From our first session I was conscious of working towards a respectful and trustworthy alliance (Rubin, 2011). Siegel (2010) describes the concept of alliance as the quality and strength of the collaborative relationship, and that empathy is essential to be able to understand the client’s point of view.

In the beginning of our work together, I focused on getting to know Fay. She was open to exploring art materials, talking and reminiscing. She took a firm liking to watercolour paint, preferring strong colours, partly because I think she could see them. When I organised watercolours for her, she always asked me to name them as I set them out. Over time I realised she would remember the placement of the colours. This enabled her to choose her preferred colours independently. This routine was also enacted when I set out other materials such as textas, paint pens and paint sticks. To choose a painting surface she ran her hand over the paper, and preferred to use textured watercolour paper or acrylic canvas paper.

For the first six months I did not find her medical history to be a deterrent to engaging in the processes of art-making. For the last four months there was a steady decline in her willingness to engage in art therapy, socialise with others and in her stamina for art-making. Episodes of low mood, chronic pain and complications of dialysis, together with poor sleep, were affecting her quality of her life. She was experiencing repeated episodes of frustration and hopelessness.

At the beginning of our work together, Fay was able to engage in over an hour of art-making and socialisation. In the last six weeks her art-making was reduced to only a few minutes. She socialised less, and frequently took her meals in her room. The tone and content of her conversations changed. It was generally focused on expressing frustration about dialysis treatment, feeling trapped in a sick body, wanting to die but being afraid.

In the final six weeks of our work I took to visiting Fay at the renal clinic once a week. The clinic staff reported an escalation of challenging behaviours while she was receiving dialysis. I learned that her compliance and mood were declining to such an extent while at these appointments that her doctor informed her that dialysis would cease at the clinic if this continued. The only option would be admission to hospital or no dialysis. Without this treatment Fay would die very quickly from renal failure.

When I arrived, Fay usually felt unwell, and often reported feeling angry and frustrated. Within the RAC home she frequently said that art-making was the only way she could relax. At dialysis she refused to make art on her own and so together we collaborated and worked on images together, or I would make an image under her guidance. She commented that watching me and working in this way also relaxed her. When she was relaxed, she told me, her body hurt less and she felt less angry.

Fay had experienced ongoing challenges around noncompliance with health procedures (blood-sugar assessment) and medications (refusing insulin), yelling, swearing and aggression. These had been long-term issues and were present before Fay’s move into RAC. They had escalated in the last twelve months as her renal failure entered its final stage. Fay refused to participate in any assessments on admission to RAC in 2018, and she had not been assessed or supported for mental health concerns in the last two years.

This exposes a gap in the provision of holistic care within the Commonwealth-funded RAC model. The current Commonwealth-funded instrument, the Aged Care Funding Instrument (ACFI) (Department of Health, 2020) is used to allocate Australian Government funds in the form of subsidies to RAC providers who will allocate resources to core needs among the residents. One of the three domains assessed on entry is titled ‘Behaviour’, which in part assesses mood. It specifically addresses symptoms of depression.

To qualify for a subsidy from ACFI the resident is required to undertake a range of assessments to be completed within a month of their moving into aged care. If a resident refuses, they do not qualify for extra support. Even if Fay had complied with the assessments, ACFI does not provide funds or services for mental health counselling or other mental health services within the RAC model. Only pharmacological interventions for mood, such as antidepressants, are provided for. In Fay’s case, even if medications were prescribed, she had the right to refuse them. Holistic person-centred care, when I view it from Fay’s needs, is multilayered and nuanced. Aspects of care that she requires for psychological support are neglected through the current Commonwealth-funded model.

Older adults are able to self-assess their health (Nordhus, 2015; Partridge, 2019). Fay’s expressions of feeling hopeless and being ready to die were documented by a few staff, myself included. However, she denied this when asked by two GPs servicing the care home and again with a specialist. Self-reporting research confirms that older adults under-report medical symptoms and their severity (Partridge, 2019). I speculate that in this case it may have been due in part to medical staff’s lack of establishing rapport with the client before asking probing questions. 

I observed that the materials and processes of art-making used in a therapeutic setting gave Fay a safe and supported way of communicating and connecting with her body, memories, thoughts and feelings.

Fay’s health and stamina were quite variable over the four or so hours that she attended dialysis. When I arrived for our sessions (usually two hours into the treatment) she could often be experiencing symptoms such as pain, cramping, variable blood pressure and nausea. I learned to begin very quietly. I would say hello and ask her if I could sit and keep her company. This usually elicited “I don’t care, I’m too sick” as the response. I would sit quietly, smile, then avert my gaze, my art bag on my lap. I let Fay direct any conversation. This usually didn’t take long, as she was curious about what might be in my art bag.

I worked collaboratively with Fay in the processes of art-making while at dialysis. One of her arms was connected via a cannula to the dialysis machine and had to be kept in a specific position. Her other arm (non-dominant) was continually used to measure blood pressure via a cuff for the whole period of treatment. There was a very limited range of movement for that arm as well. On one of our collaborations we constructed her family tree. Fay didn’t do any art-making for this project, though she guided and made all aesthetic decisions from the size and shape of the tree to the colours that were chosen, the media, and the size and placement of leaves and fruit. The leaves and fruit represented family members. Information Fay wanted included for each family member’s leaf or fruit was their name and age. Her family tree consisted of her mother and father, her two brothers, two ex-husbands, her children, their partners and their children. We completed the family tree over one sitting of 90 minutes.

It was through the construction of the image of a tree with its leaves and fruit that Fay and I were in part reconstructing a narrative of her past. Through this remembrance I discovered what Stern (2018) would call a key therapeutic metaphor for understanding Fay’s current thinking about her life. The key, according to Stern, is that the narrative points to the origin of a pathology, or vulnerability, to her core self. When it was hard for me to know the subjective early life Fay experienced, I relied on the intersubjective therapeutic relationship. It allowed me to enter and share her current affective state in an empathetic and supportive way. Stern describes that the sharing of affective states is the most relevant and appropriate feature of the therapeutic encounter. I interpreted affect sharing as my ability to share the space of the experience and communicate that I was there. This could be through a light touch, a facial expression, or I might offer a few words. I offered a response and gauged its level of acceptance as to whether I was on the right track.

Fay described her relationship with her mother in very positive ways, such as “she took care of me and my children”. She only referred to her brothers a few times, to say that they were dead. During the constructing of the image of her family tree she referred to them this way again. Sometimes she muttered as we were working, “they are dead, they are all dead”. Death had become a pivotal narrative for Fay. It was layered with her own current experiences of life-limiting illness and the end stages of renal failure. She seemed stuck there. Stuck in the helplessness of it.

During this session it was the first and only time that I would hear the names of her family members, rather than terms such as mother or daughter. She also asked me to include the cultural names for herself, her siblings and her parents. This was the only time she spoke these names. Her identity, heritage and culture became deeply significant in the moment. I felt I was recording some kind of epitaph.

The placement of the family members as ‘leaves’ was carefully considered for herself and her mother. This confirmed for me the deep connection she had had and still felt for that relationship. She asked for one of her three daughters to be placed under her leaf on the tree. Fay said that this daughter was her favourite. The word favourite touched a painful nerve for me. I wondered whether being the favourite was a good experience for this child, as it wasn’t for me. I was never confident or secure in knowing how acceptable or unacceptable I was to my mother. I felt her attention and behaviour was always conditional. Referring to Bowlby’s internal working model (IWM) theory, Fonagy (2001) writes that if a child perceives the carer’s IWM as rejecting them, then the child’s own IWM reflects this. In the self–other relationship they perceive themselves as unlovable. Reflecting on this, I would describe it as I felt I was disappointing to my mother. My mother, like Fay, has a diagnosis of bipolar and has not complied with treatment or medications. Up to my adulthood she had also verbalised frequently that her life was hopeless, and she had threatened or tried to take her life on a few occasions.

My experiences with Fay often felt similar to my experiences with my mother. At times I found this unsettling. In between sessions, on a few occasions, I would avoid walking by her room. I needed space to process my own reactions to working with Fay. I learned over the ten months to better maintain my objective therapist frame while working with my client’s personal and subjective experiences, and in turn my own. This was largely achieved through completing a number of response art (Fish, 2019) self-portraits and client portraits. I would complete these portraits post art therapy with Fay. I also engaged in witness writing (Rubin, 2011), to reflect on the product, the art processes and any feelings or thoughts that were aroused at the time and for a period after. I began presenting these portraits at weekly supervision. In this forum, I felt well supported to explore my learning and ongoing questions.

Siegel (2010) says the intention towards and interest in accepting and understanding another is crucial in healing relationships. Fay said, at times during our work together, that I made her feel important. I understand this to suggest that Fay experienced a felt sense of being seen, or attachment, during our therapeutic work. Fonagy (2001) describes Sroufe and Waters’ understanding or goal of attachment as “felt security” (p.13). This felt sense of attachment, Fonagy writes, is applicable to every stage of life and not just to maternal caregiving. It is also influenced by the social environment. Fonagy further elaborates that our level of felt security directly influences our ability to self-regulate. This learning resonates with me as I reflect on the ten months that I worked with Fay. My observations were that while Fay spoke very fondly of her relationship with her mother, suggesting a secure attachment style, her capacity to self-regulate often appeared quite impulsive, avoidant and/or resistive. This didn’t align to a secure attachment. I wondered, then, if the death of her mother and, for me, the threats and actions of attempted suicide by my mother contributed to a feeling of abandonment in us both. Perhaps this ‘felt’ sense was part of our attunement to each other.

Fonagy (2001), describing the work of Stern on attachment, writes that our lived experience shown through our relationships and connections to others is key to our mental health. Fay and I developed an amenable working relationship. I learned to relax and be flexible concerning what the art in art therapy looks like. Fay worked independently with materials and processes on her own images. From time to time we worked together. On a few occasions, I drew under her direction. She observed me art-making, while guiding the activity through her choices of media and colours.

Through my modelling flexibility, consistency in demeanour and respect for her memories, thoughts and feelings, I think Fay found art therapy helpful. She was developing an openness towards exploring her personal stories and feelings through our working alliance (Rubin, 2011). Fay’s sometimes overt displays of resistance at her care home and at dialysis, I suggest, could be considered as natural defensive reactions (Rubin, 2011). Their purpose, I think, was to communicate physical pain, and her experience of the intolerable emotional pain of isolation and hopelessness.

Three weeks from our ending, I visited Fay at dialysis. She complained of stomach ache and of being cold. I adjusted her blankets and told her that I had bought some new art supplies. I opened my art box, showed her the colours, and described them.

I opened my pad of paper and drew a simple bullseye-type pattern with a few circles. I showed her the box of colours and invited her to choose
her favourite. She chose red. I took off the lid and wound the paint up, just like a lipstick. I asked her if she would like to try using her left hand. She said no, it hurt.

“I can show you. I’ll use my left hand, just like you, today,” I said. I coloured a portion of the circle red. I explained that I hardly had to press at all. As she watched me, I checked in with her and asked her how her day was going. We talked while I coloured. She asked me what colour I would use next. I replied that I was not sure. I asked her if she would like to choose one for me. She did. I placed the previous colour within her reach. After about 15 minutes Fay spontaneously picked up the red paint stick and began to colour.

Shortly after, we took a break while two nurses came and attended to a procedure. Fifteen minutes later I returned to the room. I turned the page over and intuitively suggested that we draw something together. I asked her to choose the colours for our drawing. She chose red for herself and blue for me. “What shall we draw?” she asked. I replied, “What if we start with a line and see what happens?” Still using my left hand, I drew a wobbly circle with the blue paint stick. Fay drew a circle shape in red, next to and touching mine (Figure 2). I immediately got a sense that we were visually and symbolically communicating in a new way. It was like Fay was saying, “This is something new, I’m sticking close but I’m coming with you.”