Malchiodi (2006) provides an example of what an art therapy session involves and how it is different from an art class. “In most art therapy sessions, the focus is on your inner experience—your feelings, perceptions, and imagination. While art therapy may involve learning skills or art techniques, the emphasis is generally first on developing and expressing images that come from inside the person, rather than those he or she sees in the outside world. And while some traditional art classes may ask you to paint or draw from your imagination, in art therapy, your inner world of images, feelings, thoughts, and ideas are always of primary importance to the experience.
Therapy comes from the Greek word therapeia, which means ‘to be attentive to.’ This meaning underscores the art therapy process in two ways. In most cases, a skilled professional attends to the individual who is making the art. This person’s guidance is key to the therapeutic process. This supportive relationship is necessary to guide the art-making experience and to help the individual find meaning through it along the way. It helps the individual trust themselves more.
The other important aspect is the attendance of the individual to his or her own personal process of making art and to giving the art product personal meaning—i.e., finding a story, description, or meaning for the art. Very few therapies depend as much on the active participation of the individual (p. 24).” In art therapy, the art therapist facilitates the person’s exploration of both materials and narratives about art products created during a session.
Art therapy can take place in a variety of different settings, as therapists each have their own preferred methods of constructing therapy, and a range of intended goals depending upon the client’s case. Renowned art therapist, Dr. Ellen G Horovitz, describes the breadth of tasks and roles art therapists might have to assume, “My responsibilities vary from job to job. It is wholly different when one works as a consultant or in an agency as opposed to private practice. In private practice, it becomes more complex and far reaching. If you are the primary therapist then your responsibilities can swing from the spectrum of social work to the primary care of the patient. This includes dovetailing with physicians, judges, family members, and sometimes even community members that might be important in the caretaking of the individual.” Some art therapists find it vital for the progression of the therapy and the therapeutic relationship, to ensure that each session with a client occurs in the same space and at the same time, from week to week, a similar notion of psychology in general. Additionally, art therapy is offered on either the individual or group level depending on which is better for the individual based upon assessment.
Art therapy is also prevalent in schools as a means of therapeutic tools for children because of their interest in art and creativity as a means of expression. Art therapy can benefit children with a variety of issues, such as learning disabilities, speech and language disorders, behavioral disorders, and other emotional disturbances that might be hindering a child’s learning . Similar to other psychologists that work in schools, art therapists should be able to diagnose the problems facing their student clients, and individualize treatment and interventions. Art therapists work closely with teachers and parents, in order to implement and carry out their therapy strategies.
Art therapists and other professionals use art-based assessments to evaluate emotional, cognitive, and developmental conditions. There are also many psychological assessments that utilize artmaking to analyze various types of mental functioning (Betts, 2005). Art therapists and other professionals are educated to administer and interpret these assessments, most of which rely on simple directives and a standardized array of art materials (Malchiodi 1998, 2003; Betts, 2005). The first drawing assessment for psychological purposes was created in 1906 by German psychiatrist Fritz Mohr (Malchiodi 1998). In 1926, researcher Florence Goodenough created a drawing test to measure the intelligence in children called the Draw–A–Man Test (Malchiodi 1998). The key to interpreting the Draw-A-Man Test was that the more details a child incorporated into the drawing, the MORE intelligent they were (Malchiodi, 1998). Goodenough and other researchers realized the test had just as much to do with personality as it did intelligence (Malchiodi, 1998). Several other psychiatric art assessments were created in the 1940s, and have been used ever since (Malchiodi 1998).
Notwithstanding, many art therapists eschew diagnostic testing and indeed some writers (Hogan 1997) question the validity of therapists making interpretative assumptions. Below are some examples of art therapy assessments:
The Diagnostic Drawing Series (DDS)
The Diagnostic Drawing Series (DDS) is a three-picture art interview designed by Barry M. Cohen and Barbara Lesowitz in 1882. It is one of the most commonly taught art therapy assessments and, with more than 50 DDS studies to date, it is the most researched arttherapy tool worldwide. Cohen and Lesowitz also wrote the DDS Rating Guide that directs Metal heath professional as to how to score the DDS. The Rating Guide for the DDS evaluates the client based on structures within the drawings rather than the content.
The DDS is perhaps the most standardized of all art therapy assessments and relies on both empirical methodology and social science theories. Administers also pay special attention to the behaviors and behavioral changes of the test-taker. The DDS is traditionally administered to adolescents and adults, but there are versions that are geared toward the assessment of children.
The test consists of three drawings and the test-taker has fifteen minutes to complete each. The test-taker is given flat-sided chalk pastels, an 18X24 inch sheet of white paper, and the test-taker is should be seated at a table or desk of appropriate height for the subject.
- Picture 1—“Make a picture using these materials”
- Picture 2—“Draw a picture of a tree”
- Picture 3—“Make a picture of how you are feeling using lines, shapes, and colors.”
Interpretation Significant training is required to interpret the results of this assessment. Interpretations are made based on:
- Color: types, usage, blending, and original use
- Lines and Shapes, enclosure of lines and shapes, ground lines, sky lines; quality of lines, length, space usage
- Integration and abstraction
- Representation of the image in context: how is the image placing in its environment?
- Use of people and/or animals
- Inanimate objects
- Movement portrayal
- How the pastel was used by the test-taker
- Placement on the page
Strengths and Weaknesses of the DDS: The DDS is the most researched of all art therapy assessments and many drawings are archived for reference. Cohen and Lesowitz provided a quantifiable assessment for art therapists to use around the world. The test also has protocol and controls for the influence of medications and pharmaceutical confounding factors. The DDS is generally considered to be a reliable and valid assessment tool. The weaknesses of the test are rooted in the complexity of interpretation and subsequent lack of true scientific measurement. In general, projective tests tend to be much more unreliable than objective tests. The art therapist must have significant training in order to appropriately evaluate the test-taker.
The Mandala Assessment Research Instrument (MARI)
In this assessment, a person is asked to select a card from a deck with different mandalas (designs enclosed in a geometric shape) and then must choose a color from a set of colored cards (Malchiodi 1998). The person is then asked to draw the mandala from the card they choose with an oil pastel of the color of their choice (Malchiodi 1998). The artist is then asked to explain if there were any meanings, experiences, or related information related to the mandala they drew (Malchiodi 1998). This test is based on the beliefs of Joan Kellogg, who sees a recurring correlation between the images, pattern and shapes in the mandalas that people draw and the personalities of the artists (Malchiodi 1998). This test assesses and gives clues to a person’s psychological progressions and their current psychological condition (Malchiodi 1998). The mandala originates in Buddhism; its connections with spirituality help us to see links with transpersonal art.
The House-tree-person test (HTP) is a projective test designed to measure aspects of a person’s personality. The test can also be used to assess brain damage and general mental functioning. By virtue of being a projective test, the results of the HTP are subjectiveand open to interpretation by the administrator of the exam. HTP was designed by John Buck and was originally based on the Goodenough scale of intellectual functioning. Buck included both qualitative and quantitative measurements of intellectual ability in the HTP (V). A 350-page manual was written by Buck to instruct the test-giver on proper grading of the HTP, which is more subjective than quantitative.
Administering the Test: HTP is given to persons above the age of three and takes approximately 150 minutes to complete based on your level of mental functioning. During the first phase, the test-taker is asked to draw the house, tree, and person and the test-giver asks questions each picture. There are 60 questions originally designed by Buck but art therapists and trained test givers can also design their own questions, or ask follow up questions. This phase is done with a crayon. During the second phase of HTP, the test-taker draws the same pictures with a pencil or pen. Again the test-giver asks similar questions about the drawings. Note: some mental health professionals only administer phase one or two and may change the writing instrument as desired. Variations of the test may ask the person to draw one person of each sex, or put all drawings on the same page.
Examples of follow up questions:
- After the House: Who lives here? Is the occupant happy? What goes on inside the house? What’s it like at night? Do people visit the house? What else do the people in the house want to add to the drawing? [Chicago School of Professional Psychology 1]
- After the Tree: What kind of tree is this? How old is the tree? What season is it? Has anyone tried to cut it down? What else grows nearby? Who waters this tree? Trees need sunshine to live so does it get enough sunshine?
- After the Person is drawn: who is the person? How old is the person? What do they like and dislike doing? Has anyone tried to hurt them? Who looks out for them?
Interpretation of results:
The subjective analysis of the test takers responses and drawings aims to make inferences of personality traits and past experiences. The subjective nature of this aspect of the HTP, as with other qualitative tests, has little empirical evidence to support its reliability orvalidity. This test, however, is still considered an accurate measure of brain damage and used in the assessment of schizophrenic patients also suffering from brain damage.
In this drawing assessment and therapeutic intervention, the patient is asked to draw a road. This is a projective assessment used to create a graphic representation of the person’s “road of life.” The road drawing has the potential to elicit spontaneous imagery that represents the client’s origins, the history of his or her life process, experiences to date, and intent for the future – even from a single drawing (Hanes, 1995, 1997, 2008). The road’s reparative features or its need for “periodic upgrade” can serve as a metaphor for the client’s capacity for change and restoration (Hanes, 1995, 1997, 2008).
Standards of practice in the United States
Board certification, registration, and licensure
In the United States, art therapists may become Registered (ATR), Board Certified (ATR-BC), and, in some states, licensed as an art therapist, creative arts therapist (LCAT; NY State only), or professional or mental health counselor (many states). The ATCB Code of Professional Practice is divided into five main categories; General Ethical Principles, Independent Practitioner, Eligibility for Credentials, Standards of Conduct, and Disciplinary Procedures (ATCB 2005). Becoming a registered ATR requires that one complete a graduate-level program in art therapy from an accredited university, as well as completion of practicum and an internship, and additional clinical experience post-graduation with supervision from a professional clinician.
For more information on how to become licensed, US art therapists should contact the state licensure board in the state in the US in which they wish to practice. Art therapy students who are preparing for practice in the field should consult with their academic advisers about what courses are necessary to meet board certification and/or licensure requirements. Licensure is generally needed to obtain reimbursement for services as an independent practitioner and in some states, is required by law in order to practice independently. To receive certification, a significant amount of coursework and clinical experience is required. Depending on where an art therapist practices geographically, certification is not always necessary in becoming a professional art therapist. Typically, the minimum requirement is a master’s degree in art therapy, or a master’s degree in related counseling or psychology fields, with an art therapy focus. According to The American Art Therapy Association (AATA), it is imperative that master’s program students must successfully take courses in a variety of studio art disciplines as a means of signifying artistic proficiency. Additionally, students are required to take at least 48 credit hours at the graduate level in particular psychology related topics, as well as successfully partaking in practica and internships.
In countries other than the US, art therapists should contact governmental or regulatory boards that oversee the practice of mental health or health care professions to identify any specific coursework or education that is needed. Because art therapy is still considered a developing field, most countries do not regulate its practice and application.
In order to apply for an ATR or other registered art therapist certifications, students are required to complete 1,000 hours of direct client contact post-graduation from a master’s program. After obtaining an ATR, individuals have the opportunity to apply for Board Certification from the Art Therapy Credentials Board by passing an examination. Like many psychology-related licensing, art therapy licenses vary by state, and having a license does not necessarily mean a therapist is nationally certified.
General ethical principles
One topic covered in this section describes the responsibility art therapist have to their patients (ATCB 2005). According to the ATCB, art therapists must strive to advance the wellness of their clients, respect the rights of the client, and make sure they are providing a useful service (2005). They cannot discriminate against patient whatsoever, and may never desert or neglect patients receiving therapy. Art therapist must fully explain to their patients what their expectations of the patients will be at the outset of the professional relationship between the two. Art therapists should continue therapy with a patient only if the client is benefiting from the therapy. It’s against the principles established by the ATCB for art therapist to have patients only for financial reasons.
Another topic of this section discuses the competency and integrity art therapists must possess (ATCB 2005). The ATCB states art therapists must be professionally proficient and must have integrity (2005). Art therapists must keep updated on new developments in art therapy. They are only supposed to treat cases in which they are qualified as established by their training, education, and experience (ATCB 2005). They are not allowed to treat patients currently seeing another therapist without the other therapist’s permission (ATCB 2005). Art therapists must also observe patient confidentiality (ATCB 2005).
Other topics covered in this section discuss other responsibilities of art therapists. This responsibilities include, “responsibility to students and supervisees, responsibility to research participants, responsibility to the profession” (ATCB 2005). This section also establishes the rules by which art therapists must follow when making financial arrangements and when they chose to advertise their service (ATCB 2005)
Independent practitioners are art therapists who are practicing independently or responsible for the service they are providing to paying clients. This section covers the credentials for independent practitioners.
Independent practitioners must provide a safe and functional environment to conduct art therapy sessions (ATCB 2005). According to ATCB, “this includes but is not limited to: proper ventilation, adequate lighting, access to water supply, knowledge of hazards or toxicity of art materials and the effort need to safeguard the health of clients, storage space for art projects and secured areas for any hazardous materials, monitored use of sharp objects, allowance for privacy and confidentiality, and compliance with any other health and safety requirements according to state and federal agencies which regulate comparable businesses” (2005).
This section also establishes the standards for independent practitioners to follow when dealing with financial arrangements.. Basically it states that the art therapist must provide a straight forward contract to the payer of the therapy sessions. It also states that the art therapist must not deceive the payers or exploit clients financially.
The last topics this section sets standards for address treatment planning and documentation (ATCB 2005). Art therapists must provide a treatment plan that assists the patients to reach or maintain the highest level of quality of life and functioning. This involves using the clients’ strengths to help them reach their goals and address their needs. Art therapists are also required to record and take notes that reflect the proceedings of the events of therapy sessions. According to ATCB, the following is the minimum of which must be documented: “the current goals of any treatment plan, verbal content of art therapy sessions relevant to client behavior and goals, artistic expression relevant to client behavior and goals, changes (or lack of change) in affect, thought process, and behavior, suicidal or homicidal intent or ideation” (2005) and a summary of the “clients response to treatment and future treatment recommendations” (2005).
Eligibility for credentials
This section of the ATCB Code of Professional Practice outlines the process by which art therapy students receive their credentials. It discusses the standards for eligibility and describes the application process. It also states that the ATCB certificates are the property of the ATCB and that any art therapist who loses their certificate and still claim to have ATCB credentials can be punished legally. It also discusses the procedure to follow when accused of wrong doing related to art therapy. Lastly, it discusses the wrong doings related to art therapy that therapists can be convicted for with a felony or another criminal conviction. These wrong doings include rape, sexual abuse, assault, battery, prostitution, or the sale of controlled substances to patients.
Standards of conduct
This section of the ATCB Code of Professional Practice addresses in detail confidentiality, use of clients’ artwork, professional relationships, and grounds for discipline.
Art therapists are not permitted to disclose information about the clients’ therapy sessions. This includes “all verbal and/or artistic expression occurring within a client-therapist relationship” (ATCB 2005). Art therapist are only allowed to release confidential information if they have explicit written consent by the patient or if the therapist has reason to believe the patient needs immediate help to address a severe danger to the patients life. Also, therapists are not allowed to publish or display any of the patients work without the expressed written consent of the patient.
The standards of a professional relationship between art therapists and clients are covered in this section. Within a professional relationship, art therapists are banned from engaging in exploitative relationships with current and former patients, students, inters trainees, supervisors, or co-workers. The ATCB defines an exploitative relationship as anything involving sexual intimacy, romance, or borrowing or loaning money. Within professional relationships, therapists are to do what they feel is best in the clients interest, shall not advance a professional relationship for their own benefit, and shall not steer their patients in the wrong direction.
The breaking of any of the standards established in this section is grounds for discipline.
The content contained in this section of the ATCB Code of Professional Practice specifically discusses in legal and technical detail the entire disciplinary procedures for wrong doings in art therapy (2005). Main topics covered in this section cover: “submission of allegations, procedures of the Disciplinary Hearing Committees, sanctions, release of information, waivers, reconsideration of eligibility and reinstatement of credentials, deadlines, bias, prejudice, and impartiality”
While the ATCB oversees disciplinary procedures for art therapists, if an art therapist is licensed, the state board through which the art therapist is licensed carries out disciplinary action for violations or unethical practice.
Art Therapy has bona fide research in various venues: phenomenological, heuristic, quantitative, qualitative, etc. Numerous articles, books, NIH reports, etcetera are replete with information that attests to the efficacy of Art Therapy as evidence-based, effective treatment. However, it has been noted that Art Therapy’s effectiveness is not well understood through unsubstantiated claims, uncited research, or vague generalizations.
People always search for some escape from illness and it has been found that art is one of the more common methods. Art and the creative process can aid many illnesses (cancer, heart disease, influenza, etc.). People can escape the emotional effects of illness through art making and many creative methods.
Hospitals have started studying the influence of arts on patient care and found that participants in art programs have better vitals and less complications sleeping. Artistic influence doesn’t need to be participation in a program, but studies have found that a landscape picture in a hospital room had reduced need for narcotic pain killers and less time in recovery at the hospital.
Art therapists have conducted studies to understand why some cancer patients turned to art making as a coping mechanism and a tool to creating a positive identity outside of being a cancer patient. Women in the study participated in different art programs ranging from pottery and card making to drawing and painting. The programs helped them regain an identity outside of having cancer, lessened emotional pain of their on-going fight with cancer, and also giving them hope for the future.
Studies have also shown how the emotional destress of cancer patients has been reduced when utilizing the creative process. The women made drawings of themselves throughout the treatment process while also doing yoga and meditating; these actions combined helped to alleviate some symptoms 
Art therapy has been used in a variety of traumatic experiences, including disaster relief and crisis intervention. Art therapists have worked with children, adolescents and adults after natural and manmade disasters, encouraging them to make art in response to their experiences. Some suggested strategies for working with victims of disaster include: assessing for distress or post traumatic stress disorder (PTSD), normalizing feelings, modeling coping skills, promoting relaxation skills, establishing a social support network, and increasing a sense of security and stability