Art therapy

Art therapy
Two convict artists busy in drawing designs of carpets on graph papers at Industrial Workshops of Central Jail Faisalabad, Faisalabad, Pakistan in 2010
MeSH	D001155

Because of its dual origins in art and psychotherapy, art therapy definitions vary. It can either focus on dealing with the art-making process as therapeutic in and of itself ("art as therapy"), or on the psychotherapeutic transference process between the therapist and the client who makes art. The therapist interprets the client's symbolic self-expression, as communicated in the art, and elicits interpretations from the client.” The tenets of art therapy involve humanism, creativity, reconciling emotional conflicts, fostering self awareness, and personal growth.

Definitions

According to the 'What is Art Therapy?' brochure from the website of (BAAT - British Association of Art Therapists),

“Art therapy is a form of psychotherapy that uses art media as its primary mode of communication. It is practised by qualified, registered Art Therapists who work with children, young people, adults and the elderly. Clients who can use art therapy may have a wide range of difficulties, disabilities or diagnoses. These include, for example, emotional, behavioral or mental health problems, learning or physical disabilities, life-limiting conditions, brain-injury or neurological conditions and physical illness. Art therapy may be provided for groups, or for individuals, depending on clients’ needs. It is not a recreational activity or an art lesson, although the sessions can be enjoyable. Clients do not need to have any previous experience or expertise in art.”

The American Art Therapy Association describes it this way:

"(a)rt therapy is 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."

"Art therapy is a mental health profession that uses the creative process of art making to improve and enhance the physical, mental and emotional well-being of individuals of all ages. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behaviour, reduce stress, increase self-esteem and self-awareness, and achieve insight. Art therapy integrates the fields of human development, visual art (drawing, painting, sculpture, and other art forms), and the creative process with models of counseling and psychotherapy."

History

Art therapy is a relatively young therapeutic discipline. It first began around the mid-20th Century, arising independently in English-speaking and European areas. In England, as in the U.S., the roots of art therapy lay mainly in art education, the practice of art, and developmental psychology.

According to David Edwards, an art therapist in Britain, “(n)umerous and often conflicting definitions of art therapy have been advanced since the term, and later the profession, first emerged in the late 1940s (Waller and Gilroy, 1978).” Edwards states, “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 creative energy of the frequently inhibited patient’ (Hill, 1948: 101–102). This, Hill suggested, enabled the patient to ‘build up a strong defence against his misfortunes’ (Hill, 1948: 103).” So, the birth of art therapy goes back to the painter, Adrian Hill, who suggested artistic work to his fellow inpatients, while he was treated in a tuberculosis (T.B.) sanatorium. That began his artistic work with patients, which was documented in 1945 in his book, Art Versus Illness.

Edward Adamson, “the father of art therapy in Britain”.

The artist Edward Adamson (1911-1996), recently demobilised after WW2, joined Adrian Hill to extend Hill’s work to the British long stay mental hospitals. Adamson started at Netherne Hospital in Surrey in 1946, and continued until his retirement in 1981. Adamson established an open art studio, allowing people to come and paint: a radical act when those detained in the 'asylums' were living in bleak conditions, profoundly excluded from society, with minimum dignity, autonomy or even personal possessions. He continued, working alone with hundreds of people, for 35 years. He and his life partner and collaborator, John Timlin (b 1930), published ‘Art as Healing’, their book on his work and the Adamson Collection, in 1984. His importance in the complex history of British Art Therapy is widely accepted, though by the end of his career his point of view was seen as at odds with the evolving psycho-dynamic era in Art Therapy; and his practice, as personal to him. Adamson saw that people recovered - ‘healed’, in his terms- through the act of expressing themselves through art. The act of creating was all that mattered – how not to influence, distort or impinge on self-expression, the artist’s or therapist’s primary concern. He saw the space where he worked as an art studio, and himself an artist, “somewhere in between” the clinical staff and the patients . He encouraged 'free expression' by letting people come to paint or sculpt without comment or judgment by him. He abhorred psychological interpretation, which he dismissed as ‘the therapist’s own projections’ onto the work. Such views did not endear him to the emerging Art Therapy profession. His working style has been termed 'non-interventionist' by Hogan, and is not a practice that would probably be recognised as that of contemporary Art Therapy. Adamson, by keeping all the work done in his daily, progressive art studios over 35 years, collected an estimated 100,000 works - of which 6000 by over a hundred people survive as the Adamson Collection (at Lambeth Hospital in South London between 1997 and 2012; and currently almost all re-located to the Wellcome Library in anticipation of a securer future in several international institutions). He exhibited work from the Collection from 1947 on, and internationally until his death in 1996. Adamson believed the exhibiting of the Collection educated the public about the creativity and humanity of those with mental illness: "Adamson was an educator, who saw the socio-cultural intervention of showing these people’s works to the public who had excluded them - and showing it as an important contribution to their culture - as a way to change public opinion”. There is debate about whether work should be shown: questions about the creator's consent, confidentiality, capacity, and intention; and whether these works are always clinical records or can be outsider art.

Around the same time as Hill and Adamson, Margaret Naumburg, a psychologist in the U.S.A., also began to use the term “art therapy” to describe her work. Naumburg’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.”

U.S. pioneers, Margaret Naumburg and Dr. Edith Kramer, started their art therapy at around the same time as Hill. In the late 1940s, Margaret Naumburg created “psychodynamic art therapy.”, whereas, Edith Kramer derived art therapy out of artistic practice.

According to New York University’s website, “Margaret Naumburg, an eminent pioneer in the field, offered courses and training seminars on the graduate level in New York University’s Department of Art and Art Professions. This tradition was continued when Edith Kramer came to the University in 1973 to develop a master’s program in Art Therapy. By 1976, the Master of Arts in Art Therapy program had obtained approval from the New York State Education Department, and in 1979, New York University’s Graduate Art Therapy program was one of the first of five programs to receive approval from the American Art Therapy Association.”

Dr. Edith Kramer, ATR-BC, HLM, was born in Vienna, Austria, where she studied art, drawing, sculpture and painting, during the Bauhaus movement. After arriving in the United States in 1938 as a refugee, she became a U.S. citizen in 1944 and continued to pursue the practice of art. Dr. Kramer was founder of the graduate program at New York University and Adjunct Professor of Art Therapy in the Graduate Art Therapy Program from 1973 to 2005. During that time, she was also Assistant Professor of the Graduate Art Therapy Program at George Washington University in Washington, D.C., from 1972 to 2000.

Edith Kramer received an honorary doctorate in 1996 from Norwich University in Northfield, VT. Currently, Dr. Kramer is Adjunct Associate Professor George Washington University where she teaches a Psychodynamic Processes course. She maintains a studio where she paints, etches, and sculpts and specializes in art therapy with children and adolescents. The American Art Therapy Association gave Dr. Kramer the award of "Honorary Life Member,” a mark of highest esteem.

Dr. Edith Kramer has authored seminal papers and books, and is renowned as a social realist painter, sculptor, print-maker and mosaicist. Edith Kramer’s starting point was art therapy work with children, which was documented among other groundbreaking literature, in the book, “Art as Therapy with Children.” She also wrote Art Therapy in a Children's Community.

In more recent history, Judith A. Rubin, Ph.D., ATR-BC, has been a groundbreaking author and film maker in the field of art therapy for decades. She is a licensed clinical psychologist, board certified Art Therapist, Assistant Professor in the Department of Psychiatry, University of Pittsburgh, and a faculty member of the Pittsburgh Psychoanalytic Institute. Dr. Rubin received a B.A. in art from Wellesley, an M.Ed. from Harvard, and a Ph.D. in Counseling Psychology from the University of Pittsburgh. Dr. Rubin stands out through her work, which is in the tradition of Helen Landgarten, who also set forth the concept of clinical art therapy. Dr. Rubin’s work includes books, book chapters, films and journal articles on art therapy.

At Lesley University in Cambridge, Massachusetts, the “(e)xpressive Therapies Program was established more than 30 years ago as one of the first graduate schools in the United States to train professionals in this emerging field,” according to the University’s website, Shaun McNiff, Norma Canner and Paolo J. Knill were involved in this program’s creation.

Dr. Shaun McNiff is an author and professor at Lesley University in Cambridge, Massachusetts. He left law school in 1969 to pursue painting and sculpture, then worked as the art therapist at Danvers State Hospital (a.k.a., the “State Lunatic Hospital at Danvers”), a residential treatment and care facility for the mentally ill, in Danvers, Massachusetts. In 1973-1974, he established the first graduate program there (then Lesley College) to integrate all of the arts in both therapy and education. The international profession of Expressive Arts Therapy grew from that work. Prof. McNiff recruited Norma Canner to work with him; she was known as a pioneer in dance therapy and for her work with children and youth with disabilities. Canner left Tufts University to work with McNiff at Lesley. McNiff also recruited the musician Paolo Knill from Switzerland, who had trained in physics and engineering. Prof. McNiff received a doctoral degree from the Union Institute and established a program in Advanced Graduate Studies in Creativity, Imagination, and Leadership at Lesley. He is a past president and Honorary Life Member of the American Art Therapy Association and is also on the faculty of the European Graduate School, Arts, Health and Society Division.

Paolo J. Knill, Ph.D., Dr. h.c., is Provost of the European Graduate School and Professor Emeritus at Lesley University in Cambridge, MA. Dr. Knill was born on July 11, 1932, in Switzerland and is a scientist, artist, therapist, educator and musician. Dr. Knill holds Master’s of Science in Aerodynamics and Structural Mechanics with a minor in Humanities and Applied Psychology from the Swiss Institute for Technology ETH Zurich. He studied Organizational Consulting and Management Consulting at the Massachusetts Institute of Technology (MIT), during which time, he was also a Research Fellow at the Aerospace Lab and an Adjunct Faculty for Music. He completed his certificate for Youth and Family Counseling in 1970, then completed his Ph.D. in Psychology at the Union Graduate School in Ohio in 1976.

According to the website of Mount Mary College in Milwaukee, Wisconsin, “Mount Mary College has expanded its art therapy program to include a professional doctorate degree, announced President Eileen Schwalbach, Ph.D. Approval for the doctorate in art therapy was received April 25, 2011, from the North Central region's Higher Learning Commission (HLC). With an emphasis on professional competencies, the advanced degree program incorporates more than a traditional research degree and is the first of its kind in the U.S. It is also Mount Mary's first doctorate program.” The Doctorate of Art Therapy is a practitioner-oriented advanced degree that prepares already credentialed art therapists with competencies over and above those of master's level professionals.

Art therapy and outsider art

The relation between the terms Art Therapy and Outsider Art has been debated in many academic discussions, especially in regard to the practical application of both professions. The term 'Art Brut' was first coined by French artist Jean Dubuffet to describe art created outside the boundaries of official culture. Dubuffet used the term 'Art brut' to focus on artistic practice by insane-asylum patients. The English translation Outsider Art has been first used by art critic Roger Cardinal in 1972.

Both terms have been criticized because of their social and personal impact on both patients and artists. Art Therapy has been accused of not putting enough emphasis on the artistic value and meaning of the art productions of the artist, considering them only from a medical perspective. This led to the misconception of the whole outsider art practice, while addressing therapeutical issues within the field of aesthetical discussion. Outsider Art, on the contrary, has been negatively judged because of the labeling of the artists' work, i.e. the equation artist = genius = insane. Moreover, the business-related issues on the term outsider art carry some misunderstandings. While the Outsider Artist is part of a specific Art System, which can add a positive value to both the artist's work as well as his personal development, it can also imprison him within the boundaries of the system itself.

Application

An art therapist watches over a mental health patient during an art therapy workshop in Senegal.

As a mental health profession, art therapy is employed in many clinical and other settings with diverse populations. Art therapy can be found in non-clinical settings, as well as in art studios and in creativity development workshops. Closely related in practice to marriage and family therapists and mental health counselors, U.S. art therapists are licensed under various titles, depending upon their individual qualifications and the type of licenses available in a given state. Art therapists may hold licenses as art therapists, creative arts therapists, marriage and family therapists, counselors of various types, psychologists, nurse practitioners, social workers, occupational therapists, rehabilitation therapists or others. Art therapists may have received advanced degrees in art therapy or in a related field, such as psychology, in which case they then obtain post-master or post-doctorate certification as an art therapist. Art therapists who meet credentialing requirements set by the national credentialing body, the Art Therapy Credentials Board (ATCB), initially become Registered (ATR), then Board-certified (ATR-BC), after which they may go on to earn the supervisory credential, Art Therapy Certified Supervisor (ATCS). Art therapists work with populations of all ages and with a wide variety of disorders and diseases. Art therapists provide services to children, adolescents, and adults, whether as individuals, couples, families, or groups.

Using their evaluative and psychotherapy skills, 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, cope with stress, work through traumatic experiences, increase cognitive, memory and neurosensory abilities, improve interpersonal relationships and achieve greater self-fulfillment. Many art therapists draw upon 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 who are professionals trained in both art and therapy and hold a master or doctoral degree in art therapy or certification in art therapy, obtained after a graduate degree in a related field. Other professionals, such as mental health counselors, social workers, psychologists, and play therapists combine art therapy methods with basic psychotherapeutic modalities in their treatment. Assessing elements in artwork can help therapists understand how well a client is in-taking information.

Pediatric trauma patients

The efficiency of treatment interventions for post traumatic disorder in children have not been researched upon extensively. Linda Chapman and fellow psychologists however, have researched on the effectiveness of art therapy on pediatric trauma patients. Early in the research, analysis showed that there were no significant reductions in PTSD (post traumatic stress disorder) symptoms between the patients and the control group. However, acute stress disorder symptoms were reduced for the children who received the art therapy intervention.

Purpose

Art Mediums commonly used in Art Therapy

The purpose of art therapy is essentially one of healing. Art therapy can be successfully applied to clients with physical, mental or emotional problems, diseases and disorders. Any type of visual art and art medium can be employed within the therapeutic process, including painting, drawing, sculpting, and photography. Art therapy stands in contrast with other kinds of creative or expressive arts therapies that use dance, music or drama. One of the major differences between art therapy and other forms of communication is that most other forms of communication elicit the use of words or language as a means of communication. Studies have demonstrated the efficacy of art therapy, as applied to clients with memory loss due to Alzheimer’s and other diseases; stroke residuals; cognitive functioning; traumatic brain injury; post-traumatic stress disorder (PTSD); depression; dealing with chronic illness; and aging.

A typical session

Adult Male doing Art Directives

Malchiodi (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. It helps the individual trust themselves more.

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 therapy can take place in a variety of different settings, as therapists each have their own preferred methods of constructing therapy, and a range of intended goals depending upon the client’s case. Renowned art therapist, Dr. Ellen G Horovitz, describes the breadth of tasks and roles art therapists might have to assume, “My responsibilities vary from job to job. It is wholly different when one works as a consultant or in an agency as opposed to private practice. In private practice, it becomes more complex and far reaching. If you are the primary therapist then your responsibilities can swing from the spectrum of social work to the primary care of the patient. This includes dovetailing with physicians, judges, family members, and sometimes even community members that might be important in the caretaking of the individual.” Some art therapists find it vital for the progression of the therapy and the therapeutic relationship, to ensure that each session with a client occurs in the same space and at the same time, from week to week, a similar notion of psychology in general. Additionally, art therapy is offered on either the individual or group level depending on which is better for the individual based upon assessment.

Art therapy is also prevalent in schools as a means of therapeutic tools for children because of their interest in art and creativity as a means of expression. Art therapy can benefit children with a variety of issues, such as learning disabilities, speech and language disorders, behavioral disorders, and other emotional disturbances that might be hindering a child’s learning . Similar to other psychologists that work in schools, art therapists should be able to diagnose the problems facing their student clients, and individualize treatment and interventions. Art therapists work closely with teachers and parents, in order to implement and carry out their therapy strategies.

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 (DDS) is a three-picture art interview designed by Barry M. Cohen and Barbara Lesowitz in 1882. It is one of the most commonly taught art therapy assessments and, with more than 50 DDS studies to date, it is the most researched art therapy tool worldwide. Cohen and Lesowitz also wrote the DDS Rating Guide that directs Mental heath professional as to how to score the DDS. The Rating Guide for the DDS evaluates the client based on structures within the drawings rather than the content.

The DDS is perhaps the most standardized of all art therapy assessments and relies on both empirical methodology and social science theories. Administers also pay special attention to the behaviors and behavioral changes of the test-taker. The DDS is traditionally administered to adolescents and adults, but there are versions that are geared toward the assessment of children.

The test consists of three drawings and the test-taker has fifteen minutes to complete each. The test-taker is given flat-sided chalk pastels, an 18X24 inch sheet of white paper, and the test-taker is should be seated at a table or desk of appropriate height for the subject.

Administration

• Picture 1—“Make a picture using these materials”
• Picture 2—“Draw a picture of a tree”
• Picture 3—“Make a picture of how you are feeling using lines, shapes, and colors.”

Interpretation Significant training is required to interpret the results of this assessment. Interpretations are made based on:

• Color: types, usage, blending, and original use
• Lines and Shapes, enclosure of lines and shapes, ground lines, sky lines; quality of lines, length, space usage
• Integration and abstraction
• Representation of the image in context: how is the image placing in its environment?
• Use of people and/or animals
• Inanimate objects
• Movement portrayal
• How the pastel was used by the test-taker
• Placement on the page

Strengths and Weaknesses of the DDS: The DDS is the most researched of all art therapy assessments and many drawings are archived for reference. Cohen and Lesowitz provided a quantifiable assessment for art therapists to use around the world. The test also has protocol and controls for the influence of medications and pharmaceutical confounding factors. The DDS is generally considered to be a reliable and valid assessment tool. The weaknesses of the test are rooted in the complexity of interpretation and subsequent lack of true scientific measurement. In general, projective tests tend to be much more unreliable than objective tests. The art therapist must have significant training in order to appropriately evaluate the test-taker.

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

Main article: House-Tree-Person test

The House-tree-person test (HTP) is a projective test designed to measure aspects of a person’s personality. The test can also be used to assess brain damage and general mental functioning. By virtue of being a projective test, the results of the HTP are subjective and open to interpretation by the administrator of the exam. HTP was designed by John Buck and was originally based on the Goodenough scale of intellectual functioning. Buck included both qualitative and quantitative measurements of intellectual ability in the HTP (V). A 350-page manual was written by Buck to instruct the test-giver on proper grading of the HTP, which is more subjective than quantitative. In contrast with him, Zoltán Vass published a more sophisticated approach, based on system analysis (SSCA, Seven-Step Configuration Analysis).

Administering the Test: HTP is given to persons above the age of three and takes approximately 150 minutes to complete based on your level of mental functioning. During the first phase, the test-taker is asked to draw the house, tree, and person and the test-giver asks questions each picture. There are 60 questions originally designed by Buck but art therapists and trained test givers can also design their own questions, or ask follow up questions. This phase is done with a crayon. During the second phase of HTP, the test-taker draws the same pictures with a pencil or pen. Again the test-giver asks similar questions about the drawings. Note: some mental health professionals only administer phase one or two and may change the writing instrument as desired. Variations of the test may ask the person to draw one person of each sex, or put all drawings on the same page.

Examples of follow up questions:

• After the House: Who lives here? Is the occupant happy? What goes on inside the house? What's it like at night? Do people visit the house? What else do the people in the house want to add to the drawing?
• After the Tree: What kind of tree is this? How old is the tree? What season is it? Has anyone tried to cut it down? What else grows nearby? Who waters this tree? Trees need sunshine to live so does it get enough sunshine?
• After the Person is drawn: who is the person? How old is the person? What do they like and dislike doing? Has anyone tried to hurt them? Who looks out for them?

Interpretation of results:

The quantitative measure of intelligence for the House-tree-person has been shown to highly correlate with the WAIS and other well-established intelligence tests.

The subjective analysis of the test takers responses and drawings aims to make inferences of personality traits and past experiences. The subjective nature of this aspect of the HTP, as with other qualitative tests, has little empirical evidence to support its reliability or validity. This test, however, is still considered an accurate measure of brain damage and used in the assessment of schizophrenic patients also suffering from brain damage.

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).

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). 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). Becoming a registered ATR requires that one complete a graduate-level program in art therapy from an accredited university, as well as completion of practicum and an internship, and additional clinical experience post-graduation with supervision from a professional clinician.

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. To receive certification, a significant amount of coursework and clinical experience is required. Depending on where an art therapist practices geographically, certification is not always necessary in becoming a professional art therapist. Typically, the minimum requirement is a master’s degree in art therapy, or a master’s degree in related counseling or psychology fields, with an art therapy focus. According to The American Art Therapy Association (AATA), it is imperative that master’s program students must successfully take courses in a variety of studio art disciplines as a means of signifying artistic proficiency. Additionally, students are required to take at least 48 credit hours at the graduate level in particular psychology related topics, as well as successfully partaking in practica and internships.

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.

Post-Masters

In order to apply for an ATR or other registered art therapist certifications, students are required to complete 1,000 hours of direct client contact post-graduation from a master’s program. After obtaining an ATR, individuals have the opportunity to apply for Board Certification from the Art Therapy Credentials Board by passing an examination. Like many psychology-related licensing, art therapy licenses vary by state, and having a license does not necessarily mean a therapist is nationally certified.

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. 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.

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. It also states that the art therapist must not deceive the payers or exploit clients financially.

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. 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. 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 wrongdoing related to art therapy. Lastly, it discusses the wrongdoings related to art therapy that therapists can be convicted for with a felony or another criminal conviction. These wrongdoings 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.

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

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. The ATCB defines an exploitative relationship as anything involving sexual intimacy, romance, or borrowing or loaning money. 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.

The breaking of any of the standards established in this section is grounds for discipline.

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 wrongdoings 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”

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.

Uses

General Illness

People always search for some escape from illness and it 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.

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 doesn't need to be participation in a program, but studies 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.

Cancer diagnosis

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

Studies have also shown how the emotional destress of cancer patients has been reduced 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

Disaster relief

Art therapy has been used in a variety of traumatic experiences, including disaster relief and crisis intervention. Art therapists have worked with children, adolescents and adults after natural and manmade disasters, encouraging them to make art in response to their experiences. Some suggested strategies for working with victims of disaster include: assessing for distress or post traumatic stress disorder (PTSD), normalizing feelings, modeling coping skills, promoting relaxation skills, establishing a social support network, and increasing a sense of security and stability

Bereaved Children

Art therapy and other creative, humanistic intervention strategies are becoming popular methods for working with life-threatened patient and for working with the family members of patients who die- particularly bereaved children.Art therapy stimulates the conscious and unconscious expression of the mourning process in adult and child patients.Children are at greater psychological risk because their grief is less overt and can occur months or even years after the death.Group therapy is used to provide social sanction for the expression of that grief and to promote adaptive mourning responses.

See also

• List of therapies
• Adrian Hill
• Edward Adamson
• Art and dementia
• Rawley Silver
• Carl Jung
• Bruce Moon
• Rhodha Kellogg
• Margaret Naumburg