Art Therapy

Journal of the American Art Therapy Association

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Art Therapy With Puppet Making to Promote

Emotional Empathy for an Adolescent With Autism

Bani Malhotra

To cite this article: Bani Malhotra (2019): Art Therapy With Puppet Making to Promote Emotional
Empathy for an Adolescent With Autism, Art Therapy, DOI: 10.1080/07421656.2019.1645500

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 Art Therapy: Journal of the American Art Therapy Association, 0(0) pp. 1–10, # AATA, Inc. 2019
Art Therapy With Puppet Making to Promote Emotional
Empathy for an Adolescent With Autism
Bani Malhotra
Abstract
There is a growing interest in understanding how
individuals with autism spectrum disorder (ASD) experience
empathy to explore their social-emotional and
communication impairments. Although there has been
considerable research into autism and cognitive empathy,
research into emotional empathy is scarce, and there is less
on the impact of teaching social skills. This study explores
the use of art therapy with puppet making and puppetry
using the Expressive Therapies Continuum (Kagin &
Lusebrink, 1978) to promote emotional empathy in
individuals with ASD within the larger goal of addressing
socialization.
Empathy is a complex multidimensional concept
composed of cognitive and affective components (Davis,
1983). Cognitive empathy (CE) is the ability to under-
stand another person’s perspective and mental state. This
function, known as theory of mind (ToM) or mentalizing
(Frith & Frith, 1999), is critical for effective social inter-
actions (Dvash & Shamay-Tsoory, 2014). CE is consid-
ered to be dependent on cognitive capacities, such as
memory and cognitive flexibility (Davis, 1983).
Emotional empathy (EE) or affective empathy (AE) has
been described as an emotional response to perceived feel-
ings of another person (W€ollner, 2012). It is “the ten-
dency to mimic the verbal, physiological and/or
behavioral aspects of another person’s emotional experi-
ence/expression, and thus to experience/express the same
emotions oneself” (Hsee, Hatfield, Carlson, & Chemtob,
1990, p. 328).
Individuals with autism spectrum disorder (ASD)
are characterized as having impairments in social inter-
action and communication, which makes studying
empathy especially relevant. It is well established that
individuals on the autism spectrum have difficulties with
CE and perspective taking (Baron-Cohen &
Wheelwright, 2004). However, there is now a wide
range of theoretical views that people with autism lack
CE but not EE. Previous literature has been inconclusive
Bani Malhotra is an art therapist in Philadelphia, PA.
Correspondence concerning this article should be sent to the
author at bani.malhotra13@gmail.com
Color versions of one or more of the figures in the article
can be found online at www.tandfonline.com/uart.
1
in reporting significant differences in emotional empathy
in ASD using the Interpersonal Reactivity Index (IRI;
Davis, 1983; Rueda, Fernandez-Berrocal, & Baron-
Cohen, 2015; Trimmer, McDonald, & Rushby, 2017)
and multifaceted empathy test (Dziobek et al., 2008).
Other studies have used neuroimaging and psycho-
physiological techniques such as skin conductance level,
facial electromyography, and heart rate to index social
responses such as arousal and elicit empathy dimensions
in ASD. Neuroanatomical evidence has indicated the
presence of interpersonal and intrapersonal systems
necessary for emotional empathy (Dvash & Shamay-
Tsoory, 2014). Research also suggests that motor
empathy (tendency to mimic motor movements of
another person) or mirroring is linked to EE (Behrends,
M€ uller, & Dziobek, 2012). Mirroring in movement has
been correlated with social interactions, reduction of
negative symptoms in autism, and increased self-
awareness (Hildebrandt, Koch, & Fuchs, 2016). In
explaining low CE and high EE in autism, Smith (2006)
regarded autism as cognitive empathy deficit disorder
(CEDD), suggesting that people with autism might emo-
tionally empathize with others but might not be able to
express this empathy in overt or ordinary ways due to
overwhelming empathic connection and inability to “step
back” from empathic connections.
Art Therapy and Autism
Art therapy research with autism continues to
expand on its use to enhance communication, externaliz-
ing feelings of anxiety and allowing for positive develop-
ment of self-esteem and relationship skills (Martin,
2009a). Little research has been conducted on the mani-
festations of core deficits of autism in adolescence and
adulthood (Betts, Harmer, & Schmulevich, 2014).
Previous literature draws attention to the importance of
the art therapist–client relationship, and the dialogue in
the artwork to promote emotional regulation as well as
to facilitate the communication process (Betts, 2005).
Evans and Dubowski (2001) noted the need for order
and structure in art therapy as important for children
with autism. According to Betts et al. (2014), art therapy
in schools for students with autism is aimed at working
on goals regarding cognitive growth, emotional regula-
tion, adaptive behavioral styles, and physical
2 ART THERAPY WITH PUPPET MAKING
development. The use of art materials with visual and
tactile diversity facilitates sensory modulation, emotional
regulation, flexibility, and attachment with ASD individ-
uals (Durrani, 2014; Schweizer, Knorth, & Spreen,
2014). Isserow (2008) suggested implications for art
therapy in developing joint attention through shared tri-
adic relation of the image, client, and therapist as a
foundation to construction of affective and cognitive per-
spective taking. Martin (2009b) and Allen (2009)
asserted that artwork can serve a function of an object
that children and adolescents can refer back to over
time, in the form of a coping strategy.
Expressive Therapies Continuum
The Expressive Therapies Continuum (ETC) was
developed by Kagin and Lusebrink (1978) as a schematic
framework for visual expression based on three levels of
information processing. The three levels are kinesthetic/
sensory (K/S), perceptual/affective (P/A), and cognitive/
symbolic (C/Sy), and a creative level that can apply
through any or all of these (Kagin & Lusebrink, 1978).
According to Lusebrink (2010), the kinesthetic, percep-
tual, and cognitive components of the ETC could be
enhanced through the use of resistive materials (pencils,
crayons, or markers), whereas fluid media (watercolor,
paints) could be used to enhance sensory, affective, and
symbolic aspects of information processing. The overall
choice of art material could improve other weaker levels
of ETC. In describing the best practices for art therapy
with ASD, Van Lith, Stallings, and Harris (2017) high-
lighted the use of ETC to reflect the use of art materials
with therapeutic aims. The authors suggested a “top-
down” approach starting with materials at the cognitive/
symbolic level to encourage relationship building with
the client and addressing goals related to cognitive
growth and then moving toward a gradual transition to
introduce more sensory and kinesthetic fluid materials.
Puppetry in Therapy
Puppetry has been used as a valuable medium in
therapy (Bernier & O’Hare, 2005) and psychotherapy
(play therapy, art therapy, drama therapy) to express dif-
ficult feelings and engage in conflict resolution (Bender
& Woltmann, 1936; Jenkins & Beckh, 1942). Cassell
(1965) wrote that children are more easily able to
express their feelings through a puppet because it enables
children to release feelings that they are unable or
unwilling to express directly. Puppets in therapy have
been regarded as an extension of self or the environment
and range from simple to complex types of puppets
including paper bag hand puppets, finger puppets, and
marionettes (Bernier, 1983). Puppetry in art therapy
involves puppet making for use in play designed to meet
specific therapeutic goals (Bernier, 1983; Gerity, 1999).
Puppetry has also been widely used in therapy as a diag-
nostic tool (Howells & Townsend, 1954; Irwin &
Shapiro, 1975). Using puppets with clients with ASD
promotes empathetic responding and self-awareness
(Emery, 2004; Schrandt, Townsend, & Poulson, 2009),
as well as communication (Trimingham, 2010). Based
on the aforementioned literature, this in-depth case
study aimed to describe how puppetry in art therapy
could enhance emotional empathy for a child with ASD.
Case Design
Client
Lisa (pseudonym) was a 16-year-old African-
American female diagnosed with ASD who received edu-
cation and therapeutic services from a nonpublic special
education day school in an urban area. Autism preva-
lence studies differ across gender and racial or ethnic
groups, indicating a lower prevalence or underreporting
of autism in African Americans (Mandell, Ittenbach,
Levy, & Pinto-Martin, 2007). I worked with Lisa as an
art therapy intern and had been working with her for
4 months prior to implementing puppet making. Lisa
previously received art therapy from my site supervisor
for 6 years. I secured informed consent from the client’s
parents and assent from her.
Measures
Face Stimulus Assessment. The Face Stimulus
Assessment (FSA) is an art therapy assessment designed
for individuals who have communication difficulties
(Betts, 2003, 2016). The FSA includes a series of three
images (depicting a complete face stimulus, an outline,
and blank paper) designed to reveal the client’s capacity
for memory and visual retention. The FSA provides
graphic equivalents of diagnostic criteria for autism
through a modified version of the Formal Elements Art
Therapy Scale (FEATS; Betts, 2013; Gantt & Tabone,
1998). Its reliability and validity for FSA has been estab-
lished for a population with attention deficit/hyperactiv-
ity disorder in South Korea (Kim et al., 2014).
Interpersonal Reactivity Index. EE was assessed
using the IRI (Davis, 1983), which is a self-report meas-
ure used with ASD individuals in previous literature.
The IRI includes 28 items on a 5-point Likert scale
ranging from does not describe me well to describes me
very well. The measure has four subscales—perspective
taking, fantasy, empathic concern (EC), and personal
distress—of which EC is the measure of EE. The IRI
was originally validated on college student populations
and since, has been widely used across populations in
several languages (Konrath, 2013).
 MALHOTRA
Figure 1. Finger Puppets Examples
Session Plan
The puppetry intervention consisted of 12 30-min
art therapy sessions over the course of 3 months. These
sessions were incorporated into Lisa’s regular art therapy
treatment as usual and were based on her Individualized
Education Program (IEP) goals toward emotional regula-
tion and socialization. I developed the structure and con-
tents of the sessions based on previous literature,
experience working with the participant, and suggestions
from my supervisor.
I employed three distinct styles of puppet making.
The puppet tasks ranged from simple to more complex
types (Bernier, 1983), thereby using the ETC model
with a goal of engaging materials that could facilitate
cognitive to sensory/kinesthetic interaction. I made three
samples of each type of puppet to offer Lisa more
choices and encourage originality (Figure 1). Each of
these samples displayed facial features to correspond to
uniform emotions: happy girl, sad boy, and neutral elder
man. I created one as an older man because Lisa missed
several older male teachers and her older brother.
I explained the workings of each puppet, modeled
movements and tone, and allowed Lisa as much time as
needed. Each puppet making was followed by client-
directed unstructured puppet play to encourage spontan-
eity. Bernier (2005) stated that client-directed puppet
play involves the client taking on the role of script
writer, actor and puppeteer, and director, and engages
the therapist by taking on roles according to the client’s
direction. During sessions when she did not want to cre-
ate or play with puppets, I encouraged Lisa to create a
self-portrait focused on facial expressions and emotions
to maintain focus on self-awareness. At the beginning
and end of the 12-week puppet making and puppet
play, I administered a pre- and post-FSA and IRI. To
3
provide further structure to the session, every other week
Lisa chose one feeling to explore from the following cat-
egories: sad/loneliness/grief, happy/calm/excited, and
anxious/nervous/worried. These feelings were grouped as
such because Lisa often used them interchangeably. Her
selection also offered an opportunity to assess if Lisa
would choose different emotions from one style of pup-
pet making to another, and from puppet making to pup-
pet play.
I wrote process and progress notes following each
session that included behavioral observations, client ver-
balizations, and photographs of the client artwork and
puppets. This process ensured accurate reporting, reflex-
ivity, and identifying connections to art therapy theory
and the ETC.
Summary of Art Therapy Sessions
Lisa used different media to explore different emo-
tions during the puppet making and puppet play
(Figures 2 and 3). Table 1 presents a brief summary of
the 12 sessions indicating the task, emotion explored,
and media used. The sessions were notable for four over-
arching themes: (a) interpersonal interactions, (b) intra-
personal processes, (c) awareness of others’ emotions,
and (d) externalization.
Interpersonal Interactions
Lisa used art therapy sessions to explore both posi-
tive and negative interpersonal interactions. She
described her positive interactions with previous male
teachers (“He’s fashionable, telling jokes”) and negative
interactions with one of her classmates (“Stay away from
[student], don’t have to talk to her”). She displayed a
4 ART THERAPY WITH PUPPET MAKING
Figure 2. Bag Puppet
range of emotions when describing different relationships
expressing loneliness of missing her brother, who was
away at college, as well as other men including teachers,
a behavioral health specialist, and a janitor. She often
engaged in puppet play selecting the boy or the man
puppet model. In suggesting ways to help the puppet in
interactions to deal with loneliness, nervousness, and
stress, Lisa said the following:
“Hey puppet, wake up, let’s not think of the tough
times anymore.”
“Say hi, I need a break.”
“Go out for an ice cream, have fun in the park, go on
swings, jump, ropes, have all the free time.”
“Write an e-mail to old teacher; do teacher time,
independent work, math drill.”
The art making seemed to have provided Lisa an
opportunity for connection with the intern as well. Lisa
initiated the first puppet play with my supervisor and
subsequently started requesting help during puppet mak-
ing and eventually engaging in puppet play with me
Figure 3. Finger Puppet
while the supervisor observed. The puppet play also
involved a natural opportunity to practice appropriate
social interaction when Lisa initiated a kiss to make the
sad puppet feel better during Session 7.
Intrapersonal Processes
Lisa demonstrated awareness of intrapersonal proc-
esses through her focus on facial features in the artwork.
Even though her schema in art remained the same, she
displayed awareness through an attempt at modeling
facial expressions as well focusing on the mouth, eyes,
skin color, hair, tone, and movement of the puppet.
This was also true when Lisa made her self-portrait in
Session 8 (Figure 4). She was aware of her somatic
symptoms when engaging in intrapersonal communica-
tion, such as, “Sometimes stress can be tight; my eyes
are watering.” Lisa’s engagement in intrapersonal com-
munication is also noted with her independent use of
her coping strategies, such as coloring rainbows especially
when she needed a break. Furthermore, it was observed
that her handwriting while journaling became illegible
with excessive overlapping and loose line quality when
she appeared upset.
Lisa represented intrapersonal awareness by commu-
nicating complex emotions. She described loneliness due
to missing her brother (“He’s going out with his friends,
I feel worried”) and former teachers (“You feel lonely
when you miss people”). Other examples included
 MALHOTRA 5

Table 1. Summary of Sessions

Session Task Emotion Media

1 Pre-FSA Markers
2 Pre-IRI
3 Paper bag puppet making Loneliness Markers
4 Paper bag puppet play Loneliness
5 Finger puppet making Worried Paint, tempera sticks, markers, yarn, felt cloth
6 Finger puppet making Excited Paper craft, markers, yarn
7 Finger puppet play Calm
8 Self-portrait Markers
9 Sock puppet making Worried Yarn, felt cloth, paper
10 Sock puppet play Nervousness Felt cloth
11 Post-FSA Markers
12 Post-IRI
Note. FSA ¼ Face Stimulus Assessment; IRI ¼ Interpersonal Reactivity Index.

Awareness of Others’ Emotions

Lisa displayed curiosity about others’ thoughts and

emotions including mine or those of the puppets. She
validated the puppets’ experiences of emotions by offer-
ing her suggestions to cheer them. In one instance, dur-
ing sock puppet making, I was confused about Lisa’s
request for more paper to draw eyes even though she
had added them using the felt cloth on her sock, not
knowing that she wanted to add further details. She
observed my nonverbal behavior and said, “Confused is
when you don’t understand something.” In another
instance, she stated, “My dad will be so proud of me for
turning my day around.”

Externalization

Lisa used personal experiences to explore the three

categories of emotions, and particularly perseverated on
loneliness in all three puppet-play instances. During the
sock puppet play (Figure 5), Lisa explored the same
theme of missing teachers by externalizing her feelings
onto the puppet as her class teacher: “She is feeling wor-
ried because she is missing her old teachers. … I have
to do a lot of documents. Going to e-mail old teachers
and meet them soon when they visit.” When coming up
with suggestions to make the puppet characters feel bet-
ter, she often suggested her own preferred activities.
Figure 4. Self-Portrait
FSA and IRA Indicators

I measured the results for the second pictures of the

validating herself (“It’s okay, puppet is not finished”),
self-regulating (“Hard times are over, don’t think about
it”), and scripting expected behavior (“I can tell if I need
a break, do not hit anyone, do not throw things”). A
recurrent clue of Lisa indicating lingering emotions was
noted through her use of the word still (“I still miss my
brother,” “We’re still talking about Mr. [for-
mer teacher]”).
FSA using the FEATS modified rating sheet (Figure 6).
The pre-FSA results on the nine scales are #1
Prominence of Color–5, #2 Color Fit–3, #3 Implied
Energy–5, #4 Logic–4, #5 Realism–4, #6 Developmental
Level–3, #7 Details of Objects and Environement–2,
#8 Line Quality–3, #9 Perseveration–2. The post-FSA
results are #1–5 #2–4 #3–5 #4–5 #5–4 #6–3 #7–2 #8–3
#9–2. There was no notable change in Lisa’s FSA scores
6 ART THERAPY WITH PUPPET MAKING
as her schema remained the same. However, the color fit
and details on the eyebrows improved in the post-FSA.
The pre- and post-IRI scores indicated an increase in the
EC scale and no notable change in the other three scales
(Table 2).
Figure 5. Sock Puppet
Figure 6. Pre- and Post-Face Stimulus Assessment
Implications
Including puppets in art therapy served as a catalyst
for encouraging interpersonal and intrapersonal interac-
tions, awareness of others’ emotions, and externalizing
of feelings for the participant, all of which are crucial
processes in developing emotional empathy. The art
therapy assessment and the self-report empathy measure
provided insights on the direct changes noted in
her responses.
The puppets functioned as a safe and somewhat
controllable physical object for exploration of complex
feelings. The use of puppets served as a medium to
externalize Lisa’s feelings of loneliness and anxiety.
Trimingham (2010) proposed a similar process in pup-
petry with autism: “children are confronted with an
externalization of themselves, a sudden focus away from
their closed inner world, as if another presence suddenly
shares their lonely perception of the world” (p. 256).
Lisa explored emotional conflict and confusing experien-
ces through puppet play, thereby using puppetry in
improvising to engage in problem solving through the
Table 2. Interpersonal Reactivity Index (IRI) Scores
IRI Scale Pre-IRI Post-IRI
Perspective taking (PT) scale 19 19
Fantasy (FS) scale 12 10
Empathic concern (EC) scale 9 19
Personal distress (PD) scale 6 8
 MALHOTRA
process of doing it, and not merely imposing a rational
outcome (Bernier, 1983; Trimingham, 2010). Lisa also
used the puppets in mirroring movements and facial
expressions of the therapist and then independently used
hand gestures to express feelings through the puppet.
This can be correlated with increased social interaction
and self-awareness in motor empathy (Hildebrandt et al.,
2016). Puppets have been regarded as transitional objects
linking the inner and the outer worlds. Lisa would con-
stantly bring up attachment to her brother and old
teachers in puppet play, thereby using puppets as a
“bridging” space or an extension or representation of the
self or aspects of others in the environment (Bernier,
2005). The puppet also functioned as a transferable cop-
ing skill, an object added to Lisa’s “coping bag” that she
could remember and refer to in the future.
Although previous literature suggests different forms
of inclusion of puppets in therapy (finger puppets, hand
puppets, marionettes, shadow puppets), virtually nothing
could be found on the role of the ETC (Kagin &
Lusebrink, 1978) in puppet making. A range of art
materials were offered to Lisa for puppet making. Lisa
started the first puppet using only resistive materials,
such as markers, which generally activate the left-hand
components of ETC: kinesthetic, perceptual, and cogni-
tive. The rainbow schema, destruction of material (thin-
ning of paper bag with excessive coloring) and
predominance of outlines with rigid structure, support
the psychopathological variation in Lisa’s visual expres-
sion (Lusebrink, 2010). In subsequent sessions, Lisa used
various fluid mediums and textures including paints,
yarn, felt cloth, and paint sticks, engaging the sensory
and affective levels of ETC. The structure of simple to
complex puppet forms (bag, finger, sock) might have
mobilized exploration on different levels of the ETC
during the course of the intervention.
The FSA results correspond to many of the graphic
equivalents of Diagnostic and Statistical Manual of
Mental Disorders diagnostic criteria for ASD (Betts,
2013). Lisa’s graphic developmental level matches the
quality of drawings by latency-age children with more
detail for individual features. This corresponds to her
significant global cognitive deficits in comparison to
same-age peers conforming to the diagnostic criteria of
impairment in social interaction and communication.
The FSA has direct implications on measurement of cog-
nitive capacities (memory and cognitive flexibility) for
CE as noted in the literature (Davis, 1994). Lisa also
displayed schema stalemate, drawing the same schema of
human face with little or no changes in the self-portrait
(Martin, 2008).
The findings from the IRI (Davis, 1983) on the EC
scale indicate a remarkable increase from the pre- to
post-self-report measure. The preassessment of the EC
subscale for Lisa was notably lower than the perspective
taking subscale. This conforms to the experimental evi-
dence suggesting a significantly low score on the EC
scale of the IRI (Trimmer et al., 2017). A consequential
7
change in Lisa’s EC scale suggests a change based on
the art therapy intervention. This use of the IRI as a
pre–post measure raises questions of EE as a state or trait
measure. Considering the change in EC measure, I sus-
pect that EE could be a state-based measure dependent
on the empathetic response to others’ expressive behavior
(Nezlek, Schutz, Lopes, & Smith, 2007). Krahn and
Fenton (2009) reported that for a response to count as
empathetic, it must be informed by an understanding of
both oneself and another. This study shows evidence in
the qualitative data with interpersonal and intrapersonal
themes that emerged for Lisa as a result of art therapy.
Smith (2006, 2009), in proposing CEDD to be a part
of autism, explained that even though people with aut-
ism might share others’ emotions, they might be unsure
about its source or how to manage it, making it a strug-
gle for ASD people to step back from the overwhelming
empathic connections resulting in an empathic imbal-
ance. This case study also indicated that Lisa often exter-
nalized her own emotions on others, not clearly
distinguishing theirs from hers.
An in-depth exploratory case study details provides
directions for further research for incorporating puppets
in art therapy when working with clients with ASD.
Even though I observed that Lisa incorporated the pup-
pets as a coping strategy, it would be crucial to follow
up the extent of usage of puppets and its continued
influence on EE. A limitation of the IRI scale as a verbal
measure was noted as some of the questions were beyond
Lisa’ s comprehension. Future investigation warrants
inclusion of a more appropriate EE measure suited for
individuals with ASD. Considering the versatility of the
nature of puppets and previous literature on the effect of
movement on EE, further study on embodiment using
puppetry with ASD would be crucial in investigating
EE. This case focused on the puppets’ facial expressions.
Effects of a broad range of puppets with full body with
movements could shed further light on their usefulness.
It will be worthwhile to consider neuroimaging and psy-
chophysiological techniques as an objective measure for
EE pathways, especially with the ETC approach.
Conclusion
Overall, this case study supports the use of puppets
in art therapy as symbolic of a surrogate therapist
(Brown, 2005) or the art therapist’s third hand (Kramer,
1986). This reciprocal and reflexive interrelationship of
the art or puppet, therapist, and the client facilitated
Lisa’s ability to process situations and scenarios. These
interactions helped her brainstorm solutions for coping
with difficult emotions for the puppet and in turn for
herself. This protocol provides insight into the know-
ledge and understanding of art therapy as a treatment
for adolescents with autism, and therapeutic puppetry as
a nonconfrontational tool for socioemotional and behav-
ioral development leading toward EE.
8 ART THERAPY WITH PUPPET MAKING
Acknowledgments
I would like to acknowledge Stacey Nelson, LCPC,
LCPAT, ATR-BC, internship supervisor and Donna
Betts, PhD, ATR-BC, The George Washington
University Art Therapy capstone advisor, for their
support and guidance.
ORCID
Bani Malhotra https://orcid.org/0000-0002-
6995-1942
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