second edition HANDBOOK OF HiT edited by Cathy A. Malchiodi < . ao© 2012 The Guilford Press A Division of Guilford Publications, Ine. 72 Spring Street, New York, NY 10012 wwwguilford.com Alll rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher Printed in the United States of America This book is printed on acid-free paper. Last digit Is print number: 9 8 The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standarc's ff practice that are accepted at the time of publication. However, in view of the possibility of human ertor or changes in behavioral, meatal health, or medical Sciences, neither the authors, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of sxich information. Readers are encouraged to confirm the inlormation contained in this bock with other sources. Library of Congress Cataloging-in-Publication Data Handbook of ant therapy / edited by Cathy A. Malchiodi, — 2nd od. pcm Includes bibliographical references and index. IGBN 978-1-60918.975-4 (hardback) 1. Aris—Therapeuticuse—Handbooks, manvals,ete. 1. Malchiedi, Cathy A RC489.A7H365 2012, 616.871655—de23 2011029694- Psychoanalytic, Analytic, and Object Relations Approaches Contents . THE ART AND SCIENCE OF ART THERAPY + A Brief History of Art Therapy Randy M. Vick . Art Therapy and the Brain Cathy A. Malehiodi Art Therapy Materials, Media, and Methods Cathy A. Malehiodi |. Art Therapy in Practice: Ethics, Evidence, and Culeural Sensitivicy Cathy A, Malehiodi CLINICAL APPROACHES TO ART THERAPY Cathy A. Malchiodi |. Humanistic Approaches Cathy A. Malchiodi Cognitive-Behavioral and Mind-Body Approaches Cathy A. Malchiodi and Aimee Loth Rozum . Solution-Focused and Narrative Approaches Shirley Riley and Cathy A. Malchiodi Developmental Art Therapy Cathy A. Malehiodi |. Expressive Arts Therapy and Multimodal Approaches Cathy A. Malchiodi xill 27 a2 53 87 75 89 103 14 130xiv 13. 14. 15. 7 Iv. 18. 20. 2k. 22. 2. 24, 25. 26. Contents | CLINICAL APPLICATIONS WITH CHILDREN AND ADOLESCENTS - Drawing and Storytelling as Psychotherapy with Children Masahiro Tanaka and Madoka Takada Urhausen . Using Drawing in Short-Term Trauma Resolution William Steele and Caelan Kuban Arc and Play Therapy with Sexually Abused Children Eliana Gil An Art Therapy Approach to Attention-Deficit/Hyperactivity Disorder Diane S. Safran Art Therapy with Children on the Autism Spectrum Robin L. Gabriels and Lyndsay J. Gaffey . Medical Art Therapy with Children Tracy Council! Art Therapy with Adolescents Gretchen Miller CLINICAL APPLICATIONS WITH ADULTS Art in Counseling Samuel T. Gladding, Creativity and Aging: An Art Therapy Perspective Cathy A. Malchiedi Art Therapy with Adults with Severe Mental lliness Susan Spaniol Art Therapy in Addictions Treatment: Creativity and Shame Reduction Marie Wilson Art Therapy with Combat Veterans and Military Personnel Cathy A. Malchiodi Art Therapy and Domestic Violence Cathy A, Malchiedi and Gretchen Miller CLINICAL APPLICATIONS WITH GROUPS, FAMILIES, AND COUPLES Group Art Therapy: An Interactive Approach Diane Waller Developing Themes for Art Therapy Groups Marian Liebmann Group Approaches with Sexually Abused Children P. Gussie Klorer 41 \4a7 162 \75 192 205 222 241 259 263 278 288 302 320 335 349 353 368 383a7. 28. 29. Vi. 30. 31. Contents Using Art Therapy with Medical Support Groups Cathy A. Malchiodi Art Therapy with Families and Couples Cathy A. Malchiodi Art Therapy with Children in Grief and Loss Groups Aimee Loth Rozum ART-BASED ASSESSMENTS A Brief Overview of Art-Based Assessments Cathy A. Malchiodi What Art Can and Cannot Tell Us Frances F. Kaplan APPENDIX A. Credentials, Education, Supervision, Standards of Practice, and Ethical Standards APPENDIX B. Resources Index xv 397 409 422 433 435 446 458 485 487PART I THE ART AND SCIENCE OF ART THERAPY INTRODUCTION Art therapy is based on the idea that the creative process of art making facili- tates reparation and recovery and is a form of nonverbal communication of thoughts and feelings. Like other forms of psychotherapy and counseling, it is, used to encourage personal growth and has been employed in a wide variety of settings with children, adults, families, and groups. It is an approach that can help individuals of all ages create meaning and achieve insight, find relief from overwhelming emotions or trauma, resolve conflicts and problems, enrich daily life, and achieve an increased sense of well-being (Malchiodi, 2006). Art therapy supports the belief that all individuals have the capacity to express themselves creatively and that the product is less important than the therapeutic process involved. The therapist's focus is not specifically on the aesthetic merits of art making but on the therapeutic needs of the person to express him- or herself, That is, what is important is the person's involvement in the work, choosing and initiating art activities that are helpful to the person, assisting the person in finding meaning in the creative process, and facilitating the sharing of the experience of image making with the therapist. While other forms of therapy are increasingly effective, helping profession als are using art therapy with individuals of all ages and with a variety of popu- lations. Art therapists, counselors, psychologists, psychiatrists, social workers, marriage and family therapists, allied health professionals, and even physicians are using art expression with adults, children, and families. With the advent of brief forms of therapy and the increasing pressures to complete treatment in a limited number of sessions, therapists are finding that art activities help2 THE ART AND SCIENCE OF ART THERAPY individuals to communicate relevant issues and problems quickly, thus expedit- ing assessment and intervention. Even the simplest drawing task offers unique possibilities for expression that complements and, in many cases, helps a child or adult to communicate what words cannot. The field of art therapy, while a recognized form of treatment, is still some- what of a mystery fo many professionals, Therapists who use art with their cli- ents know that it is an effective form of intervention, but most do not know its rich history, theories about why it works, and what its benefits and limitations are asa form of therapy and evaluation. This first section of the book provides the reader with an overview of how art therapy came to be, the impact of neuro- science on the field, what we know about why it is effective, basic principles of practice, and art materials and media Chapter 1 provides a brief history of art therapy and describes the many influences from disciplines including art, psychiatry, and medicine that guided the course and development of the field. During the last six decades art therapy has grown from a modality practiced predominantly in psychiatric hospitals to become a primary form of treatment in inpatient milieus, outpatient clinics, domestic violence shelters, residential facilities, trauma units, medical settings, and community centers. Whereas people with mental illness, physical disabili- ties, or cognitive deficits were once the principal populations, now it is com- mon to see art therapy applied to children suffering from abuse and neglect: families or couples in distress; children with learning disabilities; people with cancer, HIV, or other serious illnesses; older adults with dementia, Alzheimer’s disease, or disabilities; individuals with addictions or chemical dependencies; and bereaved children and parents. Wherever psychotherapy is used as treat- ment, art therapy is now a commonplace form of intervention Because it is a relatively new field, there is still debate on how to define art therapy. Some therapists see it as modality that helps individuals to verbalize their thoughts and feelings, beliefs, problems, and worldviews. By this defini tion, art therapy is an adjunct to psychotherapy, facilitating the process through both image making and verbal exchange with the therapist. Others see art itself as the therapy; that is, the creative process involved in art making, whether it be drawing, painting, sculpting or some other art form, is what is life-enhancing and ultimately therapeutic. In actuality, both aspects contribute to art therapy’s effectiveness as a form of treatment and most art therapists subscribe to both definitions in their work. Image making does help people to communicate both through image and words and, with the guidance of a therapist, can assist individuals in expressing what may be difficult to say with words alone. We are also beginning to understand the benefits of asking clients to create drawings or other art forms in therapy.Introduction 3 Artistic expression is an activity that involves the brain in ways that can be used to enhance therapeutic treatment and evaluation. Chapter 2 explains more about “art therapy and the brain,” how neuroscience is informing a growing under- standing of art expression in therapy, and why art therapy may be appropriate in addressing a variety of disorders. Chapter 3 is new to this edition of the Haidbook; it covers art materials and media used in therapy. All helping professionals who use art in treatment and assessment should be well versed in this topic because knowledge of materials and media is key to successful application of art-based approaches. Readers will learn more about traditional materials used in the field as well as photography and the impact of digital media (computers, software, and other technology) that are impacting practice in the early 21st century. Chapter 4 is also a new addition to this text and provides a brief review of art therapy practice including ethics, research, and cultural sensitivity. While art therapy ethics documents are similar to those employed in most other men- tal health professions, they are distinguished by one characteristic: concern for client-created art expressions and related issues of storage, retention, and con- fidentiality. As a field, art therapy is also subject to proving its effectiveness as an intervention. Chapter 4 briefly summarizes some of the existing evidence on therapeutic outcomes of art therapy and emerging best practices, based on cur: rent information. Additionally, there are specific cultural and diversity issue: the application of art therapy that professionals must consider in their work with clients of all ages and backgrounds. Art therapy is an exciting, dynamic field, one that continues to evolve in terms of depth and applications. For those who are art therapists, art is central to their work and is the basis of their worldview of therapy in general. For coun- selors, social workers, psychologists, psychiatrists, and others, art may be a tool that is employed as an adjunct to verbal therapy. This first section introduces all helping professionals who use art activities in clinical work to the histori- cal foundations of this field, emerging neuroscience paradigms, the role of art materials and media in treatment and evaluation, and the importance of ethical, evidence-based, and culturally sensitive practice. in REFERENCE Malchiodi, C. A. (2006). The art therapy sour ‘book (2nd ed.). New York: McGraw-HillCHAPTER 1 A Brief History of Art Therapy Randy M. Vick his history of art therapy focuses on the precursory and continuing trends that have shaped theory and practice and the literature that reflects this development. Scholarship, like history, builds on the foundations laid by others. | am indebted to the authors of four other histories that I found to be particularly useful in the prepa- ration of this chapter. Both Malchiodi (2006) and Rubin (2010) have assembled his- tories based on contributing trends, as did Junge and Asawa (1994) who have pro- vided extensive details on the personalities and politics involved in the formation of the American Art Therapy Association. My fourth primary source, MacGregor (1989), while never intended as a book about art therapy, has proven to be an excel- lent “prehistory” of the field. Each of these references provided information as well as inspiration; I encourage readers to consult them for additional perspectives. Finally, it should be noted here that art therapy was not a phenomenon exclusive to the United States. Readers interesied in art therapy’s development in Europe should consult Waller's (1991, 1998) and Hogan's (2001) books on this subject. History is like a tapestry with each colored thread contributing not only to the formation of the image but to the strength and structure of the fabric itself. Imagine for a moment a tapestry with bobbins of different-colored threads, each adding, a hue that becomes part of a new cre of this field ation, and we can better understand the history INFLUENCES FROM THE DISTANT PAST AND NEIGHBORING FIELDS Art therapy is a hybrid discipline based primarily on the fields of art and psychol- ogy, drawing characteristics from each parent to evolve a unique new entity. But 5aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.A Brief History of Art Therapy 7 MORAL TREATMENT For much of human history mental illness was regarded with fear and misunder- standing as a manifestation of either divine or demonic forces. Beginning in the late 18th century, however, the “moral treatment” movement advocated recogniz- ing the individual humanity of “the insane” (Hogan, 2001). Reformers such as Ben- jamin Rush in the United States and Philippe Pinel in France made great strides in creating a more humane environment for theit patients. Sigmund Freud, Ernst Kris, and others contributed to this rehumanization by theorizing that rather than being random nonsense, the productions of fantasy revealed significant informa- tion about the unique inner world of their makers (MacGregor, 1989; Rubin, 2010). Building on these theories, many writers began to examine how a specific sort of creative product—art—could be understood as an illustration of mental health or disturbance (Anastasi & Foley, 1941; Arnheim, 1954; Kreitler & Kreitler, 1972), Other authors began recognizing the potential art has as a tool within treatment (Win- nicott, 1971). Hogan (2001) credits the British pioneer Adrian Hill with coining the phrase “art therapy” in 1942; soon enough, the term began to be used to describe a form of psychotherapy that placed art practices and interventions alongside talk as. the central modality of treatment (Naumburg, 1950/1973) The significance psychoanalytic writers placed on early childhood experiences made the crossover of these theories into education an easy one (Junge & Asawa, 1994). Some progressive educators placed particular emphasis on the role art played in the overall development of children (Cane, 1951/1983; Kellogg, 1969; Lowenfeld, 1987; Uhlin, 1972/1984). This trend toward the therapeutic application of art within educational settings continues today (Anderson, 1978/1992; Bush, 1997; Henley, 1992), PSYCHOLOGICAL ASSESSMENT AND RESEARCH In addition to psychoanalysis and the rehumanization of people with mental illness, one of the strongest trends to emerge within modern psychology has been the focus on standardized methods of diagnostic assessment and research. Whether discuss- ing the work of a studio artist or the productions of a mentally ill individual, Kris (1952) argues, they both engage in the same psychic process, that is, “the placing of an inner experience, an inner image, into the outside world” (p. 115). This “method of projection’ became the conceptual foundation for a dazzling array of so-called projective drawing assessments that evolved in psychology during the 20th century (Hammer, 1958/1980). These simple paper-and-pencil “tests,” with their formalized procedures and standardized methods of interpretation, became widely used in the evaluation and diagnosis of children and adults and are still employed to a lesser degree today (though often with revamped purpose and procedure). Two paral- Jel themes from this era are the relatively unstructured methods of art assessment8 THE ART AND SCIENCE OF ART THERAPY (Elkisch, 1948; Shaw, 1934) and the various approaches to interpreting these produc- tions (Machover, 1919/1980). The impact of psychoanalysis on the early development of art therapy was pro found. Hammer's (1958/1980) classic book on drawing as a projective device illus- trates the diversity within this area; the inclusion of two chapters on art therapy by pioneering art therapist Margaret Naumburg demonstrates the crossover of influ- ences, Many of the more common stereotypes about art therapy (specific, assigned draw ings; finger painting; and the role of the therapist in divining the “true mean- ing” of the drawings) can, in fact, be traced directly to this era. Nearly all the major art therapy writers from this time developed their own methods of assessment consisting of batteries of art tasks with varying levels of structure (Kramer é& Schehr, 1983; Kwiatkowska, 1978; Rubin, 1978/1984; Ulman & Dachinger, 1975/1996). Even today, the notion that artworks in some way reflect the psychic experience of the artist is a fundamental concept in art therapy. Despite this common history, there are distinctions between the approach to assessment used in psychology and that found in art therapy. The key difference is the art therapy perspective that the making and viewing of the art have inherent therapeutic potential for the client, a position not necessarily held by psychometri- cians. In addition, art therapists tend to use more varied and expressive materials and to deemphasize formalized verbal directives and stress the role of clients as interpreters of their own work, Finally, art therapists are also quite likely to impro- vise on the protocol of standardized assessments to suit a particular clinical pur- pose (Mills & Goodwin, 1991), Anemerging theme in the literature is the unique role the creative arts therapies can play in the assessment and evaluation of clients (Bruscia, 1988; Feder & Feder, 1998). Contemporary developers of art therapy assessments have abandoned ortho- dox psychoanalytic approaches in favor of methods that emphasize the expressive potential of the tasks and materials (Cohen, Hammer, & Singer, 1988; Cox & Frame, 1993; Gantt & Tabone, 1997; Landgarten, 1993; Silver, 2002). Early art therapy researchers also looked to psychology and embraced its empirical approach for their research (Kwiatkowska, 1978), More recently, models from the behavioral sciences and other fields have been used as resources in con- ducting art therapy research (Kaplan, 2000; MeNiff, 1998; Wadeson, 1992) THE DEVELOPMENT OF THE ART THERAPY LITERATURE The development of any discipline is often best traced through the evolution of that field’s literature. The historian’s convention of artificially dividing time into seg- ments is employed here to illustrate three phases of growth in the profession of art therapy.A Brief History of Art Therapy 9 Classical Period (1940s to 1970s) In the middle of the 20th century a largely independent assortment of individuals began to use the term “art therapy” in their writings to describe their work with clients. In doing so, these pioneering individuals began to define a discipline that was distinct from other, older professions. Because there was no formal art therapy training to be had, these early writers were trained in other fields and mentored by psychiatrists, analysts, and other mental health professionals. The four leading writers universally recognized for their contributions to the development of the field during this period are Margaret Naumburg, Edith Kramer, Hanna Kwiat- kowska, and Elinor Ulman. The lasting impact of their original works on the field is demonstrated by the fact that their writings continue to be used as original sources in contemporary art therapy literature. More than any other author, Naumburg is seen as the primary founder of American art therapy and is frequently referred to as the “mother of art therapy” (see Junge & Asawa, 1994, p, 22). Through her early work in the innovative Walden School, which she founded with her sister Florence Cane (1951/1983), and later in psychiatric settings she developed her ideas and, in the 1940s, began to write about what was to become known asart therapy (Detre et al, 1983), Familiar with the ideas of Freud and Jung, Naumburg (1966/1987) conceived her “dynamically oriented art therapy” to be largely analogous to the psychoanalytic practices of the day. The clients’ art productions were viewed as symbolic communication of unconscious material in a direct, uncensored, and concrete form that Naumburg, (1950/1973) argued would aid in the resolution of the transference While Naumburg borrowed heavily from the techniques of psychoanalytic practice, Kramer took a different approach by adapting concepts from Freud's per- sonality theory to explain the art therapy process. Her “art as therapy” approach emphasizes the intrinsic therapeutic potential in the art-making process and the central role that the defense mechanism of sublimation plays in this experience (Kramer, 1971/1993). Kramer's (1958, 1971/1993) work in therapeutic schools (as opposed to Naumburg’s psychiatric emphasis) allows for more direct application of her ideas to educational settings Ulman’s most outstanding contributions to the field have been as an editor and writer. She founded The Bulletin of Art Therapy in 1961 (The American Journal of Art Therapy from 1970 until it ended production in 2002) when no other publication of its kind existed (Junge & Asawa, 1994). In addition, Ulman (along with her coeditor Dachinger; 1975/1996) published the first book of collected essays on art therapy that served as one of the few texts in the field for many years. Her gift as a writer was to precisel: Problems of Definition,” Ulman (1975/1996) compares and contrasts Naumburg’s and Kramer’s models so clearly that it continues to be the definitive presentation of this core theoretical continuum. nthesize and articulate complex ideas. In her essay “Art Therapy10 THE ART AND SCIENCE OF ART THERAPY The last of these four remarkable women, Kwiatkow'ska, made her major con- tributions in the areas of research and family art therapy. She brought together her experiences in various psychiatric settings in a book that became the foundation for working with families through art (Kwiatkowska, 1978). Like Kramer, she had fled Europe at the time of World War II, adding to the list of émigré thinkers who influ- enced the development of mental health disciplines in the United States. She also coauthored a short book that helped introduce the field of art therapy to the general public (Ulman, Kramer, & Kwiatkowska, 1978}. Each of these pioneers lectured wiclely on the topic of art therapy and served as one of the field’s first educators. It was also during this period that the first formal programs with degrees in art therapy were offered (Junge & Asawa, 1994; Levick Goldman, & Fink, 1967). Finally, it is important not to forget the other early pioneers working in other parts of the country, such as Mary Huntoon at the Menninger Clinic (Wix, 2000), who made contributions to the developing profession as well. Middle Years: Other Pioneering Writers (1970s to Mid-1980s) The 1970s through the mid-1980s saw the emergence of an increasing number of publications that presented a broader range of applications and conceptual perspec- tives (Betensky, 1973; Landgarten, 1981; Levick, 1983; McNiff, 1981; Rhyne, 1973/1995; Robbins & Sibley, 1976; Rubin, 1978/1984; Wadeson, 1980), although psychoanal- ysis remained a dominant influence. The development of the literature was also enriched during this period with the introduction of two new journals: Art Psycho- therapy in 1973 (called The Arts in Psychotherapy since 1980) and Art Therapy: Journal of the American Art Therapy Association, in 1983 (Rubin, 2010). The increasing number of publications, along with the founding of the American Art Therapy Association in 1969, evolved the professional identity of the art therapist, credentials, and the role of art therapists vis-a-vis related professionals (Shoemaker et al., 1976). It is noteworthy that it was during this period that Lucille Venture (1977) wrote the first art therapy doctoral dissertation. Contemporary Art Therapy Theories (Mid-1980s to Present) The art therapy literature continues to grow. In 1974, Gantt and Schmal published an annotated bibliography of sources relating to the topic of art therapy from 1940 to 1973 (1,175 articles, books, and papers), yet Rubin (2010) notes that in that same year there were only 12 books writlen by art therapists, a number that crawled to 19 some 10 years later. By the mid-1980s this pace began to increase so that there were over 100 titles available, and this number continues to climb rapidly. Rubin (2010) also speculates that art therapists may be more comfortable with an intuitive approach than other mental health practitioners because as artists they “pride themselves on their innate sensitivities, and tend to be anti-authoritarian and anti-theoretical” (p- 117). Approximately 21% of art therapists surveyed by the American Art TherapyA Brief History of Art Therapy u Association described their primary theoretical orientation as “eclectic,” the single largest percentage reported (Elkins & Stovall, 2000). This position is in keeping with one delineated by Wadeson (in Rubin, 1987/2001) and should not be surprising in a field that itself draws from a variety of disciplines. The next five most frequently reported models, psychodynamic (10.1%), Jungian (54%), object relations (4.6%), art as therapy (4.5%), and psychoanalytic (3.0%), all place a strong emphasis on intra- psychic dynamics, and this cumulative 276% suggests that much contemporary practice is still informed by generally psychodynamic concepts (Elkins & Stovall, 2000). In a landmark book, Approaches to Art Therapy, first published in 1987, Rubin (1987/2001) brought together essays by authors representing the diversity of theo- retical positions within the field, Perspectives from these and other relevant sou are briefly summarized here, res PSYCHODYNAMIC APPROACHES The ideas of Freud and his followers (see Malchiodi, Chapter 2, this volume) have been part of art therapy since the earliest days, although contemporary writers are more likely to apply terms such as “transference” and “the defense mechanisms” {o articulate a position rather than employ classic psychoanalytic techniques with any degree of orthodoxy. Kramer, Rubin, Ulman, and Wilson (all cited in Rubin, 1987/2001) and Levick (1983) all use psychoanalytic language and concepts. Inter- pretations of the newer developments in psychoanalysis such as the theories of Klein (Weir, 1990), self psychology (Lachman-Chapin), and object relations the- ory (Robbins) can also be found in the art therapy literature (both cited in Rubin, 1987/2001), With his emphasis on images from the unconscious, it was natural for Jung’s concepts of analytical and archetypal psychology to cross over into art therapy (see Malchiodi, Chapter 2, this volume). Work by Edwards and Wallace (both cited in Rubin, 1987/2001), McConeghey (1986), and Schaverien (1992) all reflect this empha- sis HUMANISTIC APPROACHES Elkins and Stovall (2000) suggest that only a small number of art therapists oper- ate from a humanistic position (among humanistic, Gestalt, existential, and client- centered; the highest response was to the first category, with 2.9%). Yet if these approaches can be defined as sharing “an optimistic view of human nature and of the human condition, seeing people in a process of growth and development, with the potential to take responsibility for their fate” (Rubin, 1987/2001, p. 119), these figures belie a sentiment held by many art therapists (see Malchiodi, Chapter 3, this volume).aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.A Brief History of Art Therapy Is ‘sment and treatment tech- Landgarten, HB. (1993). Magazine photocollege: A multicultural a nique. New York: Brunner/Mazel. Levick, M. F. (1983). They could not talk so they drew: Children's styles of coping and thinking. Springfield, IL: Thomas. Levick, M. F, Goldman, M. J,, & Fink, P. J. (1967). Training for art therapists: Community mental health center and college of art join forces. Bulletin of Art Therapy, 6, 121-124. Linesch, D. (1993). Art therapy with families in crisis. New York: Brunner/Mazel. Lowenfeld, V. (1987). Therapeutic aspects of art education. American Journal of Art Therapy, 25, 111-146. Lusebrink, V. B. (1990). Imagery and visual expression in therapy. New York: Plenum Press. MacGregor, J. M. (1989). The discovery of the art of the insane. Princeton, NJ: Princeton Univer ity Pros. Machover, K. (1949/1980). Personality projection in the drawing of the human figure. Springfield, IL: Thomas. Malchiodi, C. A. (1999a). Medical art therapy with adults. London: Kingsley. Malchiodi, C. A. (19996). Medical art therapy wwith children. London: Kingsley. Malchiodi,C. A. (2006). The art therapy sourcebook. Los Angele: McConeghey, H. (1986). Archetypal art therapy is cross-cultural art therapy. Art Therapy: Journal of the American Art Therapy Association, 3, 111-114. MeNiff, 8. (1981). The arts and psychotherapy. Springfield, IL: Thomas. MeNiff, S. (1992). Art as medicine: Creating a therapy of the imagination, Boston: Shambhala. MeNiff, 8. (1998). Art-based research. London: Kingsley. Mills, A., & Goodwin, R. (1991). An informal survey of assessment use in child art therapy. Art Therapy: Journal of the Ar: Therapy Association, 8, 10-13. Moon, B. L. (2009). Existential art therapy: The canvas mirror. Springfield, IL: Thoma Moon, C. H, (2002). Studio art therapy: Cultivating the artist identity ia the ari therapist. London: Kingsley. Naumburg, M. (1950/1973). Intreduction to art therapy: Studics of the “free” art expression of behavior problem children and adolescents as.a means of diagnosis and therapy. New York: Teachers College Press/Chicago: Magnolia Street. Naumbuarg, M. (1966/1987). Dynamically oriented art therapy. New York: Grune & Stratton/ Chicago: Magnolia Street. Nucho, A. ©. (1987). The psychocybernetic model of art therapy. Springfield, IL: Thomas. Prinzhorn, H. (1922/1995). The artistry of the mentally ill, Vienna, Austria: Springer-Verlag (Original work published in German) Rhyne, J. (1973/1995). The Gestalt art experience. Monterey, CA: Brooks/Cole/Chicago: Mag- nolia Street Riley, 5. (1999). Contemporary art therapy with adolescents, London: Kingsley. Riley, $, & Malehiodi, C. A. (1994). Integrative approaches to family art therapy. Chicago: Mag nolia Street. Robbins, A,, & Sibley, L. (1976). Creative art therapy. New York: Brunner/Mazel. Rogers, N. (1993). The creative connection: Expressive arts as healing. Palo Alto, Behavior Books. Rubin, J. A. (1978/1984). Child art therapy: Understanding and helping children through art. New York: Van Nostrand Reinhold /Wiley. Rubin, J. A. (1987/2001). Approaches to ari therapy: Theory and technique. New York: Brunner/ Mazel/Philacelphia: Brunner-Routledge. Lowell House. Science andaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Therapy and the Brain 9 Additionally, the stories of individuals with brain damage from injury, illness, and stroke are clarifying the relationship between art making and brain function. Miller and Cummings (2006) relate the story of Sandy Allen who had a large tumor near the speech areas of the cerebral cortex that was eventually removed from her brain's left temporal lobe. Surgery to the left side of the brain sometimes affects speech. Allen began to have problems with language and reading after removal of the tumor. But the surgery had a second, surprising effect: her right hemisphere was stimulated and prompted an interest in art. In contrast, Sandy Allen’s interests were in science and medical studies before her surgery. In brief, the right side of the brain is generally associated with emotion, spatial orientation, and creativity. In Allen’s case, the damage to her language area might, in part, explain her newly found creativity. While her case is unusual, it adds to a growing amount of evidence that the human brain is quite fluid and not binary as once believed. The experiences of artists with progressive brain damage or dealing with the after-effects of strokes have also been informative. Drago et al. (2006) evaluated an artist’s entire career of paintings, both before and after her medical condition began causing brain damage due to dementia. The researchers concluded that the artworks created later in the course of the disease displayed more artistic skill, but they also appeared less complete and emotionally powerful. Drago and her colleagues con- jectured that the damage to the womar’s temporal lobe increased her artistry, yet hampered her ability to finish her work. Studies of visual artists have also noted that poststroke work was markedly different from prestroke work; whether or not an abstract or a representational style was demonstrated was dependent on the region of the brain damaged by stroke (Bogousslavsky, Hennerici, Bazner, & Basetti, 2010). Savant syndrome, a condition characterized by exceptional artistic, musical, or mathematical talent, has also added knowledge about art expression and the brain. Savant syndrome often appears during childhood and may be associated with autism, illness, stroke, or seizure. Nadia is one of the more famous cases of advanced artistic development in an individual with autism (Malchiodi, 1998). Nacia’s art eventually became less advanced and more average as she approached puberty and may have been the result of underlying neurological dysfunction (Selfe, 2011). While very few people with autism are artistic savants, cases such as Nadia provide a window to the neuroscience of advanced creative abilities. Oliver Sacks (1996) cites the autistic savant Stephen Wiltshire, who is also known as the “human camera” because he can draw detailed landscapes from memory. Sacks speculates that Wiltshire may have the obsessive focus that many savants seem to have, despite brain dysfunction that prevents language and communica- tion. In people with autism, neurons that affect areas of the brain contributing to emotion and social interaction may not fully develop or form appropriate connec- tions. Asa result, many people with autism have difficult engaging with others, but may be more comfortable repeating specific tasks such as drawing, Finally, art making is an experience that can simultaneously engage many parts of the brain including the cortical (symbolizing, decision making, and planning),aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Therapy and the Brain 23 Art therapy is one way being, explored to reestablish healthy attachments, both through therapist and client, and through encouraging healthy interactions between parent and child, Riley (2001) cites how art activities are being used in early childhood attachment programs and how simple drawing exercises can be used to resolve relational problems and strengthen parent-child bonds. She explains that the nonverbal dimensions of art activities tap early relational states before words are dominant, possibly allowing the brain to establish new, more productive pat- terns, Similarly, Klorer’s (2008) work with severely abused and traumatized chil- dren demonstrates the compelling power of art and play therapy in treating, attach- ment disorders and improving parent-child bonding. Siegel (1999) and Schore (2003) believe that interactions between baby and care- taker are right-brain-mediated because during infancy the right cortex is develop- ing more quickly than the left. Siegel also observes that just as the left hemisphere requires exposure to language to grow, the right hemisphere requires emotional stimulation to develop properly. He goes on to say that the output of the right brain isexpressed in “non-word-based ways” such as drawing a picture or using a picture to describe feelings or events. According to this idea, art therapy may be an impor- tant modality in working with attachment issues, among other emotionally related disorders or experiences NEUROPLASTICITY Neuroplasticity (also called brain plasticity) is the ability of the brain to renew and, in some cases, to even rewire itself to compensate for deficits or injuries (Doidge, 2007). Brain plasticity is more easily accessible early in life, underscoring the impor- tance of intervention with young children in order to enhance attachment, affect regulation, interpersonal skills, cognition, and emotional development. But there is evidence that neuroplasticity exists throughout the lifespan, well into old age. In fact, Cohen (2000) describes a resurgence of creativity and the ability to learn new skill sets well into the seventh and eighth decades of life (for more information, see Malchiodi, Chapter 19, this volume on creativity and aging). Alders and Levine- Madori (2010) provide growing evidence for art therapy to enhance cognitive per- formance and perception of cognitive ability in older adults, underscoring that art making may be an important experience related to neuroplasticity and a therapou- tic method to help rewire areas of the brain related to executive functions Methods such as cognitive-behavioral therapy (CBT) are the direct outcome of the acceptance that the brain can adapt and change in response to intervention. Because the brain is malleable and flexible, depression, obsessive-compulsive dis- order, and anxiety disorders can be modulated by interventions such as CBT that can stimulate chemical change (Linden, 2006) (see Malchiodi & Rozum, Chapter 7, this volume, on art therapy and CBT). In a similar sense, repetitive, reward-driven activities including art making and crafts “rewire” the striatal-accumbens-corticalaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.CHAPTER 3 Art Therapy Materials, Media, and Methods Cathy A. Malchio he central use of art materials makes what happens in an art therapy session dif- ferent from all other psychotherapy approaches. Individuals in art therapy are encouraged to engage in some form of visual self-expression; in general, this can be an activity involving constructing, arranging, mixing, touching, molding, gluing, drawing, photographing, filming, painting, and/or forming, among other actions (Malchiodi, 2002). With the rapid increase in digital technology, it may also be an activity that includes keyboards, computer screens, and other novel or nontradi- tional devices for image making (Malchiodi, 2000; Moon, 2009; Seiden, 2001). Art therapy is influenced not only by various psychotherapeutic approaches to working with people, but also by the domain of visual art. Early in its history, art therapy was influenced by traditional materials and methods used in milieu therapies in psye! gs in the mid-20th century. These setting emphasized painting and sculpture for self-exploration and art making as a form of rehabil tation, activity therapy, and/or occupational therapy. Since that time, art therapy has expanded into the realm of psychotherapy and counseling and into new set- tings including community-based agencies, social services, art studios, and schools that have affected the adaptation of methods and introduction of new media. More recently, digital media (digital cameras, photo-enhancement software, and Inter- net communication) are having a significant impact on how images are created, transformed, and transmitted, reframing how art therapy takes place and how it is delivered in an electronic world. ic se 7aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Therapy Mcterials, Media, ard Methods 31 part, to support perceptions of self-efficacy and self-worth and improve individuals’ abilities to produce products with meaning and aesthetic value. MEDIA USED IN ART THERAPY, PLAY THERAPY, AND EXPRESSIVE THERAPIES There are many additional media used in art therapy that cannot be strictly classi- fied as visual art materials because they cross over into the domains of play therapy and expressive arts therapy. By some definitions, art making is considered a form of play and has been historically used as part of play therapy techniques with children and families (Webb, 2007; Gil & Drewes, 2005). Play therapists include art materials for the creation of self-made toys and props (Kottman, 2010) and to stimulate mul- timodal and integrative experiences involving art making, play, and music (Oak- lander, 2007). Art therapists also often encourage clients to use their art expressions as cata- lysts for storytelling, dance, or dramatic enactment (see Malchiodi, Chapter 10, this volume, on expressive arts therapies for more information). Mask making, costume creation, and puppet making, among others, are examples of visual art-based pro- cesses that naturally promote performance, sound, and movement. For example, making a musical instrument such as a drum may be used as a catalyst for self expression through rhythm and sound; creating a puppet often naturally leads to storytelling; and designing a face mask may be used to facilitate drama or role play (Figure 3.1). FIGURE 3. Self-created masks in dramatic enactment and role play.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Therapy Materials, Media, ard Methods 35 FIGURE 3.3. Author's Picassohead image. CASE EXAMPLE Josh, a 10-year-old boy, was admitted to a children’s hospital for injuries from an all-terrain vehicle accident. Josh underwent several painful surgical procedures and had a difficult time adjusting to his hospital stay. On three occasions he was non- compliant with medical procedures and had to be restrained in order for nursing staff to administer medications and IVs. He did enjoy working with the art therapist and child life staff and in particular liked using an iPad (a portable and compact computer device that can be used bedside) to make images. To help Josh get settled down, the art therapist introduced apps (short for soft- ware applications) called SpinArt Studio and Spawn Glow. Both apps are easy to use and involve making colorful designs through spinning virtual paint (SpinArt) or moving colorful lines around the screen using one’s fingers Figure 3.4). Josh often became so occupied with using the iPad to make designs that the nursing staff could more easily give him an injections or perform routine medical procedures without Josh becoming anxious or complaining about pain. After a few days, the art therapist taught Josh about another way to make art on the iPad through an app called Doodle Buddy. The Doodle Buddy program has numerous drawing tools (colored pencil and paintbrush lines) and special effects that only require the use of a finger on the screen like the apps previously men- tioned. It is a particular good program for children because they enjoy using these tools and effects along with the stamps that allow them to add icons for animals, environmental elements, and other objects or emoticons (such as a “smiley face”). An audio feature can be selected so that each stamp makes its own sound when the artist places a stamp on the digital artwork. Making an artwork only takes a few minutes by fi selecting a background (a color or environmental scene such as aaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Therapy Materials, Media, ard Methods 39 + Exposure fo art. Both the fields of art therapy and the arts in healthcare are recognizing the importance of exposure to art through lectures, museums, and exhibits; the Internet has also provided opportunities to introduce art images and art history to art therapy clients and patients in hospitals. Expo- sure increases knowledge of art practices and impacts individuals’ prefer- ences for materials, media, and methods that suit their creative needs. How neuroscience informs artistic expression and image processing is a fifth trend that continues to influence the collective knowledge of art therapy, wellness, and art making. Emerging neuroscience data on image formation, sensory experi- ences, and creativity, clinical reports, and client narrative will continue to inform the field of art therapy about how art materials support therapeutic goals and objec- tives in work with children, adults, and groups (Malchiodi, 2006, 2008). It is also likely that in the future art therapy will have to more clearly define applications of materials, media, and methods for various populationsand settings. Aside from authors like Seiden (2001), Moon (2009), and a few others, there has been relatively little written specifically about materials and media; there are com- paratively few references to art making practices outside the traditional realm of drawing, painting, collage, and sculpture. Undoubtedly, as art therapy populations and settings continue to change and expand, how the field describes best practices involving media will evolve to meet client needs and as new ii available via research on the impact of specific art methods used in therapy. formation becomes CONCLUSION This chapter has only skimmed the surface on applications of art materials, media, and methods used in therapy; chapters throughout this book demonstrate many of these applications and readers are encouraged to use the reference and resource list for further information. All therapists who use art in treatment and assessment should be well versed in this topic as well as the changing landscape defining what constitutes art materials, media, and methods; how clients prefer to communicate via art expression; and how digital media in particular continues to impact therapy in general. The continuum of art making is ever widening with the proliferation of technology and through emerging definitions of art itself in the 2ist century. REFERENCES Association for Play Therapy. (2009). Play therapy best practices. Fresno, CA: Author. Austin, B. (2009). Technology, art therapy, and psychodynamic theory: Computer animation with an adolescent in foster care. In C, Moon (Ed.), Materials and media in art therapy (pp. 199-213). New York: Routledge. Canter, D. . (1987). The therapeutic effects of combining Apple Macintosh computers andaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Theropy in Practice 43 2006). These include, but are not limited to (1) storage and retention of art expres- sions; (2) ownership of art expressions; (3) exhibition of art expressions and confi- dentiality; and (4) art-based assessment. Storage and Retention of Art Expressions Like written records, art expressions created in therapy require storage in a secure place that is safe from theftor damage and ensures protection of privacy (Malchiodi, 1998; Moon, 2006). The storage and retention of art expressions brings up both legal and ethical issues involving artworks as records of treatment. For example, how long does atherapist retain art expressions created bya client? Are digital or photo- copies acceptable for record retention? Many of these questions are only answerable by reviewing multiple guidelines, including those provided by credentialing orga- nizations, licensure boards, and state and federal laws on patient records. In brief, any helping professional who uses art as part of treatment must seriously consider how drawings and other artworks created by clients are stored and how records of such expressions are maintained. Ownership Most art therapists believe that clients ultimately own the artwork they create dur- ing treatment. However, in some situations, the institution or agency may specify ownership of patient art expressions; when minors are clients, parents or caregivers may legally own their children’s art products under some circumstances. Addition- ally, some practitioners feel it is important to permanently retain some art expres- sions that may become evidence in a court of law or may be useful to keep for future art therapy sessions. Exhibition of Art Expressions and Confidentiality Confidentiality, an ethical issue that is the basis of all therapeutic relationships, is defined as the responsibility to protect clients from unauthorized disclosure of information within the therapeutic relationship (Corey, Corey, & Callanan, 2010). Art therapists regard art expressions created within the therapeutic context as con- fidential material. There is general agreement in art therapy codes of ethics that cli- ent identity is disguised when displaying art expressions (Art Therapy Board, 2010). At the same time, there is also consensus that there are circumstances when the uniqueness of a drawing, painting, or sculpture makes confidentiality difficult (Wilson, 1987). In addition, some artwork may reveal very specific informa- tion about a child or adult that could compromise that individual's safety because it provides information that others could easily recognize (Malchiodi, 1998, 2008). For example, children who have been or are suspected of being abused or just by their status of being minors under law often require special consideration when it comes Credentialsaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Theropy in Practice 47 CULTURAL SENSITIVITY Cultural sensitivity in art therapy includes not only attention to ethnicity, but also degree of acculturation, environment, regionalization, family, extended family and peers, socioeconomic status, gender, disability, development, and religious or spiri- tual affiliations (Malchiodi, 2005). Art therapists have addressed the implications of culture with a variety of populations, mostly from the perspective of race and ethnicity (Dokter, 1998; Hiscox-Riley & Calisch, 1998; Hocoy, 2002). It is also referred to by several names including cross-cultural art therapy (Hocoy, 2002) and multicul- tural art therapy (Hiscox-Riley & Calisch, 1998), In all cases, culturally competent practice and application of art therapy with children, adults, families. groups, and communities with sensitivity to diversity in all its forms is the common denomina- tor. Echoing the 20th-century work of C. G. Jung, McNiff (2009) observes that the universal and cultural symbols of art and myth contribute to a basis of understand ing, multicultural issues in art therapy. Additionally, some of what can be applied to the culturally competent use of art therapy comes from what is known about art expression and the artistic traditions of various cultural groups around the world. Most contributions to the topic of culture and art therapy practice have restated the importance of addressing culture in therapeutic work, mirroring what psychia- iry, psychology, and counseling have observed about cultural sensitivity. In other words, while relatively little is known about the impact of culture on art therapy per se, there is general consensus that art therapy should address and respect culture in assessment and treatment. In brief, art therapists, like their professional coun- terparts in mental health and medicine, endeavor to provide service to others in a respectful, culturally sensitive manner and seek to increase their understanding of clients’ worldviews through supervision, education, and self-evaluation of personal values and beliefs. With specific regard to art therapy, helping professionals using any creative methods in therapy consider how individuals appraise these methods, including biological, psychological, social, spiritual /religious, and cultural perspectives. They also bear in mind any developmental aspects and individuals’ personal preferences for creative expression through art because diversity and worldview influence how adults and children perceive art materials and any associated props or toys offered. Gil and Drewes (2005) provide one of the few comprehensive overviews on how culture affects children’s play and creative expression in therapy, underscoring sen- sitivity to what types of props and materials are presented with attention to devel- opment, gender, and culture. For example, animals differ among cultures and have a variety of meanings; it is important to be open to a variety of responses and con- notations related to personal experiences and worldviews, Helping professionals should have art media that are adaptable to various cultures, including clays and drawing materials in a range of tones that approximate different skin colors. Photo collage materials should reflect a variety of cross-cultural images, including ethnic- ity, families, lifestyles, and beliefs. Craft materials such as fabric, yarn, beads, and other objects may be helpful in stimulating individuals whose experience with artaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.Art Theropy in Practice 5 Cohen, J., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press. Corey, G., Corey, M,, & Callahan, P. (2010). Isswes and ethics in the helping professions (8th ed.). Pacific Grove, CA: Brooks /Cole. Dokter, D. (1998). Art therapists, refugees, and migrants: Reaching across borders. London: Kings- ley. Elkis-Abuhoff, D,, Goldblatt, 8, Gaydos, M., Coratto, S. (2008). The effects of clay manipula- tion on somatic dysfunction and emotional distress in patients diagnosed with Par- kinson’s disease. Art Therapy: Journal of the American Art Therapy Association, 25(3), 122-128. . & Drewes, A. (Eds). (2005). Cultural issues in play therapy. New York: Guilford Press. oy, A. (2006). Art therapy, research, and evidence-based practice. Thousand Oaks, CA: Sage. Gross, J. & Haynes, H. (1998). Drawing facilitates children’s verbal reports of emotionally laden events. fournal of Experimental Psychology, 4, 163-179, HiscoxRiley, A., & Calisch, A. (1998). Tapestry of cultural issues in art therapy, London: Kings- ley Hocoy, D. (2002). Cross-cultural issues in art therapy. Art Therapy: Journal of the American Art Therapy Association, 19(4), 141-145. Junge, M. (2010). The modern history of art therapy in the United States.Springfield, IL: Thomas. Kalmanowitz, D,, & Lloyd, B. (2002). The portable studio: Art therapy and political conflict Initiatives in former Yugoslavia and South Africa. London: Health Education Authority. Kaplan, F. (2000). Art, scieuce, and art therapy: Repainting the picture. London: Kingsley Knill, P, Barbs, H., & Fuchs, M. (2004), Minstrels of the soul: Intermodal expressive therapy, ‘Toronto: Palmerston Press. Lev-Wiesel, R., & Liraz, R. (2007). Drawings versus narratives: Drawing as a tool to encour- age verbalization in children whose fathers are drug abusers. Clinical Child Psychology and Psychiatry, 12(1), 65-75. Levine-Madori, L. (2009). Uses of therapeutic thematic arts programming (TTAP Method®) for enhanced cognitive and psychosocial functioning in the geriatric population. Amer- ican Journel of Recreation Therapy, 8(1), 25-31. Malchiodi, C. A. (1988). Bringing art therapy to China. American Journal of Art Therapy, 27(2), 54-60. Malchiodi,C. A. (1995). Does a lack of art therapy research hold us back? Art Therapy: Journal of the American Art Therapy Association, 12(4), 218-219. Malchiodi, C. A. (1998). Understanding children’s drawings. New York: Guilford Press. Malchiodi, C. A. (2005). The impact of culture on art therapy with children. In E. Gil & A Drewes (Eds.), Cultital issues in play therapy (pp. 96-111). New York: Guilford Press. Malchiodi, C. A. (Ed.). (2008). Creative intervention with traumatized children. New York: Gui ford Press. Malchiodi, C. A. (2009a). A Facebook page for your private practice? Retrieved January 12, 2011, from wiviv psychologyteday,coni/blog /the-healing -arts/200907 facebook-fan-page-your- private-practice. Malchiodi, C. A, (2009b). Art therapy meets digital art and social multimedia. Retrieved January 12, 2011, from wi.psycholog ytoday.com /blog the-healing-arts/200911/art-therapy-meets- digital-art-and-social-multimedia. MeNiff, S. (1998). Art-based research. London: Kingsley. Gil,