Art therapy developed as a distinct form of psychotherapy in the second quarter of this century. The development of other forms of creative expressive therapies soon followed. There is a wide diversity of approaches and theories in art therapy. Art therapists may be highly directive or quite "hands off". Particularly in art therapy's early development, the art production was seen as something the clinician analyzes and about which the "untrained" patient has little objective insight.

One approach to art in therapy requires the therapist simply to be present and aware as a mostly silent, mindful witness to the client producing art during sessions, and to be non-intrusive, allowing the natural course of healing to unfold. In some approaches, the forms or images created between sessions are treated as rich symbolic material which is discussed in the therapeutic setting. The images in the art work are viewed as representations of the unconscious forces of the psyche.

Others conceive the creative process as the raison d'etre of art in therapy, whereby the individual, on many levels, confronts and further understands her/himself. In discussing the power of creativity, Rogers (1993) emphasizes, "The creative process is healing. The expressive product supplies important messages to the individual. However, it is the process of creation that is profoundly transformative" (p. 7).

Thompson (1989) reports that, "When Adrian Hill [using art while recovering from tuberculosis] first coined the term "art therapy" in 1938, he meant simply that the art does the therapeutic work" (p. 3). Many in the art therapy field debate to what degree the art expression, in contrast to therapeutic interventions, is healing, and/or how much "the doing" of art is the transforming process, or to what degree the product functions as a meaningful symbol. Naumburg (1973) reports:

As art therapists gained experience and sophistication their techniques and approaches for effectively promoting change and personal growth in the client became equally sophisticated. In the 1960's and 1970's art therapy was highly influenced by "the human potential movement and the various therapy approaches that were closely associated with it" (Rhyne, 1984 p. xii). Workshops, conferences, national associations, books, and graduate programs in art therapy and creative expressive therapies seemed to blossom overnight. The first master's degree in art therapy was offered at Hahnemann Hospital in Philadelphia in the late sixties. Until that point art therapy was taught in New York City by Margaret Naumburg, and in Washington, D.C. at the Washington School of Psychiatry. In 1970 the American Art Therapy Association held it first annual conference as a small gathering; by 1980 over twenty master's degree programs had been started and more have developed since. Art therapy was finally able to stand as a legitimate discipline incorporating elements of both art and therapy. The art therapist today may be either an auxiliary therapist or primary therapist with significant issue case loads.

As art therapy moved into the domain of acknowledged psychotherapeutic modalities, its early development was divided into two camps -- "art psychotherapy," originated by Margaret Naumburg (1966), and "art as therapy," promoted by Edith Kramer (1971). Both theories were based in Freudian thought, the former emphasizing interpretation and the latter emphasizing the art process. Although some felt the approaches were incompatible, Ulman (1975) integrated them into her own theory of art therapy. Harriet Wadeson (1987) went even farther, including "not only graphic arts but other modalities of expressive therapies" (p. xxi) and she espoused an eclectic approach to art therapy "shifting gears as the situation seems to require." Rubin (1987) suggests in a practical sense today, "Most art therapists are primarily pragmatic in their orientation, doing whatever seems to work best most of the time" (p. 275).

The practicality of art therapists can be noticed in reviewing a wide assortment of print on the subject. Possibly more than any other modality in psychotherapy, creative expressive therapy literature emphasizes more the practical activity in the therapy session itself, rather than complex and abstract theories about what is happening with the therapeutic process. Perhaps the presentation of the exercises, process and the events occurring in the therapy session tend to be portrayed more frequently because artists and those attracted to art are physical doers; and when using creative expression in therapy one can often visually "see" the therapy process taking place. Furthermore, through the painting or sculpture one can actually physically put one's hands on the aspects of the therapeutic process and the product.

Theories of Art Therapy

Art therapists are not only practical doers who spend time in the clinical setting and try to nab what time they can for retreat to their own art studios, they are also active theorists and have amassed a wide range of theories for why and how art therapy works. The two approaches which started art therapy, "art psychotherapy" and "art as therapy", have gained many sisters, cousins and neighbourly approaches and theories explain the efficacy of creative expression as healing. In Approaches to Art Therapy, Judith Rubin (1987) outlined sixteen major theoretical approaches to the practice of art therapy:

In addition, each of the following authors refers to other theorists and therapeutic approaches which are not part of Rubin's primary list:

• Sean McNiff (1989), Depth psychology of Art;
• Aina Nucho (1987), A Psychocybernetic model of art therapy;
• Tessa Dalley (1984), Art as Therapy;
• Margaret Keyes (1983), Inward Journey, Art as Therapy;
• H.Y. Kwiatkowska (1978),
• Family Therapy and Evaluation Through Art;
• Arthur Robbins (1970), Creative Art Therapy.

Both lists are still not exhaustive of the variety of theoretical approaches under whose form different art therapists have aligned themselves.

Art therapy may be practised with children, adolescents, adults or the aged, with an individual or groups, in private practice, clinics, prisons, medical or psychiatric hospitals, old age homes, schools, or as a form of self therapy. In addition to dealing with psychological issues, art therapy is used in therapy with learning disorders, physical illnesses, and in business management with group dynamics and organizational development. The field of art therapy stands on its own and has undergone many developments and refinements.

Jungian Analytic Art Therapy

Although not trained as an artist, Jung was acquainted with the use of personal discovery through art activity from a first hand perspective. Through much of Jung's life:

particularly at times of personal crisis, Jung drew, painted, and sculpted representations of his inner experiences. He makes it clear that this was not a peripheral activity, but on the contrary was a vivid source of personal insight into his situation (Edwards in Rubin, 1987, p. 93)

Jung's theoretical work emphasizes the importance placed on imagery, symbols and the role of creativity in the unconscious. Jung's affinity with art as a means of personal insight and change agent is commented on in 1931 in The Practice of Psychotherapy in which he describes his reasoning for encouraging his patients to spend time at creating art:

Jung's perception expects that the patient interact with the painting, that it is not just the simple painting of pretty pictures, but, (1966) "It is necessary besides to have an intellectual and emotional understanding of them: they must be consciously integrated, made intelligible, and morally assimilated. We must subject them to a process of interpretation." (Jung, 1966) Predating the formal development of art therapy by two decades, Jung is fairly accurately describing some of the basic essentials of art as therapy.

The psychoanalyst Kris's (1952) viewpoint was that relaxation in artistic activity allowed a purposeful and constructive form of regression separate from the fantasies of dreams. For Kris the dilemma for the artist is to balance a personal dance between creation and criticism; the creative letting go is poised with a finely controlled functional regression. As Dalley (1983) clarifies, "When regression goes too far, the symbols become too private, whereas when there is too much control, the result will be cold, mechanical and uninspired" (p. 9).

Gestalt Art Therapy

Janie Rhyne writes that many of the difficult to explain and rather abstract connections between the theories of gestalt psychology and gestalt therapy are far more "easily observable in the activity of art therapy...the concepts are transposed into vivid percepts as we engage in expressive art experience." (Rhyne in Rubin, 1987, p. 172). Rhyne (1984) in Gestalt Art Experience describes the psychotherapeutic use of art as "gestalt art experience" and often uses that phrase rather than "gestalt art therapy" to describe her work. The three constituents of Gestalt, Art and Experience are described directly following: dreaming, feeling, thinking, acting, expressing, and being aware at the same time that you are the person who is doing all of this" (p. 6).

In the creative process, the artist reconnects with that too often lost awareness and "beingness" which the child brings to creative painting or other activity. In art activity, one may experience delight, anger, joy, sorrow, or splendid play. In Rhyne's (1984) view, whatever the experience, the client is encouraged to let it be and to have awareness of the experience.

-"Gestalt" is describe by Rhyne as "the ability to perceive whole configuration - to perceive your personality as a totality of many parts that together make up the reality of you" (p. 9)

Gestalt theory concerns itself with: the perception and relatedness of the whole; the closure and connectedness to those things incomplete; configurations of "figure/ground relationships, dynamic movement, contact/boundaries, coherence and fragmentation" (Rhyne, 1980, p. 77). These are visual and perceptual concepts of the environment. Gestalt therapy applies these elements of perception to human relationship, and to the organization of the internal psyche. Fagan and Shepherd (1970) explain:

Gestalt psychology originated as a theory of perception that included the inter-relationships between the form of the object and the processes of the perceiver.... Gestalt thinking emphasized "leaps" of insight, closure, figure-ground characteristics, fluidity of perceptual processes, and the perceiver as an active participant in his perceptions rather than a passive percipient of the qualities of form (p. 3).

-"Art" of the gestalt art experience Rhyne (1984) considers as: "the forms that emerge from our individual creative experiencing" (p. 7).

Rhyne sees humans as having an inherent desire to make things. The forms created in the gestalt art experience become an extension of that desire to make. In gestalt art experience, the how, and why, and what of that making are often left up to the client. The form which unfolds is as wonderfully unique and individual as the person who makes it.

According to Corey (1982), the gestalt art therapist encourages the client to "carry out their own therapy as much as possible" (p. 98). The emphasis is on experience and awareness in moving through to closure of unfinished business. Like gestalt therapy, gestalt art experiences are often practised in groups, and the mutual support and sharing in the group process is seen as a vital part of the closure and completeness.

Through association with existential philosophy and phenomenology, gestalt therapy encourages personal responsibility and authentic and innate potential. The therapist attempts genuine contact with the client and transference is not encouraged; rather the therapist enters into a mutual, present-centered, person-to-person therapeutic relationship which allows for changes in both therapist and client.

Depth Psychology of Art

Another group argues that art therapy should not be over-analyzed and the productions of art therapy belongs in part to the realm of other and transpersonal. In Depth Psychology of Art, Shaun McNiff (1989) tries to wrestle away the hold analysts have on art therapy. Allen (1990), in a book review states:

McNiff questions the conventional view that art therapy owes so huge a debt to Freud for defining the unconscious, since that legacy also contains the misguided certainty that images which form the unconscious can be explained rationally. He suggests that analytic judgement arrests the process of discovering meaning in an image. (p. 115)

McNiff suggests we place art in a context which it has historically often served, as an artifact that embraces the human search for sacred meaning and a spiritual order. "To express the purpose of art he coins the term "Ensoulment," to make manifest the soul" (Allen, 1990). McNiff (1989) suggests taking art away from the fortification of science and acknowledging its role today where it has served humanity for millennia as "a manifestation of primary religious instincts" (p. 20).

Directed Vs. Nondirected Art Therapy

The degree to which the therapist should comment on and direct or simply observe and acknowledge the client's art therapeutic process has been debated. In the far extreme of art in psychotherapy, the analyst can be traditionally Freudian. As in dreams, the creation of art can be allowed spontaneous unfolding, but when it comes to gaining understanding, the "good Doctor" "knows" what the patient is unable to see, encourages transference and clearly directs and controls the understandings of symbolic significance of the picture. Ulman (1975) suggests, in its most patriarchal forms:

Expressive therapy centers on the expression of emotion within the framework of the therapeutic relationship. It is an integral part of psychotherapy and should be strictly the doctor's province, for it is often so profoundly revealing to the patient as to be extremely dangerous in any other hands. (p. 7)

Moving to less rigidity while still retaining Freudian theory, Naumburg shifts the application of the analyst's perceptions and suggests:

I believe it is this perspective of accepting the client's experience and not imposing a therapist-generated interpretation on the client which allows many of Naumburg's clients to create significant natalistic womb imagery.

In another mode of highly directive art therapy described by Oster and Gould (1987) in Using Drawings in Assessment and Therapy: a Guide for Mental Health Professionals (pp. 85-107.), the client is asked to draw very specific types of pictures, and as the therapy develops is asked to combine images from certain pictures or to redraw images in a different light all in what appears to be an effort to control and direct the treatment towards very specific objectives which the therapist has chosen.

In the example Oster and Gould discuss, (1987) the therapist directs a highly ambivalent and paranoid seventeen year old male to draw a series of "worst reality," "best reality," "worst fantasy," and "best fantasy." The drawings reveal a variety of controlled and organized views of the world, as well as rather terrifying imagery. The drawings reflect the young man's inner turmoil, yet reveal a high need for control. Oster and Gould (1987) describe how specific therapeutic goals:

The therapist then had David begin a drawing in which he integrated all four of the above fantasies. The therapist's goal with this kind of drawing was to help David see that he did not necessarily have to "split" and withdraw into his fantasies. (Oster and Gould, 1987, p. 93)

In different degrees, apparently, this form of directed drawing continued throughout David's therapy, in an effort to move him towards what the therapist viewed as healthy insights and appropriate changes. The therapist seemed to predetermine the next issue David needed to confront, conceptualize or accept. For David to properly address this next stage of the therapy process, the therapist created the next "drawing directive" which would allow David to make the proper progress.

The therapist in art as therapy may operate on a wide continuum of interpretation, comment and direction. Approaches to using art in therapy can vary, on the one hand, from having, for the client, a defined agenda and a goal which is clearly expressed by the therapist (Clifford, 1986), to, on the other hand, allowing materials and their uses to flow freely and unobstructed with the therapist simply making comments primarily of support and acknowledgment. Keyes (1983) relates from Inward Journey:

Norma Clifford, a therapist colleague of mine, tells her clients, "My job is not to give answers, but to ask the best questions." Keyes (1983) agrees, explaining, "Art therapy does not answer the questions. It provides a process to clarify and deepen the questions" (p. 4). The therapist serves as a guide while the individuals are left to interpret their own experience and make their own discoveries.

Thomson (1989) points out that the extreme non-interference approach to the use of art in therapy is revealed in a studio note left by Lyddiatt:

No Comments

No Questions

No Standards

In the above approach, the therapist is alert to the therapy process, yet active primarily as a witness to the journey. Lyddiatt (1972) suggests this is an experience of silence and yet of mindful presence. For the therapist this concept is often difficult to understand in our daily western modern busy-ness of the everyday world. Lyddiatt (1972) explains that in a mindful witness there is "a deliberate effort to let a mood speak without seeking to control it, and without being overwhelmed by it" (p. 3).

For much of the work I do with art in the therapy setting I clearly function as witness - I am present, I see and hear, I empathize and acknowledge, and I may ask the client to summarize or clarify. The client, in the end, is the one who knows his/her own truth.

In terms of the perceptions I may have accumulated, and tentative conclusions I may have drawn, I prefer to ask open ended questions leaving discovery and insight to the client. When insights have been shared I will summarize, acknowledge, and support. When an issue seems to be pressing but the client is not talking about it directly, and it seems to me the right time to discuss it I will ask permission to ask about something. Then I proceed with the clear designation that this is my perception, wondering or sense, but it is not something the person should automatically own or accept as truth. There is a continual fine line in seeking client permission and subtly directing choice.

Healing with Art

Harriet Wadeson (1980) in Art Psychotherapy lists six major dynamics which are at play in the healing process of art therapy. These are: imagery; decreased defenses; objectification; permanence spatial matrix; creative and physical energy. The following summarizes Wadeson on these points (Wadeson, 1980, pp. 8-12):

- Imagery: Images made up our thought processes before words, and as word language develops we still continue to form thought through images. Imagery as early conceptual perception forms part of the base for personality and mental development. If dreaming is an accurate portrayal of the unconscious then images flourish in the unconscious.

- Decreased Defenses: Art activity is not the dominant means of communication and organizing of thought processes therefore it lacks some of the habituated defenses associated with verbalization. As creatures of a left brain culture many of our defenses are expressions of rational left brain activity. Art activity, however, bypasses some of these cognitively driven psychological inhibitors.

- Objectification: Through art, psychological material can be projected into an external object, thereby distancing from the inner self. As the artworks are mentally, emotionally and physically manipulated and transformed, so too is inner experience. In particular, overwhelming inner experience which is contained in an art object can be held at a safe psychological distance, and from the safety of that vantage point can be investigated and worked through.

- Permanence: Unlike the verbal content of therapy which can be forgotten, or, at least, the detail of discussion blurred with time, productions of therapeutic art will retain their chronicle of the therapeutic work. The therapeutic content in the art can be returned to later for further processing. In addition, as the layers of healing are peeled away, the initial unconscious elements of the art work can begin to have greater conscious meaning and therapeutic significance.

- Spatial Matrix: Art productions are not confined by the linear restrictions of language, time, relationship in space and the rational logic of order. As such, art process and images may better represent the human experience, particularly in areas where linear words are insufficient.

- Creative and Physical Energy: Wadeson (1984) describes a phenomenon of increased energy in the creative process. She believes this charges both the individual and group with greater alertness and participation.

- Emotional Discharge: Art is synonymous with expression, and expression is synonymous with emotional release. As talk in therapy allows and encourages therapeutic discharge of emotional anxiety, creative expression can also be a means of telling and letting go of a buried or pent up feeling. Emotions which are difficult to articulate with verbal language can have greater opportunity for release through artistic expression.

- Art Activity as Altered State of Consciousness: Artistic expression also allows or even encourages shifts in levels of consciousness or modes of processing. Early, as well as other, traumatic material may be reverberating in dissociated states of consciousness (Stewert, 1987), or non-ordinary states of consciousness (Grof, 1985). Art activity may have particular advantages for reaching these states.

- Assisting the Preverbal to Become Verbal:
Pre- and perinatal experiences are preverbal and, like art, are nonverbal. This may be one reason why they are such friendly partners. Art work brings the preverbal to one level of consciousness. Observation, writing and discussion bring the material to another level.

- Psychological Induction and Suggestion:
Part of personal transformation as a result of art activity derives from the visually implied expectation of change. The energy surfacing in the creative process or the images themselves can imply and therefore release, understanding and new ways of relating. For the artist, consciously and unconsciously, these can serve as concrete suggestions and induction for change. Art images, then, reach deep into the psyche and are actively held there for long periods of time.

- Emotional Repatterning Through Art:
The art process may break through deeply habituated emotional patterns. Through emotional release and through reframing which arise through the art process or the visual content of art, new perceptions of the self and relationships are made possible.

- Physical Repatterning:
Emotional and psychological issues often impact on and are stored in the body. Art work has a particular facility, frequently far superior to words, for permitting the expression of somatic sensation and anxiety. Through visual expression, and, quite importantly tactile experience and kinaesthetic movement, body blocks and patterns can be released and repatterned.

- A Holistic Synthesis of the Person:
Art ctivity engages the individual on numerous levels consciously and unconsciously. As such, art as a therapeutic modality has a innate affinity with a holistic approach to the person. In addition, art activity has a propensity for use in conjunction with other modalities, allowing its efficient use in eclectic or holistic approaches which incorporate a wide range of therapeutic approaches.

The text: Properties of Natalistic Art.discusses each of these healing properties of art in much greater detail, in particular as they relate to natalistic art activity.