With its focus on nonverbal representations of the client’s internal world, specifically in the form of 2D paintings and drawings, art therapy would suggest itself as a potentially fruitful area of inquiry with regard to the question of types of mental images in psychotherapy. There are close parallels between the production of internal mental images and the production of physical art. Interestingly, Levine (1999)
identifies imagination as the core unifying concept in the psychotherapeutic practice of expressive arts rather than creativity. Art therapy is similar to the talking therapies in that it encompasses a very wide range of therapeutic approaches both in terms of practice and also in terms of underpinning philosophy (Malchiodi 2005). As can be seen from the following definition given by the American Art Therapy Association (2011), art therapy is characterised by specific techniques in the service of generic therapeutic goals;
‘Art therapy is a mental health profession that uses the creative process of art making to improve and enhance physical, mental and emotional well-being. The creative process involved in artistic self-expression helps people resolve
24
conflicts and problems, develop interpersonal skills, reduce stress, and increase self-esteem and self-awareness .’
In general, the practice of art therapy is informed by the theoretical orientation of the practitioner, and these orientations are drawn from a range of psychotherapeutic schools e.g. psychoanalytic, object relations, cognitive-behavioural, humanistic, and transpersonal. Thus, the artwork produced by the clients (similarly to clients’ mental imagery in psychotherapy) is viewed through a particular theoretical framework. Consequently, there has been an emphasis on application rather than transtheoretical conceptualisation with regard to the artwork. Although this is beginning to change as the findings of recent neuroscience research appear to support the therapeutic
potential of embodied processes and this offers a potentially new focus for a unifying model (Malchiodi ibid).
2.5.1 Clients’ Art Productions as Assessment Tools
However, there is one specific practice in the field of art therapy that is different to the talking therapies with regard to imagery i.e. the use of clients’ art productions as psychiatric, behavioural, and developmental assessment tools. As these standard tests rely on systems of classification and categorisation – the bases of typologies – it is important to examine this practice in more detail.
Although the main emphasis in this therapeutic modality has been on helping the client develop insight by exploring their art productions, there has been a tradition within art therapy in North America of using these productions as sources of useful diagnostic information (Betts 2005). There are two main schools of thought with regard to using art for assessment purposes and both of these, although informed by radically different epistemologies, are predicated on the belief that patterns in the components and structure of the individual art production reveal the psychological condition or state of the individual. At one end of the continuum is the medical model and a well-established assessment tool is the Diagnostic Drawing Series devised by Cohen and Lesowitz (Cohen et al. 1994). This was the first art therapy assessment for adults to be systematically correlated with the nomenclature of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The structure of drawing is deemed to correlate with the mental state of the client.
25 At the other end of the continuum would be the humanistic school in particular the Jungian approach that is informed by a structuralist perspective whereby individual artworks reveal universal symbols and archetypes (Bergeron et al. 2003). An example of this would be the use of a projective imagery standard test such as the Mandala Assessment Research Instrument devised by Joan Kellogg (Cox 2003) which assesses psychological development relating to stages of individuation in adults.
Plotted at various points in-between on the continuum would be an array of assessments that are standard practice in the field. These usually take the form of projective drawing tests based on principles laid down by the Swiss psychoanalyst Rorschach (Groth-Marnot 2009) who believed that the subject’s response to
ambiguous inkblots provided diagnostic information regarding his or her personality. Each drawing assessment has a particular systemised interpretation; examples would include the following: Person Picking an Apple from a Tree (PPAT) (Lowenfield 1957) which is an attitudinal assessment test often used with children and adolescents; House-Tree-Person (HTP) (Jolles 1971) for measuring self-esteem; the Silver
Drawing Test (SDT) and Draw A Story (DAS) (Silver 2005) assess emotional states and cognitive skills in children and adolescents. The spatial arrangement of elements of the picture is considered to be a particularly significant and reliable instrument of assessment in several tests e.g Bach (1960) cited in Bergeron (Bergeron et al. ibid) developed and empirically tested a quadratic system in her work with severely ill children whereby each quadrant related to a particular aspect of child’s life concerns; and Jolles (1971) cited in Bergeron (Bergeron et al. ibid) developed a simpler binary spatial division of pictures, where the picture is most concentrated will reveal a bias i.e. towards the lower half equates with being reality bound and towards the top half with tendencies to living in fantasy.
In general the standard drawing assessment tests in art therapy comprise an ad hoc collection that has developed over the last sixty years. More recently there have been some interest in developing more technical and systemised tests that do not rely on subjective interpretations of pictorial content (Betts ibid) , one example of this would be the Formal Elements Art Therapy Scale (FEATS) (Gantt & Tabone 1998). This test is based on analysing variables in picture, such as colour and line. Gantt and
26 Tabone contend that this type of analysis, which is non-psychological, allows for a more objective identification of patterns emerging in clients’ artwork.
A major objection to the use of art productions as assessment tools, which is particularly significant for my research study, is the poor evidence base for their validity (Furth 1988), much of which is based on small scale research (Betts ibid.) One quantitative study (Groth-Marnot & Roberts 1998) of the validity of projective drawing tests e.g. House-Tree-Person, concluded that there was no support for its claim to measure self-esteem. In one large scale study carried out by Bergeron (Bergeron et. al ibid) to test the validity of the quadrant schema, used in analytical Jungian psychology, as a reliable assessment tool, only one association was confirmed i.e. that of unconscious material and the lower left quadrant. They concluded that the claims made for this assessment tool are not proved and need further empirical
investigation. In Betts (ibid:xi) study, she arrived at a similar conclusion regarding the entire field;
‘Variability of the concurrent validity and inter-rater reliability meta- analyses results indicates that the field of art therapy has not yet produced sufficient research in the area of assessments and rating instruments to determine whether art therapy assessments can provide enough information about clients or measure the process of change that a client may experience in therapy.’
In conclusion, it would seem that, despite the promising area of drawing assessment tests, art therapy has not developed much in the way of generic typologies relating to clients’ art productions. The only non-psychologically based assessment test (FEATS) does show some potential for a more inclusive transtheoretical approach. However, I note with interest, that Silver’s (the originator of the well-established SDT and DAP tests mentioned earlier) new publication (2010) explores the link between drawing and metaphorical thinking. Once again cognitive linguistics particularly conceptual metaphor is being suggested as a potential base for a more unified theory of art productions – one that is not grounded in a particular psychological model of human development.