“‘ I could draw it,’ a dreamer often says to us, ‘but I don’t know how to say it.’” So said Sigmund Freud (1963, p. 90). Considering that Freud regarded dreams to be “the royal road to the unconscious,” it is surprising that he did not ask his patients to do so.
Put another way, Irvin Yalom discusses the difficulty in communication between client and therapist, preventing a real knowing of one another:
A series of distorting prisms block the knowing of another.... First, there is the barrier between image and language. Mind thinks in images, but, to communicate with another, must transform image into thought and then thought into language. That march, from image to thought to language, is treacherous. Casualties occur: the rich, fleecy texture of image, its extraordinary plasticity and flexibility, its private nostalgic emotional hues—all are lost when image is crammed into language. (Yalom, 1989, p. 180)
In art therapy, work with images is at the core of treatment.
Although art therapy is a relatively young and small profession, it is very broad, with art used in a number of different ways with varying populations. Most art therapy sessions, whether individual, group, couple, family, or community work, include a period of art-making followed by discussion, in which the art therapist encourages verbal reflection about the image(s) created. Although in the early days of the profession art therapists may have thought in terms of interpretations of the images and sometimes provided these interpretations to the client, for the most part art therapists today urge clients to do their own self-exploration. Many art therapists assure their clients that artistic excellence or even talent is not expected. The purpose of art therapy is self-expression and self-exploration.
Figure 1 is a plaster casting made by Debra Paskind, ATR-BC, LCPC, now an experienced art therapist and art therapy educator. She made this art piece while still an art therapy student, showing her impression of art therapy, in which she is looking into multiple mirrors and pulling material out of her head to explore.
To give a brief overview of the variety in this work, the venues in which art therapists work with their diversity of populations may suggest how the goals and conditions of treatment may differ widely as the therapists determine the nature of the work. Traditionally, art therapists worked in psychiatric settings, such as hospitals and clinics. As the profession has grown, art therapy has expanded to use in schools, especially those for emotionally and behaviorally disturbed children; in facilities for the elderly, both day centers and nursing homes; in substance abuse programs; in hospital units for medical illnesses, especially cancer; in facilities for survivors of sexual and physical abuse, both children and adults, as well as perpetrators; in shelters for the homeless; in immigration centers, including programs for victims of torture; in penal facilities such as jails and prisons; in after-care programs; in community relief programs; and in many more.
Although art is used with many populations to promote insight, with many others it is more an activity for socialization and the enhancement of self-esteem, particularly in centers where clients stay for long periods of time, such as after-care facilities, shelters for the homeless, facilities for the elderly, and community centers. As is evident from these many venues, the art is likely to be used very differently with specific populations and treatment facilities, with respect both to the art materials used and the kind of art projects encouraged. Nevertheless, there are advantages to using art that would apply to many treatment conditions.
As stated by Freud and Yalom, we think in images. We thought in images before we had words, knowing our mother’s face before we could think or say, “Mama.” Because we had images before words, it is likely that imagery forms a significant foundation layer in personality development. Moreover, psychotherapy clients often have had experiences that cannot be expressed in words, especially aspects of trauma. These experiences, embedded in deeper layers than the verbal, often surface in drawings and paintings.
People diagnosed with acute schizophrenia have been able to depict hallucinations and delusions readily in their artwork. Given the idiosyncratic nature of hallucinations and delusions, these people often live in an envelope of isolation. Depicting these phenomena in their art expressions allowed for communication that bridged the moats of isolation that surrounded them.
Because most clients are much less familiar with making art than with talking, surprising and unexpected things often come out in the artwork that would have been repressed in verbal communication alone. These unintended characteristics can form the leading edge of increased insight; for example, when a client drew a face that looked angry while denying such feelings, she was able to identify the feelings in the drawing and eventually came to own them.
The frequent misconception that artistic ability is necessary for self-expression in art may actually work in reverse. Those experienced in art-making may actually be better able to defend themselves in art expression. For example, an elderly man diagnosed with agitated depression, who had been a draftsman, created peaceful landscapes, denying that his pictures had any meaning. Eventually, however, he depicted himself as a smoldering volcano.
Catharsis is an especially important aspect of art-making. Clients can do whatever they want to the paper. One middle-aged woman who had made two serious suicide attempts murdered her husband many times on the paper over the course of her treatment before eventually settling into relative contentment in her marriage.
Craig, an adolescent diagnosed with paranoid schizophrenia, whom his parents feared would harm his little sister, was dragged into the National Institutes of Health Clinical Center by seven police officers. Since the research protocol for the schizophrenia project there kept the patients free of medication, most of them regressed on admission. The staff was fearful of potential violence in Craig, but he was one of the few patients who did not decompensate. The reason? He loved to draw. He spent many hours, both in art therapy sessions and on his own, drawing intricate pictures of the Judgment Day, the Mother of the Universe, and various delusions, discharging his feelings in this more productive way. Despite his elaborate paranoid delusional system, he even came to trust me with his “secrets.” In Figure 2, he has drawn sperm cells and scrota being pulled into the sun-ovum (upper right). He is riding in the central object with the eye for protection. He said that anyone looking at this picture would become psychotic. Wadeson (1980) gives a more detailed account of work with this patient.
Unique to art therapy is the permanence of the art product, which can provide some interesting possibilities. It is not subject to the distortion of memory, as ephemeral words may be, and cannot be denied. Sometimes clients look back on an earlier drawing and are surprised to discover how they felt at that time. New insights may emerge as a result. Most important, looking at the artwork over time allows both the client and the art therapist to discern patterns that may not be recognized when the art pieces are viewed singly. Also, the art is evidence of significant milestones in the ongoing development of the therapeutic process and in this way may be very encouraging.
The art product can also serve as interesting data for research and for communicating about a patient’s status to other staff members. For example, with some suicidal patients, the art was often the first expression of renewed suicidal ideation, which could then be shared with staff for the patient’s protection.
Whereas speaking is a sequential form of communication, an art piece displays a spatial matrix, which is more often the way a situation is experienced. For example, if a client is exploring family relationships, instead of sequentially describing each family member and their relationships with one another, a picture can show the family dynamics all at once, which of course is the way the client experiences it. A woman can show her mother in an angry fit but close to her brother, her father removed from the other family members, herself small and sad, neglected by the others, and so forth. In family art therapy it is especially productive to ask each family member to make a picture of the family. When family members share these drawings, there are often surprises about perceptions that have never been communicated. If the father appears on the periphery of every picture, it is difficult for him to deny that his family sees him as removed from them, for example.
Another interesting way to explore family dynamics is with the use of clay. After clients have reflected on their figures and the relationships among them, I often ask them to change the clay tableau to the way they would like the family to be. This activity usually arouses very strong feelings.
Some groups, particularly those that meet in the evening, started out sluggishly with a check-in, proceeded to the art-making phase, and afterward miraculously came to life. The change in energy level became activated by art-making. This change is thought to be the result of stimulating creative energy. It may be related to the release of physical energy as well, which is very different from the more passive sitting and talking that is characteristic of verbal therapy.
There is also the particularly interesting contagion in group art therapy, in which the members are stimulated in their own art-making by the creative expression of the others. In a group, they come to know one another by their images and artistic styles.
In a sense, the roots of art therapy can be said to reach back to prehistory, when our ancestors painted animals in the caves of Lascaux, France, 17,000 years ago, or Australian Aboriginals made rock paintings that date back 40,000 years. Since before recorded time, humans used images to make their mark. In the early twentieth century there was much interest in the art of the insane, most notably as exhibited in the Heidelberg Collection that gathered works from the major mental hospitals of Europe. The mother of art therapy was Margaret Naumburg, an educator trained in both Freudian and Jungian analysis, who asked her clients to draw and “free associate” to their art. Working in New York, Naumburg began training other art therapists in the 1950s. Her contemporary was Edith Kramer, an artist who worked with children, also in New York. Whereas Naumburg utilized a more analytical approach, Kramer believed that the art-making process was healing in and of itself, and she based her work on the concept of sublimation.
In the 1960s, Elinor Ulman, a Washington, DC, art therapist, founded an art therapy journal that served to unite the handful of art therapists practicing around the country, and in 1969 the American Art Therapy Association was formed. University training programs were developed, and books and papers on art therapy proliferated (see Junge & Wadeson, 2006).
Currently, there are approximately 5,000 members in the American Art Therapy Association. Art therapy has also been established in other countries, but in most of these countries it is not as developed as it is in the United States. The American Art Therapy Association publishes a newsletter and a journal and holds an annual conference. There are many regional conferences as well. The terminal degree in art therapy is the master’s, and there are between 20 and 30 university training programs throughout the country. Some art therapy educators hold a PhD, often in a related area.
In most states, art therapy numbers are too small for licensure, so many art therapists are licensed as counselors or social workers. The art therapy credential is the ATR, Art Therapist Registered, available to those graduating from an approved master’s degree program and completing a specified amount of supervised experience. There is also Board Certification, ATR-BC, which ATRs may receive after passing an examination.
Art therapy studies are showing effectiveness in pain management, especially among cancer patients, and links with neurophysiology in examining art-making’s influence on the brain. Art therapists are working more and more with trauma victims, utilizing art therapy for social action, and working in areas of community crisis. Art therapists were called on to work with families of those killed on 9/11. In New York, many were involved in helping those affected to create memorials and to deal with their grief and fears. Art therapists from all over the country traveled to Louisiana and Mississippi to work with victims of Hurricane Katrina. Many traveled there over several years to work with displaced persons. The profession of art therapy is a dynamic one, continuing to expand into many areas of individual and social need, often in collaboration with other mental health professionals and in association with numerous societal facilities.
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