Art Therapy

Abstract

Art Therapy, which the National Library of Medicine's Medical Subject Headings classifies under psychotherapy, is the clinical use of art making, within a therapeutic relationship, to help people express psychological material that words reach poorly. This article treats it as a scientific object. It traces the split between Margaret Naumburg's art psychotherapy, in which the image is a route to unconscious content, and Edith Kramer's art as therapy, in which the making itself is curative; sets out the Expressive Therapies Continuum that organises media by the mental processes they recruit; reviews the cortisol and reward-pathway studies that give the practice a physiological footing; and weighs the systematic reviews on trauma, dementia, and childhood distress. Three demonstrations model the continuum of media, the reward response to art making, and a trial's number needed to treat.

Keywords: art therapy, expressive therapies continuum, creative arts

Art therapy is the deliberate use of drawing, painting, modelling, and other visual media, guided by a trained clinician, to relieve psychological distress and to make accessible what a person cannot easily say. What distinguishes it as a subject of cognitive and clinical science is not the art but the claim attached to it: that the act of making an image, and the relationship in which it is made, can change feeling and thought in measurable ways. For most of the twentieth century that claim rested on case material and the authority of its founders; over the last two decades it has been tested with controlled trials, salivary assays, and functional imaging. This article follows that arc, from the two rival theories of why art heals to the current evidence for whether, and by how much, it does.

What Art Therapy Is

Art therapy is a form of psychotherapy in which the making of visual art is the primary means of treatment rather than an incidental activity. A trained art therapist provides materials, a contained setting, and a therapeutic relationship, and uses the resulting images, and the process of producing them, to help a client express, contain, and reflect on emotional experience. The profession's standard reference defines it as the therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or challenges in living, and by people who seek personal development (Malchiodi, 2012). Two features separate it from ordinary art class or recreation: the presence of a clinician who reads the work therapeutically, and the intent that the activity be remedial rather than instructional or diversionary.

Because MeSH files art therapy beneath psychotherapy at tree position F04.754.070, the scientific questions that attach to psychotherapy attach to it as well: does it produce benefit beyond the passage of time, how much, for whom, and by what mechanism. What makes art therapy a distinctive case is its wager that a nonverbal, sensory, and symbolic medium can reach material that verbal therapies approach only indirectly, an idea that is at once its central promise and the hardest thing about it to test.

Two Founding Traditions

Art therapy in the United States grew from two women whose ideas about why art heals were opposed, and the tension between them still organises the field. Margaret Naumburg, often called the mother of the profession, came to it from psychoanalysis and treated the image as a form of symbolic speech. In her dynamically oriented art therapy, spontaneous drawing bypasses the censorship of ordinary language and gives direct expression to unconscious wishes and conflicts, which the therapist and client then interpret together much as they would a dream; the art is a road to insight, and the healing follows from making the unconscious conscious (Naumburg, 1966). This is the tradition later called art psychotherapy: art in the service of a fundamentally verbal, insight-oriented treatment.

Edith Kramer, working chiefly with children, rejected the emphasis on interpretation. For her the therapeutic action lay not in decoding the image but in the act of making it. Through what she called sublimation, the child transforms raw impulse into a formed, socially valued object, and the discipline of shaping difficult feeling into art is itself the cure; the therapist's role is to support that formative process, not to translate it into words (Kramer, 1971). Kramer named the therapist's supportive contribution the third hand, the help that furthers a client's own image without imposing the clinician's content or aesthetic. Her tradition is called art as therapy. The contrast, art as a route to insight against art as inherently healing making, is the field's founding axis, and most contemporary practice blends the two rather than choosing between them. Figure 1 places the two traditions at the ends of that axis.

The Expressive Therapies Continuum

If the two traditions supply art therapy's clinical philosophy, the Expressive Therapies Continuum supplies its working theory of media. Introduced by Sandra Kagin and Vija Lusebrink, the continuum arranges the ways a person interacts with art materials on a developmental hierarchy of information processing, from the simplest and most embodied to the most abstract (Kagin & Lusebrink, 1978). It has three principal levels, each a paired dimension. The kinesthetic/sensory level is the most basic, engaging movement and tactile sensation, the rhythm of scribbling or the feel of wet clay. The perceptual/affective level concerns form and emotion, organising a composition and expressing feeling through it. The cognitive/symbolic level is the most complex, involving analytic thought and personal symbol. A fourth, the creative level, can emerge at any point and integrates the others.

The continuum's clinical value is that it links a medium to the mental process it recruits. Fluid materials such as wet paint invite kinesthetic and affective engagement and can loosen a rigid or over-controlled client; resistive materials such as pencil or hard clay demand perceptual and cognitive structure and can contain a client who is flooded with feeling. Lisa Hinz's widely used synthesis turned the continuum into a practical framework for assessment and for choosing materials to move a client toward a level they underuse (Hinz, 2020). The idea gives art therapy something most creative therapies lack: an explicit, testable account of why a particular material, offered at a particular moment, should have a particular psychological effect. The first demonstration lets a reader move through the continuum's levels and see the process and material each one recruits.

The Neuroscience of Art Making

For most of its history art therapy justified itself clinically rather than physiologically, but a body of experimental work now gives the practice a measurable bodily footing. The most cited result concerns stress hormones. Girija Kaimal and colleagues measured salivary cortisol before and after forty-five minutes of open studio art making and found that most participants showed lower cortisol afterward, a reduction that did not depend on prior artistic skill, indicating that the act of making art, not the quality of the product, carried the physiological effect (Kaimal et al., 2016). A companion study used functional near-infrared spectroscopy to record blood flow in the brain's medial prefrontal cortex, part of the reward pathway, while participants coloured, doodled, and drew freely; all three activities raised reward-pathway activation relative to rest, with doodling producing the largest measured response (Kaimal et al., 2017).

Structural and connectivity evidence points the same way. In a randomised study of older adults, Anne Bolwerk and colleagues compared ten weeks of visual art production with ten weeks of cognitive art evaluation and found that only the production group showed increased functional connectivity between prefrontal and parietal regions of the brain's default mode network, along with improvements in psychological resilience, suggesting that the generative act of making has effects the receptive act of appreciating does not (Bolwerk et al., 2014). Together these studies convert art therapy's old clinical intuition, that making is itself curative, into physiological hypotheses that can be tested, and they begin to explain why the founders who emphasised the process may have been onto something. The second demonstration reproduces the qualitative pattern of the reward-pathway study across its three drawing tasks.

The Evidence Base

Whether art therapy works, in the sense that controlled trials can establish, is a harder question than whether it engages the body, and the honest answer is that the evidence is positive but uneven. An early review of outcome studies concluded that art therapy showed promise across a range of populations and problems but that the literature was dominated by small, methodologically weak studies from which firm conclusions could not be drawn (Slayton et al., 2010). A decade later Dafna Regev and Liat Cohen-Yatziv surveyed the controlled trials in adults and reported genuine progress, with a growing number of randomised studies showing benefit for conditions including depression, anxiety, and the sequelae of trauma, while still noting that effect sizes varied and that the field needed larger and better-designed trials (Regev & Cohen-Yatziv, 2018).

The most rigorous economic appraisal illustrates the tension between promise and proof. A United Kingdom health technology assessment reviewed art therapy for people with non-psychotic mental health disorders and found some evidence of clinical benefit but too much heterogeneity and too few high-quality trials to establish cost-effectiveness with confidence (Uttley et al., 2015). More recent syntheses are warmer: a review of art therapy as a complementary treatment for mental disorders catalogued positive results across depression, anxiety, trauma, and cognitive impairment while repeating the standard caution about study quality (Hu et al., 2021). The overall picture is of a treatment with a credible and broadening evidence base whose average effect is real but whose precise magnitude remains poorly pinned down. The third demonstration turns a controlled trial's response rates into the number needed to treat, the clinician's measure of how large that effect is.

Applications Across Populations

Art therapy's nonverbal medium makes it especially suited to people for whom talking is difficult, and the strongest applied evidence clusters in exactly those groups. In trauma, a systematic review of art therapy for traumatised adults found consistent reports of reduced trauma symptoms and improved emotional regulation, attributing the benefit partly to art's capacity to externalise and contain overwhelming memory without requiring it to be narrated (Schouten et al., 2015). The same nonverbal quality underlies its use in dementia, where a review of art therapy for Alzheimer's disease and other dementias reported improvements in mood, engagement, and behavioural symptoms, and argued that art making draws on capacities preserved late into the disease when language and memory have failed (Chancellor et al., 2014).

With children and adolescents, for whom play and image are more natural than clinical conversation, a systematic narrative review found that art therapy addressed psychosocial problems through identifiable means, the properties of the materials, the forms of expression they permit, and the therapist's stance, and it began to specify the mechanisms by which those elements produce change (Bosgraaf et al., 2020). Across these populations the recurring theme is that art therapy earns its place not as a general-purpose substitute for verbal treatment but as a specific tool for the specific problem of reaching experience that words cannot.

Mechanisms of Change

Establishing that art therapy helps still leaves open the deepest question, the one the whole field of creative arts therapies now presses: by what mechanism does it work. A scoping review of the creative arts therapies distinguished the therapeutic factors the field invokes from the mechanisms of change that would actually explain its effects, and mapped candidate mechanisms across the levels at which they might operate, from the neurobiological, through the psychological, to the social (de Witte et al., 2021). Among the mechanisms it identified were emotional regulation, the externalisation of inner states into a shareable object, symbolic distancing that lets a person approach painful material obliquely, and the reward and stress-buffering responses the physiological studies detect.

The mechanism question matters practically as well as theoretically. If the active ingredient of art therapy were known, materials and procedures could be chosen to engage it directly, and the treatment matched to the clients whose difficulty involves that mechanism, exactly the logic the Expressive Therapies Continuum anticipates. What the mechanism literature makes clear is that art therapy is not one thing: the kinesthetic release of working clay, the affective expression of a painting, and the symbolic insight of an interpreted drawing are plausibly different mechanisms recruited by different tasks, which is why a single global verdict on whether art therapy works is less useful than a specification of which task engages which process for which problem.

Current Directions

The most active front in art therapy research is the effort to put its mechanisms on a firm footing, moving the field from demonstrations that it helps toward explanations of how. The scoping review of mechanisms of change is itself the leading edge of that programme, and it sets an agenda: to test whether the emotional-regulation, externalisation, and reward mechanisms it catalogues actually mediate the observed outcomes rather than merely accompanying them (de Witte et al., 2021). This is the creative-arts analogue of the wider turn in psychotherapy research toward mechanism and process rather than branded package.

A second front is the maturing of the neuroscience. The cortisol and reward-pathway findings have prompted a wave of studies using salivary assays, functional near-infrared spectroscopy, and connectivity imaging to ask which features of art making drive the physiological response and whether those responses track clinical improvement (Kaimal et al., 2017). A third is methodological: reviews across populations converge on the same prescription, larger randomised trials with active control conditions, so that the field's real and broadening evidence base can at last support the confident effect-size estimates it still lacks (Regev & Cohen-Yatziv, 2018). The direction of travel is from a practice defended by its founders to a treatment characterised by its data.

Worked Example

The first demonstration makes the Expressive Therapies Continuum concrete. It arranges the three principal levels as a vertical hierarchy, kinesthetic/sensory at the base, perceptual/affective in the middle, cognitive/symbolic at the top, with the integrative creative level alongside. Selecting a level displays the mental processes it recruits and the kind of material that invites it, so that choosing wet paint lights the kinesthetic and affective levels while choosing a sharp pencil lights the perceptual and cognitive ones. The demonstration encodes no arithmetic; it encodes the continuum's central claim, that a material and the process it recruits are two views of the same thing.

The second demonstration turns the reward-pathway study into a comparison. It shows the relative activation of the brain's reward circuit for the three tasks Kaimal and colleagues compared, coloring, doodling, and free drawing, each raised above the resting baseline, with doodling highest, reproducing the qualitative pattern the study reported. Selecting a task highlights its bar and states that all three forms of self-expression engaged the reward pathway, the finding that gives a physiological reading to the old clinical claim that the act of making, whatever its product, is intrinsically rewarding.

The third demonstration reads a controlled trial as a clinician would. Suppose an art therapy arm produces a response in half of its patients while a control arm produces a response in thirty percent. The risk difference is the difference between these proportions, 0.50 minus 0.30, which is 0.20, meaning that art therapy produces an extra response in twenty of every hundred patients treated. The number needed to treat is the reciprocal of the risk difference, one divided by 0.20, which is 5: on these figures, five patients must receive art therapy for one additional person to respond who would not have responded under the control condition. Raising the control response to forty percent while the treatment holds at forty-five percent shrinks the risk difference to 0.05 and inflates the number needed to treat to 20, the arithmetic that shows why a small advantage over an already-effective comparator is clinically modest even when it is real. The slider moves both response rates and reads the risk difference and the number needed to treat straight off them.

Discussion

The scientific study of art therapy recapitulates, in miniature, the arc of psychotherapy research as a whole. It began with two charismatic founders and rival theories of why the practice heals, matured through descriptive and case-based justification, and has lately submitted itself to controlled trials, physiological measurement, and the discipline of the mechanism question. The founding opposition between Naumburg's art psychotherapy and Kramer's art as therapy turns out to have been an early version of the field's enduring divide, between locating the cure in insight and locating it in process, and the Expressive Therapies Continuum can be read as an attempt to dissolve that divide by mapping both insight and process onto a single scale of information processing. Table 1 sets the field's central concepts side by side.

Read as a whole, the art therapy literature is a case study in a practice becoming a science: keeping the clinical wisdom of its founders while demanding that their claims be measured. The physiological studies have begun to vindicate the intuition that making is intrinsically therapeutic, and the outcome reviews have established a real if imprecisely quantified benefit. What remains is the harder programme the mechanism reviews set out, of identifying which feature of art making produces which effect for which person, so that the treatment can be prescribed by process rather than offered as an undifferentiated whole.

Common Misconceptions

That art therapy requires artistic talent.

It does not. The cortisol study found the physiological benefit of art making was unrelated to prior artistic experience, and the whole tradition of art as therapy locates the effect in the process rather than the quality of the product (Kaimal et al., 2016).

That art therapy is just doing art to relax.

It is a form of psychotherapy delivered by a trained clinician within a therapeutic relationship, defined by its remedial intent and clinical framing rather than by the activity alone (Malchiodi, 2012).

That the image must be interpreted to be therapeutic.

Interpretation belongs to Naumburg's art psychotherapy, but Kramer's art as therapy holds that the formative act itself, not its decoding, carries the benefit, and much practice never interprets the work at all (Kramer, 1971).

That the evidence is either conclusive or worthless.

Systematic reviews find real benefit for several populations while cautioning that samples are small and designs weak; the honest reading is a credible, broadening evidence base with imprecise effect sizes, not proof and not nothing (Regev & Cohen-Yatziv, 2018).

Glossary

Art as therapy.

Kramer's tradition, holding that the therapeutic action of art therapy lies in the act of making itself rather than in interpreting the product, and that forming raw impulse into art is intrinsically curative.

Art psychotherapy.

Naumburg's tradition, treating the spontaneous image as symbolic speech that bypasses verbal censorship, to be interpreted with the client as a route to unconscious content and insight.

Cognitive/symbolic level.

The most complex level of the Expressive Therapies Continuum, engaging analytic thought and personal symbol, recruited by materials that demand planning and structure.

Creative level.

The integrative level of the continuum, which can emerge at any point and combines the kinesthetic, perceptual, and cognitive dimensions in a single fully engaged act of making.

Default mode network.

A set of interacting brain regions active during self-referential rest, whose prefrontal-parietal connectivity increased after visual art production in a randomised study of older adults.

Expressive Therapies Continuum.

A framework arranging interactions with art media on a hierarchy of information processing, from kinesthetic and sensory, through perceptual and affective, to cognitive and symbolic, with an integrative creative level.

Functional near-infrared spectroscopy.

A noninvasive imaging method that measures blood flow near the brain's surface, used to record reward-pathway activation in the medial prefrontal cortex during art making.

Kinesthetic/sensory level.

The most basic level of the continuum, engaging movement and tactile sensation, recruited by fluid or tactile materials such as wet paint and clay.

Number needed to treat.

The reciprocal of the risk difference between a treatment and its control, giving the number of patients who must be treated for one additional favourable outcome; smaller values mean a larger effect.

Perceptual/affective level.

The middle level of the continuum, concerned with organising visual form and expressing emotion through it, intermediate between embodied sensation and abstract thought.

Reward pathway.

The brain circuitry, including the medial prefrontal cortex, that signals reward and reinforcement, shown to activate during coloring, doodling, and free drawing.

Risk difference.

The difference between the response proportions of a treatment group and a control group, the absolute measure of a treatment's benefit from which the number needed to treat is derived.

Salivary cortisol.

A stress hormone measurable in saliva, used as a physiological index of stress; most participants showed lowered levels after forty-five minutes of art making.

Sublimation.

The transformation of raw impulse into a formed and socially valued product, which Kramer held to be the mechanism by which the making of art becomes therapeutic.

Third hand.

Kramer's term for the art therapist's skilled help in furthering a client's own image, supporting the work without imposing the therapist's content or aesthetic.

Key Researchers

Lisa D. Hinz. Faculty at Dominican University of California; author of the standard synthesis of the Expressive Therapies Continuum as a practical framework for assessment and material selection. ORCID - Google Scholar

Girija Kaimal. Professor at Drexel University's College of Nursing and Health Professions; leads the neuroscience of art therapy, including the cortisol and functional near-infrared spectroscopy reward studies. ORCID - Google Scholar

Edith Kramer (1916-2014). Founder of the art as therapy tradition and the graduate art therapy program at New York University; introduced the concepts of sublimation and the third hand. Wikipedia - Wikidata

Vija B. Lusebrink (1924-2022). Professor emeritus at the University of Louisville; co-developed the Expressive Therapies Continuum and wrote on imagery and the visual brain in art therapy. Library of Congress

Cathy A. Malchiodi. Founder and director of the Trauma-Informed Practices and Expressive Arts Therapy Institute; editor of the standard Handbook of Art Therapy and a leading voice on trauma-informed practice. Google Scholar - Wikipedia - Wikidata

Margaret Naumburg (1890-1983). Founder of dynamically oriented art therapy in the United States and often called the mother of the profession; established the image as a route to unconscious content. Wikipedia - Wikidata

Dafna Regev. Faculty at the University of Haifa's School of Creative Arts Therapies; reviews the effectiveness of art therapy with adults and studies the factors that make it work. ORCID - Google Scholar

Frequently Asked Questions

What is art therapy? It is a form of psychotherapy in which making visual art, guided by a trained clinician within a therapeutic relationship, is the primary means of helping a person express and work through psychological distress (Malchiodi, 2012).

Do I need to be good at art to benefit from art therapy? No. A study measuring stress hormones found that the reduction in salivary cortisol after art making did not depend on prior artistic experience, and the practice locates its benefit in the process rather than the quality of the product (Kaimal et al., 2016).

What is the difference between art psychotherapy and art as therapy? Art psychotherapy, from Naumburg, treats the image as symbolic speech to be interpreted for insight, while art as therapy, from Kramer, locates the cure in the act of making itself; most practice blends the two (Kramer, 1971).

What is the Expressive Therapies Continuum? It is a framework that arranges the ways people interact with art materials on a hierarchy of information processing, from kinesthetic and sensory, through perceptual and affective, to cognitive and symbolic, so that a material can be matched to the process a client needs to engage (Kagin & Lusebrink, 1978).

Does art therapy have measurable effects on the brain and body? Yes. Brief art making has been shown to lower salivary cortisol and to activate the brain's reward pathway, and ten weeks of art production increased functional connectivity in a brain network associated with resilience (Bolwerk et al., 2014).

Is art therapy effective, according to research? Systematic reviews report genuine benefit across depression, anxiety, trauma, and cognitive impairment, while cautioning that many studies are small and methodologically weak, so the effect is real but its precise magnitude remains uncertain (Regev & Cohen-Yatziv, 2018).

Who is art therapy especially useful for? Its nonverbal medium suits people for whom talking is difficult, and the applied evidence is strongest for traumatised adults, people with dementia, and children and adolescents (Schouten et al., 2015).

How does art therapy actually work? Reviews of the creative arts therapies identify candidate mechanisms including emotional regulation, the externalisation of inner states into a shareable object, symbolic distancing, and the reward and stress-buffering responses that physiological studies detect (de Witte et al., 2021).

References