Word and Image: Image and Word

Word and Image: Image and Word

If inequality is the primary constraint to change, it’s management must be a central feature of any therapeutic practice. Inequality is endemic to clinical practice and while it is important that some inequality exists between client and practitioner excessive inequality is detrimental to the process. Clients bring with them features that immediately render them unequal to the practitioner particularly given that most therapy is conducted through language and words. Children, people for whom English is their second language, those with an intellectual disability, drug and alcohol affected clients and the anxiety of attending therapy all accentuate the difference between the client’s capacity to understand, process, work with and remember the enquiry and advice.

Bower(note) formalizes a process that equally emphases both word and image to address this. The protocols of the first session where notes are printed on A3 sheets of paper in the client’s view, an ecogram which includes coloured lines to demonstrate the nature of each relationship and a timeline which shows events as they occurred in the life of the family and the wider system each aim to introduce image to work with words. Malcolm Robinson uses the metaphor of the double helix of the DNA molecule which is made up of two strands that wind around each other like a twisted ladder to describe this crucial relationship between word and image. Each strand is critical to the overall functioning of the whole. Another image is that of Ying and Yang where both complement and are essential to the other.

The visual image includes the symbolic; diagrams and graphs, pictures to explore and explain and kinesthetic demonstrations of concepts using the client’s body, toys, or objects. These should be used from the beginning of the therapeutic process and included in both the enquiry and advice processes on the understanding that enquiry itself is interventive.

In three one-hour sessions in the Bower Place Complex Needs Clinic this principle, which applies to all clients was used in three very different ways.

Case 1

The first was with a woman in her mid-50’s who was teary and distressed and unable to make a clear request for herself. When asked about her situation she jumped from speaking about her disrespectful adolescent daughter to her struggles with alcohol and gambling to dissatisfaction with work and loneliness. The more she spoke, the more distressed and unfocussed she became and the harder the practitioners found it to map a forward path. In the session she was given a large sheet of paper and coloured pens and a circle was drawn in the center with her name on it. She was then asked to draw all the things that were pressing on her, choosing the appropriate colour for each and drawing the circle of a size to represent its enormity and how close it was to her. As she drew, she began to reflect on each circle, becoming calmer and a way forward began to emerge.

Case 2

The next session which was conducted on-line and a first visit with a young woman and her three children who ranged in age from 3 to 7 years old. The session started late and was repeatedly interrupted by the children asking for treats or her attention and she was calm and accommodating, stopping the conversation with the therapist to attend to them. They moved in and out of the room and it was difficult for the practitioner to engage them in the process and their mother appeared unable or unwilling to insist that they participate. She explained that all three children had a diagnosis of autism spectrum disorder, and she had no capacity to control or mange them or her household. She spoke warmly of them but said that it was ‘like we are all on the same level’. Her request was for help to ‘manage the children better’. At the break the practitioners felt ill equipped to begin to meet her request. The ecogram was barely constructed, and the timeline had minimal information. Instead, they chose to present her with an image to describe her dilemma. They spoke of her being ‘half a mother’ and drew a half figure with a pink outline. However, they said children need a full mother, one who is both soft and giving but also firm and clear and able to say ‘no’ when it is best for the children. This time the figure was complete and while pink on the outside had a black line running parallel and outlining the shape. The practitioners suggested that their task would be to work with her to become a ‘full mother’ who was firm and strong but also warm and loving.

Case 3

The last family comprised a mother, grandmother and two adolescent daughters. The grandmother was eager and continually cut across the practitioner’s attempts to speak to other family members by asking them questions or urging them to speak. The more this occurred the less the mother and her daughters participated, demonstrating their disinterest by engaging with each other, yawning, or appearing to sleep. The children had been removed by child protection services for no reason that anyone could understand or explain and now had returned to their mother’s care. In attempting to explore these events, the children could only say ‘I don’t know… I don’t remember’. Instead of continuing fruitless questioning the practitioner appreciated they were constrained to speak and instead asked them to show how it had felt to be removed. Both children used multiple colours to draw a messy and chaotic circle. When asked what that felt like they said ‘confused’. They were then asked to draw a picture of how they currently felt and this time one drew a much smaller messy circle and the other a group of stick figures. Now the practitioner had a way to engage with the children that did not include the grandmother and directly related to their input. He was able to explore the difference between both pictures and points in time and speculate about what would need to change for even less confusion in their future. This became the advice for each family member to privately consider in preparation for the next session. Another way to engage and explore would be to use toys to represent people in the story and to ask the children to act out past events, the current situation, and the hoped-for future.

These three cases demonstrate ways of ensuring inequality which constrains change is addressed by ensuring both word and image are integral to the session.