International Journal of Art Therapy, 2013

Vol. 18, No. 3, 122131, http://dx.doi.org/10.1080/17454832.2013.786107

Between water and words: Reflective self-awareness and symbol

formation in art therapy

JONATHAN ISSEROW

Abstract
This article explores the development of symbols in art therapy. It is particularly interested in the moment when art materials
are lifted up from their concrete materiality and acquire symbolic significance in the context of the therapeutic relationship.
This investigation into symbol formation is explored by comparing two individuals’ different uses of water. The first is based
on Helen Keller’s encounter with water as described in her autobiography The Story of My Life (1903). This account is then
compared to the use of water by an adolescent boy with profound autism, in an art therapy session. The theoretical
perspectives of art therapy theory and developmental psychology are used to examine the particular interpersonal and
intrapersonal conditions that may be required for the development of reflective self-awareness and the emergence of
symbol formation. Some implications for practice are explored towards the end of the article.

Keywords: Helen Keller, symbol formation, reflective self-awareness, visual joint attention, autistic spectrum
disorder, theory of mind

Introduction The importance of symbols

This article explores how symbols are formed
within art therapy. It is particularly interested in
the moment when art materials are lifted up from
their concrete materiality and acquire symbolic
significance. This moment of transformation is
examined by contrasting two individuals’ very
different use of water. The first is based on a
historical and literary account of an encounter
with water as described by Helen Keller in her
autobiography The Story of My Life (1903). This
is contrasted with a profoundly autistic
adolescent boy’s use of water in an art therapy
session. Both individuals’ experience of water,
together with their respective capacity to develop
symbols, is examined through the theoretical
lenses of art therapy theory, developmental
psychology and psychoanalytic theory. Through
making the comparison, this article aims to
highlight the importance of the interpersonal
relationship out of which symbols may emerge
and be given shape in images and words. It will
explore the primary*although not exclusive*
role that visual joint attention plays in the
development of reflective self-awareness and its
relationship to symbol formation. This, it will be
argued, is of central importance to art therapy,
which is interested in the emergence and
possible emotional meaning of symbols within
the therapeutic relationship, the structure of
which is predicated on visual joint attention
(Damarell, 1999; Isserow, 2008).
It is difficult to imagine a world devoid of symbols.
The richness, complexity and expressive potential
contained in symbols are a distinguishing feature
of what it means to be human. Symbol formation
lies at the very heart of humanity enabling both
inter and intra-personal communication.
Disturbances or inhibitions in symbol formation,
either for developmental or pathogenic reasons,
often result in a substantially curtailed experience
of life. As such, the therapeutic endeavour to
enable and promote symbol formation has been
an early preoccupation of psychoanalysis (Freud,
2011; Klein, 1988; Segal, 1957, 1991) as well as
in the relatively more recent field of art
psychotherapy (Case, 2005; Dalley et al., 1987;
Dubowski, 1990; Killick, 1996; Killick &
Schaverien, 1997). In my work as an art therapist
in a profound and multiple learning difficulty
(PMLD) residential school for young people, I
have been interested in the moment when art
materials are transformed from being used
concretely (Segal, 1957) to being lifted up and
used in a more symbolic manner. Although often
momentary, this significant change has led me to
wonder what the psychological and relational
conditions might be that enable this to occur.
This shift from the absence to the acquisition of
symbol formation has nowhere been more
dramatically documented than in Helen Keller’s
autobiography The Story of My Life (Keller, 1903).
It is a description of moving from one kind of world
into another and pertinently informs some of my

# 2013 British Association of Art Therapists

 Reflective self-awareness and symbol formation in art therapy
clinical concerns. Before turning to that
remarkable*if now mythologised*dawning of
symbolic thinking, it is useful to briefly return to
Helen Keller’s life to set the moment in context.
Helen Keller revisited
The name Helen Keller is intimately linked with
the image of an individual overcoming the
isolation of blindness and deafness to become ‘a
symbol of the indomitable human spirit’
(Herrmann, 1998, p. 9). Keller was born in
Tuscumbia, Alabama, on 27 June 1880. Keller
was not congenitally blind and deaf but lost the
use of her sight and hearing following an acute
illness at 19 months of age. The doctors at the
time described it as ‘an acute congestion of the
stomach and the brain’ (Keller, 1903, p. 3),
although the illness is now thought to be
meningitis (Herrmann, 1998, p. 9). In 1886, her
Figure 1. Helen Keller and her teacher Annie Sullivan
123
mother Kate Keller was inspired by an account in
Charles Dickens’s American Notes’ (Dickens,
1842) of the successful education of another deaf-
blind child, Laura Bridgman, and travelled to a
specialist doctor in Baltimore for advice. He put
her in touch with local expert Alexander Graham
Bell who was working with deaf children at the
time. Bell advised the couple to contact the
Perkins Institute of the Blind, the school where
Bridgman had been educated, then located in
Boston Massachusetts. The school delegated a
teacher and former student, Annie Sullivan,
herself visually impaired and then only 20 years
old, to become Helen’s teacher. The meeting of
Annie Sullivan and Helen Keller marked the
beginning of a 49-year-long relationship between
teacher and pupil and one that brought them both
international acclaim (Herrmann, 1998, p. 43).1
See Figure 1: Helen with her teacher.
124 J. Isserow
From the start of their meeting, Annie began
spelling names of objects that she and Helen
encountered, using the manual finger alphabet
Annie had learned to communicate with Bridgman
at the Perkins Institute. At the time Helen had no
language, seemed profoundly unreachable and
feral. With steely determination Annie worked in
this manner with the highly spirited Helen as they
began to forge their relationship. This work in turn
laid the ground for the birth of thought, the
‘miracle’ as the amazed Victorians referred to it
(Herrmann, 1998, p. 45), which occurred a month
after Annie’s arrival at the Keller’s homestead. In
her autobiography, Keller provides a moving
account of this moment:
We walked down the path to the well-house,
attracted by the fragrances of the honeysuckle
with which it was covered. Someone was drawing
water and my teacher placed my hand under the
spout. As the cool stream gushed over one hand
she spelled into the other the word water, first
slowly, then rapidly. I stood still, my whole
attention fixed upon the motion of her fingers.
Suddenly I felt a misty consciousness as of
something forgotten*a thrill of returning thought;
and somehow the mystery of language was
revealed to me. I knew then that ‘w-a-t-e-r’ meant
the wonderful cool something that was flowing
over my hand. That living word awakened my
soul, gave it light, hope, joy, set it free! There were
barriers still, it is true, but barriers that could in
time be swept away. (Keller, 1903, p. 12)
Keller’s dramatic ‘revelation’, and the return of
her capacity to think symbolically, suggests a
transformation from experiencing the world as
two-dimensional and body-dominated into a
three-dimensional, psychologically alive
permeated space. Explicit in her account is the
realisation that one thing can represent another:
the shapes of the finger-letters ‘w-a-t-e-r’ spelled
into her hand can represent the cool liquid
flowing into the other. Implicit in this realisation, it
may be argued, is the awareness that this
symbol can be shared with another mind, that
being her teacher’s. This awareness of having a
mind in relation to other minds is a profoundly
human experience, enabling what Martin Buber
(2004) calls ‘IThou’ relating, that is, an
awareness of self as a person in relation to other
people.
Hobson (2004) argues that genuine
communication is based on a background of
sharing between minds, where feelings link one
person to another and where the intention to
communicate is apprehended and attended to by
the other. In the above example, it may be
speculated that Keller made the quantum leap
into something that may be close to mentalisation
(Fonagy, Gergely, Jurist, & Target, 2002), that is,
the capacity to ascertain and infer others’
intentionality and mental states. Keller’s sudden
capacity to comprehend the nature of symbols
seems to be born out of her awareness of her
teacher’s passionate intention to communicate
and share the world with her and the self-
realisation that she too had a mind that could
receive such a communication. In this sense, it
can be argued that Keller’s development of
symbols was concurrently formed alongside and
dependent on her capacity for reflective self-
awareness. It is to this development in infancy
that the article now turns.
Joint attention, reflective self-awareness and
symbol formation
Keller provides a very dramatic account of the
emergence of a seemingly fully formed capacity
for symbol formation. However, in ordinary
development this is based on a far slower and
accumulative process within the infant dependent
on a range of developmental milestones marked
by two distinct ways of relating to the world.
Trevarthen’s (1993) concepts of primary and
secondary intersubjectivity respectively
encapsulate these two distinct periods of
development, which can be considered to lay the
ground for the emergence of symbol formation.
Primary intersubjectivity refers to an early
period of infant development between birth and
the second part of the first year of life. In its
simplest terms, it is characterised by the
experience of shared emotional states between
the mother2 and the infant in mutual face-to-face
engagement (Trevarthen, 1993). Diagrammatically
this can be represented by axis IM as seen in
Figure 2. The experience of sharing states of
affect between mother and infant is enabled
through a range of behaviours including affect
attunement (Stern, 1985), reciprocity (Brazelton,
Koslowski, & Main, 1974) and turn-taking
between mother and infant as well as mother’s
(M)other
(I)nfant (W)orld
Figure 2. From Hobson, 2004, p. 272
 Reflective self-awareness and symbol formation in art therapy
contiguous mirroring (Fonagy & Target, 2007) of
the infant’s state of mind. Importantly, it also
allows for periods of rest where the infant is given
a chance to look away and self-regulate before re-
engaging with mother (Stern, 1977). In his more
recent book, Stern (2010, p. 43) argues that this
experience of intersubjectivity and the sharing of
emotional experience is the ‘foundation for future
mental and emotional life’. It can be argued that
experience of primary intersubjectivity or ‘mind-
mindedness’ (Meins et al., 2002) is of profound
importance for later life and that the quality and
consistency of the care has far-reaching
implications. Within a psychoanalytic paradigm,
Winnicott’s (1971) idea of ‘primary maternal
preoccupation’ (1956) also captures this quality of
mother’s concern with her infant and their shared
emotional experience during this vital early
developmental period. One of the main
behaviours characteristics of primary
intersubjectivity in this period is that the infant is
only able to attend to one object at a time. The
infant may interact with mother or with an object
but never does he attend to both in a coordinated
way (Bakeman & Adamson, 1984) (axis IW in
Figure 2), even when mother is looking at the
same object (axis MW).
Secondary intersubjectivity
At around nine months of age the infant’s
behaviour increasingly demonstrates ‘a growing
awareness of how other persons work as
psychological beings’ (Tomasello, 1993, p. 33).
A new type of behaviour begins to emerge and
includes the sharing of attentional focus and affect
around a common object or event (Scaife &
Bruner, 1975). This new form of cooperative
intersubjectivity (person-person-object
awareness) is called secondary intersubjectivity
(Trevarthen, 1993). At this period, there is a
dawning awareness of mother having her own
mental and emotional state and the toddler
becomes as interested in her mental state as
much as the object or event itself. This secondary
intersubjectivity underpins joint attention
behaviours and not only includes the sharing of
interest but also includes the monitoring and
directing of the other’s attention around an object.
This is often achieved through the use of pointing,
gesture and referential eye contact. Sharing of
attention with a significant care-giver around a
third object or event is often accompanied and
reinforced by tremendous positive affect and
shared enjoyment.
Vision plays a central but not exclusive role in
enabling the infant to ‘locate’ the object or event,
125
targeting the domain for the shared experience.
The infant (and joint attention partner) has to be
able to follow the line of sight indicated by the
pointed finger or directional eye movement.
Doherty (2009) has explored how the unique
morphology of the human eye enables gaze
direction to be detected. Humans are the only
primate species with extensively visible white
sclera (see Figure 3). As a result, Doherty (2009,
p. 106) argues, gaze direction is easier to detect,
enabling humans to signal with gaze. The eyes,
with their capacity to focus direction of interest
and communicate affectual states, play a
significant role in shaping and locating both the
infant’s and the carer’s shared attentional field. In
the absence of vision, carers need to find
alternative sensory routes to ensure the infant
finds a way to another mind and the shared world
beyond their relationship (Frith, 2003; Hobson,
2004; Isserow, 2008).
This kind of directional gazing and declarative
pointing3 (Leung & Rheingold, 1981) shapes the
attentional focus of the other so that an object or
event that may have been in the background is
now brought to the foreground of attention. For a
toddler to follow the direction in which another is
looking or pointing strongly suggests that the
infant has an awareness of the other as a
psychological agent with its own affect and mental
states. This opens up the potential to ascertain
and apprehend different psychological states of
mind in others, laying the ground and being a
‘critical precursor’ to the development of a theory
of mind (Baron-Cohen, 2000).
At this point in his development, the toddler not
only expands his repertoire for social interaction,
but he is also able to explore the world, discerning
its potential meaning which is always socio-
contextually dependent. The prime example of
this is the visual cliff experiment (Sorce, Emde,
Campos, & Klinnert, 1985) where the toddler uses
social referencing to determine the meaning of a
visually ambiguous situation. The child is placed
on a platform that halfway along turns into a visual
cliff. The child’s mother is placed at the far end of
the platform encouraging him to crawl over. At this
point the toddler needs to be able to share
mother’s attention to the visual cliff*to step into
her shoes*and to understand mother’s facial
communication, whether she is frowning or
smiling, to determine if the situation before him is
one of danger or one of play. What is of primary
importance here is the toddler’s capacity to take
on another’s perspective and to realise the
‘meaning conferring’ (Hobson, 1993) nature of
other minds. ‘Seeing’ the world from another’s
point of view implies an awareness and self-
126 J. Isserow

Figure 3. Primate vs. human eyes

Clockwise from top left: the eyes of two marmosets, a gorilla, a chimpanzee and two humans. Note that only the humans have visible
sclera. (Photos: marmosets, Hannah Buchanan-Smith; gorilla, copyright Michelle Klailova; chimpanzee, Louise Lock; humans, Martin
Doherty)

reflection that the infant too has a mind that can
be informed by another’s perspective or, put
another way, it means looking from the outside to
see the self from the inside. From here the
connection to the development of symbolic
thinking and reflective self-awareness becomes
more possible to understand and can be
diagrammatically represented as shown in
Figure 4.
Hobson’s (2004, p. 272) relatedness triangle
(Figure 4) provides a useful conceptual
scaffolding to understand how the capacity for
joint attention may develop and be intimately
linked to the related events of reflective self-
awareness and symbol formation. While clearly
symbol formation might be understood from
(M)other
A had a mind that could take on a new perspective
B
(I)nfant
Figure 4. Triangle of relatedness (Hobson, 2004, p. 272)
various perspectives, remaining a mysterious
process, the following is an attempt to provide a
possible account of its development.
In returning to the moment of symbol formation
with Keller described above, it is possible to
speculate that somewhere in her mind Helen
realised that her teacher too had a mind and that
this mind had its own interest and attention. It is
feasible to suggest that Helen ‘stepped into’ her
teacher’s shoes ‘as if’ seeing the world from her
perspective (represented in Figure 4 by the
movement ‘A’). From this position, she could
apprehend her teacher’s ‘meaning conferring
nature of her mind’ (Hobson, 1993, p. 49),
realising that her teacher could attribute the finger
configuration ‘w-a-t-e-r’ to represent the cool liquid
substance flowing through her hands
(represented in Figure 4 by the axis MW). From
here Helen could have a realisation that she too
of the water and that she could share in conferring
meaning onto the liquid by the finger alphabet
spelled out in her hand and to use the figure
configuration to represent water. This new view
(W)orld
can be represented in Figure 4 by the movement
‘B’. She realised, as Hobson says, that she could
‘intend to symbolise and make one thing stand for
 Reflective self-awareness and symbol formation in art therapy
something else’ (1993, p. 255). What is interesting
about Helen and her teacher’s communication is
that they were able to locate the shared field of
experience through the tactile domain of the finger
alphabet. As mentioned earlier, it is vision and
directional eye movement in the sighted infant
that facilitates the capacity to target and locate the
object or event that can be shared and
experienced together.4
The development described above places the
symbol in a triangular relationship to what it
signifies. In addition, the finger-shaped-letters
‘w-a-t-e-r’ do not resemble the thing itself. Rather
it is through a shared convention that meaning
has been inferred onto the finger shapes so that it
now stands as a sign (Sobchack, 1992). Similarly,
the arbitrary sounds of language and written
squiggles on a page become the shared signifiers
to their signified. While a semiotic investigation
into the complexity and difference between the
signs of symbol, icon and index is beyond the
scope of this article, it is important to note that
symbol here is used within the Peircean tradition
(Peirce, 1972) where the signifier does not
resemble the signified. Their relationship is
fundamentally arbitrary and must be acquired
through the use of another’s mind. As such, the
use of symbols is dependent on the capacity to
both share an experience with and retain a degree
of separateness from the other.
It is this triadic relationship described above
that initially develops externally to the toddler and
later becomes internalised as a function of the
mind (Hobson, 1993), through repeated
experiences. It is this capacity that can be
understood as the development of symbol
formation. However, it is important to note that far
from being a cognitive capacity, the development
of symbol formation has deep emotional roots. It
requires that the toddler is able to separate from,
while at the same time be able to identify with its
primary care-giver. The toddler’s emotional
struggle for separation can be seen in Winnicott’s
notion of the ‘transitional object’ (Winnicott, 1971)
which may be considered to exist in between the
developmental stages of primary and secondary
intersubjectivity (Trevarthen, 1993). Its role attests
to the emotional challenge of separation required
to perceive objects as separate, objective and
outside the self. This places emphasis on the
importance of the earliest relationship out of which
symbol formation may develop. After all, as it is
possible to speculate, it is Helen’s experience of
being held in mind by another mind that became
the precursory step towards being able to think
about her own mental activity and internalise the
127
experience of secondary intersubjectivity
(Trevarthen, 1993), as described above.
Reflective self-awareness and symbol formation
in an art therapy session
Having explored Keller’s use of water along with
the possible dynamics involved in the formation of
symbols from a developmental perspective, the
article now turns to look at the capacity for symbol
formation of a profoundly autistic adolescent boy
within an art therapy session. These sessions
form part of a treatment programme in a school
that works with young people with PMLD, in the
south east of England. The examination of
reflective self-awareness and symbol formation is
embedded in a detailed vignette, written up
immediately following the session. All personal
details of the adolescent have been changed to
preserve confidentiality and consent to use
anonymous case material has been given.
Tom
Tom is a lively, physically robust 14-year-old boy
of average height and weight, who has a
diagnosis of being on the severe end of the
autistic disorder spectrum. He has a likeable face
with bright blue eyes that constantly dart around
and a very expressive mouth which is often
scrunched up, giving him an appearance of a
perpetual smirk or grimace. He has been at the
school for nearly three years and has attended art
therapy for just under a year. He is an only child of
a Mediterranean couple and is one of the few
children at the school who has contact with his
parents. His parents have had an acrimonious
separation but, interestingly, still live in the same
house. His father occupies the lower portion of the
house while his mother lives in the upper section.
It is unknown which part of the house he sleeps in
when he returns home, which he may do around
one weekend every month. All correspondence
from the school to his parents needs to be sent to
each parent independent of the other, despite
being sent to the same address. Tom was referred
to art therapy as part of a care programme to help
him with his extreme mood swings of becoming
too ‘high’ or too ‘low’. This split in mood suggests
a direct correlation to the split within the parental
relationship.
The following extract takes place 10 minutes
into an art therapy session. The session is in a
bright dedicated art room, which has several
tables pushed together in the middle of the room
with a variety of art materials and paints laid out in
a palette and brushes on one of the tables. To the
128 J. Isserow
right of the room is a large aluminium sink
serviced by hot and cold water taps with one
spout. The hot water is connected to a gas boiler.
The water in the boiler becomes very hot, but once
empty it cools down, before heating up again. At
this point Tom had been attending therapy for
eight months and was quite familiar with the room.
With elated energy and a maniacal smile, Tom
takes the small coiled up piece of string from the
table and dips it into the yellow and orange paint
in the palette. Holding the paint-drenched string in
his hand he wildly moves to the basins opposite
the table and takes down several bowls from a
shelf above the sink. He places a large bowl into
the sink, drops the string into the bowl and quickly
turns on the hot and cold-water taps. All this
seems to be done at lightning speed and I move to
stand near Tom by the sink. I remind Tom that the
water in the tap can become very hot and that we
need to make sure that it does not become too hot
and risk getting hurt. The water gushes into the
container in the sink and Tom seems mesmerised
as he watches the now pale yellow water first fill
and then spill over the sides. The knot of string
floats at the edge of the bowl firmly holding Tom’s
attention. In an attempt to both physically and
psychologically contain Tom, I turn down the
excessively fast running taps managing both the
temperature of the water as well its flow rate. Tom
then turns the taps higher as I encourage him to
try to keep the water luke-warm. I occasionally
gauge the temperature of the water with my hand
and turn down the hot water or increase the cold.
In a devouring way he takes the string into his
mouth, fills his mouth up with water and spits out
several strong squirts of water against the splash-
back tiles behind the taps. Occasionally he takes
the string out of his mouth and rests it in the bowl.
He then drinks some of the water either directly
from the tap or from the bowl only to regurgitate it
back into the bowl. At other times he keeps the
water in his mouth and then spits it out against the
tiles in a long stream. He then flaps his hands
together in an excited way. He then takes the
string back into his mouth and plays with it in his
mouth for a while, sucking, pulling and licking at it
between his teeth and tongue.
The hot water becomes very hot and I remind Tom
to be careful and try to keep the water just warm. I
turn on the cold water, regulating the temperature
and our hands do a kind of dance around the taps
both satisfying Tom’s desire for strength of water
flow as well as making sure that it is safe to use. It
is a complicated dance as I have to both avoid his
occasional jets of squirted water directed at the
tap and avoid him pushing my ‘thermometer-
finger’ out of the stream. After reminding him
several times that the water is hot, Tom says ‘Hoh’
and almost points to the water. I say ‘Yes the
water is hot’. I then ask him if we could work
together to make warm water by mixing both the
cold and the hot together. He ignores me as the
water flows continually and fills up the overflowing
container. Drinking from the bowl, Tom then
manages with a greater capacity to regulate the
temperature of the water himself. Tom continues
to play with the string in his mouth and lap up
some water before squirting it out again.
Analysis
In this report, Tom can be seen to have an
appropriate awareness of the different materials
and their physical properties, which possibly
suggests that Tom has been able to achieve a
degree of differentiation of self from other. Tom’s
preoccupation with the string is suggestive of an
infant’s pre-natal interest in their umbilical cord,
bringing to mind Piontelli’s work (1986) of
observing pre-natal and neo-natal life. I felt at this
point that it was unclear from Tom’s use of string
how differentiated or how fused Tom was with me.
In his paper on string, Winnicott (1960) suggests
that the young boy’s obsessional use of string is
used to restore a previous state of connectedness
to his mother. I felt that Tom’s use of string placed
him somewhere on the spectrum between a
completely fused relationship and a more
differentiated one with myself, and it seemed to be
actively blurring any gaps between us.
Tom uses water in a reckless manner, letting it
endlessly fill up and spill over the sides of the
container. Similarly, I think, Tom uses the water to
fill up and spill over the container of his mouth. In
doing so he blurs all distinctions between an
inside and an outside. The difference of his mouth
to the water is further confused when Tom mixes
the water with his saliva, as well as using water to
continuously create a drinking-spitting cycle.
Perhaps the creation of jets of water from his
mouth is connected to an earlier feeding situation
where Tom may have experienced the feeding
object (breast or bottle) as a sensual jet of fluid in
his mouth. Through maintaining a degree of non-
differentiation, he is able to avoid distinguishing
whether this fluid came from a spring inside his
mouth or from a source external to him. His use of
string both inside his mouth and inside the
container which is full of running water suggests
to me that when the string is in his mouth he
concretely equates the endless running tap to his
mouth (Segal, 1957). Through using water in this
way he seems to be recreating this blurred
experience in his mouth, bypassing or obfuscating
any recognition of any separate person, possibly
 Reflective self-awareness and symbol formation in art therapy
defending himself from any knowledge and
dependency on a separate source.
From previous sessions of actually seeing and
smelling Tom regurgitate water, it is possible to
speculate from his body posture that here too he
may have been regurgitating the water from his
stomach to his mouth. This can be considered to
be indicative of a state of mind, which completely
denies the dependency on any outside source, as
here his own stomach is made to feed his mouth.
The self-generating sensation of the liquid coming
from within him also suggests that he may, in
primitive phantasy, feel as if his mouth is the tap
and that he has ownership of the feeding breast
inside him.
Despite his overwhelming interest in the water
and the string, Tom does not generate in me the
mind-numbing feelings that my work with other
children on the autistic spectrum can generate.
With Tom I felt able to persist in my attempts to
regulate the water temperature and try to reach
his mind by describing his actions and behaviour
to him, alerting him to the presence of the two taps
which could be used to enable both of us to safely
work together. His insistence on using
predominantly one tap despite the two taps being
attached to the same spout is suggestive of
Tustin’s (1981) idea of basic un-integration
between hot and cold, male and female. Similarly,
it is hard not to link his extreme and un-integrated
mood swings to the concrete, geographical
location of his parents within the same house as
mentioned above.
I am aware I experience Tom’s almost exclusive
preoccupation with the hot water as being
rejecting, making me feel left out in the ‘cold’. I
have noticed at times that Tom can leave me
feeling deeply frustrated and exasperated as he
quickly moves around the room, often avoiding
my presence. This makes me wonder if Tom’s
more manic behaviour conceals a deeper anxiety
of a deathly and lifeless state brought about by an
awareness of a separate object. His at times
manic denial of the other seems to function as a
way of keeping these depressing and catastrophic
feelings in abeyance. When he is very quiet and
withdrawn, do these more deathly feelings of loss
predominate?
My persistent attempts to help him regulate
both the intensity of the flow and temperature of
the water, for his benefit as well as my own, can
be seen as an attempt to regulate Tom’s feelings
on both a material and psychological level. There
are faint echoes here of the scene described by
Keller above, for like Keller and her teacher, we
both have our fingers in the water together, and it
enables Tom to briefly think and be aware of the
129
hotness of the water. He is able to respond to this
awareness by saying ‘hoh’ and almost points to
the tap with his fist. It is possible to speculate that
at this moment he has a greater capacity to be in
relation to my mind and that he can experience
me not just being in competition for control of the
taps, but as an accommodating person who could
take into account both his feelings and desire for
an interface with the water, as well as the physical
and potentially dangerous qualities of the hot
water.
His use of the word ‘hoh’ and pointing gesture,
following my use of the word ‘hot’, joins up our
attention to a shared experience. It is a fleeting
moment of joint attention and brings the work to
life. At that moment Tom seemed to ‘step into my
shoes’ and take on my perspective. In doing so he
could be in relation to another mind and have an
awareness of his own mind that too could pay
attention to the quality of the water being
described to him. It is these fleeting moments
when Tom manages to be in relation to, and
identification with, a human mind that the sensory
materiality of the water is lifted up to be used in a
symbolic manner. As a corollary to this, the denial
of another mind in the room seems to leave Tom
in a sensory-dominated world. Although there
must be some identification with another mind for
Tom to be able to produce the word ‘hoh’, it seems
as if this is only partial, retaining a somewhat
unclear and incomplete recognition, as he leaves
off the last consonant, which would otherwise
form a boundary.
Tom is greatly attracted to water, using it in
very ritualistic and repetitive ways. What may
have been problematic in his development may
be understood in part to reside to his
identifications, not with a person but rather with a
non-human object. It is at these moments when
he is able to be in relation to, and identified with,
a human mind that he can realise the meaning-
conferring nature of minds including his own,
which enables a greater symbolic relationship to
emerge. From a psychoanalytic view, his use of
water can be seen to move from more
transitional space (Winnicott, 1971) towards
increased triangular space (Britton, 1998) as
symbol formation begins to develop.
Implications for art therapy
The momentary engagement with Tom and our
shared attention seems vital to sustain the
liveliness of the work together. It hopefully
suggests that efforts to engage can be built on
and sustained. Even an incremental development
in Tom’s capacity to engage in relationships is
130 J. Isserow
significant. The vitality of the water completely
captivates Tom, leaving him hard to reach.
However, the water can potentially also be used
as a point of shared connection to begin to
engage him in interpersonal mind-to-mind
relating. Although the importance of joint attention
and its connection to reflective self-awareness
have been explored here in relation to an
adolescent on the autistic spectrum, I would argue
that its value can be generalised to other clinical
areas. Within any art therapy session it may be
useful to consider if and when the client is
predominantly engaged either with the art
material/art object or with the therapist, as well as
moments when the client can be in relation to all
components of the art therapeutic relationship
and in a more secondary intersubjective state of
mind (Damarell, personal communication).
Clearly the client’s early attachment patterns
(Fonagy and Target, 2007) will have a significant
impact on the quality of joint attention in art
therapy. However, the therapeutic relationship
provides an opportunity for reworking this early
experience along with the potential for new
development. Also, it is important to note that the
art-making process in art therapy has periods of
rest and self-regulation built in when the client
may move towards and away from art making
and/or the therapist in the relational dynamic.
In addition, the development of reflective self-
awareness and symbol formation is by no means
exclusive to the art therapeutic relationship. It
can be argued that making art in the presence of
a mindful other may also have significant
benefits. However, in the end it is the client’s
shared experience and capacity to take on
another point of view that may enable therapeutic
change to occur. Importantly, it is the particular
sensitivity and skill of the art therapist to know
when to make space for the client to have a more
primary intersubjective experience and when to
encourage a greater sense of secondary
intersubjectivity and attuned joint attention
(Stern, 1985). Clearly this capacity is developed
as part of the art therapists’ training, which
includes the development of a sensitivity to the
vitality affects (Evans & Dubowski, 2000)
embedded in the use of art materials, along with
the capacity to tolerate not-knowing for extended
periods; the capacity to attune to a depth of
feeling and consideration for unconscious
dynamics between all elements in the art
therapeutic triangular relationship; a depth of
understanding of the particular difficulties and
care context of a specific client group; practising
within a safe, ethical and therapeutic framework;
and a capacity to articulate and self-reflect on
practice privately and in supervision. It is this that
makes art therapy a relational environment par
excellence to facilitate the mutually enabling
processes of reflective self-awareness and
symbol formation.
Notes
1
See Herzog’s documentary ‘Land of Silence and Darkness’
(1971) for a further exploration of experiences of people who
are both deaf and blind.
2
To aid comprehension, the term ‘mother’ is used to refer to the
infant’s primary care provider. Similarly, the masculine pronoun
is used when referring to the infant.
3
For a detailed discussion on the difference between declarative
and imperative pointing, see Leung and Rheingold (1981).
4
It is possible to speculate that Helen’s formation of this capacity
was established in her earlier relationship with her primary carer
but that this was lost or forgotten due to her illness, which
appears to have left her in a highly regressed state.
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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 currently a PhD candidate at
UCL. He is the Programme Convenor for the MA Art
Psychotherapy Programme at University of
Roehampton, London.
Email: j.isserow@roehampton.ac.uk
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