Picture a patient sitting across from a therapist, unable to voice her innermost thoughts; unable to vocalise her hidden shame; unwilling, even in this safe haven, to speak aloud the fears that have plagued her since childhood.
Now imagine the same patient given a blank sheet of paper, a bottle of glue and a stack of pictures – pictures of people, pictures that express emotion, pictures of nature, and pictures that appear as one thing to one person and something else to another.
Given the freedom to express herself with art rather than words, the client opens up. She remembers her earliest days, when pencils and crayons gave her the freedom to express herself without the complication of words. Encouraged to create, both then and now, she subconsciously lets her guard down, and with it, allows her emotions to stream forward like a raging river. This is psychology and creativity melded together in a counselling context. This is art therapy.
Defining art therapy
The unique relationship between art and psychology, which both have potential for conflict and healing, can make defining art therapy difficult. Consequently, some art therapists practice primarily according to the principle that the process itself is the main healing effect (‘art as therapy’), whereas others focus on the unconscious material and the exploration of the deeper meaning of the artwork (‘art in therapy’).
In ‘art as therapy’ approaches, drawing is the main focus. Something emerges that can be experienced rationally, emotionally, spiritually or physically. The therapist also can ask clients how they felt while drawing and how this relates to their life. The emphasis is about the process, not the content of the artwork.
In ‘art in therapy’ approaches, the client explores the deeper meaning of the picture by describing what she actually sees in the picture and not what she thinks about the picture. This is often the part of art therapy when the unconscious becomes conscious, and clients realise just how connected everything in their lives is.
A great inspiration for many art therapists is Freud’s frustration with words. He noted: “We experienced it [a dream] predominantly in visual images…part of the difficulty of giving an account of dreams is due to our having to translate these images into words. ‘I could draw it,’ a dreamer often says to us, ‘but I don’t know how to say it.’” (Freud, 1916-1917; p. 90). Some ideas are difficult or impossible to put into words. Clients who can externalise their trauma, for example by drawing it on paper, can experience relief.
Images represent an alternative medium for expression and communication. Once experiences are externalised as images, it is easier to talk about them by describing the artwork or talking about the art-making process. For some people, however, producing images can be embarrassing or a destructive experience, and clients may try to avoid or resist it regardless of its beneficial potential. Despite this reluctance, the concept behind art therapy is that sharing the meaning of images may lead to a better understanding of the client’s presenting problem and create change.
Art therapy in practice
As a psychologist and art therapist, I often find that clients open up vocally after drawing. I would like to use the well-known metaphor of an iceberg to describe the two major aspects of human personality. The tip of the iceberg that extends above the water represents the conscious mind. Beneath the water is the much larger bulk of the iceberg, which represents the unconscious. Words come easier to clients’ minds and unconscious material pours quickly to the surface once they start describing their images.
Cognitive behaviour therapy (CBT) focuses on observable behaviour and conscious thoughts. This approach only works where those thoughts and behaviours can be accessed. Art therapy taps into the unconscious, where there is no concept of time, i.e., what was relevant 30 years ago might still be as relevant at present. Art therapy attempts to make the unconscious conscious and thus enable a fundamental change in the client’s thinking.
If images are interpreted, then multiple layers of meaning have to be acknowledged. This multiplicity is the essence of the depth of communication in art therapy. Through the art‑making process and exploration of the artwork, unconscious and conscious thoughts, feelings and fantasies can be expressed (Edwards, 2004). Unfortunately, clinicians from other backgrounds often use artwork to find ‘evidence’ about something that is troubling their client. Effective art therapy is not so much about identifying problems, but rather the process and exploration of the artwork. Therefore, it has to be recognised that in drawings and paintings there is an overlap of reality and fantasy (Case & Dalley, 1999). The meaning has to be ultimately negotiated between the client and the therapist. I have often found that in most cases where, for example, child abuse has occurred, it is more likely that the abuse is simply expressed by being ‘messy’ rather than actually drawing who did what to whom. Consequently, instead of making quick interpretations and judgments, art therapists must take time until the client is ready to verbalise the personal meaning of the art process and final product.
Surprisingly, most current art therapists challenge Freud’s view of symbols which frequently occur in images as products of repressed unconscious conflicts. Symbols relate to transforming and integrating personal experiences, both pathological and healthy, and should not be seen in isolation, but connected to the client’s individual experiences (Malchiodi, 2011).
Evidence for effectiveness of art therapy
While there are many claims of the effectiveness of art therapy, they are mainly based on individual case studies. A recent review article by Uttley and colleagues (2015) examined the evidence for clinical effectiveness of art therapy in populations with non-psychotic mental health disorders. In 10 out of 15 randomised controlled trials that were identified and included in the review, art therapy was associated with significant positive changes in mental health symptoms relative to the control groups. Unfortunately, a meta-analysis was not possible because of the clinical heterogeneity and insufficient comparable data on outcome measures. The review also analysed 12 qualitative studies and identified a number of benefits of art therapy for service users, including the relationship with the therapist, personal achievement and distraction. Areas of potential harms associated with art therapy were also identified in the review and related to the activation of emotions that were then unresolved, lack of skill of the art therapist and sudden termination of art therapy. These identified potential harms indicate the need for art therapy practitioners to have a strong understanding of the power of any therapeutic intervention and appreciation of issues associated with the therapeutic relationship (both of which are ‘bread and butter’ issues for psychologists), as well as appropriate training in art therapy.
Art therapists tend to look for an evidence base for their work in surveys and case studies, clinical audits and qualitative research. Edwards (2004) assessed the case study as being the most popular among art therapists because great attention is given to the individual, the complexity of the therapeutic process is acknowledged and it involves significantly less costs. The disadvantages of case study methodology are evident – independent variables cannot be manipulated and the causes of the treatment effects can be speculated but not determined rigorously as in experimental studies.
To increase the effectiveness of art therapy, it can be integrated with other therapeutic interventions that do have a more significant evidence base.
Art therapy and CBT approaches
Although art therapy has focused predominantly on emotions, some therapists also integrate cognitive and behavioural constructs into their intervention. The externalised representations, unconscious projections and underlying cognitions and feelings can be made conscious through art therapy. In further sessions, using CBT, these can then be addressed and reframed.
Alternatively, art therapists can use images as experiments on paper. The advantage of visual work is that the client may develop more positive ideas on how to behave in a certain situation by experimenting on paper. It is not clear which direction art therapy will take in its development as an approach. However, there is some evidence that art therapy can enhance traditional CBT and that CBT-based art therapy may be as effective as psychodynamic-based approaches (Rosal, 2001). With regards to the direction of the argument, it is most probable that no single definitive approach will ever be adequate to cover the complexity of individual client needs.
Both art and psychology remain equally important ingredients in defining art therapy. Although art therapists come from many different backgrounds, the majority refer to themselves as eclectic with an emphasis on the psychodynamic tradition. Images are their key focus and are seen as alternative means of an effective communication. By comparison, cognitive behavioural-based art therapists are more directive and structured. Their main advantage is that the clients can identify underlying thoughts and emotions before continuing with the ‘traditional’ CBT approach, and that clients can experiment with their cognitions and behavioural tasks on paper. Marrying different techniques in a clear, decisive and intelligent manner appears to be the way to go for future counsellors and psychotherapists.
Given the dearth of research studies on the effectiveness of art therapy, perhaps art therapists have to start working more in conjunction with psychologists in practice and research in order for art therapy to increase its evidence base as an intervention. I have experienced the strength of art therapy for more than 20 years with my clients and have integrated it so many times with CBT and other approaches, that I can look confidently towards a future where art therapy will become a part of every psychologist’s toolkit.
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