Beyond Words: Reframing therapy through art
I was on my older sister’s apartment’s red couch in my pajamas when I received an email from Liz Goll Lerner, a licensed professional counselor and licensed clinical art therapist in private practice based in Washington D.C., that read, “I know this is short notice but I had some cancelations today. I was planning on hiking later this afternoon. You wanted to come to the office, but would you be up for hiking and talking?”
I had only been in Washington D.C. for two and a half weeks, but the appeal of getting out of a pristinely clean city filled with people who own 15 suits had grown large already. I responded with urgent finger pads on my laptop keyboard. Within minutes, I was changed and out the door walking to the metro station.
Surrounded by the lush Maryland landscape and a thick bank of clouds, Lerner and I began down the dirt path paralleling a part of the Potomac River I had never seen before. In my backpack was a pale-blue notebook full of small diagrams, half of them crossed out, half of them smudged from the paper pages rubbing up against the inky, black pen. I draw these diagrams almost every night, when I’m anxious, when I can’t sleep, when I can’t stop my eyes from closing and lighting up freeways in my brain of electrifying nerves. I don’t know much about why I draw them, but what I do know is that when I feel consumed by anxious thoughts, the only thing I can manage to do is draw them.
According to the American Art Therapy Association, art therapy aims to reconcile emotional conflicts, foster self-awareness, manage addictions, reduce anxiety and develop social skills. This makes sense. In fact, it’s fundamental: One of humanity’s basic needs is to create. But how exactly can creating art heal mental wounds? Though art therapy has been explained to me through therapists, scientific journals and online testimonies, it wasn’t all that clear to me — or that believable. I wanted not only to understand the science of how art therapy works, but also to understand the impact it can make, and through this, understand if it truly works. And I wasn’t the only one.
A 2014 study by Lukasz Konopka, professor of clinical psychology at The Chicago School of Professional Psychology, notes that art therapy has the ability to change someone’s brain — a concept called brain plasticity or neuroplasticity — but for years was based just on “subjective data and testimonies.” And that’s the key: “Based on subjective data and testimonies” is a phrase that has hindered art therapy as a viable psychological treatment method, especially in comparison to other types of therapy, namely, the champion of them all: cognitive behavioral therapy.
Cognitive behavioral therapy — a hands-on, goal-oriented therapy that focuses on reframing negative thoughts — has a mounting pile of evidence backing it and that pile is only growing. Los Angeles Times writer Eric Jaffe reports that CBT “has performed as well as antidepressants medication in treating depression in recent studies.”
CBT has real results, it performs really well in randomized controlled research and those results are proven, articulated and shared. CBT is so popular and accessible there are even online programs, like SHUTi and CBT for Insomnia, that can walk clients through CBT questioning to start retraining their brains.
I’ve practiced CBT in attempts to reduce anxiety I developed from a sleeping disorder. I filled in white worksheets that asked me to reframe my thoughts. I found it interesting and helpful in a non-immediate way. CBT didn’t evaporate my anxious thoughts, but over the course of what has now been years, a tiny part of CBT — the physical part — has helped me tremendously. Physically creating the thoughts in my mind as words on a page helped me articulate my anxiety, stabilize my mind and materialize my disorder. Inky words describing my thoughts visibly in front of me created a distance between my thoughts and myself, an objectification that is crucial (and incredibly difficult) to improving any mental health disorder.
Sometimes, I drew diagrams to accompany this writing, because I liked the way they looked or because I thought they were funny. I thought of drawing them as pleasant: It is enjoyable to create art. But I reasoned that the diagrams were a result of something I wrote about. I reasoned that the writing, the ideas behind my diagram, were what was helping me feel less anxious.
As Lerner and I paused at an overlook, where you could almost see waterfalls in the distance, I realized I wasn’t giving the diagrams that were stuffed away under my rain jacket, out of Lerner’s sight enough credit.
Lerner was a pioneer of the growing profession of art therapy.
“Art therapy is very old, but it is also very young,” she said to me with her head down, watching the rhythm her hiking boots were making against the gravel.
In many ways art therapy’s origins are ancient because art is ancient — think hieroglyphics and Greek architecture. But art therapy as a profession isn’t ancient. Though it has made enormous strides, art therapy today is still unheard of in numerous cities, towns and countries. Lerner and her colleagues were at the very start of it.
“It was really exciting to be working in the profession time at a time when we were introducing the field in places that didn’t really understand it and had not used it yet,” she said.
The complicated aspect of art therapy is that when you are helping people understand how to use something that compliments how they live, you have to show them. Lerner and her colleagues had to create the opportunity to be able to show people. Often, this took the form of proposals and demonstrations called in-services in hospitals.
Listening to the rhythm of my own boots, I tried to think of the first time I was exposed to the idea of art therapy and what my reaction to it was? Did I believe it to be a medical treatment? Did I believe it could just make you happy? Or did I believe it could cure?
According to Heidi Bardot, director of the Art Therapy program at George Washington University, one of the first founding art therapy graduate programs, art therapy developed as a specific medical practice after World War II. It was a response to soldiers developing what was at the time called “shell shock” and today is diagnosed as post-traumatic stress disorder.
The National Intrepid Center of Excellence, which is part of the Walter Reed National Military Medical Center in Bethesda, Md., guided men who served in Iraq in the creation of painted masks to express how they feel after being wounded in war. After Sept. 11, art therapists set up exhibits where victims could come and share their experience of trauma through art. Creating art created self-esteem. Creating art externalized their experience. After Hurricane Katrina, Karla Leopold, an art therapist from California, treated children impacted by the storm with opportunities to express their experience through drawings. Leopold observed a repeating pattern in the images children affected by the hurricane drew of their homes: The homes changed from square to triangular. All the children who drew triangular houses were children who were rescued from a rooftop.
“Particularly in our world right now, where there have been hurricanes and disasters and shootings, art therapists have been called in to do this work because it is so powerful and effective and really helps people in the moment, as well as long term,” Lerner said.
I thought of my own job this summer — my tiny internship where I sat at a tiny desk scrolling through press releases and statements about the tragedies that have happened. Fifty dead in the Orlando shooting; headlines and political messaging repeat the phrase “the deadliest mass shooting in America” until our ears burn off. The killing of Alton Sterling, another name to add to the list. Three police officers fatally shot in Baton Rouge, a French holiday attack in Nice, an attack in Munich, violence meeting violence when five more police are killed in Dallas during a protest about police shootings.
Nearing the end of our hike, Lerner took me a bit off the trail to one of her favorite spots. Sitting in the curve of two large rocks overlooking the crest of the waterfall, I asked, “Do you think I could have a session with you? To really understand what this is all about?”
Today there are just four states where trained art therapists can obtain an art therapy license, and four states that license art therapists under other related mental health licenses. This means that if you live in any other state than Kentucky, Maryland, Mississippi, New Mexico, New York, Pennsylvania, Texas, Wisconsin, attend and graduate from an art therapy graduate program and are trained and degreed, you are still limited as an art therapist.
Without a license, health insurance companies will not sign on to reimburse or fund any of your clients for art therapy services. Without a license, the public does not know whether you are a qualified art therapist. Without a license, art therapists don’t have the credibility from the medical world as they continue to develop and progress their profession.
The AATA’s mission is to advocate for expansion of access to professional art therapists and lead the nation in the advancement of art therapy as a regulated mental health and human services profession. AATA is working to gain independent licensure for art therapists in states to enable health insurance companies to reimburse and fund services.
An art therapy license would mandate qualifications and the scope of practice in state law, which in turn will more accurately reflect the academic and clinical training required to be an art therapist.
Bardot explained to me that though currently art therapists can apply for a license under counseling licenses, this door will eventually get shut.
“The counseling world is wanting to separate from everyone else, which, you know, most fields do at some point,” Bardot said. “Those licenses will become exclusive to only counselling programs. So it is becoming quite an important task that we do get licensure. Otherwise we are going to have graduates who can’t get a job and get reimbursed for their work or any of that.”
Donna Betts, president of the board of the American Art Therapy Association, echoed this: A lack of licensure deprives art therapist of a distinct professional identity.
But it is more complicated than just a nice, neat title for art therapists. Betts emphasized that recent advancements in understanding how art-making impacts neural pathways in the brain has encouraged other mental-health practitioners to include art materials and art therapy methods in their practice.
“The result has been to add to the public’s confusion about what art therapy involves and the level of training required for effective practice of art therapy,” she stated in an AATA report. “ … Individuals using art therapy methods and art materials in their mental health practice without appropriate or adequate clinical training pose significant risk to the emotional stability of their clients.”
In Michigan, there is no art therapist licensure program. Amber James, the Michigan Association of Art Therapy’s legislative chair, has drafted a bill that is almost ready to be presented to Michigan state legislators. This bill, tentatively called the Art Therapy Licensure Bill, spells out the protections for those receiving art therapy and their therapists.
“There are people practicing art therapy in Michigan that are not art therapists,” James said. “They don’t have the training, they don’t have master's degrees, they don’t have a background in psychology, they don’t know the ethical standards of practice, they don’t have the competency that art therapists have.”
The bill would ensure anyone practicing art therapy has been trained according to AATA’s educational standards, completed all medical contact hours — including 100 hours of supervised practicum, 600 hours of supervised art therapy clinical internship and more than 1,000 hours of direct client contact — received credentials from the Art Therapy Credentials Board and passed the proficiency exam. The bill would legitimize art therapy as a psychological treatment option in Michigan.
Furthermore, the bill brings into view the issue of privileged communication, defined as any conversations that occur within a protected relationship.
When a person sees a therapist, certain information they share with the therapist is protected. Right now, art therapists and their patients don’t have this same type of protection.
James noted that sometimes therapists are put in compromising situations. “Because art therapy isn’t very well understood, sometimes people — administrators or places where there would be art therapy programs — have this idea that it’s more about aesthetics, creating something,” she said.
“But the stuff that is created in art therapy isn’t meant for the purpose of being pleasing, it’s therapy, it’s not always pretty … In the same way you wouldn’t go in and record someone’s therapy session and play it, you wouldn’t take someone’s art work and display it.”
At the University of Michigan, there are few places you can find art therapy being used or developed.
Patricia Reuter-Lorenz, the department chair of the University’s Psychological Department, noted that the department does not cover art therapy in their curriculum in any formal way.
Though it is not offered in any established curriculum at U of M, there are approximately 35 AATA-Approved graduate programs across the country.
Todd Sevig, director of Counseling and Psychological Services, said CAPS does not offer stand-alone art therapy.
“We have incorporated tenets of art therapy, expressive therapy and simply using art to express one’s self, emotions, thoughts, feelings, in many of our groups and workshops,” Sevig noted. “Also, at times, individual counselors will incorporate in individual therapy.”
C.S. Mott Children’s Hospital does have an open studio model where patients and their families can work with an art therapist in between appointments at the hospital.
Sitting at the table across from Lerner, I tried not to have an agenda for the session, not to think of one specific problem or one specific story I wanted to express. Lerner and most art therapists don’t have a one-size-fits-all approach to each session. Each individual session is approached differently, depending on what is going to be most effective for the client.
After she showed me art supplies but before I created any art, she had me sit back and asked me a series of questions with my eyes closed. These questions had me visually imagine a place where I was calm and content. From there, she asked me to try to see a color and a shape to the feeling and place I was seeing in my head. I was thinking of a memory sitting on a doc on Lake Winnipesaukee in New Hampshire. When I thought of a color, I thought of blue; when I thought of a shape, a rectangular blob came to mind.
I opened my eyes and stared at the white page in front of me. I reached for pastels because I hadn’t used pastels since I was in the fifth grade and wanted to smear them with my fingers. I felt ridiculous drawing such an abstract shape.
Lerner spoke about how often you physically carry an experience with you, and how creating a piece of art is a kinesthetic experience, expressing this experience with art materials assists the release of physical tension as well as helps the individual process the thoughts and emotions related to the experience. Though I agreed — I liked the feeling of the chalky pastels on my rough finger tips and I knew how writing or diagramming at night was a productive physical release — there was something else, a much more basic physical component to the session that really made the difference for me.
When I was done, Lerner placed the image in front of us: two feet away from me, two feet away from her.
These two feet created distance between my life and what we were talking about — also my life. Through everything we discussed, literally and symbollically about my life, we both knew there wasn’t the directed pressure of actually talking about my life until I was ready.
In my experience with other therapy practices, a therapist sits in front of you and discusses your life with you. Anything wrong with your life is something wrong with you, and you walk out the door an hour later feeling disillusioned by the experience.
The disillusion is circular: I’m having this problem, something is wrong with me, let’s talk about how to fix it, so now this is yours to take away and fix, and when you don’t fix it, when you are back again for the next session, there you are again: You are the root of your own problems.
Practicing art therapy has been shown to affect how your brain processes information, predominantly visual and somatosensory information. But identifying exactly which brain processes are affecting an individual’s emotional outcome isn’t black and white.
Luminary art therapist Vija Lusebrink notes in The Journal of Art Therapy Association, “A human being functions as a whole organism, and at any given time, many brain processes and areas are active and involved.”
Konopka’s study acknowledges this same trend. “To gain acceptance and credibility from the medical establishment, art therapy is, seemingly, hoping to assign unique artistic processes to specific brain structures, but the specific brain effects of the artistic process are difficult to study,” she writes.
“Nevertheless, through neuroscience, art therapy is attempting to locate particular brain areas or activity patterns that may be devoted exclusively to art-making,” she continues. “Yet, this specificity presents a problem — the brain does not distinguish between the processes used to create a scientific invention and a work of art — the brain undergoes identical activity sequences and manipulations.”
Furthermore, though the dominant narrative surrounding art therapy is to work to provide more opportunities for research, leading to more evidence-based explanations, there is debate over if more empirical evidence is even what the art therapy world needs.
Carolyn Husky a Athabasca University alum, proposes in her master’s thesis that some scholars, such as Tibbets and Rossal, believe that more research and empirical evidence is exactly what art therapy doesn’t need.
Today, bloggers from Neuroscience in Art Therapy debate, too, if this streamlining of art therapy is even productive. One blogger argues that no matter if it is “better” or not, more evidence based search will streamline art therapy making it a more “linear, clear-cut process that is more insurable and funding-friendly.”
Exploring feelings and finger painting hasn’t gotten art therapy far in the professional world, but research proving neurological pathways are affected by art-making have. Could our society's tendency to validate treatment methods based on empirical evidence only actually complicate a field that best remain in the abstract?
I finished my session with Lerner calmer and more settled than when it began. And though I thought of the big blue blob on my paper and all her comments on lifestyle, the most powerful thing that I couldn’t shake was something she mentioned at the beginning of the session: “Words are limiting. That is what we got, so we make good use of them. But art gives you so much more.”
I thought I understood how speaking words, and more intensively writing words, were how therapy is communicated and how the abstractness of mental health issues can manifest in a tangible form. When the words I was speaking in therapy weren’t working, at least the words in my journal — and not the diagrams — were reframing my thoughts.
But Bardot helped me realize instances when humans do not have this ability to articulate their lives. “When you have a rich dream where you felt right in midst of it, color, your body responding emotionally to the dream, and you wake up and try to describe it to someone, but it just kind of drifts away … We often times talk about how trauma is like that.”
“Even something simple like a car accident,” she said. “Those images are stored as ‘flashbulb memories.’ They are not stored as a continuous story but stored separately in your brain. You see the headlights in front of you, then you see your foot on the brake, then you see the car getting closer.”
“The idea is if you can combine the images together and if you can create them on paper you are kind of distancing yourself from that image, from that memory, and so then, you can talk about the picture with perspective.”
Externalizing the memory by drawing it on paper, makes it easier to put explanation to the images we feel and experience in our heads.
The entire concept of art therapy is that words are not enough, so why would we limit this profession that exists at a specific intersection of the most scientific and most human to be defined only by words — only by empirical evidence recorded by words in scientific journals. Art therapy does and will continue to have this type of evidence proving its effectiveness, but, just as I found, the most impactful explanation of art therapy was nothing I could read about. My understanding only occurred when I sought out the experience myself, when I created an image, when I put abstract thoughts into boundless art.