Francis Dixon Lodge is a therapeutic community in Leicester with a capacity for up to 15 residents. The Lodge also runs a day and out-patient service. The residential programme runs from Monday to Friday (with residents returning home at weekends), and comprises twice daily community meetings, twice weekly small group psychotherapy sessions, a once weekly art therapy group and a once weekly care-planning group. There is also structured time for recreational activities, housekeeping tasks and involvement in assessment of referrals. In addition to planned groups, a crisis meeting can be called at any time by any community member who feels they or another member are struggling in some way. This involves calling on the community to think about how to manage the situation, and is the way that therapeutic communities challenge impulsive behaviours. Individuals may not be at a stage where they feel able to manage their feelings at the time and are likely to ‘act out’ in self-destructive ways, but others around them may be able to offer advice and support. With time, it is hoped that they are able to develop more elastic impulse control (Reference CamplingCampling, 2001).

Staff and patients

The staff have a broad range of experience and include nurses, doctors, psychotherapists, a social worker, an art therapist and both psychology and nursing students. The client group mainly consists of those labelled as having ‘ severe personality disorder’, the majority being best described as borderline type. Self-harm, somatic complaints, comorbid substance misuse and eating disorders, and a history of childhood abuse are all common. Clients are frequently referred with a history of lengthy contact with acute psychiatric services, often including difficult admissions where self-harm behaviour has escalated. As a result of such experiences as adults with healthcare professionals and disturbed relationships in childhood it is hardly surprising that residents are often mistrustful on admission.

Art therapy

As a senior house officer joining the community for a 6-month placement, I felt very fortunate to have been given the opportunity to experience something that many of my colleagues do not have exposure to during their training. So when it was suggested that I could join the art therapy group as a co-facilitator, I readily accepted, wanting to derive as much experience from my stay as possible. It was only after accepting that I realised that I had no understanding of what the group would involve. I naively assumed that it would be based on residents producing artwork in a manner similar to my previous experiences at day hospitals, as a form of recreational activity rather than as a medium for their therapy. I even wondered if I would be expected to join in and paint as well! Thankfully, prior to joining the group I received supervision from the team's art therapist to prepare me for what was involved.

The term ‘art therapy’ was first used in the 1940s by Adrian Hill, an artist who worked with people recuperating from tuberculosis. He found that these sanatorium patients were able to use the artwork not just as a form of occupation but as a medium through which anxiety and trauma could be expressed. During the 1950s, art therapy groups usually existed in an informal open studio format where patients were free to come and go and discuss their work individually with the therapist. By the late 1960s and 1970s this had progressed to the development of formal groups with defined boundaries and greater attention paid to group dynamics. For further information on the history of art therapy see Waller (Reference Waller1991). Art therapists today possess both a degree in art and a Master of Arts or Master of Science degree in art therapy and are state-registered. It is a mode of therapy highly valued by users. Karterud & Pedersen (Reference Karterud and Pedersen2004) compared subjective benefit of a range of therapeutic groups and showed that the art therapy group received the highest user satisfaction ratings.

Francis Dixon Lodge

Art therapy was introduced at Francis Dixon Lodge a few years ago in response to the staff team's feeling that it would be beneficial for residents who were finding it difficult to articulate their feelings. At times, residents may feel ‘stuck’ in the groups but may be able to produce an image in art therapy that expresses their feelings. The art therapy group at Francis Dixon Lodge runs once weekly for 90 min and is attended by all residents. It is led by a trained art therapist, and co-facilitated by regular staff members with an interest in the group. The session is divided into two stages. During the initial stage the residents come together to create their work in the presence of the facilitators. This is then followed by a period of discussion, where everyone present is able to view the work that has been produced, and thoughts and feelings about the work are explored. Currently at the Lodge the artwork takes place in the dining room and the group moves into the lounge for the discussion period, but a dedicated art therapy room is in the process of being set up that will be accessible to both the staff and residents at all times. However, several residents have experienced difficulty working in the dining room related to issues around eating and transference issues relating to memories of family and school.

As with all groups at the Lodge, boundaries of the group are set by the community. All residents are expected to make a commitment to attend and to make every effort to remain in the room, even if they have finished their artwork before the group is scheduled to end. If a resident is struggling to the degree they feel unable to stay in the room, there is an expectation that they will inform the group and go to wait in the discussion room for the rest to join them. This boundary is felt to be particularly important as it encourages residents to stay with their feelings evoked by the work rather than distracting themselves with a coffee and a cigarette for example, only to enter the discussion period unable to access those feelings. Following the discussion, the art therapist keeps the work in an individual folder for each resident, thus building up a ‘portfolio’ of their work that they can access at any time and keep when they leave. This provides them with a tangible, lasting record of their therapy which is open to later reflection. The facilitators meet for after-group supervision, when the work and the group dynamics are discussed further.

Patients’ perspective

On joining the group, it quickly became apparent that several of the residents struggled with the art therapy. A common observation shared by many was how difficult it was to spend quiet time focusing on themselves, then to be left with a concrete reminder of their issues in the form of their work. For some, it would be a major achievement to be able to produce any artwork at all. At times, the group could become a channel for destructive feelings and resistance, especially if following a difficult community meeting. The group could be a place to protest, particularly against the ‘task’ to produce some work. Boundaries were frequently challenged, on occasion work would be produced but then promptly destroyed before it had been seen by others. Some would attempt to either ‘plan’ their work prior to the session or always produce work in a very similar style, perhaps in an attempt to avoid the vulnerable feelings that freer expression might bring. Some residents would refuse to take part at all and others would leave the group early without letting the group know. If such behaviour occurred it would be challenged during the discussion group. At other times the group came together in a cohesive way. I recall one group in particular, where the community was reeling from some extremely destructive behaviour by a resident that had resulted in widespread disruption to many community meetings and conflict among both residents and staff. Expecting the group to be fragmented and resistive, I entered with a feeling of dread but was pleasantly surprised to find the majority of the residents were keen to come together and use the group. Later on, during the discussion that followed, they were able to talk openly and constructively about the difficulties within the community.

Author's perspective

Much more than the artwork itself is open to exploration or comment during the discussion group, including body language and choice of materials. I was struck by how much could be learned about the residents’ states of mind and relationships within the community simply by sitting back and observing them working. Some residents used fragile or messy materials, producing work that required handling with special care after the session lest it would be damaged or deposit colour on to the surroundings. In these situations it often felt as if the resident was communicating their need to be looked after and borne in mind. It was common for some residents to produce images so small that they were easily overlooked by the group, and this could be likened to the experience shared by many of feeling insignificant within the community. I noticed that such individuals were able to increase the size of their work as their confidence grew. During my time in the group it was also not uncommon for new issues to be introduced through the artwork long before they could be spoken about within the community. It seemed to be therapeutic for such images with important, but as yet undisclosed, meanings to be simply acknowledged by the group. For example, one resident produced a sinister looking picture of a monster creeping out of a box. Some weeks later they were able to elaborate further and begin to talk about envious feelings for which they felt deeply ashamed.

Conclusion

I feel that my placement at Francis Dixon Lodge has been of huge value to me both professionally and personally, and my experience there was greatly enhanced by my involvement in the art therapy group. I would thoroughly recommend this experience to other senior house officers who are offered such an opportunity in the future.

Declaration of interest

None.