When the COVID-19 pandemic broke out, I knew that my usual art therapy rooms and materials would no longer be available, and I would have to completely redefine my art therapy practice. Like most of my colleagues, I was worried and anxious. I was searching for ways to stay connected.
In this situation of isolation and helplessness, my impulse was also to work creatively and to connect with other people in an artistic way.
I saw this as a chance to look for new opportunities for creative work and to devise something completely different. In my work in a psychiatric hospital, my primary question was not how to reach my patients; in a situation that was defined by fear and uncertainty, I saw my role as offering a protected space for a new framework of artistry.
In order to return to normal life, patients in forensic psychiatry have to complete a strictly regulated course of treatment. But what happens when the orienting compass no longer operates? How are patients supposed to complete a staged treatment plan, loosening clinical restrictions, when they are not permitted the freedom to leave the hospital? Everything that used to be considered normal now belonged to the past.
From one day to the next, art therapy in forensic psychiatry changed during COVID-19 restrictions: there were no more programs with patients from several hospital wards, and patient participation in the art therapy studio was limited under strict hygienic regulations. I was only permitted to work in one ward, rather than welcome patients from a number of different wards into the studio. Splitting up the groups in this way resulted in smaller groups. Art therapy was characterized by spontaneity and flexibility (as to place, time, and methods), but the new situation required new rules and new topics for creative composition. Three examples are discussed below.
Forensic psychiatry deals with themes of psychiatric assessment and treatment as well as criminal commitment. It protects the public and provides therapy to address the condition of the person who is being admitted for treatment. The primary concern is with motivating patients to cooperate and encouraging them to engage in therapeutic measures. The therapy treatment plan follows a multi-modal treatment concept (biological, cognitive behavioral, psychodynamic therapy, behaviour-modification strategies, occupational therapy, sports, etc.) and attempts to select and adapt different therapeutic approaches to the individual. In addition to individual and group therapeutic discussions, creative non-verbal therapies, such as art, music or body therapy, also play an important role. The client group described in this article are women working through their addictions, who have been committed for forensic psychiatry under the German Criminal Code.
As an art therapist, I mainly work with two dimensional images, but my personal interests as an artist go further (Stanoeva 2019). That is why I often support patients in the design of three-dimensional artworks (Stanoeva 2018). These become moulded through the use of wool, tape, and other materials, or created through physical experiences in space.
Stanoeva, A. 2017, Give Me Salt and Bread. Photograph of object with apple and transparent paper. Munich, Germany: Private Collection.
Three-dimensional art is an opportunity to approach new perspectives.
It can potentially transform hopeless or stuck situations (Schmeer 2007, p.190), offering a chance to leave the picture plane in order to inhabit greater physical progression and immersive encounters with materials.
Stanoeva, A. 2020, Remain Connected. Photograph of image in playful enactment. Munich, Germany: Private Collection.
Joseph Beuys, for example, introduced a new distinction between the definitions of sculpture and plastic arts and described the latter as something ideal and spiritual (Famulla 2009, p.79). He associated his new understanding of plastic arts with movement, and summarised this synthesis with the expression “Movement is plastic” (Kufus & Veiel,2017). Beuys viewed movement as a kind of instant plastic art, which, as such, necessarily manifests itself in simple and complex actions of the body: “Plastic is an energetic process, and nothing material or intelligible – it can hence only be experienced spiritually, if at all” (Famulla 2009, p.123).
COVID-19 is a challenge with limitations for each of us, one which poses the question about the definition of place, image or therapeutic space.
The crisis should be a chance to recognize that language and images are not the only channels of communication between therapist and patient. Movement is mostly related to bodily sensations and emotional experiences. Therefore, it appears as an additional way of creating progression in the therapeutic process.
Stanoeva, A. 2017, The Safe Space. Photograph. Munich, Germany: Private Collection
During the course of forensic therapy, patients need to adhere to the conditions of their stay by going through various stages of treatment that sequentially offer extended personal freedoms. Telephone and visitation times are strictly supervised. While all of our social lives were reduced to contact online or by telephone during COVID-19, the women on the forensic psychiatry ward were not allowed to use the internet or social media. They were prohibited from going outside the institution, and visits by family members and friends were not permitted.
The uncertainty exacerbated their fears and worries, as well as their longing for their families. “I hope society won’t forget us”, said one patient with serious concerns about what impact the crisis would have on her life and therapy outcomes.
In order to determine the results of their forensic treatment, the patients’ restrictions are gradually relaxed, following a step-by-step plan. It is fundamentally important that the women assume personal responsibility by committing to agreements, demonstrating reliability, remaining motivated, and communicating openly and honestly. They must also be able to develop relationship bonds. Each patient should also have a capacity for critical reflection, and to discern perspectives for their future. In a further course of therapy, a long-term trial outside the institution is important, through the search for a job and an apartment, as well as the client’s recognition of risk factors and early warning signs. This strictly regulated course of treatment is oriented towards re-creating the normal structures of everyday life, to which patients return upon their discharge.
A small group of three patients meets to paint together. Uncertainty is great because of the coronavirus crisis. The group agrees to create a large picture together. One patient takes the initiative and paints a motif for everyone—a big boat. The boat is playfully enlivened and creatively fitted-out with various elements: people, animals, furniture, etc. The picture appears integrated and harmonious. Everyone works together without dividing up the paper territorially or drawing visible boundaries. Everything intermingles and the boundaries become fluid.
The main theme in the picture is the coronavirus crisis, and the statement of the women is: “We are all in the same boat!” Together they are searching for a safe place where there is no coronavirus.
They design a place of refuge (Steiner 1993; Steiner 2014; Weiß 2009) to escape from fear and uncertainty. Although the motif is a place where people can shelter together, it is by its nature also a dynamic, moving element, a means of transport in which people can keep on sailing whilst being protected. The need for security, protection, and rescue becomes very clear.
Stanoeva, A. 2020, We Are All in the Same Boat. Photograph of image with oil pastel. Munich, Germany: Private Collection.
A small group of four women paint colour islands in a green meadow in the courtyard. Each patient creates her own painting, which expresses her current mood. Pieces of fabric are provided in different colours. The women pick a colour and construct their own colour islands on the lawn. Faces showing different emotions are also provided, to facilitate emotional expression. The “state of mind” exercise begins with a ball of yarn, which is passed around in a circle, creating a connection in the group. When the exercise is finished, the yarn is cut from the ball and used to thread together the sheets of paper, which have a hole punched in the corner. The yarn is knotted to close the circle.
Everyone paints a shape or colour expressing their current emotion, while the circle of pictures remains connected by the yarn. This playfully creates a common potential space, known as a transitional space, in order to promote therapeutic development (Winnicott 1971).
The circle of yarn is gradually rotated clockwise so that the pictures move from one island to the next, until everyone has added something to all the pages. The question asked is “What does it need?” Each picture returns to its author, who is given the opportunity to paint the finishing touches and, if necessary, to make final changes to the picture.
Stanoeva, A. 2020, Islands of Colour on the Lawn [Photograph]. Munich, Germany: Private Collection.
Four patients work together on a picture that deals with movement, changing perspectives and maintaining social distance. In contrast to the previous task in which the images were moved around in a circle, here the women themselves circle around the picture. The picture is thus a central element in the space, remaining on the table and serving as the point of connection for the group. The patients turn in a circle around a large sheet of paper and position themselves on the four sides of the rectangular pages (which are also the four points of the compass), to occupy one painter position each. Each person paints something and then moves one place clockwise until she gets back to the beginning and once again can add something to the picture.
The group facilitates a common design around a connecting element in the middle of the space, as well as a change of perspective through their movement around the table.
Movement as a creative action (Koch, 2017) leaves traces in space (Famulla, 2009) and provides an additional communication channel in the therapeutic space (Stanoeva, 2018). At the same time, this task maintains the necessary social distancing, and gives people time to observe and contemplate until they reach the painter position again. The bridge theme introduces additional questions: “What kind of bridge are we painting?” (in terms of size and use of materials); “Where is this bridge located?” (what kind of urban or rural landscape dominates), and “What does this bridge connect?” At one time you find yourself in front of the bridge, another time behind it, and you can play with these perspectives: “Where have I come from?”, “Where do I want to go (what are my goals)?” and “Where am I right now?”
Stanoeva, A. 2020, The Bridge. Photograph of image with oil pastel. Munich, Germany: Private Collection
Like any other life crisis, the global crisis caused by COVID-19 activates previous emotional injuries. It drives people to their limits, finds the sore points of the soul or confronts them with learned behaviour patterns. A crisis of external origin brings us back to situations in which we were subject to events within which we had no control. The phenomenon of a child who has been forgotten confirms this assertion. Forensic patients who live in a closed system, which has few points of contact with reality, can suddenly trigger fears related to being forgotten by society. The patients were not particularly worried about the restrictions on their freedom; it is more that the discontinuation of family visits intensified a deeper, primal fear of being abandoned, locked up or stuck inside a closed system.
In an extraordinary situation that confronts us with unknown challenges, we tend to look for answers in past history.The more uncertain the future appears, the more intensely our primal experiences and archetypes are stimulated. Cultural memory allows us to connect with one another through shared human archetypes (Holm-Hadulla, 2011, p. 13). As part of this memory, the creation myths express the idea of how the world changes from chaos to a cosmic order. As Holm-Hadulla writes: “Creativity is related to people’s need for order in the face of chaotic disorder. In almost all known myths, this order, after it is established, must be defended through continuous creative activity against destructive forces” (Holm-Hadulla 2012, p. 229). In other words, humankind is familiar with imbalances in nature and has tried to respond with an imaginative spirit and creativity.
Archetypal forces that are activated by isolation include, for example, the search for belonging and connection, and the search for a larger whole to which we all belong.
Given the common cultural images that imprint our human memory and our belonging to the collective unconscious, we can assert that we are all parts of the whole, and the cosmic (Stanoeva 2016, p. 63). The quest of many patients for spirituality and for higher powers is hardly surprising from this standpoint. The archetypal also appears in the image of the boat, which is reminiscent of Noah’s Ark.
At this time of challenges in all domains of life, art therapy also has the task of reinventing itself: redefining the setting, creating new spaces and ways to reach clients, and accessing new connections and methods.
With flexibility and mindfulness, art therapy should be able to elicit more movement in a situation that is at a standstill, thus promoting new connections among people and strengthening the community.
The bridge, for example, is a topic that allows us to create new connections: to join the past, present, and future into one picture; to position oneself pictorially in the here and now; to reflect on our previous path and to determine our future direction with new goals. Belonging and a sense of community can also be strengthened by striving for a symbolic connection, for example through the yarn as a connecting element between the sheets of paper. Art therapy in a group setting supports the emergence of a common “nutrient medium” and a sense of belonging (Stanoeva, 2018, p. 94). This can also foster hope and optimism in the patient, who has the capacity to respond and manage crisis.
Famulla, R. (2009) Joseph Beuys: Künstler, Krieger und Schamane. Die Bedeutung von Trauma und Mythos in seinem. Gießen, Psychosozial-Verlag.
Holm-Hadulla, R. M. (2011) Kreativität zwischen Schöpfung und Zerstörung. Göttingen: Vandenhoeck & Ruprecht.
Holm-Hadulla, R.M. (2012) Kreativität zwischen Schöpfung und Zerstörung. In Titze, D. (Ed.) (2012). Zeichen setzen im Bild. Dresden: Sandstein Verlag.
Koch, S. C. (2017) Was hilft, was wirkt? Wirksamkeit und Wirkfaktoren der Tanz- und Bewegungstherapie. Zeitschrift für Sportpsychologie, 24 (2), 40-53. DOI 10.1026/1612-5010/a000191
Kufus, T. (Produzent) & Veiel, A. (Regisseur) (2017) Beuys [Film]. Germany: Berliner zero one film GmbH in Kooperation mit Terz Filmproduktion, SWR, ARTE und WDR.
Schmeer, G. (2007) Das Ich im Bild. Ein psychodynamischer Ansatz in der Kunsttherapie. Stuttgart: Klett-Cotta.
Stanoeva, A. (2016) Bunte Lebensspuren: Kunsttherapeutische PapierMosaik Methode. Kunst & Therapie, 1, 56-63.
Stanoeva, A. (2018) Bewegung. Verortung. Abgrenzung. Gruppendynamische Prozesse in der Kunsttherapie bei Menschen mit Borderline-Persönlichkeitsstörung. Musik-, Tanz- und Kunsttherapie, 1, 72-94.
Stanoeva, A. (2019) Im Grenzbereich zwischen Kunst und Therapie: Eine Einbettung der kunsttherapeutischen PapierMosaik Methode in den eigenen künstlerischen Prozess. Kunst & Therapie, 1/2, 50-63.
Steiner, J. (1993) Psychic Retreats. Pathological Organizations in Psychotic, Neurotic and Borderline Patients. London: Routledge. German: Orte des seelischen Rückzugs. Pathologische Organisationen bei psychotischen, neurotischen und Borderline-Patienten. Stuttgart: Klett-Cotta, 3. Aufl. 2006
Steiner, J. (2014) Seelische Rückzugsorte verlassen. Therapeutische Schritte zur Aufgabe der Borderline-Position. Stuttgart: Klett-Cotta.
Weiß, H. (2009) Das Labyrinth der Borderline-Kommunikation. Stuttgart: Klett-Cotta.
Winnicott, D. W. (1971) Playing and Reality. London: Tavistock. German: Vom Spiel zur Kreativität. Stuttgart: Klett-Cotta, 2. Aufl. 1979.
Avgustina Stanoeva is an artist and art therapist (MA), psychologist (BSc), and art historian (BA), with additional training in C.G. Jung’s Analytical Psychotherapy. She is a founding member of the European Federation of Art Therapy (EFAT) and active member of the EFAT’s Research Committee. Mrs Stanoeva currently practices art therapy in Forensic Psychiatry for Women in Bavaria, Germany. Her research is focused on personality disorders, cultural identity, and movement in art therapy. She can be contacted at firstname.lastname@example.org.