The Sources and Applications
Francesco Franza1, 2, 3
1 Psychiatric Rehabilitation Center “Villa dei Pini”, Avellino – Italy
2 Psychiatric Studies Centre (Cen.Stu.Psi.)
3 Neamente Association, Mercogliano (AV), Italy
Art therapy is a therapeutic tool used in numerous pathological, physical, and mental conditions. Difficult to define, art therapy has undergone various phases of success over the years. Several studies have demonstrated its effectiveness, although the results of international literature searches often need to be more consistent. Our brief review of this therapeutic tool’s state-of-the-art aims to provide valuable and applicable information in clinical practice. Knowledge of the limits and fields of application can help healthcare professionals to maintain in the most appropriate way avoiding enthusiasm or despondency. It is a therapeutic tool; as such, it must be used to improve patients’ functioning and quality of life.
Parole chiave: Art-Therapy; Brut therapy; Primary psychosis; Evolution; Outside art.
Art is considered a mediator (between the person with mental disorders and the therapist), which offers a safe and indirect means of connection with oneself and with others. So, art can become therapeutic support. Art Therapy as a form of psychotherapy has been practiced for over 60 years (Hogan, 2001). It can become a complementary treatment for mental disorders (Hu et al., 2021). Art therapy, as a non-pharmacological medical complementary and alternative therapy, has been used as one of the medical interventions with good clinical effects on mental disorders. The British Association of Art Therapists defines art therapy as «a form of psychotherapy that uses art media as its primary mode of communication. Clients who are referred to an art therapist need not have experience or skill in the art. The art therapist is not primarily concerned with making an aesthetic or diagnostic assessment of the client’s image. The overall aim of its practitioners is to enable a client to change and grow on a personal level through the use of art materials in a safe and facilitating environment» (BAAT – British Association of Art Therapists website, 2023).
Art therapy is a form of expressive therapy that uses the creative process of making art to improve a person’s physical, mental, and emotional well-being. Many countries have formalized art therapy schools, institutes, and training centers. In Italy, among the various schools, Italian Art Therapy stands out, an association founded in 1982 with the aim of promoting the practice of Art Therapy and Dance Movement Therapy in Italy (Associazione Art Therapt Italia website, 2023). Metaphors, symbols, and the expressive use of art materials combine to create a rich language for self-expression and the opportunity to translate strong emotions into an artistic expression. Differences in scale or perspective, tone, color, and metaphors allow for a potentially sophisticated articulation of thoughts and feelings (Hogan, 2015).
Like other therapeutic strategies, art can extend individual abilities beyond what nature initially granted the compensatory power of art on individual emotional and psychological fragility (Attard & Larkin, 2016; West, 2008). Art acts as an extension of the individual’s mind. Creativity allows us to expand outwards the desire to communicate the inner world to others. Beyond training schools, Art Therapy arises from the inner world of everyone to heal psychological and social wounds. The descriptive need and the framing in repeatable and shareable boundaries have determined the need for structuring. Only some forms of Art Therapy have been described in this article. The article focuses only on some forms, inviting the reader to refer to more detailed manuals that adequately describe this therapeutic procedure. The purpose of our article is to provide little information to spread this form of therapeutic expression to professionals and people with mental illness and their loved ones.
1.1 Art Therapy definitions
The definition of art is culturally specific. Indeed, many societies that create splendid rock paintings do not have a word for art in their language (White, 1992). Numerous and often conflicting definitions of art therapy – or art psychotherapy – have been advanced. From a contemporary perspective, art therapy may be defined as a form of therapy in which creating images and objects plays a significant role in the psychotherapeutic relationship between the art therapist and the client (Cherry, 2022).
The British Association of Art Therapists (BAAT), for example, currently defines art therapy as follows: «Art Therapy is a form of psychotherapy that uses art media as its primary mode of communication. Clients who are referred to an art therapist need not have previous experience or skill in art, the art therapist is not primarily concerned with making an aesthetic or diagnostic assessment of the client’s image. The overall aim of its practitioners is to enable a client to effect change and growth on a personal level through the use of art materials in a safe and facilitating environment».
Other national professional associations provide similar, but also subtly different, definitions. The American Art Therapy Association (AATA), for instance, defines art therapy as follows: «Art therapy is the therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or challenges in living, and by people who seek personal development. Through creating art and reflecting on the art products and processes, people can increase awareness of self and others cope with symptoms, stress, and traumatic experiences; enhance cognitive abilities; and enjoy the life-affirming pleasures of making art» (American Art Therapy Association, 2023).
Art therapy involves both the process and products of image making (from crude scribbling to more sophisticated forms of symbolic expression) and providing a therapeutic relationship. The aims of art therapy vary according to the particular needs of the individuals with whom the art therapist works, and these needs may change as the therapeutic relationship develops. For one person, the art therapy process might involve the art therapist encouraging them to share and explore an emotional difficulty through creating images and discussion.
Art therapy is action-oriented and experience-based. Such inherent qualities differentiate it from other forms of therapy and make it particularly effective for various client populations. Art therapists work with individuals, couples, families, and groups in diverse settings, including hospitals, schools, psychiatric and rehabilitation facilities, community mental health clinics, wellness centers, forensic institutions, crisis centers, senior communities, veteran’s clinics, juvenile facilities, correctional institutions, and other community facilities. Art therapy’s methods and treatment objectives differ depending on the setting and client population.
2 At the source of art
Art is known as one of the earliest forms of communication, dating back to the cave art of the Palaeolithic age (Roberts, 2007). The oldest cave painting was found in the El Castillo cave in Cantabria, Spain, and dates back 40,000 years to the Aurignacian period (Lewis-Williams, 2002). The human being begins to leave the projections of his inner world through expressive and emotional communication that is shared and understood. Some authors believe that even commonly used tools such as stone tool skills can be considered as a mental representation of the builder. He must know the techniques necessary for the preparation of core stones through symbolic representation and creativity. Lewis-Williams argues that human creativity arises out of necessity. «It is important – he claims – to notice that human creativity and symbolism was linked to social diversity and change, not to stable, history-less society. Change stimulates; homeostasis anaesthetizes» (Lewis-Williams, 2002).
The technically useful tool becomes a symbolic object in a period defined by Steven Mithen as “the Big Bang of human culture”. In the time 60,000 – 30,000 years ago, the survivor of human evolution, Homo Sapiens sapiens, becomes the architect of the cultural and artistic explosion (Mithen, 1999). Deacon believes that Modern Human «was born when art was born», when for the first time in its history he attributed a symbolic meaning to an object he builds (Deacon, 1997). Archaeologists have often described the Middle/Upper Paleolithic transition as a time of cultural explosion. In this period, the «restructuring of social relations» (Alcaro & Carta, 2019; White, 1993), the appearance of economic speciation (Hayden, 1993), and the origin of language (Kaas, 2019; Whallon, 1989) developed. Mellars suggests that «the emergence of complex, highly structured language» could «potentially, have revolutionized the whole spectrum of human culture» (Mellars, 1989). The evolutionary changes of the neocortex allowed the impressive mental abilities of humans and the development of artistic symbolism (Brown et al., 2012).
In ancient times, art has played a key role in the care, considering symbols and signs (spirals, mazes, Egyptian hieroglyphics, cuneiform script of the Sumerians, Chinese ideograms), information needed in healing rituals, as well as a form of communication (Balter, 2009). With the birth of religions, symbolic representation was used to protect to control emotions, anxiety, and fear (Alcorta & Sosis, 2005). The hunter-gatherers developed «the cognitive underpinnings of belief in supernatural agents, the role of ritual in promoting cooperation, and the contribution of morally punishing high gods to the growth and stabilization of human society» (Peoples et al., 2016).
Art in the history of the Home sapiens sapiens in the following centuries has become the transposition of the essence of human’s emotional and psychic inner world. With the birth of psychoanalysis, psychiatry, and modern neuroscience, art entered the tools of professionals who take care of the discomfort of people suffering from mental disorders. Art therapy has become a therapeutic tool. But is it really so?
3 History of Art Therapy
In the twentieth century, modern psychiatry has influenced art as a means of treatment, showing interest in cohesion between the images and the unconscious and highlighting a link between art and the interior world. In the twentieth century, modern psychiatry began to use art as a means of therapy, identifying a close link between images projected from the unconscious and artistic expression, between art and the inner world. Sigmund Freud, who opened a glimpse into the unknown unconscious world by interpreting dream images, never considered artistic representation a healing tool (Freud, 1997, new edition). Kraepelin and Jaspers, on the other hand, Kraepelin and Jaspers used their patients’ drawings to diagnose the disease. Jung encouraged his patients to draw their own dream images and saw art as a gateway to feelings and an analysis of the self that resides in the unconscious, which must be brought to light. «If an author – he stated – is ill, i.e., mentally ill, it is very probable that whatever he produces bears the imprint of his illness» (Jung, 1993). The doctor, anthropologist, and philosopher Cesare Lombroso, in the book “Genio e Follia” (Genius and Madness, 1887) (Lombroso, 2021) studied the art of mental illness and proposed an etiology of brilliance (neurosis, trauma, intoxication dependent on a cortical irritation. Hans Prinzhorn, psychiatrist, art collector,
He ferociously criticizes these conclusions, calling them grave forms of prejudice. Prinzhorn believed that «Lombroso’s ideas stray from the proper understanding of the artistic production of the sick, shifting attention to the process of creating the image and psychic roots» (Pettinari, 2019). The cultural ground was fertile for the development of art therapy.
3.1 Art Brut
The term “Art Brut” refers to an artistic trend born in France with the works of naive artists, prisoners, and patients suffering from psychiatric disorders without experience or specific artistic training. The concept of Art Brut was invented by Jean Dubuffet (Süzen, 2020). In occupied Paris in the 1940s, French artist Jean Dubuffet began advocating a progressive view of art. Through research exploring the “raw” art, he collected works, pictures, and paintings of people affected by psychiatric patients outside the academic tradition. Dubuffet considered that with «Art Brut, the wild state or freedom should not be conceived as fixed places, but as directions, aspirations, trends […] like a pole, a wind that blows more or less strongly» (Dubuffet, 1986).
Before this artist, however, some authors had already begun to publish works on the art of patients with psychiatric disorders. Hans Prinzhorn, German psychiatrist, and art historian, in fact, published the book “The Artistry of the Mentally Ill” (Bildnerei der Geisteskranken) in 1924. In the book he described the works collected in various German, Swiss, and Italian psychiatric hospitals, giving life to the artistic concept of “Art Brut”. It should be remembered that the French psychiatrist Paul Menier published a book in 1907 using the nickname Marcel Reja. Prinzhorn claimed that «The configurative process, instinctive and free of purpose, breaks through in these people without any demonstrable stimulus or direction – they know not they do» (Prinzhorn, 1972).
In 1947 Jean Dubuffet found a space in the basement of Réné Drouin’s Parisian gallery that became the Foyer de l’Art Brut. Although the exhibition spaces were limited, he exhibited the works of various artists suffering from psychosis (Adolf Wölfi, Aloïse Corbaz, Triper and others). In 1948 he founded the Compagnie de l’Art Brut, including André Breton among its members.
Over time, the term Art Brut has assumed a historicized physiognomy that coincides with the Collection de l’Art Brut in Lausanne. Donated by Jean Dubuffet, this collection is housed in an 18th-century castle, the Château de Beaulieu, owned by Lausanne. In polemic with museum art and the general aesthetics of the Western world, in his anti-cultural book Asphyxiating Culture Dubuffet argued for the genuine creativity of ordinary people “It may be that artistic creation, with all that free inventiveness requires, takes place at a higher level of tension in a nameless crowd of ordinary people than in circles that think they have a monopoly on them. In 1964, he launched the publication of the Art Brut booklets. So, Jean Dubuffet, the French painter, and sculptor founded the art movement Art Brut movement. «By this [Art Brut], we mean pieces of work executed by people untouched by artistic culture, in which therefore mimicry, contrary to what happens in intellectuals, plays little or no part so that their authors draw everything (subjects, choice of materials employed, means of transposition, rhythms, ways of writing) from their depths and not from clichés of classical art or art that is fashionable. Here we are witnessing an artistic operation that is completely pure, raw, reinvented in all its phases by its author, based solely on his impulses. Therefore, art is manifested as the sole function of invention, and not those constantly seen in cultural art, of the chameleon and the monkey» (from Jean Dubuffet: L’Art Brut Prefere Aux Arts Culturels 1949. Galleria René Drouin. https://www. artbrut.ch /en_GB/art-brut/what-is-art-brut).
In Anglo-Saxon culture, this artistic trend has taken the name of Outsider Art thanks above all to the English art historian Roger Cardinal (Di Stefano, 2021). By this term, Cardinal emphasized, it means the extraordinary work created by people who are somehow on the margins of society and who, for any combination of reasons, find themselves unable to adapt to the conventional demands – social and psychological, as well as artistic – of culture who inhabit (Maclagan, 2010).
Art therapists understand art techniques and proficiently use materials to facilitate non-verbal communication. By the middle of the 20th century, many hospitals and mental health facilities began including art therapy programs after observing how this form of therapy could promote patient emotional, developmental, and cognitive growth. The discipline continued to grow from there, becoming an essential tool for assessing, communicating, and treating children and adults alike.
4 The therapeutic language of art (symbols and psychotherapy)
The idea that creative expression can contribute to healing has been embraced in many cultures. Intrapsychic, creative, emotional, and expressive communication occurs through symbolic representations. The primary symbolic representation that characterizes human beings is language. Thanks to language, man has a system of signals and symbols that no living being has. Through the complex world of the structure of this tool of expression, he can formulate and create something entirely new. It is the power of the creative tool of language. (Eibl-Eibesfeldt, 1993).
«Language’s ways of representing objects, events, and relationships – says Terrence Deacon (1997) – provide an effective economy of reference like no other». Language is pervasive and inseparable from internal ideological constructs. We represent ideas, concepts, emotions, memories, and hopes through its symbolism. However, the symbolism is complex. The American philosopher Peirce distinguished three categories of relational representational associations: the icon, the index, and the symbol. When we say something is a “symbol,” we refer to a social convention, a tacit agreement, or an explicit code that establishes the connecting relationship (Nöth, 2010). The symbolic representation contains the shared communication between conventionally and culturally accepted elements. Out of the shared context, the symbolic representation lost its meaning.
With the discovery of artistic creativity, men in the Upper Paleolithic tried to imitate nature. They began to gain some mastery over nature and, perhaps, the confidence to celebrate nature. Humans were beginning to cope with intangible fears, anxieties, and mysteries, perhaps in concert with an increased awareness of their intellectual powers and consciousness (Johanson & Edgar, 1996).
Art has always had a symbolic and therapeutic value. It has been used as a healing tool for more than a century.
However, only in recent years have systematic and controlled studies examined the therapeutic effects and benefits of the arts and healing. In several areas of creative artistic expression (music engagement, visual arts, movement-based creative expression, and expressive writing), there are clear indications that artistic engagement has significantly positive effects on health (Stuckey & Nobel, 2010).
Art as an expressive language provides an entrance into the relationship with patients. Through the stimulation of creativity, a non-threatening communication tool and a comfortable cognitive space are provided for the patient. When patients enter the places of art therapy, they find the tools they need to develop their creativity. Emotions, thoughts, and feelings live in the body and communicate through the body. The symbolic dimension (art, music, dance, painting, and so on) reconfigures the experience of living. In this form of therapy, art becomes a means to access the inner world and open up to the outside world (d’Errico, 2017). Drawing materials, musical instruments, devices, computers, and other forms of media are in these places. Education professionals invite them to use them. They invite them to draw whatever they choose and even make a statement in pictures that represent their feelings about being in the therapeutic setting. This approach allows the patient to overcome fears of incapacity and to feel judged and challenged. Cognitive abilities are stimulated through an approach free from pressure or judgments.
The art therapist uses and proposes the evocative powers of each tool used. Patients may feel adequate and supported by a therapist uninterested in verbal cross-examination. Instead, their therapist is interested in their views of their world as expressed through images (Riley, 2001).
Why is all of this important? The development of neuroscience has posed new questions on the interpretation of external reality and the decoding of the stimuli received from it. External visual, auditory, olfactory, and other stimuli are decoded in specific brain areas through complex and interconnected neuronal networks. The world as we see it is a construct built slowly by each of us over years of experimentation (Gombrich, 1962). The interaction of the emotional and experiential experiences of the individual modulates the elaboration of the symbolic aspects of the perceived or imagined object. The brain’s structure means that the final result is universally confluent in identifying shared stimuli. In the case of an interpretation of an abstract symbolism or one not supported by social identifications, there will be a purely subjective interpretation, the result of the individual’s history (Kandel, 2016).
It is possible to understand art therapy only with a correct understanding of symbolism. Symbols, similarities, and analogies sometimes need clarification. Symbolism arises from an interpsychic conflict between the repressive tendencies of the unconscious mind and the repressed – «only what is repressed is symbolized; only what is repressed needs to be symbolized» (Kandel, 2016). Only by understanding the symbolism can an art therapy be developed that is useful for healing the wounds of discomfort and disease. Dealing with the terminological differences and similarities of words such as similarity, analogy, and analogies is the first step of the Art Therapy therapist (de Botton & Armstrong, 2016). A simile indicates an explicit comparison between two different things. The analogy produces a correspondence between a familiar idea and a similar “object”. Symbolism is the result of an intrapsychic conflict. The symbol represents the fruit of the repressive tendency of the unconscious mind (Jones & Churchill, 1994). Symbolism arises from an intrapsychic conflict between the repressive tendencies of the unconscious mind and the repressed – «only what is repressed is symbolized; only what is repressed needs to be symbolized» (Jones, 1916). Through symbols, we can give shape or form to our experience of the world and may provide the basis for self-understanding and emotional growth.
5 Art-Ateliers and practice
The Art-Ateliers are artistic and therapeutic laboratories of psychiatric rehabilitation facilities, where patients translate their thoughts into expressive forms. The relationship between the therapist and the patient is essential. However, art therapy differs from other psychological therapies because it is a three-way process between the client, the therapist, and the image or artifact (Case & Dalley, 2014). Art therapists are master-level clinicians who work with people of all ages across many practice settings, such as hospitals, schools, private practice, psychiatric and rehabilitation, and crisis centers (American Psychiatric Association, 2020).
In addition to the art therapist’s background, training, and theoretical orientation, his practice will also be influenced by the particular needs of the patient group with whom he works and the institutional context within which this work takes place. The art therapist will work within a multidisciplinary professional group where he will have to share the initiatives, activities, and evaluation of each case. Communication and sharing are fundamental elements within a working relationship. The nature of the organizations in which art therapists work will influence their ability to establish and maintain a therapeutic practice appropriate to the workplace setting. (Finkel & Bat Or, 2020).
6 Art Therapy in Primary Psychosis
Primary psychosis can be described as a heterogeneous group of mental disorders characterized by delusions and/or hallucinations, together with other clinical manifestations involving the different psychopathological spheres. Negative symptoms, cognitive deficits, ideational disorganization, and behavioral disturbances are strongly present in these patients. When we consider primary psychoses, we include a group of disorders, including schizophrenia, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, and other disorders (Maj et al., 2021). The NICE guidelines sustain the importance of alternative and supportive therapeutic strategies for the management of the symptomatic complexity of these pathologies (NICE – National Collaborating Centre for Mental Health, 2014). These guidelines recommend that art therapies can be offered to all people with schizophrenia, particularly for the alleviation of negative symptoms (Bastiampillai et al., 2016). Nice identifies that arts therapies include «art therapy or art psychotherapy, dance movement therapy, body psychotherapy, drama therapy and music therapy».
These therapies can improve the ability to relate to others and with oneself, creativity, communication, creativity, and intuition (Attard & Larkin, 2016). Ultimately, art therapy can alleviate adverse symptoms such as psychosis. Among the difficulties encountered in the scientific literature search, there is that interventions were often ambiguous, making it difficult to distinguish between art psychotherapy and the use of art for enjoyment and the acquisition of artistic skills (Holttum & Huet, 2014).
Whether art therapy can be an effective rehabilitative treatment for people with brain or mental diseases (e.g., dementia (Batubara et al., 2023; Deshmukh et al., 2018), Alzheimer’s disease (Zilidou et al., 2023), Parkinson’s disease (Cucca et al., 2021), and autism (Bernier et al., 2022) studies of the effectiveness of art therapy on the symptoms of primary psychosis are not many and often contradictory or limited by low series or clinical cases. In some studies, art therapy may reduce psychopathology in schizophrenia by strengthening the patients’ sense of self (Fassino & Ferrero, 1992; Teglbjaerg, 2011).
In another study, Meng and colleagues (2005) reported unclear conclusions. Results showed improved health and social functioning after 15 weeks in patients with schizophrenia. However, these authors concluded that in the short term, a measure of social functioning showed no clear difference between groups in endpoint scores, and quality of life did not indicate the effects of art therapy.
However, the positive conclusions of these two studies were contradicted by the MATISSE trial (Crawford et al., 2010). This study aimed to evaluate group art therapy’s clinical and economic efficacy for people with schizophrenia. The MATISSE (Multi-center study of Art Therapy in Schizophrenia – Systematic Evaluation) study plans to examine the effects and cost-effectiveness of group art therapy compared to an active control treatment for people with schizophrenia. Outcomes obtained after 24 months of intervention did not appear to improve patients’ global functioning or mental health or provide more cost-effective use of resources than standard care alone (Crawford et al., 2012).
A review by Slayton and colleagues (2010) suggests that there is little evidence to support the claim that art therapy is effective in treating a variety of symptoms, age groups, and disorders. Risultati analoghi sono stati ottenuti con alter reviews (Hacking et al., 2008; Howells & Zelnik, 2009; Van Lith et al., 2013).
These studies suggest that participation in arts therapies positively benefits people with mental health challenges. Levels of empowerment, awareness, and empathy increase. These results, the authors conclude, confirm that art therapy can influence the well-being and quality of life of people with psychiatric disabilities in the environments in which they live in the context of the rehabilitation treatment process (Franza et al., 2015; Galderisi et al., 2021; Mirabella, 2015; Rampino et al., 2021).
In the more recent review (Attard & Larkin, 2016) they considered the effectiveness of art therapy in comparison with any control groups, and did not discuss the evidence for drama, music, and dance therapy. The main difficulty encountered in art therapy efficacy studies is the heterogeneity of the methods used in the various research. In fact, as highlighted in the “Treatment method” section of this review, different titles have been used under the name of art therapy. Among these, clay work or clay therapy are most frequently used (de Morais et al., 2014), creative activity group (Caddy et al., 2012; Slattery et al., 2020), art gallery-based project (Colbert et al., 2013), expressive art therapy (Hanevik et al., 2013; Vaartio-Rajalin et al., 2021).
The conclusions of the Attard and Larkin review are that the evidence for the effectiveness of the art therapy in symptom reduction and functioning for people with psychosis remains inconclusive. However, the authors believe the usefulness of art therapy but that it is necessary to study the efficacy of this therapy with more adequate RCTs.
Some authors further indicate the possibility of using the sensory and emotional experience aroused by art in museum art therapy (Thomson et al., 2020; Wei & Zhong, 2022). The museums provide a safe environment for the art therapy experience, thus promoting the process of cultural adaptation and providing a healthy and aesthetic experience with self-discovery (Mastandrea et al., 2021; Van Lith, 2016). The museum becomes a safe and welcoming place where individuals escape and can release their suppressed emotions. Wei and colleagues argue that in these places, “art therapy may enable them to discover how to express themselves, thereby reducing anxiety and promoting a sense of social belonging, which may be unattainable in other healing settings” (Wei et al., 2023).
Art therapy is an important tool for the treatment of people suffering from mental disorders, although it has also been used in other pathologies. In the various forms used, art therapy is used in rehabilitation facilities to support and integrate the work of the multidisciplinary team. His ability to represent intrapsychic contents through the symbolization can help the patient to externalize his own emotional experiences. However, scientific research on the effectiveness of art therapy has currently shown contradictory and unclear results. Individualized, randomized trials are needed for each type of art therapy to evaluate its effectiveness. However, it is important to clarify that Art Therapy finds its place and therapeutic function within individualized therapeutic programs.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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