Looking together: Joint attention in art therapy

International Journal of Art Therapy Formerly Inscape ISSN: 1745-4832 (Print) 1745-4840 (Online) Journal homepage: http://www.tandfonline.com/loi/rart20 Looking together: Joint attention in art therapy Jonathan Isserow To cite this article: Jonathan Isserow (2008) Looking together: Joint attention in art therapy, International Journal of Art Therapy, 13:1, 34-42, DOI: 10.1080/17454830802002894 To link to this article: http://dx.doi.org/10.1080/17454830802002894 Published online: 03 Jun 2008. Submit your article to this journal Article views: 2317 View related articles Citing articles: 14 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rart20 Download by: [University of London] Date: 23 November 2016, At: 20:44 International Journal of Art Therapy, June 2008; 13(1): 34
42 ORIGINAL ARTICLE Looking together: Joint attention in art therapy JONATHAN ISSEROW Abstract This paper examines the phenomenon of looking together in art therapy. It argues that the triangular relationship
on which much of art therapy theory is premised
takes as a priori the capacity of the patient to look together with the therapist at the art object. This capacity, however, cannot be taken as a given but is based on early childhood development, emerging out of the mother
infant relationship where in ordinary growth, the infant’s looking at the mother develops into looking with her. This paper explores the development of joint attention skills in relation to art therapeutic practice drawing together child developmental and psychoanalytic perspectives. Keywords: Joint attention skills, primary and secondary subjectivity, blind infants, triangular relationship, autistic spectrum disorder, theory of mind Introduction This paper aims to investigate the use and function of the eyes within art therapy. It is particularly interested in how both patient1 and art therapist look together at the art object, in an attempt to share the feeling and possible meaning that its making may hold. The act of looking together at the object is of vital importance for art therapy as it joins up the vertices of the triangle between patient, image and therapist, enabling the structure of the art therapeutic relationship. ‘Looking together’ is often such a routine phenomenon within art therapy that the behaviour itself can easily go by unobserved. It is only when working with clients where this capacity for joint attention is missing or compromised that its importance is brought to the fore. Far from being a given, this capacity to look together, co-ordinating attention and sharing affect around a third object is premised on a series of significant developmental milestones achieved within infancy (Bakeman & Adamson, 1984). Drawing on child developmental research and psychoanalytic theory, this paper explores how joint attention emerges between mother and infant in ordinary development. This understanding will then be used to inform the absence and presence of joint attention within two contrasting clinical vignettes: the first with a profoundly autistic young woman; the second with an ordinary developing adolescent boy. The paper concludes with some reflections on using child developmental research to approach the familiar art therapy concept of triadic relating in a new way. Triadic relating within art therapy The theoretical formulation of the triadic relationship between client, image and therapist has long been a source of lively investigation (Case, 2000; Dalley, Rifkind, & Terry, 1993; Schaverien, 2000; Wood, 1984, 1990). Lines of inquiry have explored the interrelational dynamic between the three constituents and how they may bring about understanding of and change within the client. Case (2000, p. 27) suggests that this conceptualisation has been a useful one, having an outer-world function of distinguishing the profession from other forms of therapy. It also has an inner-world function of exploring the dynamic intrarelationship within the art therapy room, generating much art therapy theory. Wood (1990) has conceptualised art within the triangular relationship as being akin to a third person in the room. Dalley et al. (1993) have further personified this third person, writing extensively about the reciprocal, informing and reflexive inter-relationship between the ‘three voices of art therapy’. Additional conceptualisations include the Winnicottian triangle of mother, child and transitional object (1958/1971), superimposed onto the art therapy triangle (Wood, 1984). While moving theoretically and developmentally along, the mother, father, child Correspondence: Roehampton University, School of Human and Life Sciences, Arts and Play Therapies, Whitelands College, Holybourne Avenue, London SW15 4JD, UK. Tel: 020 8392 3118. E-mail: j.isserow@roehampton.ac.uk 1745-4832 (print)/1745-4840 (online) # 2008 British Association of Art Therapists DOI: 10.1080/17454830802002894 Looking together triangular relationship also brings irresistibly to mind the classic Oedipal constellation (Britton, 1989; Freud, 1905; Klein, 1928). Case has argued that art therapy enables the fostering of the ‘third position of the Oedipal triangle, in that bringing in the medium creates a triangular interaction’ (2006, p. 207). Other writers have explored the particular dynamics of transference, counter-transference and aesthetic counter-transference within the triangular relationship (Case, 2000; Schaverien, 2000; Simon, 1995; Wood, 1990). Case (2000) has challenged the simplicity of the triangular shape arguing for more complex forms to match the multiple and refracted projections within the art therapy room. Schaverien (2000) has explored how different emphases on the triangular axis may determine the kind of therapy being practiced (i.e. whether it is art therapy, art psychotherapy or analytic art psychotherapy). Back to basics The above theories describe how the patient, therapist and art object may be linked up from a variety of perspectives. However, behind this rich and complex body of knowledge lies an a priori assumption which supposes that the patient can use their eyes to look together with the therapist at the art object. The capacity to look together and share feelings in a linked-up triangular way
on which the above theories are premised
though, has its developmental precursors in infancy. This capacity is a result of a fundamental developmental milestone in the growth of the child’s mind. Its significance marks the achievement of a group of emotional and cognitive abilities that are known collectively within child development research as joint attention skills. These skills are characterised by the development of a range of socially embedded behaviours and include the infant giving, showing and pointing things out to others; often looking back and forth between objects and the other’s eyes; requesting objects to play with and initiating games (Hobson, 1993, p. 266). Damarell (1999) has written about the absence of the idea of joint attention within art therapy theory, suggesting that ‘an important opportunity to recognise that the triangular relationship involves two pairs of eyes and a target object’ (1999, p. 45) has been missed. Damarell goes on to suggest that this omission may be as a result of the concept of ‘joint attention’ emerging from the field of developmental psychology, a theoretical framework not often drawn on within art therapy literature, despite its potential to add significant support and insight. Notable exceptions to this can be found in the work of Damarell (1999); Evans and Dubowski (2001); Hosea (2006); and Case (2006). 35 My interest in joint attention skills has emerged out of my work at a school for profoundly autistic young people and a contrasting experience of working within a Child and Family Consultation Service. Children at the school often avoid eye contact, becoming mesmerised by inanimate objects which seemed to function as autistic objects (Tustin, 1981) denying any knowledge of a separate ‘live object’ (Alvarez, 1992) within the room. The capacity to look together at an object in any shared or joined up manner seems like a developmental quantum leap away. This is in striking contrast to the children at the Consultation Service who are able, in a more ordinary manner, to look at me and with me at the art object they have produced. This striking contrast in experience of relating between these two contexts has prompted me to ask: What might be the developmental conditions within the infant which enable triadic relating to occur? What are the developmental implications should this capacity be compromised? How can this understanding inform the work of art therapy whose premise, broadly speaking, is one of an overlap of coordinated looking, thinking and feeling around the art object? It is to this development of joint attention skills that this paper now turns. Joint attention skills Joint attention skills are a group of behaviours which usually develop within the latter part of the infant’s first year of life and include the sharing of attentional focus and affect around a common object (Scaife & Brunner, 1975). Joint attention episodes are triadic in nature and involve the alternating co-ordination of attention to the object and to the parent. It is socially embedded, emerging before language, and is clearly a part of proto-communication (Newson & Newson, 1975). It not only includes the sharing of attention with another but also includes the monitoring and shaping of the other’s attention around an object. This is often achieved through the use of pointing, gesture and referential eye contact. An example of this can be Figure 1. 36 J. Isserow seen in Figure 1 where a young child and her mother share the experience of looking together at an event or object outside the picture plane. It is possible to speculate that their enjoyment is as much to do with the sharing of the experience, as the event itself. The development of the capacity to look and feel together has its roots in the infant’s earliest relationship (Bates, 1979). Prior to the relative sophistication of triadic relating, infants are engaged almost exclusively with dyadic interactions which include a significant amount of time where the infant and his or her care-giver look at each other. Fraiberg suggests that the mother
infant ‘engagement of the eyes is part of the universal code of the human fraternity, which is read as a greeting and an acknowledgement to the ‘‘other’’ long before it can have meaning for the infant’ (1974, p. 210). This visual acknowledgement and experience of mutual gazing between mother and infant is central to the establishment of the infant’s attachment to his or her mother or primary care-giver (Holmes, 1993). The perceptual nature of the eyes forms one of the main sensory domains where the infant’s intersubjective experience of the other is shaped. Looking at each other provides a conduit for the sharing of affect, which along with other psychophysiological care such as holding, protecting and containing enables the mother
infant relationship to grow (Holmes, 1993). The meeting of eyes between infant and mother provides a point of mind-to-mind connection and connectedness. Frith suggests that the infant’s communication and social competency is acquired through the understanding of the ‘language of the eyes’. The sharing of mental states underpins the varied meaning that the gaze may take. ‘If there were no mental states, then a language of the eyes would not exist’ (Frith, 1989, p. 143). Stern (1985) has closely followed how reciprocal eye contact between mother and infant is dependent on the primary care-giver’s capacity for sensitive attunement. This includes allowing for moments of stimulation as well as rest between periods of interactions where the infant is given the space to self-regulate before re-engaging with the other. Trevarthen’s idea of ‘primary inter-subjectivity’ (1979) encapsulates this behaviour at this period and refers to the infant’s capacity to attend to only one person at a time in an inter-affective manner. At around six months of age the infant begins to orientate himself not only to the object but also to his care-giver’s attitude to the object. Trevarthen calls this joint sharing of interest in another object ‘secondary intersubjectivity’ (1979), requiring a flexibility of orientation to begin to see things from the other’s point of view. Through the intimate inter-affective experience of the mother’s mind, the infant begins to realise that other people have minds separate to his own (Baron-Cohen, 2004; Hobson, 2002). From here the infant is gradually able to construct a theory about the existence of other minds. With this ‘theory of mind’ (Baron-Cohen, 2004) the infant becomes aware that other people have thoughts and attitudes to objects and events in and of their own right. As such, the other’s thoughts and attitudes towards the third object become as interesting as the object itself. The theory of mind hypothesis has also influenced recent psychoanalytic and attachment theory research into borderline personality disorder. Fonagy, Gergely, Jurist, and Target (2004) have proposed that joint attention and associated mirroring activity between care-giver and baby are central to the development of mentalisation. Mentalisation is broadly defined as the ability to appreciate the existence of mental states both in ourselves and in others, and that these internal intentional states influence the behaviour of people in the world. This ‘knowledge’ about minds enables an understanding of emotions, thoughts, feelings and intentions which in turn underpins communication and relationships with others. Joint attention skills culminate when infants’ interactions become triadic as object-focused attention becomes embedded in social contexts (Bates, 1979; Harding & Golinkoff, 1979). As the child develops he uses proto-declarative gesturing to actively share attention to an event, object or ‘topic’ (Leung & Rheingold, 1981). Bates (1979) suggests that the capacity for joint attention becomes consolidated at around 13 months where the infant readily enters into nonverbal referential communication with a person about a present object (Bates, 1979; Harding & Golinkoff, 1979). Looking together at an object therefore entails firstly the understanding that other people have minds separate from one’s own; secondly, that other minds have thoughts of their own which can be directed to other objects and events in the world; and thirdly the capacity to orientate to the other’s point of view (Hobson, 1993). It is useful here to differentiate between protodeclarative and proto-imperative pointing. Proto-declarative pointing is used by the infant in an attempt to shape attention and share an experience with the other and is marked by the presence of affect. It is indicative that the child has an understanding of other people’s intentionality (Diessel, 2006). In contrast, the intention of proto-imperative pointing by the child is the achievement of a concrete goal, such as a toy that is out of reach or a biscuit in the cupboard. Congenitally blind infants Having established the role of looking and feeling together in the growth of joint attention, it is useful
as a corollary
to explore the development of joint attention skills in congenitally blind infants where this Looking together perceptual apparatus for looking is either impaired or compromised. Selma Fraiberg’s longitudinal study of ten blind infants has pointed to how dependent primary care-givers are on eye-to-eye contact with their babies to determine levels of engagement and recognition. Fraiberg writes about the need for eye contact in mother
infant relation: when the eyes do not meet ours in acknowledgement of our presence, it feels curiously like a rebuff. Certainly, mothers attribute ‘knowing’ and ‘recognition’ to a baby’s sustained regard of the face long before he can actually discriminate and recognise faces . . . (1974, p. 210) Fraiberg’s work highlights the developmental danger for blind infants who cannot make an emotional connection to their primary carer through visual means. The consequence for the blind infant of not finding a common sensory domain to share mental states with his care-giver is perilous and there are a significant number of blind children who show grave impairment in their human
object relationships as a result, according to Fraiberg. In order to mitigate against the loss of relational connectedness as a result of impaired vision with these children, Fraiberg and her team help care-givers become aware of and shift their focus to the ‘hand language’ employed by their blind infants. This hand language is a means of establishing that vital human link to another mind within the first months of life. This idea of ‘hand language’ seems to function developmentally in a similar way to Frith’s idea of ‘eye language’, as both serve to share mental states between infant and mother. When intersubjectivity cannot be achieved through the immediacy of visual contact between mother and infant, it needs to be found in other sensory domains, if developmental complications are to be avoided. Intersubjectivity through the tactile delicacy of the hands, rather than through the dance of the eyes provides such an alternative route. Interestingly blind infants, who manage to have an early experience of inter-affectivity, develop delayed joint attention skills which occur at around two years of age (Hobson, 2002). Looking together and autism In comparison to blind infants, there is another clinical group that find eye contact problematic, albeit for very different reasons. Young children and adults on the autistic spectrum often experience great difficulties in making eye contact with ‘live company’ (Alvarez, 1992). This difficulty is so marked that avoidant eye contact is seen as one of the foremost indicators of early childhood autism (Hobson, 2002, p. 257). Frith (1989, p. 143) argues against the reliability of this commonly held understanding that children with autism avoid eye contact. Instead, she suggests 37 that these children do not differentiate their quality of looking between inanimate objects and people; however, it is the animate objects who complain about this experience. Both Frith and Hobson agree that the central difficulty with autistic spectrum disorder (ASD) children seems to be the ‘disruption in these children’s capacity for reciprocal, affective relatedness with others’ (Hobson, 1993, p. 258). As such these children are in danger of never discovering the ‘language of the eyes’ between mother and child. Hobson (2002, p. 192) suggests that the blind toddlers under two and autistic toddlers both have difficulties with developing joint attention skills but for different reasons: In each case there is something that makes it very difficult for the young child to relate to someone else’s orientation towards the world and towards himself . . .The difference between them is that in the case of blindness, the child cannot see how other people relate to the world; in the case of the sighted child with autism, the child cannot see how other people relate to the world. (Hobson’s emphasis) While blind infants may be enabled to ‘see’ how people relate to the world, through the help of a sensitive care-giver, ASD children face greater difficulties. Lack of inter-affective relatedness compromises the infant’s capacity to understand people as having minds of their own with their own points of view about objects and events in the world. The child’s ability to move out from their single perspective and ‘step into the other’s shoes’ is also significantly curtailed. As a result, the development of a mental picture of the other’s mind is disrupted and their capacity to look together is significantly under-developed. Within art therapy theory the impact of this developmental deficit has been explored by Dubowski (1990), Tipple (1993), Tipple (1994) and Evans and Dubowski (2001). Psychoanalytic perspectives on looking together The use and function of the eyes in early development has a long history of exploration within psychoanalytic literature (Freud, 1910; Winnicott, 1971; Wright, 1991). In addition, the capacity to relate triadically has also been extensively examined within this field. From a psychoanalytic perspective the external behaviour of joint attention skills can be seen to be determined by the infant’s internal capacity to see himself as separate from whole objects as well as able to think triadically about the inter-relationship between objects. The awareness of being separate necessitates the awareness that people have relationships to other people and objects from which he can be excluded (Britton, 1989; Freud, 1905; Klein, 1928). The manifest capacity to see the connection between people and objects separate from self is predicated on 38 J. Isserow the infant’s internal shift from dyadic to triadic (or Oedipal) relating and the development of ‘triangular space’ (Britton, 1989) in the child’s mind. Burhouse (2000, p. 64) suggests that the infant’s capacity for triangular thinking where the ‘child can begin to think about the links between himself, his environment and other minds’ is dependent on the acknowledgement of being on the outside of a parental couple. Similarly, the capacity for the patient to think about the link between himself, the art object and the art therapist’s mind is dependent on this earlier Oedipal struggle. Looking back and forth between the art object and the therapist’s eyes requires knowledge and toleration of triadic relating, where two things can be held simultaneously in mind, requiring the capacity for ‘two track thinking’ (Alvarez & Furgiuele, 1997). Interestingly, according to Klein (1928), Oedipal relating emerges towards the end of the second half of the first year of life, which corresponds closely in time to the emergence of joint attention skills according to developmental research (Bates, 1979; Trevarthen, 1979). Clinical application Keeping the over-lapping perspectives of psychoanalysis and developmental psychology in mind, it is now possible to explore how this understanding of joint attention may inform clinical work. Two contrasting case vignettes are presented, one with a profoundly autistic young women; the other with an ordinary developing adolescent boy. To maintain client confidentiality, all names have been changed. Mary I first met Mary when working in a residential school for children and young people with severe learning difficulties, located in a rural village in the South-East of England. Many of the children were diagnosed as being on the autistic spectrum disorder with challenging behaviour. Mary was coming up to her 17th birthday when I first met her. She had a slightly plump, round face, and she looked younger than her years. This youthful quality was added to by her dark hair being pulled back into a neat ponytail at the back of her head. She had been living at the school for several years and little was known of her early childhood experience. Her mother kept in tenuous contact with her carers. Mary was referred to art therapy as her carers were concerned about her selfinjurious behaviour when she became distressed. Despite these episodes, Mary was a quiet young woman. On meeting Mary I was aware that she was highly adept at looking everywhere but at me or she would look straight through me at a black hole somewhere behind my head. Making direct eye contact seemed to be too difficult an option for her. She had a tendency to rock hypnotically in her chair when seated at the art table or on the balls of her feet when standing in the room. She would often vigorously bite the back of her hand when she became particularly agitated. She never used spoken language but would respond to the occasional simple requests and verbal prompts after some encouragement. I worked with Mary for seven months prior to her leaving the school. Mary always came compliantly to her weekly sessions and would mostly sit at the art table gently rocking in her chair. She would often suck at the palm of her hand so that it was wet with saliva or allow her saliva to drench her clothes and the table that she was sitting at. Repetitively, she would hold this glistening wet hand up in front of her face, trailing a thread of saliva from her mouth to her hand, before returning her hand to her mouth. She would then line up her eyes, following the glistening thread, linking up her mouth and her hand. Outside of this idiosyncratic behaviour, Mary’s visual line of focus had a hollowness and far-away quality. It mostly felt as if she was in a world of her own and I was often aware of the pull to slip into a dull mindlessness of my own when working with her. In attempts to keep mentally alive within the sessions, I would suggest that she could use the art materials. This she would do after much encouragement and would pour out paint into large amorphous puddles on the paper (Figure 2). She seemed more interested in the flowing quality of the materials than what they could do. Much of the work revolved around her making these large messy paintings within the boundary of the piece of paper. My comments to her either about the quality of her use of material or her use of paint and saliva to blur the distinction between self and other, never seemed to impact. Over the course of time Mary’s over-flowing use of paint and saliva prompted me to suggest that she make use of the flowing water and containers in the Figure 2. Looking together large aluminium sink located in the corner of the room. This was done in an attempt to offer both a practical and psychological way to hold her and her work. Mary was able to make greater use of the water and containers, becoming more enlivened at the sink. She was eager to place her hands into the flowing water and would frequently bring her wet hand up to her mouth. Her eyes often became transfixed by the flowing water in a more mindless manner reminiscent of her use of saliva. However there were times when she would tip out the container or turn on and off the tap when I spoke to her about the container being either full or empty. Although materials were all used in a very concrete manner, there was the occasional glimmer of a shared experienced when Mary seemed to briefly become aware of my words and presence in the room. Discussion The striking factor of my time with Mary was the overriding absence of any shared quality to our work. She would often fix her stare into the distance and there was little evidence of coordinated looking between the image and my eyes in any referential way. It predominantly felt as if my mind, my thoughts and my words held no interest for her. Mary’s haunting lack of eye contact often left me feeling as if I was not there and it felt like there was little differentiation between how she related to an inanimate object compared to a live person in the room. Martin Buber makes a distinction between ‘I
Thou’ and ‘I
It’ relating (1958), the latter of which seems to accurately describe the way that Mary related to me in the art therapy room. As the work progressed it often felt like a real struggle to remain mentally alive to her. Mary’s use of her saliva and flowing quality of the paint seemed to suggest that its liquid quality was being used to maintain a fused and primitive state of mind. The concrete connection between her hand and mouth seemed to be reinforced by her gaze as she followed the bridging thread of saliva. It may be speculated that Mary was using her eyes to obfuscate the difference between her hand and her mouth. Possibly even seeing parts of herself as different, separate but connected, felt terrifying for her. This use of saliva and paint is reminiscent of Tustin’s conceptualisation of the ‘autistic object’ which ‘is an object which is experienced as being totally ‘‘me’’’ (1981, p. 118). Any awareness of a ‘not-me’ or of difference of self and other seems to have been obviated, as difference would threaten the frightening possibility of relating. If there is no distinction between self and other then ‘nothing can get in but more importantly, nothing can get out’ (1981, p. 118). Her fixed focus on her saliva suggests that possibly she 39 used her eyes to close off any gaps in experiencing difference and experiencing the other. It is possible to speculate that Mary’s lack of differentiation between self and other curtailed her experience of me as having a mind of my own which could be interested in her art work, providing another perspective to her own. Without an awareness of other minds Mary would not be able to develop a theory of mind, and to look at things from another point of view, all of which are important for the development of joint attention. I wondered about Mary’s early experiences of intersubjectivity in light of her difficulty in sharing mental states. Hobson suggests that ‘autistic children’s deficient capacity for affectively grounded interpersonal relations seriously constrains both their connectedness to and differentiation from other people, and for this reason impairs their capacity to symbolize’ (1993, p. 255). Mary seemed to use the art materials in a very concrete manner to sustain this lack of connectedness and differentiation. In working with Mary there was an attempt to reach her mind through art-making where there always was the potential for the art materials to take on a more expressive or symbolic quality. Towards the end of the work with Mary her use of water in the containers at the sink had, at times, a quality that suggested that she was more aware of objects having an inside and an outside which could be separate (Bion, 1962). It was at these moments when she seemed dimly aware of another mind in the room and became responsive to my words that there was a greater sense of a shared experience
although these were momentary and fleeting. However, these experiences sustained the work and belief in the art therapeutic relationship which could be maintained despite the lack of visual joint attention. Dyadic relating posed significant difficulties for Mary. This was evident in her avoidant eye contact and quality of looking at people as if they were the same as furniture. Mary’s capacity to relate triadically seemed to be a considerable developmental achievement away. Working with her highlighted the enormity and importance of the need to establish a shared experience with the other, in order for a therapeutic relationship to develop. Paul Paul was referred to art therapy as part of a treatment offered to him and his family within a Child, Adolescent and Family Consultation Service in the South-East of England. Paul was 12 years old when I met him, he was tall for his age, had brown hair and a pleasant and expressive face. From the start of our work, Paul was very insightful into and articulate about his difficulties. Based on a single episode, he complained of being anxious at school in case he was 40 J. Isserow sick. This anticipatory anxiety had developed to the point that it deterred him from attending for extended periods of time. His background was one of being the youngest child in the family with two much older siblings who had already left the family home. Paul’s parents were also experiencing marital difficulties, a constant concern for Paul. Another difficulty for Paul was going to sleep at night, which seemed to precipitate a great deal of separation anxiety for him. In an attempt to help him, his mother had begun to sleep on a spare mattress in his bedroom. In his sessions Paul was engaging and quick to work with the art materials. In his first session he chose to work with clay, looking up at me every now and then before returning to his interest to shape the clay. Once it was finished he placed it on the table between us and we were able to talk together about his experience of making and about the object itself: a disembodied head in a state of fright (Figure 3). When I wondered with Paul if there might be a link between the look of fright on the clay head and his own feelings, he became quiet, seemed to think about this for a moment or two before shrugging his shoulders saying ‘maybe’. Discussion Paying close attention to how Paul both coordinated and alternated his gaze between the art object and myself hopefully highlights how the act of looking together often goes by unnoticed. However, it contrast to Mary, Paul’s looking together seems to be in the service of object relating. His referential and coordinated eye contact during the making of the clay object suggests that Paul is aware that I have a mind of my own. Indeed it is possible that he was using his eyes to determine what kind of mind he had in the room with him. Paul’s ‘maybe’ suggests that at the moment when I make a connection between what he has made and how he feels, he can orientate himself towards another perspective, demonstrating a flexibility of perceptual orientation. At that moment it seemed as if Paul was stepping out of his perspective and looking at the clay head from another’s point of view. Psychoanalytically, this capacity to reflect on self is founded on the recognition of the sexual link between the parental couple (Britton, 1989). The fact that his mother was now sleeping in his room might indicate that it was this very issue of Oedipal relating that Paul was struggling with now as an adolescent, in the face of his parents’ marital difficulties. Although this paper is restricted in its focus to how the art therapeutic relationship is underpinned and informed by joint attention, it is interesting to note that both Mary and Paul seemed to be struggling with the similar issue of separation. Mary’s limited use of her eyes and rigid focus on her wet hand seemed to function as a way of denying any sense of separateness from her surroundings, maintaining a fused state of mind. As such, her eyes were used to avoid any awareness of other people and the possibility of relating to them. Paul on the other hand had a far greater developed mind seemingly grown from an early experience of emotional relatedness. Paul was struggling to use his eyes to gain insight into himself and begin to ‘look’ at some of his difficult feelings of being separate, in relation to his artistic production and the mind of the therapist. The development of joint attention skills also has implications for art-making itself. Damarell (1999) links the infant’s graphic development with the joint attentional behaviour of proto-declarative pointing, where there is ‘a transition from pointing to literally drawing another person’s attention to a phenomenon in the shared environment’ (p. 45, Damarell’s italics). Paul’s art object ‘points’ to his difficulties and can be understood as declarative in nature. While Mary’s use of paint has the potential for being thought about together, she seems to display little awareness that she can ‘point’ to her image as a target for both of us to think about. Conclusion Figure 3. The paper has attempted to explore the patient’s capacity to alternate attention to the art object and the therapist in art therapy by investigating how this Looking together capacity for joint attention emerges between mother and infant in ordinary development. It has argued that joint attention skills emerge out of the infant’s intersubjective experience of looking at the primary care-provider and slowly develops during the latter part of infancy into looking with her. It is dependent on the infant’s understanding that other people have minds separate to their own; that others’ minds have thoughts of their own which can be directed to objects and events in the world, as well as the infant developing the capacity to orientate to the other’s point of view. It also requires that the infant pays attention to both social and object aspects of their surroundings. Psychoanalytically, it is dependent on the capacity to see self as separate in relation to whole objects, as well as tolerating being on the outside of the parental couple enabling the child to think about the inter-relatedness of objects. Clearly understanding how patients use their eyes within sessions is a complex issue. The implication for art therapy is that the patient requires the underlying cognitive and emotional skills (Burhouse, 2000, p. 51) of joint attention should they be able to look, think and reflect on their own position and the position of their image within the session. Looking together at the art object is determined by the dance of the eyes between patient, therapist and art object. It requires an interaffective experience, enabled by the therapist’s sensitive and attuned (Stern, 1985) responses to the patient as well as the patient’s capacity to share affect with the therapist. Thinking around what the image may reflect or mirror back (Winnicott, 1971; Damarell, 1999) to the patient may need to be supported by the therapist within the triangular relationship. The development of joint attention by congenitally blind infants suggest that the vital element is to have a shared experience between mother and infant and the need to find alternative sensory fields for contact, should the visual senses be impaired. The above work with Mary confirms the need to establish a shared experience within art therapy before joint attention can develop. For patients such as Mary, the tactile qualities of the art materials can potentially provide an alternate domain for this shared experience. The dependence on the use of the eyes and visual joint attention skills (Scaife & Brunner, 1975) in art therapy distinguishes it from other forms of therapy. The development of visual joint attention between the ordinary developing infant and his mother has and continues to be extensively investigated by developmental psychology. As such, this body of knowledge offers another point of view where new links to existing understanding in art therapy can be made. As looking together at the physical art object is such a ubiquitous and distinguishing feature of art therapy, it seems important to begin to integrate some of this 41 research into our own theoretical thinking and understanding of the art therapeutic relationship. Acknowledgements I would like to express my gratitude to Barrie Damarell for his thoughtfulness in helping bring this paper into fruition. Note 1 In this article ‘patient’ and ‘client’ are used interchangeably. In addition, pronouns used for client/patient and infant are in the masculine unless referring to a specific individual. Similarly, the feminine pronoun is used for ‘primary care-giver’ and ‘therapist’. This is done to aid comprehension. References Alvarez, A. (1992). Live company: Psychoanalytic psychotherapy with autistic, borderline, deprived and abused children. London: Routledge. Alvarez, A., & Furgiuele, P. (1997). Speculations on components in the infant’s sense of agency: The sense of abundance and the capacity to think in parentheses. In S. Reid (Ed.), Developments in infant observation: The Tavistock model (pp. 123
139). London: Routledge. Bakeman, R., & Adamson, L. (1984). Coordinating attention to people and objects in mother
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13. Wright, K. (1991). Vision and separation. London: Free Association Books. Biographical details Jonathan Isserow is a state registered art therapist who has worked extensively within child, adolescent and family psychiatry. He has an MA in Psychoanalytic Observational Studies from the Tavistock Clinic and is the Programme Co-ordinator for the MA Art Therapy training at Roehampton University, London.