Art therapy

Art therapy
Two convict artists draw designs of carpets on graph paper at Industrial Workshops of Central Jail Faisalabad, Faisalabad, Pakistan, in 2010
MeSH	D001155

Art therapy (also known as arts therapy) is a creative method of expression used as a therapeutic technique. Art therapy originated in the fields of art and psychotherapy and may vary in definition.

Art therapy may focus on the creative art-making process itself, as therapy, or on the analysis of expression gained through an exchange of patient and therapist interaction. The psychoanalytic approach was one of the earliest forms of art psychotherapy. This approach employs the transference process between the therapist and the client who makes art. The therapist interprets the client's symbolic self-expression as communicated in the art and elicits interpretations from the client.^[1] Analysis of transference is no longer always a component.

Current art therapy includes a vast number of other approaches such as: person-centered, cognitive, behavior, Gestalt, narrative, Adlerian, family (systems) and more. The tenets of art therapy involve humanism, creativity, reconciling emotional conflicts, fostering self-awareness, and personal growth.^[2]

Definitions

Various definitions of the term "art therapy" exist,^[3] each reflecting the historical narrative or theoretical underpinnings of its proponents.

The British Association of Art Therapists defines art therapy as:

...a form of psychotherapy that uses art media as its primary mode of communication. It is practised by qualified, registered Art Therapists who work with children, young people, adults and the elderly.^[4] Clients who can use art therapy may have a wide range of difficulties, disabilities or diagnoses. These include, for example, emotional, behavioral or mental health problems, learning or physical disabilities, life-limiting conditions, brain-injury or neurological conditions and physical illness. Art therapy may be provided for groups, or for individuals, depending on clients' needs. It is not a recreational activity or an art lesson, although the sessions can be enjoyable. Clients do not need to have any previous experience or expertise in art.

The American Art Therapy Association defines art therapy as:

...the therapeutic use of art making, within a professional relationship, by people who experience illness, trauma or challenges in living, and by people who seek personal development. Through creating art and reflecting on the art products and processes, people can increase awareness of self and others cope with symptoms, stress and traumatic experiences; enhance cognitive abilities; and enjoy the life-affirming pleasures of making art.^[5]

Art therapy is a mental health profession that uses the creative process of art making to improve and enhance the physical, mental and emotional well-being of individuals of all ages. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behaviour, reduce stress, increase self-esteem and self-awareness, and achieve insight. Art therapy integrates the fields of human development, visual art (drawing, painting, sculpture, and other art forms), and the creative process with models of counseling and psychotherapy.^[5]

Uses

As a mental health profession, art therapy is employed in many clinical and other settings with diverse populations. Art therapy can also be found in non-clinical settings, as well as in art studios and in creativity development workshops. Closely related in practice to marriage and family therapists and mental health counselors, U.S. art therapists are licensed under various titles, depending upon their individual qualifications and the type of licenses available in a given state. Art therapists may hold licenses as art therapists, creative arts therapists, marriage and family therapists, counselors of various types, psychologists, nurse practitioners, social workers, occupational therapists, or rehabilitation therapists. Art therapists may have received advanced degrees in art therapy or in a related field such as psychology in which case they would have to obtain post-master's or post-doctorate certification as an art therapist. Art therapists work with populations of all ages and with a wide variety of disorders and diseases. Art therapists provide services to children, adolescents, and adults, whether as individuals, couples, families, or groups.

Using their evaluative and psychotherapy skills, art therapists choose materials and interventions appropriate to their clients' needs and design sessions to achieve therapeutic goals and objectives. They use the creative process to help their clients increase insight, cope with stress, work through traumatic experiences, increase cognitive, memory and neurosensory abilities, improve interpersonal relationships and achieve greater self-fulfillment. The activities an art therapist chooses to do with clients depend on a variety of factors such as their mental state or age. Many art therapists draw upon images from resources such as ARAS (Archive for Research in Archetypal Symbolism) to incorporate historical art and symbols into their work with patients. Depending on the state, province, or country, the term "art therapist" may be reserved for those who are professionals trained in both art and therapy and hold a master or doctoral degree in art therapy or certification in art therapy obtained after a graduate degree in a related field. Other professionals, such as mental health counselors, social workers, psychologists, and play therapists combine art therapy methods with basic psychotherapeutic modalities in their treatment. Therapists may better understand a client's absorption of information after assessing elements of their artwork. ^[6]

Trauma in children

The efficiency of treatment interventions for post-traumatic stress disorder (PTSD) in children have not been researched extensively. Linda Chapman and fellow psychologists have, however, researched the effectiveness of art therapy on pediatric trauma patients. Early in the research, analysis showed that there were no significant reductions in PTSD (post traumatic stress disorder) symptoms between the patients and the control group. However, acute stress disorder symptoms were reduced for the children who received the art therapy intervention.^[7]

Another use that is becoming more prevalent is aiding in the recovery of eating disorders. There are a few reasons why this type of treatment is helpful when treating eating disorders. One reason is the ease of communicating deep issues non-verbally. In many cases people use food restriction as a way to gain control and divert attention from a much deeper problem in their lives. These deeper issues are in most cases so hard to deal with that the use of art, pictures, and movement can provide needed insight. The way this works is through the interpretation of the things that the patient has drawn. There are many things to look for when interpreting art work. Not only do you look at what is on the paper and the symbolism in that, attention also needs to be paid what is not there, the things that people omit from a work can be just as informative. The placement of each part of the art work will provide insight. Art therapy also allows the individual to play a vital role in recovery as well as track their progress. A third reason is that it helps to build a more aware and healthy relationship with the individual's body. One major way art therapy helps with this is through a technique called Body image tracing. Body image tracing is where a patients compare the outline of how the perceive their body to a true out line of their body. Because of these reasons art therapy has been a useful and quite successful tool in many venues, including out and in-patient treatment facilities, hospitals, schools, and private practices.^{[8] [9]}

Art therapy can be used to help at-risk children, which is stated in Stella A. Stephney's book titled, "Art Therapy With Students At Risk: Fostering Resilience and Growth through Self-Expression." This is a second edition and it includes information about adolescents and how art therapy can help them work through their issues in a different way than regular therapy. In an article written by Shirley Riley titled, "Art Therapy with Adolescents," she talks about the usefulness of art therapy and how doing art therapy over the more conventional talk therapy, can actually help adolescents trust their therapists more and be more open and expressive. The article also discusses how adolescents find it more comfortable to express themselves with pictures or drawings than to talk about their feelings. Some adolescents who are acting out might be battling depression and would rather hurt themselves and feel the physical pain than feel the internal pain. ^{[10] [11]}

General illness

People always search for some escape from illness and it has been found that art is one of the more common methods. Art and the creative process can aid many illnesses (cancer, heart disease, influenza, etc.). People can escape the emotional effects of illness through art making and many creative methods.^[12] Sometimes people cannot express the way they feel, as it can be difficult to put into words, and art can help people express their experiences. "During art therapy, people can explore past, present and future experiences using art as a form of coping".^[13] Art can be a refuge for the intense emotions associated with illness; there are no limits to the imagination in finding creative ways to express emotions. Hospitals have started studying the influence of arts on patient care and found that participants in art programs have better vitals and fewer complications sleeping. Artistic influence doesn't need to be participation in a program, but studies have found that a landscape picture in a hospital room had reduced need for narcotic pain killers and less time in recovery at the hospital.^[12]

Art therapy has been shown to help students ages 11 to 18 with autism spectrum disorder to increase their social skills. There was improvement in assertion scores, and hyperactivity scores and internalizing behavior (harming oneself) significantly decreased with art therapy sessions.^[14]

Research has also indicated that art therapy can increase a child's willingness to participate in therapy and can be an effective component to social skills training (Epp, 2008). Furthermore, research has demonstrated that art therapy can offer an outlet for a child with autism to express his or her feelings and thoughts without resorting to tantrums when communication proves too frustrating. Certain methods in art therapy, such as using comic strips, have been shown to be an effective way to teach communication skills by encouraging discussion and analysis (Epp, 2008). Results of a study by Epp (2008), which focused on merging different forms of art therapy with group therapy for treating autism, showed that social skills and problem behavior both demonstrated improvement when art therapy was employed in a group setting.^[15]

Art classes also can have a therapeutic effect on retired people's well-being. Retired participants who regularly took art classes were interviewed about their previous art class participation. They felt that painting gave a sense of satisfaction and achievement with their many free hours. It also boosted confidence (from noticing improvement over time in their paintings), productivity, and offered an opportunity for participants to be encouraged to discuss art with others.^[16]

Cancer diagnosis

Art therapists have conducted studies to understand why some cancer patients turned to art making as a coping mechanism and a tool to creating a positive identity outside of being a cancer patient. Women in the study participated in different art programs ranging from pottery and card making to drawing and painting. The programs helped them regain an identity outside of having cancer, lessened emotional pain of their on-going fight with cancer, and also giving them hope for the future.

In a study involving women facing cancer-related difficulties such as fear, pain, altered social relationships, etc., it was found that: "Engaging in different types of visual art (textiles, card making, collage, pottery, watercolor, acrylics) helped these women in 4 major ways. First, it helped them focus on positive life experiences, relieving their ongoing preoccupation with cancer. Second, it enhanced their self-worth and identity by providing them with opportunities to demonstrate continuity, challenge, and achievement. Third, it enabled them to maintain a social identity that resisted being defined by cancer. Finally, it allowed them to express their feelings in a symbolic manner, especially during chemotherapy."^[17] Another study showed those who participated in these types of activities were discharged earlier than those who weren't.^[17]

Studies have also shown how the emotional distress of cancer patients has been reduced when utilizing the creative process. The women made drawings of themselves throughout the treatment process while also doing yoga and meditating; these actions combined helped to alleviate some symptoms.^[12]

A review of 12 studies investigating the use of art therapy in cancer patients by Wood, Molassiotis, and Payne (2010) investigated the symptoms of emotional, social, physical, global functioning, and spiritual controls of cancer patients. They found that art therapy can improve the process of psychological readjustment to the change, loss, and uncertainty associated with surviving cancer. It was also suggested that art therapy can provide a sense of "meaning-making" because of the physical act of creating the art. When given five individual sessions of art therapy once per week, art therapy was shown to be useful for personal empowerment by helping the cancer patients understand their own boundaries in relation to the needs of other people. In turn, those who had art therapy treatment felt more connected to others and found social interaction more enjoyable than individuals who did not receive art therapy treatment. Furthermore, art therapy improved motivation levels, abilities to discuss emotional and physical health, general well-being, and increased global quality of life in cancer patients.^[18]

Disaster relief

Art therapy has been used in a variety of traumatic experiences, including disaster relief and crisis intervention.^{[19][20][21][22][23]} Art therapists have worked with children, adolescents and adults after natural and manmade disasters, encouraging them to make art in response to their experiences. Some suggested strategies for working with victims of disaster include: assessing for distress or post traumatic stress disorder (PTSD), normalizing feelings, modeling coping skills, promoting relaxation skills, establishing a social support network, and increasing a sense of security and stability.^{[24][25][26][27]}

Bereaved children

Art therapy and other creative, humanistic intervention strategies are becoming popular methods for working with life-threatened patient and for working with the family members of patients who die- particularly bereaved children. Art therapy stimulates the conscious and unconscious expression of the mourning process in adult and child patients. Children are at greater psychological risk because their grief is less overt and can occur months or even years after the death. Group therapy is used to provide social sanction for the expression of that grief and to promote adaptive mourning responses.^[28]

Homeless youth

Art therapy has also been specifically used in the context of youth homelessness. In a healthcare project, titled "Colour My Voice", funded in part by the Wolper Jewish Hospital Health Foundation in Sydney, Australia, a number of homeless youth participated in an art therapy program at the Caretakers Cottage Youth Refuge in Bondi, New South Wales. The program aimed to assist teens who became homeless due to domestic violence, abuse, neglect, and family breakdowns.^[29][30][31]

The art program sought to empower these youth to express their feelings, emotions and every day challenges, to give them practical strategies into their own healing processes. The program also sought to empower these youth to make positive life choices despite their current circumstances. A selection of case studies were published by Caretakers Cottage, outlining the experiences of six of the homeless youth who participated in the art therapy sessions. The publication also outlines particular strategies for use by art therapy practitioners.^[30][31]

Incarceration

Art therapy may be a beneficial treatment for incarcerated women. A residential substance abuse program called New Beginnings in a detention facility has used art therapy as a means of treatment for incarcerated women. The therapy sessions were weekly and lasted 2 hours. During the first 15 minutes of the art therapy session, the topic of therapy was discussed. The topics were self-esteem, fear, self-defeating behaviors, treatment goals, barriers for recovery, and self-sabotage. The clients then worked on an exercise relating to the topic for 45 minutes in tables of four. Exploring deeper thoughts, positive reinforcement and feedback, confidence building, and clarification of thinking were encouraged by the art therapist. The clients were resistant at first, claiming "I can't draw." However, they began to share their works and offer insight on other inmates' work after one or two sessions. Group cohesion increased after the inmates began expressing different perspectives on their work and others. Simple art media was offered, to ensure that the clean-up process and technique of the materials was not difficult or intimidating. Art therapy in the program was used to help clients recognize their defense mechanisms that conceal their fear of inadequacy or to create a sense of safety and peace, increase confidence, express feelings verbally, and identify feelings. Therefore, art therapy can be used as a tool in incarceration settings with women for mental health and substance abuse.^[32]

In a case study by Hongo, the research suggests the beneficial nature of group art therapy in a prison context. The population was observed and interviewed through a session, with positive results noted throughout. The conclusions suggested that it has positive effect on group dynamic and morale, as well as therapeutic benefits. An interesting perspective made by the researchers was the cost effective nature of group therapy. Using this model allows for maximum therapeutic value made with minimal resources available.^[33]

Distraction

Distraction from sadness using art therapy may be a better alternative than venting sadness. Two studies by Drake and Winner (2012) published from the American Psychological Association compared venting (expressing negative feelings) and distraction (expressing something that is not related to negative feelings) in one study. To distract oneself, the participants were told to draw something unrelated to a sad film they had watched. The participants who had vented were told to draw something related to the film. In study 2, the participants were told to think of a sad event and were put into the venting, distraction, and calming position or sitting conditions. The sitting condition allowed the passage of time to be evaluated. In study 1, the distraction method in which the participants drew something unrelated to the sad film significantly improved negative mood compared to the venting condition. In study 2, the distraction method in which the participants drew a house (something unrelated to the sad event), had significantly improved negative mood compared to venting (drawing the sad event) or the sitting condition (sat quietly for 10 minutes). Therefore, art therapy could be beneficial to people suffering from depressive moods through a way of distraction rather than venting.^[34]

Art therapy has also been used to develop problem resolution and emotional regulation skills in children.

As an approach to problem solving

Congdon (1990) discusses art therapy's benefits in terms outside the traditional approaches within the clinical world of therapists purporting that art therapy should be used not just to help treat mental illness but as a tool to help individuals solve problems in day to day living.^[35]

Dyslexia

"It is a widely held opinion that dyslexia is associated with remarkably artistic creativity."^[36] This leads to us to look at art schools to see if there are high numbers of people who have dyslexia. The answer is yes, there is an unusually high correlation between people with dyslexia and art students. The question should be why? There are speculations that dyslexics have differing brain structures and functions. There tends to be a lack of objective studies that confirm the art and dyslexia relationship. The Wolff and Lundberg article implies that it isn't that easy to get into art school; that people with dyslexia earn their entrance into the art schools on artistic merit, as an easy way out of conventional academics. Corlu, Özcan, and Korkmazlar suggest that further research is a valid research concern. There are studies that seemingly coincide with the concept that people with dyslexia see the world differently. There seems to be evidence that dyslexics have a superior level of visuospatial skill.^[37] Gross and Bornstein^[38] think that dyslexia might be due to a difficulty in treating mirror images as the same stimulus, when taking into consideration words that are commonly switched, such as god and dog, no and on, and saw and was.

In a study done by Rankin, Riley, & Davies^[39] they found that there is a pattern in drawings that can positively identify people with dyslexia.

Rees thinks that art is a very helpful tool for people with learning disabilities, by supporting and validating their emotional and mental health.^[36][40] English higher educational institutions are currently implementing art therapies for disabilities provisions. Art is being recognized as a valid course of action for helping people with dyslexia. There is a group of people who believe that even if dyslexics have poor drawing skills, they are still found in art programs.^[40][41]

Dementia

Creative activities, like art therapy, have been found to stimulate many areas of the brain at the same time, which is said to promote a healthy brain functioning, by strengthening the plasticity of neural connections.^[42] As a result, there has been a rise in the use of art therapy, music therapy and other creative arts psychotherapy interventions for people suffering from Dementia and Alzheimer's disease. Although there are still no definitive cures for these ailments yet, art therapy has been found to increase the quality of life for some patients. ^[43][44] Several studies have claimed to increase the overall well-being of Alzheimer's patients by using art therapy to reduce stress and depression levels while increasing social behavior and self-esteem.^[43][42] Art therapy can provide these patients with an alternative mode of expression that promotes communication, and connection with others.^[44][45]

Art therapy has also been shown as a potential way to help recognize the onset and stages of Dementia. For example, the early stages of Alzheimer's can be difficult to diagnose because patients can conceal their outward symptoms. However, by using art therapy techniques, such as the Clock-drawing test, patients may reveal the first signs of dementing.^[46]

So far most of the research around art therapy and Alzheimer's has been anecdotal observation, so there is still no cause and effect results between these dementing illnesses and their artistic manifestations. ^[47]

Schizophrenia

A systematic review investigated the effects of art therapy as an add on treatment for schizophrenia:

Art therapy plus standard care compared to standard care for schizophrenia-like illnesses^[48]

Summary
Randomised studies are possible in this field. Further evaluation of the use of art therapy for serious mental illnesses is needed as its benefits or harms remain unclear.[48]
Outcome Findings in words Findings in numbers Quality of evidence Global outcome Leaving the study early Adding art therapy to standard care does not seem to decrease the chance of leaving the study (for any reason) compared with those receiving standard care. These findings are based on data of low quality. RR 0.97 (0.41 to 2.29) Low Mental state Average score (SANS, high = poor) On average, people receiving art therapy plus standard care scored a little lower than people treated with standard care. There was a clear difference between the groups, but, at present the meaning of this finding in day-to-day care is unclear. This finding is based on data of low quality. MD 2.3 lower (4.1 lower to 0.5 lower) Low Quality of life Average score (Perc.Qo.L, high = good) On average, people receiving art therapy plus standard care scored a little higher than people treated with standard care. There was no clear difference between the groups and this finding is based on data of low quality. The meaning of this finding in day-to-day care is unclear. MD 0.1 higher (0.27 lower to 0.47 higher) Low No study reported any data on outcomes such as adverse effects and information relating to time in services

Purpose

The purpose of art therapy is essentially one of healing. Art therapy can be successfully applied to clients with physical, mental or emotional problems, diseases and disorders. Any type of visual art and art medium can be employed within the therapeutic process, including painting, drawing, sculpting, photography, and digital art.^[49] Art therapy stands in contrast with other kinds of creative or expressive arts therapies that use dance, music or drama. One of the major differences between art therapy and other forms of communication is that most other forms of communication elicit the use of words or language as a means of communication. Studies have demonstrated the efficacy of art therapy, as applied to clients with memory loss due to Alzheimer's and other diseases; stroke residuals;^[50] cognitive functioning;^[51] traumatic brain injury; post-traumatic stress disorder (PTSD);^[52] depression; dealing with chronic illness;^{[53][54][55][56]} and aging.^[57][58] However, the potential healing power of art therapy has not been thoroughly studied in certain patients, such as trauma victims with disorders such as PTSD. "....Art therapy is not being properly reviewed. Art therapists report remarkable results from work with combat veterans, traumatized victims, sexual abuse survivors and survivors of natural disasters... Published case stories and research projects also support the efficiency of the approach. Yet no major clinical studies have been launched to scientifically examine the outcomes of art therapy as treatment for PTSD."^[59] One proposed learning mechanism is through the increased excitation, and as a consequence, strengthening of neuronal connections.^[60] This process is known as long-term potentiation (LTP). Another purpose of art therapy is determining existing disorders. Trauma, depression, schizophrenia, and PTSD are just a few mental illnesses that can be detected through art therapy.^[61] "Sixty-four renal transplant recipients, 6-21 yr of age, were evaluated using self-report measures (CDI and Davidson) and art-based assessments. Subject art was analyzed by art therapists using seven of the 14 elements of the (FEATS), to assess depression. Unlike CDI and Davidson self-report testing, all patients were able to complete the art-based directives. When self-report measures and art-based assessments were combined, 36% of the study population had testing results consistent with depression and/or post-traumatic stress. The FEATS assessments identified a subset of patients who were not identified using the self-report measures. There was a correlation between CDI and Davidson scores (p < 0.0001), Davidson scores correlated with hospital days (p = 0.05), and FEATS correlated with height Z score (p = 0.04) and donor type (p = 0.01). Patients who required psychological interventions including antidepressant therapy, psychological counseling and psychiatric hospitalization during the year after the study were identified as depressed."^[61] As art therapy grows in popularity and gains recognition, the purpose will become more clear and branch out to different patients. The purpose of art therapy is to provide a new healing opportunity to those who will benefit most from alternative therapy methods. In conclusion, art therapy is one of multiple medicines to create peace in the patience's mind.

A typical session

Malchiodi (2006)^[62] provides an example of what an art therapy session involves and how it is different from an art class. "In most art therapy sessions, the focus is on your inner experience—your feelings, perceptions, and imagination. While art therapy may involve learning skills or art techniques, the emphasis is generally first on developing and expressing images that come from inside the person, rather than those he or she sees in the outside world. And while some traditional art classes may ask you to paint or draw from your imagination, in art therapy, your inner world of images, feelings, thoughts, and ideas are always of primary importance to the experience.

The word "therapy" comes from the Greek therapeia, which means 'to be attentive to.' This meaning underscores the art therapy process in two ways. In most cases, a skilled professional attends to the individual who is making the art. This person's guidance is key to the therapeutic process. This supportive relationship is necessary to guide the art-making experience and to help the individual find meaning through it along the way. It helps the individual trust themselves more.

The other important aspect is the attendance of the individual to his or her own personal process of making art and to giving the art product personal meaning—i.e., finding a story, description, or meaning for the art. Very few therapies depend as much on the active participation of the individual (p. 24)." In art therapy, the art therapist facilitates the person's exploration of both materials and narratives about art products created during a session.

Art therapy can take place in a variety of different settings. Art therapists may vary the goals of art therapy and the way they provide art therapy, depending upon the institution's or client's needs. After an assessment of the client's strengths and needs, art therapy may be offered in either an individual or group format, according to which is better suited to the person. Art therapist Dr. Ellen G. Horovitz wrote, "My responsibilities vary from job to job. It is wholly different when one works as a consultant or in an agency as opposed to private practice. In private practice, it becomes more complex and far reaching. If you are the primary therapist then your responsibilities can swing from the spectrum of social work to the primary care of the patient. This includes dovetailing with physicians, judges, family members, and sometimes even community members that might be important in the caretaking of the individual."^[63] Like other psychotherapists in private practice, some art therapists find it important to ensure, for the therapeutic relationship, that the sessions occur each week in the same space and at the same time.^[64]

Art therapy is often offered in schools as a form of therapy for children because of their creativity and interest in art as a means of expression. Art therapy can benefit children with a variety of issues, such as learning disabilities, speech and language disorders, behavioral disorders, and other emotional disturbances that might be hindering a child's learning .^[64] Similar to other psychologists that work in schools, art therapists should be able to diagnose the problems facing their student clients, and individualize treatment and interventions. Art therapists work closely with teachers and parents in order to implement their therapy strategies.^[64]

Art-based assessments

Art therapists and other professionals use art-based assessments to evaluate emotional, cognitive, and developmental conditions. There are also many psychological assessments that utilize artmaking to analyze various types of mental functioning (Betts, 2005). Art therapists and other professionals are educated to administer and interpret these assessments, most of which rely on simple directives and a standardized array of art materials (Malchiodi 1998, 2003; Betts, 2005).^[65] The first drawing assessment for psychological purposes was created in 1906 by German psychiatrist Fritz Mohr (Malchiodi 1998).^[65] In 1926, researcher Florence Goodenough created a drawing test to measure the intelligence in children called the Draw–A–Man Test (Malchiodi 1998).^[65] The key to interpreting the Draw-A-Man Test was that the more details a child incorporated into the drawing, the MORE intelligent they were (Malchiodi, 1998).^[65] Goodenough and other researchers realized the test had just as much to do with personality as it did intelligence (Malchiodi, 1998).^[65] Several other psychiatric art assessments were created in the 1940s, and have been used ever since (Malchiodi 1998).^[65]

Notwithstanding, many art therapists eschew diagnostic testing and indeed some writers (Hogan 1997) question the validity of therapists making interpretative assumptions. Below are some examples of art therapy assessments:

Diagnostic Drawing Series

The Diagnostic Drawing Series (DDS) is a three-picture art interview designed by Barry M. Cohen and Barbara Lesowitz in 1982. It is one of the most commonly taught art therapy assessments and, with more than 60 DDS studies to date, it is the most researched art therapy tool worldwide. Cohen and colleagues wrote the DDS Rating Guide that directs mental health professionals on how to score the DDS. The related research, based on the structure rather than the content of the drawings, offers a way for the art therapist to contribute to the diagnostic process.^[66]

The Diagnostic Drawing Series is standardized and was designed to be compatible with empirical social science methodology. Administrators also pay attention to the behaviors and behavioral changes of the test-taker. The DDS is designed to be administered to people aged 13 and over, but there are versions that are geared toward the assessment of children.^[67]

The assessment is administered at a table. The subject is given flat-sided chalk pastels and 18 X 24 inch white drawing paper.

Research on the DDS uses criteria that includes the following:^[67]

• Color: number used
• Enclosure
• Line length
• Space usage
• Integration
• Movement
• Placement on the page

The DDS has a drawing archive for reference. Cohen provided a quantifiable assessment for art therapists to use around the world. The test protocol attempts to control for the influence of medications and pharmaceutical confounding factors. The DDS is considered to be a reliable and valid assessment tool, and evidence continues to accrue to support this.^[68] In general, projective tests tend to be much more unreliable than objective tests.^[69] Training in the Diagnostic Drawing Series increases administrators' ability to apply research findings to the appropriate assessment of the subject.^[66]

Mandala Assessment Research Instrument

In this assessment, a person is asked to select a card from a deck with different mandalas (designs enclosed in a geometric shape) and then must choose a color from a set of colored cards. The person is then asked to draw the mandala from the card they choose with an oil pastel of the color of their choice. The artist is then asked to explain if there were any meanings, experiences, or related information related to the mandala they drew. This test is based on the beliefs of Joan Kellogg, who sees a recurring correlation between the images, pattern and shapes in the mandalas that people draw and the personalities of the artists. This test assesses and gives clues to a person's psychological progressions and their current psychological condition (Malchiodi 1998). The mandala originates in Buddhism; its connections with spirituality help us to see links with transpersonal art.

House–Tree–Person

The House-Tree-Person test (HTP) is a projective test designed to measure aspects of a person's personality. The test can also be used to assess brain damage and general mental functioning. By virtue of being a projective test, the results of the HTP are subjective and open to interpretation by the administrator of the exam.^[70] HTP was designed by John Buck and was originally based on the Goodenough scale of intellectual functioning. Buck included both qualitative and quantitative measurements of intellectual ability in the HTP (V). A 350-page manual was written by Buck to instruct the test-giver on proper grading of the HTP, which is more subjective than quantitative.^[70] In contrast with him, Zoltán Vass published a more sophisticated approach, based on system analysis (SSCA, Seven-Step Configuration Analysis).

Administering the Test: HTP is given to persons above the age of three and takes approximately 150 minutes to complete based on the person's level of mental functioning. During the first phase, the test-taker is asked to draw the house, tree, and person and the test-giver asks questions each picture. There are 60 questions originally designed by Buck but art therapists and trained test administrators can also design their own questions, or ask follow up questions. This phase is done with a crayon.^[70] During the second phase of HTP, the test-taker draws the same pictures with a pencil or pen. Again the test-giver asks similar questions about the drawings. Note: some mental health professionals only administer phase one or two and may change the writing instrument as desired. Variations of the test may ask the person to draw one person of each sex, or put all drawings on the same page.^[70]

Examples of follow up questions:

• After the House: Who lives here? Is the occupant happy? What goes on inside the house? What's it like at night? Do people visit the house? What else do the people in the house want to add to the drawing?^[71]
• After the Tree: What kind of tree is this? How old is the tree? What season is it? Has anyone tried to cut it down? What else grows nearby? Who waters this tree? Trees need sunshine to live so does it get enough sunshine?^[70]
• After the Person is drawn: who is the person? How old is the person? What do they like and dislike doing? Has anyone tried to hurt them? Who looks out for them?^[70]

Interpretation of results:

The quantitative measure of intelligence for the House-tree-person has been shown to highly correlate with the WAIS and other well-established intelligence tests.^[70]

The subjective analysis of the test takers responses and drawings aims to make inferences of personality traits and past experiences. The subjective nature of this aspect of the HTP, as with other qualitative tests, has little empirical evidence to support its reliability or validity. This test, however, is still considered an accurate measure of brain damage and used in the assessment of schizophrenic patients also suffering from brain damage.^[70]

Road drawing

In this drawing assessment and therapeutic intervention, the patient is asked to draw a road. This is a projective assessment used to create a graphic representation of the person's "road of life." The road drawing has the potential to elicit spontaneous imagery that represents the client's origins, the history of his or her life process, experiences to date, and intent for the future – even from a single drawing (Hanes, 1995, 1997, 2008). The road's reparative features or its need for "periodic upgrade" can serve as a metaphor for client's capacity for change and restoration (Hanes, 1995, 1997, 2008).

History

Although art therapy is a relatively young therapeutic discipline, its roots lie in the use of the arts in the 'moral treatment' of psychiatric patients in the late 18th century, this moral treatment, Susan Hogan argues, "arose out of utilitarian philosophy and also from a non-conformist religious tradition",^[72] and in a re-evaluation of the art of non-western art and of the art of untrained artists and of the insane.^[73]

Art therapy as a profession began in the mid-20th century, arising independently in English-speaking and European countries. The early art therapists who published accounts of their work acknowledged the influence of aesthetics, psychiatry, psychoanalysis, rehabilitation, early childhood education, and art education, to varying degrees, on their practices.

The British artist Adrian Hill coined the term art therapy in 1942.^[74] Hill, recovering from tuberculosis in a sanatorium, discovered the therapeutic benefits of drawing and painting while convalescing. He wrote that the value of art therapy lay in "completely engrossing the mind (as well as the fingers)…releasing the creative energy of the frequently inhibited patient", which enabled the patient to "build up a strong defence against his misfortunes". He suggested artistic work to his fellow patients. That began his art therapy work, which was documented in 1945 in his book, Art Versus Illness.^[75]

The artist Edward Adamson, demobilised after WW2, joined Adrian Hill to extend Hill's work to the British long stay mental hospitals. Other early proponents of art therapy in Britain include E. M. Lyddiatt, Michael Edwards, Diana Raphael-Halliday and Rita Simon. The British Association of Art Therapists was founded in 1964.^[77]

U.S. art therapy pioneers Margaret Naumburg and Edith Kramer began practicing at around the same time as Hill. Naumburg, an educator, asserted that "art therapy is psychoanalytically oriented" and that free art expression "becomes a form of symbolic speech which…leads to an increase in verbalization in the course of therapy."^[78] Edith Kramer, an artist, pointed out the importance of the creative process, psychological defenses, and artistic quality, writing that "sublimation is attained when forms are created that successfully contain…anger, anxiety, or pain."^[79] Other early proponents of art therapy in the United States include Elinor Ulman, Robert "Bob" Ault, and Judith Rubin. The American Art Therapy Association was founded in 1969.^[80]

National professional associations of art therapy exist in many countries, including Brazil, Canada, Finland, Israel, Japan, the Netherlands, Romania, South Korea, and Sweden. International networking contributes to the establishment of standards for education and practice.^[81]

Diverse perspectives exist on history of art therapy, which complement those that focus on the institutionalization of art therapy as a profession in Britain and the United States.^[82][83][84]

Outsider art

The relation between the fields of art therapy and outsider art has been widely debated. The term 'art brut' was first coined by French artist Jean Dubuffet to describe art created outside the boundaries of official culture. Dubuffet used the term 'art brut' to focus on artistic practice by insane-asylum patients. The English translation "outsider art" was first used by art critic Roger Cardinal in 1972.^[85][86]

Both terms have been criticized because of their social and personal impact on both patients and artists. Art therapy professionals have been accused of not putting enough emphasis on the artistic value and meaning of the artist's works, considering them only from a medical perspective. This led to the misconception of the whole outsider art practice, while addressing therapeutical issues within the field of aesthetical discussion. Outsider Art, on the contrary, has been negatively judged because of the labeling of the artists' work, i.e. the equation artist = genius = insane. Moreover, the business-related issues on the term outsider art carry some misunderstandings.^[87][88] While the outsider artist is part of a specific art system, which can add a positive value to both the artist's work as well as his personal development, it can also imprison him within the boundaries of the system itself.^[89][90]

Standards of practice in the United States

Board certification and registration

In the United States, art therapists may become Registered (ATR) or Board Certified (ATR-BC) (Source: http://www.atcb.org/Public/AboutTheCredentials). The ATCB Code of Professional Practice is divided into five main categories; General Ethical Principles, Independent Practitioner, Eligibility for Credentials, Standards of Conduct, and Disciplinary Procedures (ATCB 2005). Becoming a registered art therapist (ATR) with the ATCB requires that one complete a graduate-level program in art therapy from an accredited university, as well as practicum and internships, and additional clinical experience post-graduation with supervision from a professional clinician (Source: www.atcb.org/home/code). To become board-certified (ATR-BC) with the ATCB, a registered art therapist must pass a statistically vetted, nationally recognized examination, the Art Therapy Credentials Board Examination (ATCBE) (Source: www.atcb.org).

Licensure

In some states, art therapists can be licensed as an art therapist, creative art therapist (LCAT; NY State only), or professional or mental health counselor (many states). For more information on how to become licensed, US art therapist should contact the state licensure board in the state in the US in which they wish to practice. Art therapy students who are preparing for practice in the field should consult with their academic advisers about what courses are necessary to meet board certification and/or licensure requirements. Licensure is generally needed to obtain reimbursement for services as an independent practitioner and in some states, is required by law in order to practice independently. Depending on where an art therapist practices geographically, certification is not always necessary in becoming a professional art therapist. Source: http://www.atcb.org/Examinations/StateApplicants

Education standards

The entry level educational preparation for professional art therapists is a master's degree in art therapy, or a master's degree in related counseling or psychology fields, with an art therapy focus. According to The American Art Therapy Association (AATA), master's program students must have taken courses in a variety of studio art disciplines as a means of signifying artistic proficiency as a prerequisite to the master's degree. Additionally, students are required to take at least 48 credit hours at the graduate level in particular art therapy, counseling, and psychology related topics, as well as successfully partaking in practica and internships.^[91] In countries other than the US, art therapists should contact governmental or regulatory boards that oversee the practice of mental health or health care professions to identify any specific coursework or education that is needed. Because art therapy is still considered a developing field, most countries do not regulate its practice and application.

Post-master's

In order to apply for the ATR (registered art therapist) certification with the Art Therapy Credentials Board (ATCB), candidates are required to complete a minimum of 1,000 hours of direct client contact post-graduation from a master's program that is AATA-approved or a minimum of 1,500 hours from a master's program that is not AATA-approved (Source: www.atcb.org/pdf/ATR_Application.pdf). After obtaining an ATR, individuals have the opportunity to apply for Board Certification from the Art Therapy Credentials Board by passing a nationally vetted examination, the ATCBE. Practitioners are encouraged to contact their state's licensing board or the office of their state attorney general to investigate licensure, which is different from certification.

General ethical principles

One topic covered in this section describes the responsibility art therapist have to their patients (ATCB 2005). According to the ATCB, art therapists must strive to advance the wellness of their clients, respect the rights of the client, and make sure they are providing a useful service (2005). They cannot discriminate against patient whatsoever, and may never desert or neglect patients receiving therapy.^[92] Art therapist must fully explain to their patients what their expectations of the patients will be at the outset of the professional relationship between the two. Art therapists should continue therapy with a patient only if the client is benefiting from the therapy. It's against the principles established by the ATCB for art therapist to have patients only for financial reasons.^[92]

Another topic of this section discusses the competency and integrity art therapists must possess (ATCB 2005). The ATCB states art therapists must be professionally proficient and must have integrity (2005). Art therapists must keep updated on new developments in art therapy. They are only supposed to treat cases in which they are qualified as established by their training, education, and experience (ATCB 2005). They are not allowed to treat patients currently seeing another therapist without the other therapist's permission (ATCB 2005). Art therapists must also observe patient confidentiality (ATCB 2005).

Other topics covered in this section further discuss responsibilities of art therapists. These responsibilities include, "responsibility to students and supervisees, responsibility to research participants, responsibility to the profession" (ATCB 2005). This section also establishes the rules by which art therapists must follow when making financial arrangements and when they choose to advertise their service (ATCB 2005).

Eligibility for credentials

This section of the ATCB Code of Professional Practice outlines the process by which art therapy students receive their credentials. It discusses the standards for eligibility and describes the application process. It also states that the ATCB certificates are the property of the ATCB and that any art therapist who fails to maintain the credential and still claims to have ATCB credentials is subject to sanctions. It also discusses the procedure to follow when accused of criminal or ethical wrongdoing. For more information about the ATCB Code of Professional Practice, please visit www.atcb.org/home/ATCBcode.

Standards of conduct

This section of the ATCB Code of Professional Practice addresses in detail confidentiality, use of clients' artwork, professional relationships, and grounds for discipline.^[92]

Art therapists are not permitted to disclose information about the clients' therapy sessions. This includes "all verbal and/or artistic expression occurring within a client-therapist relationship" (ATCB 2005). Art therapist are only allowed to release confidential information if they have explicit written consent by the patient or if the therapist has reason to believe the patient needs immediate help to address a severe danger to the patient's life.^[92] Also, therapists are not allowed to publish or display any of the patient's work without the expressed written consent of the patient.^[92]

The standards of a professional relationship between art therapists and clients are covered in this section. Within a professional relationship, art therapists are banned from engaging in exploitative relationships with current and former patients, students, interns, trainees, supervisors, or co-workers.^[92] The ATCB defines an exploitative relationship as anything involving sexual intimacy, romance, or borrowing or loaning money.^[92] Within professional relationships, therapists are to do what they feel is best in the client's interest, shall not advance a professional relationship for their own benefit, and shall not steer their patients in the wrong direction.^[92]

The breaking of any of the standards established in this section is grounds for discipline.^[92]

Disciplinary procedures

The content contained in this section of the ATCB Code of Professional Practice specifically discusses in legal and technical detail the entire disciplinary procedures for wrongdoings in art therapy (2005). Main topics covered in this section cover: "submission of allegations, procedures of the Disciplinary Hearing Committees, sanctions, release of information, waivers, reconsideration of eligibility and reinstatement of credentials, deadlines, bias, prejudice, and impartiality".^[92]

While the ATCB oversees disciplinary procedures for art therapists, if an art therapist is licensed, the state board through which the art therapist is licensed carries out disciplinary action for violations or unethical practice.

See also

• Bibliotherapy
• Comic book therapy
• Expressive therapy
• List of psychotherapies
• List of therapies

References

External links

Library resources about Art therapy

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