WHAT IS ART THERAPY?

Numerous and often conflicting definitions of art therapy have been advanced since the term, and later the profession, first emerged in

the late 1940s . In the UK, the artist Adrian Hill is generally acknowledged to have been the first person to use the term ‘art therapy’ to describe the therapeutic application of image making. For Hill, who had discovered the therapeutic benefits of drawing and painting while recovering from tuberculosis, the value of art therapy lay in ‘completely engrossing the mind (as well as the fingers) … [and in] releasing the cre-ative energy of the frequently inhibited patient’ . This, Hill suggested, enabled the patient to ‘build up a strong defence against his misfortunes’.

At around the same time, Margaret Naumberg, a psychologist, also began to use the term art therapy to describe her work in the USA. Naumberg’s model of art therapy based its methods on,

Releasing the unconscious by means of spontaneous art expression; it has its roots in the transference relation between patient and therapist and on the encouragement of free association. It is closely allied to psychoanalytic theory … Treatment depends on the development of the transference relation and on a continuous effort to obtain the patient’s own interpretation of his symbolic designs … The images produced are a form of communication between patient and therapist; they constitute symbolic speech.

Although the approaches to art therapy adopted by Hill and Naumberg were very different, and have been superseded by subsequent develop-ments within the profession, their pioneering work has nevertheless exer-cised a significant influence. Essentially, Naumberg’s position might be described as championing the use of art in therapy, whereas Hill advo-cated art as therapy. Subtle though this distinction may at first appear, it is of crucial importance in understanding art therapy as it is practiced today. This is because art therapy has developed along ‘two parallel strands: art as therapy and art psychotherapy’. The first of these approaches emphasises the healing potential of art, whereas the second

1. Triangular relationship

stresses the importance of the therapeutic relationship established between the art therapist, the client and the artwork. The importance accorded to these respective positions is central to the whole question of where healing or therapeutic change in art therapy takes place. That is to say, whether this is due primarily to the creative process itself, to the nature of the relationship established between client and therapist or, as many art therapists would now argue, to a synthesis of the varied and subtle interactions between the two. In art therapy this dynamic is often referred to as the triangular relationship.

Within this triangular relationship greater or lesser emphasis may be placed on each axis during a single session or over time.

Towards a Definition of Art Therapy

As the profession of art therapy has established itself, definitions have become more settled. From a contemporary perspective, art therapy may be defined as a form of therapy in which creating images and objects plays a central role in the psycho therapeutic relationship established between the art therapist and client. The British Association of Art Therapists, for example, defines art therapy in the following terms,

Art therapy is the use of art materials for self-expression and reflection in the presence of a trained art therapist. Clients who are referred to an art therapist need not have previous experience or skill in art, the art therapist is not primar-ily concerned with making an aesthetic or diagnostic assessment of the client’s image. The overall aim of its practitioners is to enable a client to effect change

WHAT IS ART THERAPY?

and growth on a personal level through the use of art materials in a safe and facilitating environment.

Other national professional associations provide similar, but subtly different, definitions. 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.

In a similar vein, the Canadian Art Therapy Association and the Australian National Art Therapy Association define art therapy in the following terms,

Art therapy is a form of psychotherapy that allows for emotional expression and healing through nonverbal means. Children, unlike most adults, often cannot easily express themselves verbally. Adults, on the other hand may use words to intellectualise and distance themselves from their emotions. Art therapy enables the client to break through these cumbersome barriers to self-expression using simple art materials.

The essence of art therapy lies in the relationship it is possible to establish between art and therapy. That this relationship between the two disciplines might contain the potential for conflict, as well as healing, has resulted in its being described as an ‘uneasy partnership’. As M. Edwards comments,

It seems that sometimes one or other partner gives up the struggle so that we have art without much therapy or therapy without much art. In either case the specific advantage of the relationship between these two disciplines is lost.

It is important to note here that in art therapy this relationship is speci-fically focused on the visual arts (primarily painting, drawing and sculpt-ing) and does not usually include the use of other art forms like music, drama or dance. While there may be some overlap between these different disciplines. in the UK the therapeutic application of these arts is undertaken by therapists who, like art therapists, have received a specialised training. This is not, however, the situ-ation elsewhere in Europe. As Waller, observes, in the Netherlands ‘these professions are known as creative therapy and are much

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more closely linked in terms of training and professional development’

The Aims of Art Therapy

In practice, art therapy involves both the process and products of image making  and the provision of a therapeutic relationship. It is within the supportive environment fostered by the therapist–client rela-tionship that it becomes possible for individuals to create images and objects with the explicit aim of exploring and sharing the meaning these may have for them. It is by these means that the client may gain a better understanding of themselves and the nature of their difficulties or distress. This, in turn, may lead to positive and enduring change in the client’s sense of self, their current relationships and in the overall quality of their lives. As Storr  observes, creativity offers a means of ‘coming to terms with, or finding symbolic solutions for, the internal tensions and dissocia-tions from which all human beings suffer in varying degree’.

The aims of art therapy often vary according to the particular needs of the individuals with whom the art therapist works. These needs may change as the therapeutic relationship develops. For one person the process of art therapy might involve the art therapist encouraging them to share and explore an emotional difficulty through the creation of images and discussion; whereas for another it may be directed towards enabling them to hold a crayon and make a mark, thereby developing new ways of giving form to previously unexpressed feelings. While it is often assumed to be so, it is not the case that only those individuals who are technically proficient in the visual arts are able to make use of art therapy in a benefi-cial way. Indeed an emphasis on artistic ability – as might be the case when art is used primarily for recreational or educational purposes – is likely to obscure that with which art therapy is most concerned. That is to say, with the symbolic expression of feeling and human experience through the medium of art.

What Art Therapy Is, and What It Is Not

Although art therapy has developed considerably from its informal and ill-defined beginnings, an unfortunate legacy of myth and misunderstanding concerning its aims and methods still remains. As a consequence, the term ‘art therapy’ continues to be applied uncritically to a wide variety of thera-peutic art activities. All too frequently art therapy is viewed as a skill or technique, rather than a distinct therapeutic moda-lity. Perhaps the most obvious reason for this is that members of other

WHAT IS ART THERAPY?

professional groups have used art or image making for recreational, diagnostic or therapeutic purposes. These professions include community and hospital based artists, psychiatrists, occupational therapists, nurses  and social workers  among others. As the members of each of these diverse groups bring with them a particular approach to the image, the work of art therapists may occasionally be obscured in the resulting confusion concerning who does what. This can, regrettably, lead to boundary disputes between different disciplines and misunderstanding in the minds of colleagues and potential clients.

Art Therapy and Occupational Therapy

One profession with which art therapy has often been mistaken with respect to the therapeutic application of art is occupational therapy. There appear to be two main reasons for this. Firstly, the respective histories of art therapy and occupational therapy are inextricably linked. Up until the early 1980s many art therapists were based in occupational therapy depart-ments and their work was part of the overall service provided by them. Though this is no longer the case, many art therapists continue to work alongside occupational therapists on a day-to-day basis. Secondly, there is a long history of occupational therapists using art ‘as a therapeutic modal-ity in mental health’. This includes the use of projective techniques as an aid to diagnosis through to the use of art to foster self-awareness and com-munication .

Although the use of art in mental health settings by occupational thera-pists appears to have declined since the mid-1980s, a trend, in part, influ-enced by the development of art therapy as a profession, their work in this area is nevertheless frequently confused with that undertaken by art ther-apists. It may, therefore, be helpful to examine the areas of commonality and difference between the two professions in order to clarify further what art therapy is, as well as what it is not. In their discussion of this issue, Atkinson and Wells  identify four main areas of difference between art therapy and the use of art in occupational therapy. These they distinguish as, education and training, the use of a single arts based medium, the importance attached to the artwork, and the level of direction evident within the therapeutic approach.

Education and training

Art therapy training takes place at postgraduate level, with the vast majority of art therapists already possessing an undergraduate degree in a related

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subject; usually fine art. This is not the case for occupational therapists whose basic training is at undergraduate level.

The use of a single arts based medium

Art therapy is primarily concerned with the therapeutic application of one or more of the visual arts such as painting, drawing or sculpture. In addi-tion to the experience and understanding of these gained prior to and during their training many art therapists are actively involved with the medium of art outside their work. Indeed, this is widely regarded as essen-tial if art therapists are to remain in touch with the discipline upon which their clinical practice is based . Occupational therapists, by contrast, often use a wide range of arts based media (drama, creative writing, music, as well as paper and paint) in their work and few would claim to possess any specialist skills in these disciplines.

The importance attached to the artwork

By and large, occupational therapists tend to place far less emphasis on the artwork than would an art therapist. For art therapists product and process are integral to one another, whereas in occupational therapy the fin-ished artwork is generally regarded as being of secondary importance to the therapeutic process; the primary aim being to gain information about the client through observing their engagement with their artwork .

The level of direction evident within the therapeutic approach

Although some art therapists may suggest themes for clients to work to, most tend not to plan sessions or provide specific directions as to how the available materials should be used. Whereas an occupational therapist might, for example, attach considerable importance to the use of a partic-ular medium in a session art, therapists generally prefer to offer clients a free choice.

Variations on a Theme: The Title Debate

Another difficulty in distinguishing art therapy from other forms of art based therapeutic intervention concerns the range of titles under which art therapists now practice. There are two important aspects to this. Firstly, and often for historical reasons, in various non-clinical settings such as prisons or in social services, the title under which an art therapist is employed may vary. It is not uncommon for an art therapist working in a prison to be called an ‘art tutor’ or a ‘group worker’ in social service establishments. Secondly, and to further complicate matters, in the early 1990s there was considerable debate within the profession in the UK

WHAT IS ART THERAPY?

concerning whether or not practitioners should change their title from art therapist to art psychotherapist. Some art therapists expressed the view that the term ‘art therapy’ no longer adequately reflected the psychother-apeutic nature of the work undertaken by art therapists . In opposition to these views, other art ther-apists argued that a change of title might result in the loss of a unique pro-fessional identity and that by being linked with verbally based psychotherapy there would be a consequent loss of emphasis on the power of the creative process in art therapy. It is inter-esting to note that similar disputes and debates have surfaced periodically in the USA and ‘continue to contribute to the liveliness of the field’.

Although the membership of the British Association of Art Therapists voted to retain the title art therapist, albeit narrowly, what emerged very clearly during this period was the plural nature of the profession. This diversity of approach within art therapy is reflected in the proliferation of titles under which members of the profession now practice. In addition to art therapist and art psychotherapist, these now include analytical art psy-chotherapist , group analytic art therapist  and person-centred art therapist . In the USA, the range of titles under which art therapists practice is even more extensive and includes cognitive, gestalt, medical, phenomenological and studio approaches to art therapy; see Junge and Asawa  and Rubin. The emergence of these different titles and approaches to art ther-apy has been determined by a number of factors, including the context in which art therapy takes place, the client group with whom the art thera-pist works and the art therapist’s theoretical orientation. As a conse-quence, art therapy has come to mean different things to different people. Indeed, as Watkins  observes, there exists no natural kinship between therapists who depend upon images for their theories or thera-peutic techniques, ‘Nor does the founding of a single kind of therapy (for instance art therapy or sand play therapy) coalesce its group of practi-tioners. Within it there will be radical differences in approach to the imag-inal’. Given the potential these different theoretical positions and ways of working have for generating disagreement and fragmentation, it is a remarkable fact that art therapy in the UK has developed as a coherent and unified profession.

Why Art Therapy?

Although human communication may take many forms, in a society such as ours words tend to dominate. Not only are words the main means by which we exchange information about the world in which we live, but words are, for most people, the main means they have available for expressing and

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communicating their experience of that world. It is through words that most of us, in our daily lives at least, attempt to shape and give meaning to experience. Human experience cannot, however, be entirely reduced to words. Expressing how it feels to love or hate, to be traumatised or to suffer depression may involve far more than struggling to find the ‘right’ words. Some experiences and emotional states are beyond words. This is particularly relevant where difficulties originate in early infancy, a time when we experience the world in advance of any ability to describe it in words. It is here that art therapy offers a way of overcoming the frustra-tion, terror and isolation such experiences may engender, by providing an alternative medium for expression and communication through which feelings might be conveyed and understood.

Art therapy may prove helpful to people with a wide range of needs and difficulties for a number of reasons.

In the context of a supportive relationship making images, and thinking and feeling in images, which among other things involves the use of the imagination and the taking of risks, can further a person’s emotional growth, self-esteem, psychological and social integration.

I had heard of Sam long before I first met him. He was widely known as ‘The Artist’ within the hospital I had recently begun work-ing in, and someone I ought, therefore, to meet. When we did even-tually meet, Sam was very keen to show me his work and how it was made. Sam had spent many years in prison, during which time he had developed a highly personal way of working using the very limited materials available to him.

Using any flat surface with a texture, wax crayons, boot polish and an implement with a flat edge (in demonstrating his technique to me he used a clay modelling tool) Sam was able to create enor-mously subtle images in which figure or figures and background intermingled with a dream-like intensity. Sam evidently experi-enced considerable satisfaction in being able to produce such images at will, but expressed little interest in discussing their per-sonal significance. It was to be very much later in our relationship before he felt able to share with me the story and circumstances that led him to begin making images. It appeared to be enough that he could make them and that doing so afforded him an established identity as an artist.

Over time, however, it became increasingly apparent that Sam’s work showed no signs of change or development. Indeed he was

WHAT IS ART THERAPY?

frequently unable to make images. At such times he often complained of feeling ‘empty inside’ and would drink heavily to dull the pain or in search of inspiration. When Sam was able to make images, he tended to repeat the same mechanical gestures, and use the same formulaic shapes, over and over again. Moreover, there seemed to be no connection between the images he made and how he felt or what difficulties preoccupied him at the time. It was as though Sam’s creativity had become restricted by his own style of image making. The fact that his identity as a person, and much of his self-esteem, was bound up with being an artist who pro-duced such unusual images made it very difficult for Sam to develop new or different ways of working. To do so was too great a risk to take.

Gradually, Sam did begin to experiment with his image making. Having become a regular visitor to the art therapy department, he became increasingly confident in his use of a wide range of different media and materials. Sam was also able to draw upon the support offered to risk sharing his thoughts and feelings, both through his images and through his relationships with others.

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Through making images and objects it is possible to externalise and objectify experience so that it becomes possible to reflect upon it.

Brenda found her way to art therapy following a referral by her psy-chiatrist. In the months preceding her admission to hospital, Brenda had become increasingly anxious and had made repeated visits to her GP complaining of various illnesses for which no physical cause could be found. It was felt that art therapy might help Brenda find less disabling ways of expressing her feelings and gain some insight into her difficulties. Brenda’s referral was unusual in that unlike the majority of clients seen in art therapy she was an accomplished graphic artist. Although this made her a very obvious candidate for art therapy, to begin with Brenda actually found it extremely diffi-cult to use her skills to give form to her feelings. Brenda’s early draw-ings were little different in style or content to those she contributed to various magazines from time to time.

On one occasion, however, Brenda showed me a series of drawings she had produced as illustrations for a Russian folk tale, the Baba Yaga

In this story a young girl is sent by her stepmother to live with her aunt, an evil witch who is cruel and wants to eat her up. The young heroine eventually escapes this fate through acts of kindness and, reunited with her father at the end of the story, lived on and flour-ished.1 As Brenda told me the tale of the Baba Yaga it seemed to me that there were some parallels between her own life experiences and those of the young heroine. Her mother was often portrayed in witch-like terms, and as someone who wished her dead. Having lost her father in childhood, Brenda also longed for a father figure who would rescue her. Once made, this link between the story of the Baba Yaga and her own story opened up the possibility for Brenda to begin making images that depicted events in her own life. To begin with she was able to do so only tentatively. Later, and with growing self-assurance, feelings Brenda found so difficult to articulate through words increasingly began to find expression through her images.

Over time, a number of themes emerged in Brenda’s artwork. These included her fear of rejection and humiliation, along with feelings of helplessness and dependence. Above all, Brenda’s images began to con-vey some of the intense frustration and rage she felt in relation to her

boyfriend, mother and sisters, by whom she often felt belittled and per-secuted. This was a huge step for Brenda to take, as all her life she had been actively discouraged from expressing her anger. Through her art-work Brenda was able to reconnect with areas of her emotional life from which she had long felt alienated. Expressing how she felt, rather than suppressing, this also enabled Brenda to begin to assert her own needs and take control of her own life.

For some clients the images and objects they create may help to hold or contain feelings that might otherwise be experienced as unbearable.

Rita was a deeply troubled woman with a complex array of physical and psychological problems. Periodically admitted to hospital after having become overwhelmed by fears and delusions, Rita lived in an

in–between world. Unable to fend for herself in the outside world, she also hated the restrictions being in hospital imposed upon her life. Following her discharge from hospital Rita craved the sanctuary institutional life offered her and frequently precipitated crises that led to her read-mission. In art therapy, this ambivalence expressed itself through her erratic attendance and tendency to idealise or denigrate others, includ-ing myself. Rita’s inclination to divide her world into good and bad found expression in the very different kinds of images she produced. Her images depicted the world or people, including herself, as good or bad. One day, however, Rita produced an image that marked a signif-icant departure from this pattern

For the first time in art therapy, Rita was able to create an image that expressed her mixed feelings about herself and her struggle to live inde-pendently. The particular significance of this image only became apparent much later in art therapy when she felt safe enough to begin to explore the terror she felt in relation to being unable to separate from her mother. The importance this image had at the time it was made,

however, lay in its capacity to contain and hold the ambivalent feelings she had hitherto experienced as unbearable and inexpressible. No longer entirely stuck or frozen within her, these feelings were now out-side herself, contained within the borders of the sheet of paper on which they had been depicted.

It is through symbols that we are able to give shape or form to our experience of the world. This may provide the basis for self-understanding and emotional growth.

Made at the very end of art therapy Lily’s image carried a number of very personal symbolic meanings. Firstly, it referred to the many tears Lily had shed during her life and over the course of therapy. Less overtly, the eye also referred to her wish to be seen. As a quiet, obedient child, Lily had been an almost invisible member of her family. Although Lily had developed this survival strategy to protect herself, her invisibility left her feeling uncared for. However, while Lily longed to be looked at, she was also terrified that if seen she would be rejected. This conflict, between seeing and being seen, had played a central role in art therapy. Lily’s final image was so important

to her because while making it she came to recognise that seeing and being seen now felt safe and her fear of judgement had been replaced by feelings of self-acceptance.

The physical nature of an artwork, for example, the way line, color or shape are employed, provides a lasting record of the imaginative processes that produced it. Moreover, the permanence of art works – as contrasted to the transitory nature of verbal expression – may be espe-cially useful in enabling the art therapist and the individuals with whom they work to follow and reflect upon changes occurring during the course of therapy. This helps establish a sense of focus and continuity that might otherwise be lost or prove difficult to maintain.

Pete was referred for art therapy because he found it difficult to talk about his problems. He had been diagnosed as suffering from depression and had been drinking heavily prior to his admission to hospital. At the beginning of art therapy Pete was very with-drawn. He also found it difficult to engage with the art materials. His first images were messy, fragmented and apparently lacking

coherence. Pete seemed to be making these doodle–like images simply to pass the time. It was noticeable, however, that the cartoon character Snoopy would put in an occasional appearance

It was only much later in art therapy, after he had begun to make images in which Snoopy played a more prominent role that the sig-nificance of this became apparent. Pete identified himself with Snoopy. So much so, in fact, that he had a tattoo of Snoopy on his upper arm. Once I was aware of this it was possible for Pete and me to review his earlier work with this identification in mind. Earlier images, which appeared at the time to be devoid of emotion or per-sonal meaning, could be seen in a new light. That is, as tentative attempts to locate himself in and through his images. The appear-ance of Snoopy in images made at different times also helped us both to see more clearly the process of change, both in Pete’s images and in himself.

Although the forgoing vignettes are intended to give an indication of the ways in which art therapy may help individuals with a variety of problems, these examples are by no means exhaustive. The aims of art therapy will inevitably vary according to the needs of the individual or client group, and these may range from encouraging personal autonomy and self-motivation, to working with fantasy material and the unconscious . It is also necessary to acknowledge that for some clients making images can pose the threat of an embarrassing or destructive experience and may be resisted or avoided, irrespective of its potential benefits. This issue is explored more fully in Chapter 4.

Client groups

The range of settings in which art therapists now work is extensive and constantly developing. These include hospitals, schools, community-based centres, therapeutic communities and prisons. Art therapy is also often included as part of the services provided to particular client groups such as children, adolescents, families, older adults and individuals with learn-ing difficulties. Within these broad areas art therapists may work with indi-viduals on a one-to-one basis or with groups. Art therapists are also to be

found practicing in a number of specialist fields including work with offenders, clients who have autism, eating disorders, addictions or who have experienced physical or sexual abuse, psychosis and physical ill-nesses. Increasingly, art therapists are also to be found working privately as well as in the public sector.