This article aims to define the multiple ways that art therapy is employed in rehabilitation and how art therapists practice in rehabilitation settings. We describe the art-based practice continuum to demonstrate the various styles and practices used in rehabilitation settings. Some key contributions that art therapy can make to rehabilitation include: sensory experiences, symbolic expression, emotional expression, life enhancement, cognitive development and social connectedness. Finally, there is a discussion on the unique qualities of fostering creativity in rehabilitation and on the importance of the context where art therapy takes place.
Defining Art Therapy in Rehabilitation
Art therapy involves the discovery of new connections, relationships and meanings in a safe and non-judgmental atmosphere, which in turn provides the client with alternative perspectives on life and relationships with others. Thus, art therapy can work in multifaceted ways involving the whole person including sensory-motor, perceptual, cognitive, emotional, physical, social and spiritual aspects. Growth through art is seen as a sign of growth through the whole person (Karkou and Sanderson 2006).
Art therapy is a fluid, adaptable, and evolving field. Although art has always been an innate part of human civilisation it has only been since the Second World War that it has been properly recognised for its restorative and transformative qualities (Hogan 2001; Waller 1991). As Jones (2005) clarified, not only are we still discovering the nature of the arts but, we are also still in the early stages of understanding what art therapy does, how it does this and why it is effective.
Those who become art therapists have experience in at least one previous field of knowledge, such as: medicine, psychology, education, visual arts and social work traditions. It is through this amalgamation of knowledge and theoretical orientation that art therapists often define their practice with orientations such as, psychodynamic; humanistic (i.e. phenomenological, gestalt, person centered); psycho-educational (behavioural, cognitive behavioural, developmental); systemic (family and group therapy); as well as integrative and eclectic approaches (Jones 2005; Rubin 2001).
Art therapists work in a variety of rehabilitation settings and with a variety of issues including: mental health problems; learning difficulties, language and communication difficulties, imprisonment, medical problems, sensory or physical problems, stress, emotional and/or social problems. Each of these contexts have their own requirements for rehabilitation and art therapists need to consider what aspects of art therapy can serve within the rehabilitative process (Jones 2005). Therefore, art therapists define what they do by the context they are working in. For example, in examining individuals who survived an Acquired Brain Injury as well as the researcher's own life experience, Smith (2007) highlighted how art served as an aid to rehabilitate sense of self, self-esteem and social skills through group participation and self-exploration.
Johnson (2008) discussed how art therapy is used in prison settings and identifies this through four domains of the rehabilitative process: therapeutic, educational, prison quality of life management and societal (community involvement). He argues that art therapy is used as a form of rehabilitation that seeks to fulfil the innate desire to be productive, seek creative autonomy and as an outlet for expression. These qualities of art appeal to prisoners, just like the general public, and engage them serving as a platform to reform and reduce re-offending. The recreational nature of art therapy also serves to reduce boredom, ease mood, as well as build relationships between prisoners and staff thus promoting a safer and more cooperative environment.
How Art Therapists Practice in Rehabilitation Settings
Overview of Art Therapists' Practices
In general, art therapists avoid using medical terminology and diagnostic labels with their clients, as this is seen as questioning and limiting the individuality of the client and their individual needs. They see that the art therapist's role is to "prepare the ground for the process to start and then facilitate the continuation of the process" (Karkou and Sanderson 2006, p. 54).
The therapeutic dynamic is understood by many therapists through a construct incorporating the therapist, client and the art work (Schaverien 1990, 2000). This triangular model is most frequently used by art therapists who value an analytical approach to understand the non-verbal and verbal interactions taking place within the therapeutic milieu.
Allen (1995, 2008) suggested that the therapist's role is not to change, fix, cure or interpret the art, but, in collaboration with the client, to witness the flow of expression present in the images and, should the client desire, to discover inherent meaning in or through art. Thus, transformation occurs through self-direction as a natural unfolding of the artist's reality as expressed through the images. The more fully clients come to know themselves, the more they are able to authentically participate in life and community as well as develop an ongoing motivation towards recovery.
When the art work is complete the art therapist may assist their client to find words to describe their art work by asking them for concrete descriptions of what they see (refer to Betensky 1995, 2001 for variations of this process of inquiry). Spaniol (2003) suggested that the therapist's support and respect for the client's reality is critical in encouraging the client to talk about their art in their own words and personal style.
Spaniol (2003) emphasised three fundamental components of the art therapist's role in psychosocial rehabilitation, which can be easily applied to other forms of rehabilitation. The first is authenticity; the therapist fosters deep relationships with clients that become a model for clients' relationships with one another. Secondly, the therapist fosters creativity in the client's engagement in the arts and understands the special role that creativity can play in the lives of people with mental illness. Thirdly, the therapist supports a climate of recovery through their belief that people with mental illness can build lives of meaning and purpose despite their illnesses.
The Art-Based Practice Continuum
A recent study auditing art-based activities within the psychosocial rehabilitation sector developed an art-based practice continuum to explain the diverse range of approaches that were being adopted. They noted an ongoing tension in how art facilitators and program managers define art therapy, partly due to art therapists incorporating the practices of community arts, art education or arts/health, as well as facilitators from other related fields adopting personal growth oriented practices (Van Lith, Fenner, Schofield, Pawson and Morgan 2009). The modes, context, levels of structure and aims of the art-based practices employed in these organisations can be represented along the following continuum (see Diagram 1).
As this model highlights, art therapists embrace visual art qualities as well as incorporate therapeutic elements depending on the clients' needs in their process of rehabilitation. These varied approaches are not necessarily discretely delivered programs, but provide a range of methods which can be adapted and applied according to perceived client needs and the facilitators' training. Although this continuum relates to psychosocial rehabilitation programs it is applicable to other rehabilitation settings.
Diagram 1. Art-based Practice Continuum
|Art making individually||Studio art making||Art making with emphasis on skill development and mastery||Program facilitated and structured art groups||Individual art making with a healing purpose||Art psychotherapy|
Key Contributions of Art Therapy in Rehabilitation
Art therapy ultimately works in a strengths-based way to assist in rehabilitation through restoring the self. These will be explained in the following section under the following headings: sensory experiences, symbolic expression, emotional expression, life enhancement, cognitive development and social connectedness.
The visual and material qualities of art media and the art work are unique elements to art therapy. These offer alternatives to other strategies in rehabilitation as they work through visual, sensual and kinaesthetic experiences. This can often be perceived as unconventional in rehabilitation settings and consequently easily misunderstood.
Kagin and Lusebrink's (1978) expressive therapies continuum demonstrates the commonalities between various art forms and the defining properties of each medium. The expressive therapies continuum proposes four levels of experience: kinaesthetic/sensory (action), perceptual/affective (form), cognitive/symbolic (schema) and creative (see Hinz 2008, for an updated version of the expressive therapies continuum). Whilst art therapists may use this scale for evaluative and reflective purposes they remain cautious that a particular quality of a medium is also dependent upon the individual's interactive style and development or regression. For example, clay may be resistive for an experienced potter or regressive for a young child.
The use of symbolism and its relationship to our unconscious holds an important place in the history and development of art therapy (Edwards 2004; Rubin 2005; Schaverien 1990, 2000). Arnheim (1974) maintained that form and subject matter cannot be separated and states that even simple line expression is symbolic as it expresses visible meaning. On the other hand, Dissanayake (1992) argued that the creation of art alone is satisfying and symbolic meaning may be secondary or absent in its importance. In art therapy, it is the client's preference whether they see their imagery as visual metaphor and this may depend on whether the image developed inside or outside their conscious awareness. When this type of art is produced in art therapy, the therapist and client can obtain important information by exploring the deeper meanings. It is often seen as particularly useful in exploring dreams, goals and aspirations (Kaplan 2000).
Art therapy can serve as a means of symbolic speech, which is particularly beneficial for clients who have a good mastery of verbal communication or words, but are unable to accurately express their emotions (Liebmann 1990). For example, for clients who have limited verbal expression or those who are highly articulate but have difficulty with emotional expression, the visual arts can be employed as a means of speaking from the self. When possible a combination of verbal and non-verbal communication is encouraged as a way of acquiring new and more comprehensive understandings of what is being expressed to uncover the significance of personal meanings (Kaplan 2000; Karkou and Sanderson 2006).
Some art therapists embrace the notion that art taps into the unconscious, which allows thoughts and feelings to be expressed that may otherwise be restrained or denied (Rubin 2005; Malchiodi 1998). Kaplan (2000) concurs with this by highlighting that art therapy provides access to our personal and cultural history that would not be available through verbal means. Utilising this capacity to access awareness and communicate meaning through art can serve as an alternative to verbal interventions. Additionally, it has been argued that art is a less threatening method to disclose private information about one's feelings, allowing for a deep, thorough and yet contained exploration of the self (Tate and Longo 2002).
Art therapy also allows for the release of emotions in a contained way, referred to as catharsis. It provides access to and relief of painful or troubled emotions in a safe and therapeutic setting by creating a physiological response of relaxation or through altering mood. This act can result in feelings of empowerment as well as the experience of inner peace through art expression (Rubin 2005).
A study of art made in concentration camps during the Holocaust potentially illuminates our understanding further. Ornstein (2006) explained how prisoners instinctively used art to make sense of their traumatic experience and gain an insight into their experiences that would otherwise not have been available to them. She noted the overwhelming need to create in order to transform these experiences into expression. The image in these situations worked as a mirror of the internal world and had a confirming and supportive effect, resulting in a feeling of being understood.
The making of art is known to induce the experience of flow as a form of optimal experience producing quality of life enhancement through feelings of psychological growth, enhanced life quality and well being (Csikszentmihalyi 1990, 1996). Being in a 'flow' state through art therapy enables escapism, distraction and time out from reality, which are highly beneficial for people with ongoing mental health difficulties such as anxiety, hallucinations, delusions or for those who are highly stressed (Warren 2006). Research has also found that by being in a meditative-like state through the art process, clients are not only able to deal with highly traumatic material, but the resolving of these issues in imagery allows for insight and personal growth (Van Lith Fenner and Schofield 2009).
Dissanayake (1988) also emphasised the life altering qualities by arguing that similar to ritual and play, it enables us to imagine, fantasise, formalise and distance material as well as provide cathartic relief to tensions. She highlights that it is not just the 'thoughtless' experience that is desirable but our direct connection to the immediacy of art that restores the significance, value and integrity of sensuality and the emotional power of things. This is seen as a stark contrast to the usual indifference we are used to experiencing. This heightens our awareness making us more aware of who we are and what we want.
Dissanayake (1988) also highlighted how art assists in developing resilience as it prepares and trains us for the unfamiliar through the testing of realities. These experiences provide a reservoir from which to draw appropriate responses to experiences that have not yet been met, providing us with the strength to face new challenges. She adds that through the use of fantasy and imagination art also allows us to constantly stretch our minds and be challenged in new ways.
Our earliest human experiences are believed to be in aural and visual forms, prior to the development of verbal skills (Golomb 2004). The development and use of these capacities are often ignored or undervalued as we engage in a predominantly verbal society. Consequently, art therapist Kaplan (2000) argued the importance for children to be offered art to enhance and develop well-rounded cognitive skills that not only activates mind-brain development, but enhances creative abilities through imagination and play.
Kaplan (2000) also highlighted how art therapy facilitates problem solving. The distance that the art work provides allows clients to order, reflect, experiment and refine thoughts and experiences. Kaplan emphasises the importance of using art therapy for people with cognitive impairments due to its ability to evoke sensual pleasure and feelings of satisfaction. The importance of promoting sensory stimulation through art therapy with acquired brain injury clients has been noted. Sensory stimulation through art therapy enhances clients' awareness and attention span as well as provides a new focus through the appreciation and exploration of materials (Chantios 2005). In certain cases, as a person's cognitive impairment may decline, artistic abilities may increase and serve as compensation (Mell Howard and Miller 2003).
The stigma associated with some illnesses such as mental illness, has been identified as a key barrier to gaining employment, education, feeling like a contributing member of a community and a sense of social inclusion. In the United Kingdom, researchers have argued for the importance of maintaining and improving art-based community organisations as a solution to social exclusion (Moriarty 2002; Secker Hacking Spandler Kent and Shenton, 2007; Smith 2003; White and Angus 2003).
Parr's study (2005) focused on how art-based community groups play an important role in developing social relationships and identity beyond that of stigmatised labels. The art group was valued as an important 'stepping stone' for reintegrating into wider social relationships and situations outside project spaces. Not only was the art group seen as a way to work through everyday difficulties, but it was also seen as a form of self validation whereby participants were able to express without feeling the risk of interpretation by others. In accordance with this study, Van Lith, Fenner, and Schofield (2009) also identified how the making of art with those who have chronic mental health problems can have benefits beyond the internal self, which generates passion and meaning in life. They also highlighted the importance of making art within a group setting as this enabled clients to develop a sense of being part of a social world and a deepening of interpersonal relationships.
Importance of a Supportive Setting in Art Therapy
Art therapists highlight the value of art as having healing or therapeutic potential through the context of where it takes place. They see art therapy as a process that, given the circumstances surrounding its use, may become a powerful and life changing experience (Karkou and Sanderson 2006). The art therapy setting enables artistic expression by being safe, comfortable and empathic, which is contained by well-trained and supportive staff. This environment allows for a culture of openness, empowerment and experimentation to develop (Higgins and Newrith 1999; Waller 1991). A conscious effort from the art therapist is needed to provide and maintain a supportive psychological and physical environment within which safety and trust are engendered and nurtured, one that permits an optimal process of creativity to unfold.
Consequently, it is how the therapy takes place, the environment, the development of relationships and communication during planning and implementation stages that encourages success and determines whether or not therapeutic transformation is likely to occur (Everitt and Hamilton 2003). This is substantiated in a report describing guidelines for the practice of art psychotherapy with people prone to psychotic states (Brooker Cullum Gilroy McCombe and Mahony 2006).
This article aimed to inform the reader about some of the key areas that art therapy contributes to rehabilitation. Through this broad overview it was hoped to clarify why and how art therapy is used in rehabilitation settings. Art therapy is still in the early stages of finding suitable research approaches to further understand the qualities of its practice and benefits, as well as finding appropriate methods to evaluate practices. Nevertheless, the restorative and transformative benefits of art are gaining considerable attention in rehabilitation settings and readily being adopted as a positive, strengths-based and meaningful activity.