Art therapy

Art therapy is a form of expressive therapy that uses art materials, such as paints, chalk and markers. Art therapy combines traditional psychotherapeutic theories and techniques with an understanding of the psychological aspects of the creative process, especially the affective properties of the different art materials.

Art therapists have generated many specific definitions of art therapy, but most of them fall into one of two general categories. The first involves a belief in the inherent healing power of the creative process of art making. This view embraces the idea that the process of making art is therapeutic; this process is sometimes referred to as Art as Therapy. Art making is seen as an opportunity to express one's self imaginatively, authentically, and spontaneously, an experience that, over time, can lead to personal fulfillment, emotional reparation, and recovery^[1].

The second definition of art therapy is based on the idea that art is a means of symbolic communication. This approach, often referred to as art psychotherapy, emphasizes the products—drawings, paintings, and other art expressions—as helpful in communicating issues, emotions, and conflicts. The art image becomes significant in enhancing verbal exchange between the person and the therapist and in achieving insight; resolving conflicts; solving problems; and formulating new perceptions that in turn lead to positive changes, growth, and healing. In reality, art as therapy and art psychotherapy are used together in varying degrees. In other words, art therapists feel that both the idea that art making can be a healing process and that art products communicate information relevant to therapy are important.^[1]

Application

As a mental health profession, art therapy is employed in many clinical settings with diverse populations. Art therapy can be found in non-clinical settings as well as in art studios and in workshops that focus on creativity development. Closely related in practice to marriage and family therapists and mental health counseling, art therapists throughout the US are licensed as either MFTs, LPCs, or LPCCs and hold either registration or board certification as an art therapist (see section on Art Therapy Standards of Practice). Art therapists work with children, adolescents, and adults and provide services to individuals, couples, families, groups, and communities.

Using their skills in evaluation and psychotherapy, 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 and judgment, cope with stress, work through traumatic experiences, increase cognitive abilities, have better relationships with family and friends, and achieve greater self fulfillment. Many art therapists draw on 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 that are professionals trained in both art and therapy and hold a master's degree in art therapy or a related field such as counseling or marriage and family therapy with an emphasis in art therapy. Other professionals, such as mental health counselors, social workers, psychologists, and play therapists combine art therapy methods with basic psychological modalities to give treatment. Many art therapists in the US are licensed in one of the following fields: creative arts therapy, art therapy, professional counseling, mental health counseling, or marriage and family therapy.

Purpose of Art Therapy

The purpose of art therapy is the same as any other psychotherapeutic modality: to improve or maintain mental health and emotional well-being. But whereas some of the other expressive therapies utilize the performing arts for expressive purposes, art therapy generally utilizes drawing, painting, sculpture, photography, and other forms of visual art expression. For that reason art therapists are trained to recognize the nonverbal symbols and metaphors that are communicated within the creative process, symbols and metaphors which might be difficult to express in words or in other modalities. By helping their clients to discover what underlying thoughts and feelings are being communicated in the artwork and what it means to them, it is hoped that clients will not only gain insight and judgment, but perhaps develop a better understanding of themselves and the way they relate to the people around them. According to Malchiodi^[1] "Art making is seen as an opportunity to express oneself imaginatively, authentically, and spontaneously, an experience that, over time, can lead to personal fulfillment, emotional reparation, and transformation. The creative process can be a "health-enhancing and growth-producing experience."

What Does a Typical Art Therapy Session Look Like?

Marachi (2006) 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.

Therapy comes from the Greek word 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.

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-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). The first drawing assessment for psychological purposes was created in 1906 by German psychiatrist Fritz Mohr (Malchiodi 1998). In 1926, researcher Florence Goodenough created a drawing test to measure the intelligence in children called the Draw–A–Man Test (Malchiodi 1998). 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). Goodenough and other researchers realized the test had just as much to do with personality as it did intelligence (Malchiodi, 1998). Several other psychiatric art assessments were created in the 1940s, and have been used ever since (Malchiodi 1998).

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:

The Diagnostic Drawing Series (DDS)

The Diagnostic Drawing Series is an art therapy assessment that is correlated with the diagnosis of major psychiatric disorders (Mills, 2003). The DDS is a three drawing series that is used by mental health professionals around the world (Diagnostic Drawing Series website, 2009). In the first part, subjects are asked to draw any picture using colored chalk pastels on an 18 x 24 inch piece of paper. Then they are asked to draw a tree in the second part. In the last part of the art interview, subjects are asked to show how they are feeling using lines, shapes, and colors. Research regarding the pictures is generally based on the presence and absence of many elements, such as use of color, blending, and placement of the images on the paper (Cohen, Hammer, & Singer, 1988)...

The Mandala Assessment Research Instrument (MARI)

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 (Malchiodi 1998). The person is then asked to draw the mandala from the card they choose with an oil pastel of the color of their choice (Malchiodi 1998). The artist is then asked to explain if there were any meanings, experiences, or related information related to the mandala they drew (Malchiodi 1998). 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 (Malchiodi 1998). 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 (HTP)

In this assessment, the patient is asked to draw three separate images; a house, a tree, and a person (Malchiodi 1998). After the patient has finished the drawings, the therapist asks questions like, "How old is the person in your drawing? What is he or she doing? What is the house made of? What is the weather in this picture?" (Malchiodi 1998). This assessment is done achromatically (using lead pencil). This is a projective assessment and the house, the tree, and person in the drawing represent different aspects of the artist and the way the artist feels about him or herself (Malchiodi 1998).

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 the client's capacity for change and restoration (Hanes, 1995, 1997, 2008).

Art Therapy Standards of Practice in the United States

Board Certification, Registration, and Licensure

In the United States, art therapists may become Registered (ATR), Board Certified (ATR-BC), and, in some states, licensed as an art therapist , creative arts therapist (LCAT; NY State only), or professional or mental health counselor (many states).^[2] A Code of Professional Practice, a 17 page document summarizing the standards of practice for professional art therapists. 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).

For more information on how to become licensed, US art therapists 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.

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.

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^[3]. 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^[3].

Another topic of this section discuses 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 discuss other responsibilities of art therapists. This 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 chose to advertise their service (ATCB 2005)

Independent Practitioner

Independent practitioners are art therapists who are practicing independently or responsible for the service they are providing to paying clients. This section covers the credentials for independent practitioners.

Independent practitioners must provide a safe and functional environment to conduct art therapy sessions (ATCB 2005). According to ATCB, "this includes but is not limited to: proper ventilation, adequate lighting, access to water supply, knowledge of hazards or toxicity of art materials and the effort need to safeguard the health of clients, storage space for art projects and secured areas for any hazardous materials, monitored use of sharp objects, allowance for privacy and confidentiality, and compliance with any other health and safety requirements according to state and federal agencies which regulate comparable businesses" (2005).

This section also establishes the standards for independent practitioners to follow when dealing with financial arrangements.. Basically it states that the art therapist must provide a straight forward contract to the payer of the therapy sessions^[3]. It also states that the art therapist must not deceive the payers or exploit clients financially^[3].

The last topics this section sets standards for address treatment planning and documentation (ATCB 2005). Art therapists must provide a treatment plan that assists the patients to reach or maintain the highest level of quality of life and functioning^[3]. This involves using the clients’ strengths to help them reach their goals and address their needs. Art therapists are also required to record and take notes that reflect the proceedings of the events of therapy sessions^[3]. According to ATCB, the following is the minimum of which must be documented: “the current goals of any treatment plan, verbal content of art therapy sessions relevant to client behavior and goals, artistic expression relevant to client behavior and goals, changes (or lack of change) in affect, thought process, and behavior, suicidal or homicidal intent or ideation” (2005) and a summary of the "clients response to treatment and future treatment recommendations" (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 loses their certificate and still claim to have ATCB credentials can be punished legally. It also discusses the procedure to follow when accused of wrong doing related to art therapy. Lastly, it discusses the wrong doings related to art therapy that therapists can be convicted for with a felony or another criminal conviction. These wrong doings include rape, sexual abuse, assault, battery, prostitution, or the sale of controlled substances to patients.

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^[3].

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 patients life^[3]. Also, therapists are not allowed to publish or display any of the patients work without the expressed written consent of the patient^[3].

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, inters trainees, supervisors, or co-workers^[3]. The ATCB defines an exploitative relationship as anything involving sexual intimacy, romance, or borrowing or loaning money^[3]. Within professional relationships, therapists are to do what they feel is best in the clients interest, shall not advance a professional relationship for their own benefit, and shall not steer their patients in the wrong direction^[3].

The breaking of any of the standards established in this section is grounds for discipline^[3].

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 wrong doings 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”^[3]

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.

Effectiveness Art Therapy has bona fide research in various venues: phenomenological, heuristic, quantitative, qualitative, etc. Numerous articles, books, NIH reports, etcetera are replete with information that attests to the efficacy of Art Therapy as evidence-based, effective treatment. However, it has been noted that Art Therapy's effectiveness is not well understood through unsubstantiated claims, uncited research, or vague generalizations.

Broad Uses of Art Therapy

General Illness

People always search for some escape from illness and its 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 ^[4].

Hospitals have started studying the influence of arts on patient care and found that participants in art programs have better vitals and less complications sleeping. Artistic influence doesnt even need to be participation in a program but studys 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. ^[4]

Cancer Diagnosis

Art therapists have conducted studys to understand why some cancer patients turned to art making as a coping mechanism and a tool to creating a positive identity ouside 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 identy outside of having cancer, lessened emotional pain of their on-going fight with cancer, and also giving them hope for the future.

Studys have also shown how the emotional destress of cancer patients has been reduced through 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 ^[4]

References