CHAPTER 11
Art Therapy
Fran Nielsen
Abstract The use of group art therapy, individual art therapy and family
art therapy in an inpatient child and adolescent mental health services unit
will be described, including images and consumer feedback to demonstrate effectiveness. The artworks made in art therapy can reveal hidden
dysfunction in the young person and/or their family members. Recent
trauma research supports capacity to access this material safely through
non-verbal visual communication. Family art therapy has been a useful
intervention to support the identification of illness in a parent, to improving attunement between the parent and the child and for the parent to
detach from their child’s symptoms by agreeing to get treatment for themselves. If the patient cannot separate from the illness in the parent, their
symptoms will persist.
Keywords Adolescent • Inpatients • Mental Health • Art Therapy
The original version of this chapter was revised. The correction to this chapter
can be found at https://doi.org/10.1007/978-981-19-1950-3_21
F. Nielsen (*)
Walker Unit, Concord Centre for Mental Health, Concord, NSW, Australia
e-mail: Fran.Nielsen@health.nsw.gov.au
© The Author(s) 2022, corrected publication 2022
P. Hazell (ed.), Longer-Term Psychiatric Inpatient Care for
Adolescents, https://doi.org/10.1007/978-981-19-1950-3_11
95
96
F. NIELSEN
What the art therapy is Doing at the Walker Unit
Art Therapy is an emerging practice in mental health settings, particularly
for children and families who experience trauma induced symptoms
(Kozlowska & Hanney, 1999; Nielsen et al., 2019). Many of the young
people and their family members experience verbal communication difficulties. Where previous standard interventions have been ineffective, they
often enter the unit anxious and fatigued. The art therapist in this unit
provides structured individual, family and group-based art therapy treatment by working non-verbally with art materials as part of care. The nonverbal approach of art therapy has been effective in engaging this difficult
to treat group of young people (Nielsen, 2018; Nielsen et al., 2019, 2021).
While most psychological therapy interventions inform the framework
for art therapy, in this setting there has been an opportunity to further
develop a “responsive art psychotherapy” practice (Havsteen-Franklin,
2014; Nielsen, 2018). The art therapist has been able to contain emotionally charged projected experiences, by their capacity to provide an interpretive visual response in session. This has been particularly helpful when
the young person or their family member is in the early phases of treatment and are unable to reflect upon, or make any links between their
thoughts, feelings and behaviours.
Working on the young person’s willingness to engage is a common first
line goal in treatment. By their engagement with the art therapy in the
group programme, the young people have an opportunity to express their
distress safely, using art materials to develop an understanding of containing difficult emotions for themselves. During the group programme, it has
been important for the art therapist to facilitate their safety in this experience by participating in the art making process alongside the young people. Depending on the capacities of the young people, after the artmaking,
a discussion may occur. They are invited to look and think about the artworks made in the group process. For those unable to reflect, individual
art therapy may be recommended. This is especially helpful if themes of
trauma are emerging in the artworks. Supporting them with their capacity
to communicate difficult internal experiences safely is the focus of the art
therapy. Then by looking at what has been represented in the artworks,
over time they are able to sit with and think more about what has been
externalised in the object of the artworks made.
As many of the young people and their families experience verbal communication difficulties, art therapy can safely assist the young person and/
11
ART THERAPY
97
or family member to non-verbally communicate their feelings at a pace
that is comfortable for them and support their thinking (or more accurately incapacity to think), grounding them in the present and feelings of
safety. As the young person and/or family member engages in their artmaking, by making a response artwork an experienced senior art therapist
can non-verbally support the unintegrated fragments of their emotionally
overwhelmed experience. The sensory movements involved in artmaking
seem to enable access to dissociated experiences safely (Chong, 2015).
The implicit non-verbal communications made in the artworks can be a
useful contribution in treatment, as trauma content can be revealed in
images long before the cognition and explicit narrative is available (Bucci,
2007a; Nielsen, 2018).
Working with dissociation safely in the art therapy has been a main
component of in-session practice at the Walker Unit. Recent trauma
research supports capacity to access this material safely through non-verbal
visual communication (Coulter, 2015; Hoshino & Cameron, 2008;
Nielsen, 2018). The main goal of the art therapy in this setting is to stabilise emotional dysregulation and increase tolerance for distress. In some
cases, the family members may present as distressed as the young person.
As a right brain to right brain non-verbal activity, artmaking alongside the
family member and the young person has had the potential to evoke the
curative factor of a shared dysregulated to regulated experience (Nielsen
et al., 2021; Schore, 2011). This has given these young people and their
families hope for agency and change, despite the losses in their capacities
to verbally communicate their feelings. The images in Fig. 11.1 demonstrate how an art therapist might make a non-verbal response (right) in the
containment of the young person’s distress (represented in the images on
the left).
hoW the art therapy is implementeD
at the Walker Unit
All art therapy, individual, group and family sessions are structured and
planned with the multi-disciplinary team. When the art therapy is introduced to the young person and/or family member, there is a common
anxiety for those unfamiliar to the materials to think that art skills are
required. Often an art therapist will begin by explaining this is not the case
and that the main requirement is to ‘have a go.’ This can get under the
98
F. NIELSEN
Fig. 11.1 Young person and therapist images
wire of the reluctance to engage and appeal to their capacity to play, experiment or explore new ideas. To make a mark on the paper is the only
requirement. Boundaries within the art room are explained, for example,
not talking about other people’s work in the art room and that there is a
locked art therapy cupboard provided for storage and safety of the artworks made. This is an important intervention to ensure the safety and
containment of the shared internal experiences made explicit by the
artworks.
11
ART THERAPY
99
Three assessment sessions are often introduced when there is a referral
and after the third session, a summary is shared including images, to reflect
on the young person or family member’s availability to engage and think
about their work. After producing at least three artworks, an art therapy
consent form is signed by the young person and/or family member for the
permission to photograph or share images and include them in MDT
meetings, art therapy reports, educational in-services and/or research
publications. Some of the principles and procedures within art therapy
practice are shared. This can encourage collaboration from the young person or family member regarding their ongoing engagement, responsibilities and capacity to think about what is happening for themselves.
Images can be utilised as documents to their experience. They are able
to demonstrate capacity for change or cognition to function and can offer
information beyond text by measuring “intonation, gesture, tempo.”
(Sagan, 2019). Symbols can be another measure of a patient’s developing
capacity to communicate, by non-verbally, bringing what was implicit into
explicit conscious form (Bucci, 2007a, 2007b). Examples of the nonverbal shift from implicit, dissociative content to the more explicit symbolic content are presented in Fig. 11.2.
Fig. 11.2 Shift from dissociative to symbolic content
100
F. NIELSEN
When words are in the work the cognition is more likely to function
alongside the difficult feeling (Fig. 11.3).
The sequence in Fig. 11.4 demonstrates the layers and detail of how an
embodied image can be made and is an example of what cannot be thought
about or put into words by the young person or family member.
Where diagrammatic content is applied to the embodied feeling, consciousness and thought forms are made available to the young person or
family member. Symbolic examples in Fig. 11.5 demonstrate line and form
emerging in the imagery and demonstrate a capacity for integration of
thoughts and feelings.
When the young person is feeling distressed with thoughts of suicide or
self-harm and makes images such as Fig. 11.5, it is more possible for them
to safely integrate their feelings, strengthening their ‘emotional muscle’
and building their confidence and competencies to survive the thoughts
for a safer outcome.
When the young person is experiencing psychosis, it is almost impossible for them to integrate their thoughts and feelings, their internal experience may remain fragmented and detached. Art as therapy can provide an
option for the young people to self sooth or distract themselves, as in
Fig. 11.6.
The images in Fig. 11.7 reflect a young person who was floridly psychotic, after some time in silence they had said, “I have all these thoughts
Fig. 11.3 Words in artwork
11 ART THERAPY
101
Fig. 11.4 Embodied image
Fig. 11.5 Integration of feelings
I don’t know where they come from and they make me say things I don’t
want to say.” The image has, “I am a train” scratched into it. Such images
can assist with reality checking.
Figure 11.8 outlines a generalised process for the art therapy treatment
at the Walker Unit
102
F. NIELSEN
Fig. 11.6 Art for
soothing and distraction
Fig. 11.7 Psychotic images
Early artworks
Visual
representation
of defences.
Bear witness to
the imprinted
images of
distress and the
defensive
actions.
Artworks
facilitate topics
which are too
stressful to be
spoken.
Return to
cognitive
function
Raw
experience
Using art to
manage
overwhelming
experiences.
Focus on
emotion rather
than cognition.
Referring to
the image as a
concrete
object which
can be
reflected upon
and
acknowledged
Fig. 11.8 The process of art therapy
Exploring
meaning and
finding words,
regardless of
memory.
(Processing
content )
Using
artmaking
process and
outcome to
develop
problem
solving skills.
Artworks used
to integrate
thoughts and
feelings
Strategies
explored to
express
distress in
other ways.
11 ART THERAPY
103
the art therapy space
The art therapy room is located opposite the seclusion room which is rare
for an art room as they are usually located away from the main ward. The
art therapy room has remained low stimulus and the walls neutral for the
young person or family member to feel safe to enter. The palette of materials are limited and in ‘good enough’ condition. It is important for the
young person to understand the art therapist is not there to entertain
them. Neither is it a performance driven activity, as it might be in the
school setting. Figure 11.9 identifies the materials used and how the
table is set.
oUtcomes
A data base of images as well as the young people’s feedback has been gathered
to demonstrate effectiveness (Nielsen et al., 2019). Eighty per cent of the
young people at the Walker Unit have reported that art therapy has helped
them to express themselves safely and begin to think about how their thoughts
and feelings relate to their behaviours. Previously this had been difficult for
Fig. 11.9 Art materials
104
F. NIELSEN
them to do. Families have also contributed to feedback and reported they have
found art therapy to be helpful (Nielsen et al., 2021). The young people and
sometimes family members also contribute to their art therapy reports by
choosing their images and finding the words to communicate their experiences. This has been particularly important as a handover document for the
young person to communicate their needs, as the verbal therapies remain standard practice in the community.
conclUsion anD recommenDations
Verbal interventions may be too challenging for young people or family
members who feel unsafe with their thoughts and feelings. Supporting
them with their capacity to communicate difficult internal experiences
safely has been the focus of the art therapy at the Walker Unit with the
main goal, to stabilise emotional dysregulation and increase tolerance for
distress. Responsive art making (Havsteen-Franklin & Altamirano, 2015;
Nielsen, 2018; Nielsen et al., 2019, 2021) is an emerging clinical practice
within art therapy. This practice is used in this setting with the young
people and their families and challenges common beliefs that the purpose
of images is to solicit a narrative. There is a lack of awareness of the capacity for non-verbal visual art therapy experiences in mental health services.
A permanent 32 hour a week position has made it possible for the art
therapist in this setting to provide a consistent approach for the young
people and their families, while maintaining flexibility with the team. This
is very rare for art therapy practitioners and more positions need to be
made available to support mental health services in the future. The permanency of the role has also supported research opportunities, an important
consideration for the development of art therapy positions to be maintained in the future.
references
Bucci, W. (2007a). Dissociation from the perspective of Multiple Code Theory—
Part I. Contemporary Psychoanalysis, 43(2), 165–184.
Bucci, W. (2007b). Dissociation from the perspective of Multiple Code Theory—
Part II. Contemporary Psychoanalysis, 43(3), 305–326.
Chong, C. (2015). Why art psychotherapy? Through the lens of interpersonal
neurobiology: The distinctive role of art psychotherapy interventions for clients
with early relational trauma. International Journal of Art Therapy,
20(3), 118–126.
11 ART THERAPY
105
Coulter, A. M. (2015). Family art therapy: Dots, meaning and metaphor. In
C. Kerr (Ed.), Multicultural family art therapy (pp. 90–104). Routledge.
Havsteen-Franklin, D. (2014). Consensus for using an arts-based response in art
therapy. International Journal of Art Therapy, 19(3), 107–113.
Havsteen-Franklin, D., & Altamirano, J. C. (2015). Containing the uncontainable: Responsive art making in art therapy as a method to facilitate mentalization. International Journal of Art Therapy, 20(2), 54–65.
Hoshino, J., & Cameron, C. (2008). Narrative art therapy within a multicultural
framework. In C. Kerr (Ed.), Family art therapy: Foundations of theory and
practice. Routledge.
Kozlowska, K., & Hanney, L. (1999). Family assessment and intervention using
an interactive art exercise. Australian & New Zealand Journal of Family
Therapy, 20(2), 61–69.
Nielsen, F. (2018). Responsive Art Psychotherapy as a component of intervention
for severe adolescent mental illness: A case study. Art Therapy OnLine
(ATOL), 9, 1–38.
Nielsen, F., Feijo, I., Renshall, K., & Starling, J. (2021). Family Art Therapy: A
contribution to mental health treatment in an adolescent inpatient setting.
Australian and New Zealand Journal of Family Therapy., 42, 145–159.
Nielsen, F., Isobel, S., & Starling, J. (2019). Evaluating the use of responsive art therapy
in an inpatient child and adolescent mental health services unit. Australasian
Psychiatry, 27(2), 165–170. https://doi.org/10.1177/1039856218822745
Sagan, O. (2019). Art-making and its interface with dissociative identity disorder:
No words that didn’t fit. Journal of Creativity in Mental Health, 14(1), 23–36.
Schore, A. N. (2011). The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic Dialogues, 21, 75–100.
Open Access This chapter is licensed under the terms of the Creative Commons
Attribution 4.0 International License (http://creativecommons.org/licenses/
by/4.0/), which permits use, sharing, adaptation, distribution and reproduction
in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, provide a link to the Creative Commons licence and
indicate if changes were made.
The images or other third party material in this chapter are included in the
chapter’s Creative Commons licence, unless indicated otherwise in a credit line to
the material. If material is not included in the chapter’s Creative Commons licence
and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copyright holder.