. 1

Fig. 2

Introducing Art Therapy 129

central brown dot. When I asked her about theseflowers, she alluded to not being allowed any in herroom, adding that the buds were ‘tight carnationswhich haven’t quite opened yet’. I was promptedto think about the baby cells collected from herblood and wondered whether she had been experi-encing some anxiety in anticipation of her pendingblood count results. I felt that this apparentlyambiguous image seemed to embody two relevantaspects of a leukaemia patient’s predicament,being presented on both a conscious and uncon-scious level.

(b) The image as a scapegoat? (Fig. 3): When Ienquired about her well-being, Kathy replied thateverything was fine. However, on this occasion I hadbeen informed by staff that there were complica-tions associated with her condition, which meantthe prospect of a further bone marrow aspiration.

Kathy created a ‘holiday’ scene, and as sheworked on the sea, I was aware of the energeticway in which it was coloured in. This was adifferent approach to her previous images, whichhad been drawn in a more controlled manner. Iperceived the picture as having a rather heavy feelto it, which was reinforced by Kathy saying that theboat she had drawn looked more like a tanker thana cruiser.

In her image, I noticed that she had drawn 17people all of whom, according to her, weresunbathing; this was possibly analogous to thenumber of beds on the ward (18 in all). Could thefigure standing precariously on the front of the boatbe the 18th? When I asked where Kathy would placeherself in the picture, she replied that she was theone on the diving board, about to plunge into thesea, which I thought was rather turbulent, despiteher describing it as calm.

For a moment, I wondered whether I hadconjured up my own uncomfortable feelings re-garding this image. The following citation byRyecroft (1983) illustrates the importance of payingattention to one’s own intuitive feelings when he

writes: ‘The analyst can use thisycounter-trans-ference as clinical evidence: i.e. he can assumethat his own emotional response is based on acorrect interpretation of the patient’s true inten-tions or meaning.’ After the session, I decided tospeak to the liaison nurse, who appeared relievedto hear about my concerns, She had also beenperturbed about Kathy’s persistent air of calmness,and resolved to keep an eye on her. The aboveaffirmation led to staff gaining a broader under-standing of Art Therapy and thus a greaterawareness of the requisites for referrals.

Case study 3

Outpatients

Outpatients usually visit the hospital for periodicalcheck-ups and treatment. Most people who came tome were referred either by the breast care nurse orthe hospital councillor.

PaulaI received a referral from the breast care nurse,suggesting that Art Therapy might help this patientto cope with her recent diagnosis of secondarycancer. Paula was in her early 1930s and herprognosis was poor. She was about to beginchemotherapy treatment, which would require avisit to the hospital every third week. The sideeffects of nausea and tiredness resulted in herattending art therapy for two weeks, then missing aweek. In all, she attended six sessions.

On her first visit, Paula expressed anger and tearsat not being able to fulfil her dreams, especiallywith regard to having children. She subsequentlydipped a large brush into some thick, red posterpaint, and proceeded to pour out her feelings ontoblack paper in the form of a large, exploding ball(Fig. 4). Then a bright pink ‘jewellery box’ waspainted in the bottom left-hand corner, which Paulaexplained was to lock away her ‘stuff’. Sheinterpreted the yellow brush strokes surroundingthese images as a ‘golden aura’, apparentlysignifying a kind of protection for her feelings. Iperceived these marks more in terms of a release ofher feelings, as the whole picture appearedexplosive. Paula said that this image had providedher with an opportunity to be spontaneous, some-thing she found difficult because she always liked toplan ahead. As time went on, she was able toexpress all kinds of feelings in the sessions, throughtears, laughter, painting and talking.

ARTICLE IN PRESS

Fig. 3

130 K. Heywood

The following pastel image (Fig. 5), depicted asignpost, which Paula said stood for her reaching acrossroad, enabling her to visualise the differentdirections open to her, and thus create some orderout of the confusion in her life. To the left of this,she drew a set of scales, on which she imaginedbalancing aspects of home and work. She wasamused by her portrayal of her dog, which had onlytwo legs, and one ear that she said looked more likea party hat! The puppy had been recently acquired,with a view to bringing some fun and lightness intothe home.

On another occasion, Paula painted an imageconsisting of a pair of daffodils standing side by sideon the top of a hill (Fig. 6). I commented on theflowers, suggesting that they appeared very sturdyconsidering their position. Paula then began to talktearfully about the time she had told her husbandabout her diagnosis and predicted life expectancy,and how they needed to be strong for each other. Atthis point, it became necessary to pay attention tomy own emotions, in order to ensure that I wasadequately containing her, which Kearney8 de-scribes as ‘ypsychologically holding the one whosuffers even when there is nothing left to do, andno matter what happens.’

Paula also emphasised her apparent need toappear strong for the rest of her family, andtherefore unable to discuss her feelings with them.She said they were going through enough distresswithout seeing her going to pieces.

I thought this image significant in that it hadhelped Paula to view her relationships and hersituation more objectively. As a result, she and herhusband began to make some major decisionsregarding their future together, and communica-tion with her relatives greatly improved.

Patients’ comments:

Art therapy has helped me to realise the benefits ofcouncelling. It’s been good to talk. J.H.

I have enjoyed my visits, cried a lot and smiled a lottoo. I’m going in the direction of understandingmyself. The artwork takes my mind over yI guessit does my ‘‘spirit’’ good. J.G.H.

Being able to express myself took the mind off thereason why I was at Christies. I liked the colourfulpaints and pens provided y it is an outlet foremotions. E.D.

It was the process of creating that enabled me totalk about issues. Completing the artwork was anachievement yI wasn’t able to achieve anythingelse. S.A.

It was stimulating mentally, but relaxing using thecolours to shape your picture. It was amazing whenyou realised what it meant. K.H.

Never having experienced any kind of therapy inthe past, I was slightly sceptical, but now I am akeen advocate of therapy as a way of helping tounderstanding one’s feelings. M.M.

Conclusion

As well as having the privilege of helping manypeople through their time of suffering, I have also

ARTICLE IN PRESS

Fig. 5

Fig. 6Fig. 4

Introducing Art Therapy 131

learned a great deal from the patients. I think it isimportant to consider that Art Therapy, whilstmostly concerned with addressing problems, is alsoabout inspiring hope, strength and determination.

My work at the Christie Hospital has proved anenriching experience for various reasons. I havefound that Art Therapy could offer patients: (a)support at a time of emotional distress, (b) a way ofcoming to terms with what is often a veryfrightening and bewildering ordeal, (c) a safe placein which to express different kinds of feelings, (d) ameans of improving communication with visitorsand staff, (e) an enhanced awareness of existentialand spiritual issues, (f) an opportunity to play anactive rather than a passive role, and thus be morein control of their situation.

Through my introducing Art Therapy to theChristie, I feel that many members of staff areconfident that it will eventually attain its justifi-able recognition within the hospital. There is anobvious need for this valuable service, which isapparent from the number of referrals that Icontinued to receive until the end.

Professor Baum9 writes: ‘I believe that arttherapy is a unique vehicle for allowing patientswith cancer to express hidden emotions and thus,to some extent, provide their own psychotherapy.yI have little doubt that the drugs budget for theNHS would fall, as prescription for anxyolitics andanti-depressants would be replaced by the pre-scription of art therapy.’

Acknowledgements

I would like to thank Dr. Wendy Makin, AndreaSarginson, Simon Bell, Hilary Parker and Flis Swiftfor their constant support throughout my work.

I am very grateful to the patients, volunteers andmembers of staff at the Christie Hospital for theirparticipation in this project and contributingtowards its success.

Training and professional registration. An ArtTherapist should hold a postgraduate Diploma inArt Therapy recognised by the British Association ofArt Therapists (BAAT) and be state registered withThe Health Professions Council (HPC).

Further information. The British Association of ArtTherapists, Mary Ward House, 5 Tavistock Place,London WC1H 9SN. Tel.: 020-7383-3774; fax: 020-7387-5513.

The Creative Response (Art Therapy, Aids, Cancerand Loss), The Old Coach House, Station Road,Ardleigh, Colchester CO7 7RR.

References

1. Wood MJM. In: Pratt M, Wood MJM, editors. Art therapy inpalliative care. London, New York: Routledge, 1998. p. 1.

2. Connell C. Art therapy as part of a palliative care programme.Palliative Med 1992;6:8–25.

3. Thomas G. Art therapy and practice in palliative care. Eur JPalliative Care 1995;2(3):120–1.

4. Feldman E. HIV dimentia and counter-transference. ArtsPsychother 1993;20:317–23.

5. Guggenbuhl-Craig A. Power in the helping professions. Texas:Spring, 1971. p. 90–91.

6. Schaverien J. The revealing image. London: Jessica KingsleyPublishers, 1999. p. 3, Reprinted.

7. Winnicott DW. Society and the growing child. ‘The practice ofchild psychiatry’. In: Davies M, Wallbridge D, editors.Boundary and space, 1981. London: Karnac (Books) Ltd.,1970. p. 140.

8. Kearney M. A place of healing. Oxford, New York: OxfordUniversity Press, 2000. p. xx.

9. Baum M. Preface In: Connell C, editor. Something understood.London: Wrexham Publications/Azimuth Editions, 1998. p. 8.

Pythagoras used to say life resembles an Olympic games; a few men strain their muscles to carry off aprize: others bring trinkets to sell to the crowd for a profit; and some there are who seek no furtheradvantage than to look at the show and see how and why everything is done. They are spectators of othermen’s lives in order to better judge and manage their own. (Michel De Montaigne 1533–1592)

ARTICLE IN PRESS

132 K. Heywood