BILATERAL ART: INTEGRATING ART

THERAPY, FAMILY THERAPY,

AND NEUROSCIENCE
Carole M. McNamee

ABSTRACT: This paper describes the systemic use of a neurologi-

cally-based art therapy modality—bilateral art—that engages both
dominant and non-dominant hands in the process of creating images
in response to opposing cognitions or feelings. It describes both neu-
roscience and family therapy perspectives that argue for the use of
bilateral art. A specific protocol for bilateral art therapy is provided
along with a case study demonstrating integration of the protocol into
the systemic treatment of a young family.
KEY WORDS: family therapy; art therapy; neuroscience; bilateral art.

Bilateral art is a neurologically-based art therapy modality that

engages both the left and right hands in the process of creating
drawings in response to opposing or conflicting elements of experience.
These conflicting elements often present during the process of therapy
with individuals or families dealing with relationship issues. Once
identified, these elements are the focus of drawings, one using the
right hand and the other using the left hand. These left and right hand
drawings then become the focus of tactile exploration: the drawing of
the left hand is explored tactilely by the right hand and the drawing of
the right hand is explored tactilely by the left hand, thus engaging

Carole M. McNamee, PhD, is Research Professor and Clinical Associate, Director of

the Arts in Healthcare Project, The Family Therapy Center, Department of Human
Development, Virginia Polytechnic Institute and State University, Blacksburg, VA
24061 (cmcnamee@vt.edu).

Contemporary Family Therapy 27(4), December 2005 Ó 2005 Springer Science+Business Media, Inc. 545
DOI: 10.1007/s10591-005-8241-y
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CONTEMPORARY FAMILY THERAPY

both touch and pressure sensory systems. The goal is to engage both
the left and right brain in the process of art therapy.
McNamee (2003, 2004) described the neuroscience and family art
therapy perspectives that provide a context for the use of bilateral art.
The neuroscience perspectives include the efforts of Gazzaniga and
Sperry (as reported by Gazzaniga, 1998a, 1998b), Kandel (1985),
Siegel (1999, 2001a, 2001b), Schore (1997, 2000), and Cozolino (2002).
Gazzaniga and Sperry did seminal work on functional differences
between the right and left brain and they described the dominant
functionality of the left hemisphere in cognitive problem solving,
language, and speech. In contrast, they characterized the right
hemisphere as very poor at problem-solving, but good at visual/motor
activities and holistic thinking. Gazzaniga (1998a, 1998b) explored the
interactions between the left and right hemispheres and discovered a
left brain capable of confabulation, i.e., capable of unconsciously
manufacturing explanations for the output of the right brain.
Schore (1997) argued that the limbic system, the brain structure
associated with primary emotion, is more closely associated with the
right brain than with the left brain. Siegel (1999, 2001a, 2001b), and
Schore (1997, 2000) both argued that it is the continuously evolving
experiences embedded in our neural architecture that provide the
basis for responses to external stimuli and it is the task of psycho-
therapy or psychopharmacology to alter a neural architecture’s mal-
adaptive components. Similarly, Cozolino (2002) described the need to
integrate and balance the experiences and memories embedded in the
neural architectures of the various parts of the brain, including the
specialized right and left hemispheres.
The family therapy perspectives for using art build upon the
pioneering work of Kwiatkowska (1978) who invited families to join in
the process of making art while working with schizophrenic patients
at the National Institute of Mental Health in the late 1950s. Family
art therapy has origins similar to those that inspired the development
of family systems theory (Bowen, 1978). Both Kwiatkowska’s and
Bowen’s work emanated from their observations of and frustrations
with the interactions within the families of their schizophrenic
patients.
Since Kwiatkowska’s original formulation of family art therapy,
many others have contributed to the field (see McNamee, 2004).
Notable contributions include Landgarten (1987) who provided the
first guide for clinicians using art with families. Linesch (1993) pro-
vided a conceptual model for families in crisis and for the role of art in
the treatment of families in crisis, as well as several case studies
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demonstrating its use. More recently, Riley and Malchiodi (1994) and
Arrington (2001) provided detailed discussions of family therapy
models and the integration of art therapy interventions into these
various models.
Additional efforts that integrated art therapy with family therapy
include the development of the Kinetic Family Drawing (KFD) and
guidelines for evaluation of these drawings (Burns & Kaufman, 1970,
1972). Kymissis and Khanna (1992) and Taylor, Kymissis, and
Pressman (1998) extended the notion of the Kinetic Family Drawing to
the Prospective Kinetic Family Drawing (PKFD), in which family
members draw their family involved in an activity at some specific
time in the future.
This paper focuses on the systemic use of a specific art therapy
protocol—bilateral art. Cartwright (1999) first proposed the use of a
bilateral art protocol. McNamee (2003, 2004) and McNamee and
McWey (2004) described extensions to Cartwright’s protocol and the
first clinical experiences using the protocol in a therapeutic setting.
McNamee (2003) provided an extensive case study that chronicles the
use of bilateral art over a ninth-month-period with a middle aged
client struggling with grief, loss, and depression. McNamee (2005)
summarized the results of a retrospective study examining experi-
ences integrating bilateral art interventions into the treatment of
eight individuals and one couple. These cases demonstrated clinical
application of the intervention to a range of presenting problems
including: differentiation from family of origin, parenting, loss, trau-
ma, and self-esteem. Experiences with the protocol revealed changes
in behaviors that provided the first documented arguments for effec-
tiveness of the intervention.
There are limitations to what can be claimed. This paper describes
the use of bilateral art in a clinical setting and the data were obtained
from a retrospective review of clinical records. It is important to note
that the decision to use the bilateral art protocol is not random. The
specific instances in which the bilateral art intervention was used
were a reflection of a therapeutic response to both the client and the
client’s particular presenting problems. Thus, the results described in
this paper are those of a scientist–practitioner, not a controlled study.
The protocols and indicators for the use of bilateral art continue to be
dynamic and evolving.
The following sections provide details of the bilateral art inter-
vention protocol with individuals, a case example demonstrating the
systemic use of bilateral art, and a discussion of the results and con-
clusions.
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BILATERAL ART PROTOCOL

Bilateral art is an art therapy modality that engages both domi-

nant and non-dominant hands in the process of creating images in
response to opposing cognitions or feelings. Supplies typically include
1417 inch white paper used in landscape mode and an 8-color set of
children’s marking pens. The following outline of the bilateral art
protocol, initially proposed by Cartwright (1999) and modified by
McNamee (2003, 2004), provides detailed instructions for clinicians
interested in its application.

1. Prior to engaging the client in the bilateral art process,

place the 1417 inch white paper in landscape mode and
draw a vertical black line down the center of the paper. Usu-
ally the left side of the paper is used for the drawing of the
left hand and the right side of the paper is used for the
drawing of the right hand.
2. Determine a focus for exploration. Often the client provides
a natural focus during therapy. The focus typically
resembles a situation in which the client is struggling with
a choice between two options, how he or she feels vs. how he
or she would like to feel, where he or she is currently vs.
where he or she would like to be, two conflicting needs, two
conflicting beliefs, or two conflicting emotions, e.g., I am
good enough vs. I am not good enough.
3. Have the client assess the strength of belief in each of the
two conflicting elements of experience using a scale of 1–7,
where 7 means that the element is completely true for him
or her and 1 means that the element is not true at all for
him or her. It is important that the client focus on the
element before attempting to scale the strength of his or
her belief.
4. Have the client determine which hand is most connected to
which of the two conflicting elements of experience. Then
have the client decide which of the two elements ‘‘wants’’ to
be ‘‘drawn’’ first.
5. Place drawing supplies next to the hand that ‘‘wants’’ to
draw first. Have the client focus on the feeling associated
with the element being drawn. And then, draw in response
to the feeling on the side of the paper corresponding to the
hand that is drawing. For example, if the left hand wants to
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CAROLE M. MCNAMEE

draw first in response to ‘‘I am good enough,’’ the supplies

are placed on the client’s left hand side and the client is
asked to use his or her left hand to draw on the left side of
the paper in response to feelings associated with ‘‘I am good
enough.’’
6. Once the first element is drawn, place the drawing supplies
on the opposite side of the client, and ask the client to focus
on feeling(s) associated with the second or oppositional ele-
ment of experience. Once the client is fully focused on that
element, ask him or her to respond to the feeling on the
other side of the paper with the other hand. For the example
above, the client would use his or her right hand to draw on
the right side of the paper in response to ‘‘I am not good en-
ough.’’
7. Once both elements of the experience have been expressed,
ask the client to determine which element ‘‘wants’’ to be ex-
plored or traced first. Tracing is done with the hand that did
not create the drawing, i.e., the left hand is used to explore
the drawing made with the right hand and vice versa. Ask
the client to simply let his or her hand rest on the drawing
made by the opposite hand, and then to explore or trace the
drawing using any amount of pressure that feels appropri-
ate. In the example above, if ‘‘I am good enough’’ wants to
be explored first, the client will use his or her right hand to
reach over to the left side of the paper to explore the draw-
ing of the left hand. This process is then repeated with the
opposite element and hand.
8. Once both elements have been traced or explored by the
opposing hands, ask the client to put both hands together
and explore both drawings in any order with any pressure
or movements that seem appropriate.
9. Once the elements have been explored or traced over, ask
the client to reassess his or her strength of belief in each
element, again using the scale of 1–7 where 7 means that
the element is completely true for him or her and 1
means that the element is not true at all for him or her.
Again, it is important that the client focus on the element
before attempting to scale the strength of his or her be-
lief.
10. Finally, ask the client to reflect upon his or her experience.
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CASE EXAMPLE

The following case example illustrates the integration of bilateral

art with family therapy. The case involves the treatment of a family
including a mother, father, and two young children. The mother,
‘‘Ellen,’’ age 22, had experienced significant losses throughout her life
including a parent, a sibling, a child, and a recent miscarriage. She
struggled with separation from her children as well as setting limits
with them. Treatment consisted of 24 sessions over a period of
6 months and included 12 individual sessions with Ellen, 10 couple
sessions, and two sessions with Ellen and her children. Individually,
treatment focused on the relationship between Ellen’s experiences of
loss and her current fears of separation and abandonment, as well as
parent education. Art therapy was integrated into much of the treat-
ment, either directly in session or through homework. Of the 12
individual sessions, three used bilateral art, three used other forms of
art therapy, and the remaining six sessions included assessment and
supportive verbal therapies. Ellen was open to the use of art and
cooperative. Toward the end of our work, she presented with a few
persistent problems: fear that her daughter would not love her if she
disciplined her, an overwhelming need to handle all of the children’s
needs by herself without help from her spouse, and an inability to
leave the children with anyone else even to go to the grocery store or
take a walk. In all three cases, Ellen acknowledged that her fears/
needs were not rational and that she wished to feel differently. In each
case, the bilateral art intervention was applied with the hope of
strengthening and integrating Ellen’s more rational beliefs.
In session 11, in particular, Ellen’s need to do everything for her
children arose. Even when her spouse offered to help, she was unable
to accept the offer, feeling it was her duty to do it all. Ellen identified
the positive element ‘‘it is not my duty to do everything for the chil-
dren’’ and the opposing negative element ‘‘it is my duty to do every-
thing for the children.’’ Ellen’s bilateral art drawing is shown in
Figure 1 with her response to the positive element on the right and
her response to the negative element on the left. The drawing on the
right depicts Ellen in the foreground reading a book while her hus-
band is tending to her two children. The drawing on the left depicts
Ellen, in the foreground, as solely responsible for every aspect of her
children’s lives. Recall that the protocol asks the client to scale the
strength of his or her belief in each of the elements using a scale of 1–7
where 1 means ‘‘not true at all for me’’ and 7 means ‘‘completely true
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CAROLE M. MCNAMEE

FIGURE 1

Ellen’s First Bilateral Art Drawing with Positive Element ‘‘it is Not
My Duty to Do Everything for the Children’’ on the Right and the
Opposing Negative Element ‘‘it is My Duty to Do Everything for the
Children’’ on the Left

for me.’’ Before the bilateral art intervention, Ellen scaled the strength
of her belief in the positive element as a 4.5. Following the interven-
tion, Ellen’s scaling of the positive element increased to a 6. Similarly,
changes occurred in the scaling of negative element. The strength of
her belief in the negative element was scaled a 7 before the inter-
ventions and decreased to a 6 following the intervention.
In the 12th and following session, Ellen reported a very bad day
with her younger daughter, age two, and her struggle to set limits
with her. Ellen identified her negative element easily, ‘‘if I punish my
daughter, she won’t love me.’’ The opposing positive element evolved,
with some assistance, into ‘‘if I punish my daughter, she may get mad
but she will still love me.’’ Figure 2 shows Ellen’s response to the
positive element on the right and her response to the negative element
on the left. The drawing on the left depicts Ellen placing her child in
‘‘time-out’’ in the foreground with a resultant loss of love depicted by
the broken heart in the background. The drawing on the right shows
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CONTEMPORARY FAMILY THERAPY

FIGURE 2

Ellen’s Second Bilateral Art Drawing with Positive Element ‘‘if I

Punish My Daughter, She May Get Mad but She Will Still Love Me’’
on the Right and the Opposing Negative Element ‘‘if I Punish My
Daughter, She Won’t Love Me’’ on the Left

Ellen again placing her child in time-out in the foreground, however,

this time the background depicts Ellen and her child holding hands
despite the unhappiness depicted on the child’s face. As with the
previous experience with bilateral art, the strength of Ellen’s belief in
the positive element increased from a pre-intervention value of 1 to a
post-intervention value of 3.5. Additionally, the strength of Ellen’s
belief in the negative element decreased from a pre-intervention value
of 7 to a post-intervention value of 6.
In the 13th session 2 weeks later, Ellen reported having had two
good weeks, and that she had been able to set some limits with her
daughter and the child’s behavior was improving. Ellen also reported
that her daughter’s previously obedient behavior pattern with her
father was changing and that he was experiencing some of the
daughter’s acting out. Ellen seemed satisfied that the situation with
her daughter was changing and indicated that she wished to focus on
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CAROLE M. MCNAMEE

FIGURE 3

Ellen’s Third Bilateral Art Drawing with Positive Element ‘‘it is Ok

to Leave the Children with My Spouse, They Will Be Safe’’ on the
Left and Opposing Negative Element ‘‘it is Not Ok to Leave the Chil-
dren, Something Bad Will Happen’’ on the Right

the difficulty she had leaving her children. She described being unable
to go to the grocery store or even take a walk without her children
being with her. She acknowledged that she trusted her spouse to take
care of the children while she was gone, but she still could not allow
herself to be away from them. Ellen identified ‘‘it is ok to leave the
children with my spouse, they will be safe’’ as her positive element.
Her opposing negative element was ‘‘it is not ok to leave the children,
something bad will happen.’’ Figure 3 shows Ellen’s response to the
positive element on the left and her response to the negative element
on the right. The drawing on the left depicts Ellen in the background
shopping and thinking about the family that she has left at home
watching TV together. The drawing on the right depicts Ellen’s fears
of what may happen if she leaves her family even for a short period of
time. The strength of Ellen’s belief in the positive element increased
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CONTEMPORARY FAMILY THERAPY

from a 6 to a 7 and the strength of her belief in the negative element

decreased from a 7 to a 4 following the bilateral art intervention.
The following week, Ellen reported that she was ‘‘doing well’’ and
proudly announced that she had been to the grocery store not once, but
twice, on the previous weekend leaving the children with her husband
on both occasions. This marked the end of the family’s treatment and
subsequent telephone check-ins over 2 months yielded similar reports.
Bilateral art represented only a part of Ellen’s treatment, but it
preceded a significant change in the behaviors on which it focused.
While in each instance in which the bilateral art intervention was
used, the client’s strength of belief in the positive element increased
and the strength of belief in the negative element decreased, it is more
important to note that in each case the client’s behavior changed and
complaints associated with the foci for the bilateral art interventions
abated.

DISCUSSION

Ellen and her family benefited from family therapy that inte-
grated the use of bilateral art. Client-scaled strength in beliefs are one
measure of treatment effectiveness. While these scalings may provide
some level of assurance to therapists and/or researchers, and may
even be a positive indicator providing hope for the client, the impor-
tant measures of effectiveness are changes in client behaviors.
In Ellen’s case several changes in behavior were noted. The first
change was an observed cessation of complaints associated with the
element addressed in the bilateral art intervention. Ellen was eager to
move on to another hurdle in the sessions following the use of bilateral
art. The second change was an improved level of functioning reported
by the client. And the third change, both observed and reported, was
improved relational interactions.
Ellen reported improved functioning when she announced that
she had been able to leave her children for short periods. In the week
following the bilateral art intervention, she reported leaving her
children with her spouse to go the grocery store, not just once, but
twice in the same day.
Ellen’s reported improvements in her relational interactions fo-
cused on her ability to set limits with her daughter. In the session
following the intervention that focused on her fear of disciplining her
daughter, Ellen reported being able to set limits more consistently and
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CAROLE M. MCNAMEE

that her daughter’s behavior had improved. This improvement was

also observed in subsequent family sessions.
This case study describes an application of the bilateral art
intervention in a situation where the client expresses a cognitive
awareness or belief but struggles to ‘‘feel’’ the truth of the belief—they
believe ‘‘in their heads but not their hearts.’’ There is a need to
integrate the cognitive awareness with felt awareness. This belief in
the need to integrate is consistent with current thinking on the
resolution of trauma as stated recently by Wylie (2004)

van der Kolk continues ‘‘fundamentally, words cannot inte-

grate the disorganized sensations and action patterns that
form the core imprint of the trauma.’’ Treatment needs to
integrate the sensations and actions that have become
stuck, ... (p. 35).

For example, Ellen was able to verbalize that it was safe to leave
her children with her spouse or their grandparents so that she might
do the grocery shopping or take a walk, yet she was unable to do so.
There was a lack of connection between logical awareness and action.
In addition, this case example provides an example in which be-
liefs are distorted and actions are congruent with the distorted beliefs.
It was noted in the previous section that Ellen had difficulty setting
limits with her children because she was afraid that if she disciplined
them they would not love her. In this instance, Ellen needed help to
identify an opposing positive belief, e.g., ‘‘If I discipline my children,
they may get mad but they will still love me.’’ Then bilateral art was
applied to the client’s original negative belief and the newly identified
positive belief. As noted above, Ellen reported that she was able to set
limits with her children following the bilateral art intervention and
the intervention facilitated her ability to do so.

CONCLUSIONS

This paper presents an argument for the integration of bilateral

art with family therapy. It provides a case example demonstrating
such an integration with a young family including mother, father,
and two young children. The case study describes the situations that
led to the use of the bilateral art intervention and the reported and
observed changes in client behavior following the use of the
intervention. The bilateral art intervention appears to facilitate
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integration of a client’s cognitive or logical knowing with more

emotional ‘‘felt’’ knowing.
It is important to note the limitations of this work. Perhaps the
most significant limitation is that it is only possible to speculate on the
notion of neural integration. Advances in neuroscience are consistent
with an argument for integration and the experiences described in this
body of work are similarly consistent with an argument for integra-
tion. But the results are no more than consistent. They cannot prove
the nature of the underlying neurological change. Certainly these
results along with those reported in McNamee (2003, 2004) argue that
the use of bilateral art is promising and worthy of further investiga-
tion.
The implications for the field of marriage and family therapy fall
within both the theoretical and the practical domains. The relation-
ship between the brain’s neuronal development and interpersonal
experiences is accepted by at least some marriage and family therapy
perspectives. The notion that the use of art, and in particular
bilateral art, may alter neuronal architecture, while speculative, is
worthy of consideration by the marriage and family therapy com-
munity. In the practical domain, this effort provides a concrete pro-
tocol for interventions with individuals that reflect these theoretical
considerations.

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