The History and Theory of Art Therapy — Two Pioneers, Four Theoretical Frameworks, How It Works and What the Evidence Says

What is art therapy?

Art therapy uses art-making — drawing, sculpture, collage and more — and the resulting artwork as a medium for psychological change within a relationship with a trained therapist. The heart of it is not the polish of the finished piece but the process of making and what is experienced along the way, so it isn’t only for people who are “good at art.”

The same activity has a different purpose as a hobby or in art education. Art therapy is a clinical practice with assessment, goal-setting, a therapeutic relationship and ethical codes.

Two pioneers, two traditions

The term “art therapy” is said to have been coined in 1942 by the British artist Adrian Hill, who found that drawing aided his recovery in a tuberculosis sanatorium. In the United States, two women opened different paths.

	Margaret Naumburg	Edith Kramer
Stance	Art psychotherapy	Art as therapy
Theoretical roots	Psychoanalysis: images as symbolic expressions of the unconscious	Psychoanalysis: the sublimating function of making itself
Role of the artwork	A medium for free association and interpretation	A process that turns conflict into creative form
Therapist’s focus	Verbal dialogue about the work	Supporting the creative process and its quality

Naumburg (1966) saw images as containers for what words cannot fully express and explored their meaning with clients. Kramer (1971) held that the very process by which children translate destructive impulses into artwork is healing. Most art therapists today use both views as the situation requires. The American Art Therapy Association was founded in 1969 and the British Association of Art Therapists in 1964; in Korea, professional societies emerged in the early 1990s, establishing training and credentialing.

Four theoretical frameworks

• Psychodynamic approaches treat images in the artwork as expressions of unconscious conflict and defence, working with transference in the triangular relationship of therapist, client and artwork.
• Jungian approaches treat images as symbols and use active imagination, calling up and conversing with unconscious images. Jung saw in his own and his patients’ mandala drawings a movement towards the integration of the psyche (Jung, 1959). Mandala techniques are revisited with the evidence in Chapter 4.
• Humanistic, person-centred approaches respect the client’s subjective experience and self-exploration over interpretation. Natalie Rogers, Carl Rogers’s daughter, developed person-centred expressive arts therapy, moving across art, movement and writing (Rogers, 1993).
• Cognitive-behavioural approaches visualise the loop of thoughts, feelings and actions in images and have clients draw and rehearse coping strategies. They suit structured goals such as managing anxiety or anger.

What makes it therapeutic?

Mechanisms often proposed for art therapy include:

• Externalisation: putting tangled feelings on paper lets you look at them from a distance.
• Nonverbal processing: experiences that are hard to put into words — especially trauma memories or young children’s experiences — can be worked with through images and senses.
• Control and mastery: choosing materials and changing forms gives a sense that “I can change something.”
• Physiological relaxation: in a study by Kaimal, Ray and Muniz (2016), about three-quarters of adults who spent 45 minutes freely making art showed lower levels of the stress hormone cortisol, regardless of prior art experience. The study had no control group, however, which limits interpretation.

How strong is the evidence?

Outcome research on art therapy is still limited in both quantity and quality.

• A UK Health Technology Assessment (Uttley et al., 2015) reviewed 15 randomised trials of art therapy for non-psychotic mental health problems. Most showed more positive results than control groups, but small samples and high risk of bias made firm conclusions difficult.
• Regev and Cohen-Yatziv (2018) reviewed 27 studies with adults and found positive results across groups including cancer patients, trauma survivors and people with schizophrenia, while again noting the variety and limits of the study designs.

In short, art therapy is a promising treatment whose evidence base is still growing. Where well-established treatments exist, as for severe depression or PTSD, art therapy is best used to complement rather than replace them.

Check questions

Question 1. A child pounds clay hard in anger, makes a monster, and then calms down. What would Naumburg and Kramer each focus on here?

Answer. Naumburg would focus on exploring with the child what the monster symbolises. Kramer would focus on how the process of sublimation itself — moving the destructive impulse into the form of an artwork — is healing.

Question 2. Is the statement “Art therapy is a proven treatment for depression” accurate?

Answer. It’s an overstatement. Some studies show positive results, but many are small and of low quality, so the evidence is still limited. “Promising, but more research is needed” is accurate.

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References

• Hill, A. (1945). Art Versus Illness. George Allen & Unwin.
• Naumburg, M. (1966). Dynamically Oriented Art Therapy: Its Principles and Practices. Grune & Stratton.
• Kramer, E. (1971). Art as Therapy with Children. Schocken Books.
• Jung, C. G. (1959). Concerning mandala symbolism. In The Archetypes and the Collective Unconscious (Collected Works, Vol. 9, Part 1). Princeton University Press.
• Rogers, N. (1993). The Creative Connection: Expressive Arts as Healing. Science & Behavior Books.
• Kaimal, G., Ray, K., & Muniz, J. (2016). Reduction of cortisol levels and participants’ responses following art making. Art Therapy, 33(2), 74–80.
• Uttley, L., et al. (2015). The clinical and cost effectiveness of group art therapy for people with non-psychotic mental health disorders: A systematic review and cost-effectiveness analysis. Health Technology Assessment, 19(18), 1–120.
• Regev, D., & Cohen-Yatziv, L. (2018). Effectiveness of art therapy with adult clients in 2018—What progress has been made? Frontiers in Psychology, 9, 1531.