Art Therapy is a form of psychotherapy that uses art making as a part of the therapeutic process. Like any psychotherapy, the therapist provides the holding frame for the therapy, assesses and helps the client set treatment goals, and offers a reparative therapeutic relationship. In addition, the art therapist provides art materials and specialized training that helps the client engage in and make meaning from art making done in the service of therapy. Internal imagery and external process become visible within an art therapy session.

She hesitated at first, not wanting to reach into a brand new box of pastels. "I’m afraid," she said. I asked her to pick out a color she didn't care much for. It was a rusty red. She handed the pastel to me and gasped when I broke it in two. "It's okay to use these. It's okay if you need to break one to get the right size line." She made a first tentative line with her least favorite color….

Essential components of art therapy include selecting and using art materials, creating a visual or tactile image, and contemplating and making meaning of the art encounter and the image itself. These mental processes and physical actions create opportunities for the client to become aware of anomalies in thinking and feeling, and to create expanded options for viewing, clarifying, and making meaning of their feelings and beliefs and the events in their lives.

I encouraged her to experiment with movement: fast, slow, round, sharp, and with pressure: hard, soft. Her energy began to increase. "Pick another color now, one you really like." She unerringly reached for a soft blue-green and smoothed it into spaces unoccupied by rust-red.

Art therapy is based on the conviction that the act of making art is an embodied action that reflects concretely and/or symbolically the client's experience of being, including conflicts the client may not be aware of. How these conflicts are perceived and interpreted by the therapist is a function of the therapist's own theoretical preferences; i.e., psychoanalytic, depth analytic, object relational, social-constructivist, etc. Interpretation in this case refers to the therapist's theory-biased understanding of the phenomenon being observed. Whether the therapist provides an interpretation and/or elicits one from the client is dependent on the therapist's theoretical stance regarding the role of the therapist relative to the client.

"I notice the blue and red don't touch," I said. "I don't want the blue contaminated. It has to surround the red and keep it from spilling out," she replied firmly.

The use of art materials and processes as an integral communication within the therapeutic encounter distinguishes art therapy from counseling, psychology, and social work. While other professions might utilize art materials and art tasks in therapy sessions, such use is adjunctive to the primary verbal means of communication. Unless allied mental health professionals have acquired further training in art therapy, they usually are not qualified to use art materials and art processes for on-going intervention. While the art therapist may also utilize a primarily verbal approach in some therapy sessions, the core of art therapy service delivery is the ability of the art therapist to assess and intervene with art materials and appropriate art tasks.

"What would happen if you REALLY wrapped the red up in blue lines?" I asked, knowing that the pastel would begin to blend She experimented with this and then stopped. "I don't want to lose the differences between the two, but I like some of the blended areas, too." Then she laughed, "Okay, okay, I get it. We've been working on this, haven't we? It’s like how I try to keep my anger invisible so people will think I’m good."

The simple act of making art yields metaphors that can readily be acknowledged by the client. Asking the client to simply describe what s/he decisions she made while making the art can bring clarity to her behaviors, thoughts, and feelings in other situations as well.

I encouraged her to begin again, on a new sheet of paper, and create the next image. She began to draw a nightmare she had dreamt the night before.

Art taps into our internal images that hold keys to who we are and what we believe. Art makes visible those things that are difficult or painful see or discuss in words. Art helps the client to "see" more clearly and to feel a sense of living in a body. As a client feels, discovers, thinks and creates, new insights are gained about self, relationships, and life patterns. Art is used as a form of language in art therapy sessions, along with verbal discussion, to help the client reach a fuller self understanding. Making art not only addresses what is wounded, it also supports what is strong, encouraging the individual to live more fully in the moment. It is especially effective for discovering and claiming an authentic sense of being whole, creative, and relational.

The Function of Art in Therapy:

Art making engages mental, physical and emotional reasoning that utilizes brain structures that are quite different, yet interactive with, verbal reasoning. Making art requires flexibility, close observation, perceptual development and spatial reasoning, physical and conceptual manipulation of tools and materials, tolerance for chaos and ambiguity, the ability to sequence material use, and the cognitive and manual skills to create cohesive form.

Making the invisible visible is a major function of the art in art therapy. The concrete work, the "artifact", can

1. Provide an extension of the client's self that enlarges the client's ability to be self-observing (as in the example above)
2. Externalize traumatic memory or unfinished developmental or relational issues to relieve internal conflict and provide a means for re-processing the event or issues
3. Provide a means for re-viewing and re-framing conflicts
4. Provide permanent documentation of the therapy work
5. Make visible both immediately understood/known self experience, as well as potential symbolic meaning not yet understood.

Therapeutic Relationship in Art Therapy

Art therapy takes place within the context of a therapeutic relationship. The art therapist can adopt a role position drawn from the same theoretical bases as counseling, psychology, psychoanalysis, or social work. That role may also be drawn from traditional medicine and shamanic practices, wherein the therapist is a "healer". Thus, the therapeutic relationship may be more or less "figure" in the "ground" of art therapy, to use a Gestalt metaphor.

The art in art therapy has been called the "third hand" of the therapist by Edith Kramer, an early art therapy pioneer. I prefer to think of it as the third presence in the therapy frame. The presence of the created artifact enlarges the relationship frame by introducing a concrete manifestation of the client witnessed by both therapist and client. The artwork has an effect on both client and therapist.

Art therapy can also be done in groups of two or more people. Group art therapy provides additional interpersonal stimulus and creative impetus. Depending on the goals of the group, emphasis may be placed on the interpersonal dynamics, the acts of art making and/or the sharing and witnessing of the resulting images.

A Brief History of Art Therapy and Its Theoretical Underpinnings:

The theoretical bases for art therapy have been drawn from such disciplines as psychology, sociology, anthropology, physiology, aesthetics, and education. As a psychotherapy practice, art therapy spans the same theoretical landscapes as psychology, social work, and counseling, and reflects the history and development of psychotherapy in general, including changing understanding and preferences in modern practice.

In its formative years in the U.S., from the early 1930's through the middle 1950's, art therapy was practiced by fine artists and art educators in medical, psychiatric and educational facilities. These artists, and their medical and educational colleagues, discovered that non-verbal and pre-verbal patients "came alive" as they made art, and that the "language" of the art; i.e., the symbolic image, could be understood. Art opened windows and doors into the psyche. Suddenly patients could be seen and understood differently by themselves and the staff.

In these early years, psychoanalytic thought was a prevalent grounding theory for art therapists, who tempered it with Jungian concepts about active imagination, dream symbolism, and theories of the archetypal unconscious. Psychoanalytic theory was also a major premise for the interpretation of pictorial and sculptural images. The idea that art could be used to enhance diagnosis encouraged many early practitioners to search for keys that could decode the images. Diagnostic drawing series and protocols were developed that led art therapy onto an increasingly clinical path.

However, the apparent universality of some imaginal themes, the possibility of a visual code, and the sheer exuberance of art making and the images themselves could not be contained solely in a clinical, reductionist model. In contrast to psychoanalytic approaches, Gestalt and phenomenological practitioners emphasized a "here and now" focus, with the artwork to be understood also as an artifact of the moment: the movement, patterns, and associated meanings that occurred in the process of making and viewing the work. This approach, derived from earlier organismic theories, propelled a second trajectory of art therapy along transpersonal, humanistic lines. These two waves: the highly clinical and analytic, and the humanistic, have often been at odds with each other, but both have utilized art and art making as the primary communicative means within the therapeutic relationship. A third trajectory claimed an "art as therapy" position, and many art therapists initiated "open studios" within institutional settings, relying on the inherent power of creative process and art making to enhance individual functioning. In this approach, neither the artwork nor the therapeutic relationship was analyzed. Full confidence was placed in the inherent properties of art making to be therapeutic within the therapy setting.

These clashes among theoretical platforms remain alive today, not only in the field of art therapy, but in other versions in the allied domains of counseling and psychology as well. One only need turn to the arguments (and funding debates) between "behavioral medicine" and psychoanalytic psychotherapy to see the fundamental differences in orientation to psychotherapy treatment.

But, and it's a big but, there is increasing synthesis of theory and approach within both the larger psychotherapy community and the art therapy community. As theory moves from a polarized to a synthesized approach, the artificial distinctions between "mind" and "body" are breaking down, as are the distinctions between art "as" therapy and art "in" therapy. What unifies all therapy disciplines is the belief that human beings are capable of changing their basic beliefs about themselves and their world, and can effect changes in how they interact in the world. How those changes can take place is increasingly grounded in physiology and metaphor: the union of science and art, the integration of East and West, the unification of mind, body, and spirit. The details are in the individual theories and preferences of the practitioner and the client: should the emphasis be on the therapeutic relationship? On making art? Should we attempt to decode unconscious processes? Rely on the wisdom of the body to teach us how we "move" in the world? Can we be both rational and irrational? What theory(s) fuels art therapy now?

Basic art therapy assumptions:

Art therapy rests on the position of art making in accessing and expressing meaningful self and social constructs. Because it is a creative activity, art therapy also contains the potential to generate new options, meanings and strategies. Most art therapists agree on the following assumptions:

1. Creating art engages the whole brain, accessing both right and left hemispheres. This encourages integration of feeling, cognition, and sensation, which can create new understanding.
2. Creating art promotes visual/spatial and sequential reasoning.
3. Telling the story of the creative process and investigating the meaning of of the emergent symbolic imagery encourages increased options for meaning and outcome, which encourages cognitive re-structuring
4. Aesthetic concepts can function as relatively non threatening (re-)organizing metaphors
5. The image is the bridge between conscious and unconscious processes
6. The created work serves as archive, concretizing client awareness and understanding
7. Art making encourages spontaneity and increased affective range
8. Art making promotes self discipline
9. Art making promotes socialization
10. Art making can increase self esteem and autonomy
11. The aesthetic properties of art are in themselves a form of language and percept organization, and this "language" can be utilized as a research frame for viewing, organizing and understanding phenomena.

Art therapists are human service professionals. Art therapists are trained to observe and assess the client, to create a therapeutic framework and establish a therapeutic relationship, to set goals for treatment, to evaluate outcome of treatment, and to provide therapeutic interventions appropriate to the client's level of function and therapy goals. Art Therapy is a profession regulated by the American Art Therapy Association (AATA) and credentialed by the ATCB.

The American Art Therapy Association is the professional organization that defines and monitors the field as a whole. Formed in 1969, it sponsors a professional journal (Art Therapy), an annual conference and regional symposia. Art therapy educational programs are evaluated periodically and must conform to the prevailing standards of training established by AATA membership. AATA has developed a strong Code of Ethics and Standards of Professional Practice, and clinicians offering art therapy are advised to review and adhere to those standards. Unfortunately, art therapy is not regulated as a licensed profession by very many states, so compliance with AATA’s standards by non registered art therapists is voluntary.

ATCB, the Art Therapy Credentialing Board, was formed in 1994. It oversees the awarding of professional credentials. Registration (ATR) requires the completion of a master's degree in art therapy or a related field with specified art therapy course work. The degree must include supervised practicum. Following graduation, a specified number of post-graduate clinical hours under supervision by an art therapist, must be completed. Once the art therapist has become registered, s/he may apply to take a certification exam. After passing this exam, the art therapist may use the initials ATR-BC

An art therapist is trained to assess a client's needs for and ability to engage in art therapy, and to help the individual develop therapeutic goals and a process for reaching those goals. The art therapist must have a solid understanding of human development, personality theory, psychopathology, helping relationship practice and theory, crisis intervention and trauma theory, professional ethics and standards of practice, and the use of art methods and materials for therapeutic change and growth. The art therapist must be knowledgeable about contextual issues such as cultural and social concerns, and have a firm grasp of group theory and practice as well as individual psychotherapeutic approaches. The art therapist should be actively practicing some form of creative self expression and should have or seek personal therapy for insight and self awareness.

Experiential learning is a cornerstone of art therapy education. Until the student experiences art being used in the service of self discovery and therapeutic processes, no reading can truly bring theoretical concepts to life. Clinicians and students who are interested in incorporating art therapy into their work are encouraged to take an art therapy course, participate in an art therapy group, or work individually with an art therapist before using art therapy tools.

Art therapy education is available in colleges and universities and in a few post-graduate training institutes. Admission to these programs require an undergraduate program that includes study in art, psychology and art education. Prospective students must provide a portfolio of their own artwork and demonstrate competency (or make up deficiencies during the program) in basic art skills. The graduate program usually takes a minimum of two years to complete and includes art therapy coursework (21 hours), as well as developmental and personality theory, psychopathology, and research methods. Many art therapy students take additional coursework to make them eligible for counselor licensure as well. Extensive practicum work is required during the program, and a minimum of 1000 direct client contact hours under supervision postgraduate are required for registration. These requirements change periodically and should be checked out with ATCB prior to enrolling in graduate studies.

AATA can furnish a listing of approved programs offering training. There are many more excellent programs that are not AATA approved (meaning they have not gone through the AATA certification process yet.) Locally, (St. Louis area) an AATA approved Master of Arts degree in art therapy is offered at Southern Illinois University at Edwardsville. Students can elect to take counseling coursework as part of this program to qualify for counselor licensure. Webster University offers an undergraduate certificate within the fine arts department, and George Warren Brown School of Social Work at Washington University offers a yearly learning skills lab (an introductory course) in art therapy for social work students.

Conclusion

Art therapy is a professional discipline that is a synthesis of psychology, art, and other social science and humanities disciplines, with an increasingly substantial body of knowledge and published literature. It is regulated by a national professional organization and a national certification board. Art therapists work in hospitals, child care settings, community centers, hospice, retirement homes, wellness programs, social service agencies, prisons, medical settings, schools, and private practice.

The core of art therapy is the creative process expressed through art making within a therapeutic relationship. Art therapy can be used with children, adolescents and adults in a wide variety of settings and applications. As an integrative therapy, it offers a necessary option for clients who may need an experiential, less verbally-driven approach.

The author: Carol Lark, Ph.D., ATR-BC, CGP, is an art therapist in private practice in St. Louis, Missouri. She is co-founder of Arts Dialogues and TREC: Talking Race, Engaging Creatively, which are arts based dialogue programs that address racism, cultural diversity and other social issues. She is an artist and has exhibited drawings, prints and paintings in local and regional juried competitions. Her clinical art therapy practice is feminist psychodynamic in orientation, with phenomenological interventions, and she works primarily with adults with a wide variety of psychiatric and social treatment issues. She holds a doctorate in applied psychology and art therapy.

©Carol Lark, December, 2001. Please credit author and source when reprinting or quoting from this article.