What is Art Therapy?
What is art therapy? A rather legitimate question, often asked of me, to which I decided to respond by providing an overview of art in general and its transformation into a professionally recognized therapeutic tool.
Art therapy is an intervention aimed at helping and supporting individuals, where the therapist and patient use artistic tools within the therapeutic artistic process. It is important to emphasize the difference between verbal language, with its associated areas, and visual language, which brings emotions, feelings, and the patient’s experiences to light without intellectual mediation, through the artistic creation, in line with Paul Klee’s words: “Art does not reproduce what is visible, but makes visible”[1].
In artistic work, the patient, with artistic tools such as clay, watercolor, pencils, pastels, etc., can process their experiences through a therapeutic path without verbalization. The setting involves the therapist, the patient, and the artistic tool, connected through the therapeutic artistic process.
From Art to Art Therapy
Art is a free expression of humans who create not for a useful purpose but to resonate with their spiritual and soulful urges. The Lascaux cave represents the official birth of art[2]. Through the creation of the first artistic expressions, we see the emergence of man as such and the end of his primitive life, close to an animal condition. Art thus began its journey 18,000 years ago through various cultural epochs, initially covering celebratory, religious, political, educational, and commemorative functions, while the figure of the artist remained anonymous until the Renaissance. During the Renaissance, the artist’s figure finally emancipated from the craftsman, to whom they had been equated until then. The perception of art and the artist’s role changed. Art now has a more intimate and individualized function, such as in state portraits, and it enters the realm of the liberal arts, transitioning from idealization to individualization, visible in the increasingly realistic and contextualized portrait productions. Art has its own way of knowing and exploring, using its own language to reach truths otherwise unattainable. Art investigates the movements of the soul with Leonardo, while nature becomes something to grasp consciously[3], with Michelangelo[4] addressing willpower, the world in his Florence, and feelings with Raphael. The Flemish school sees the birth of oil painting, deeply extracting human interiority and bringing it to the surface through layers of color. Self-portraiture emerges in Flanders, and perspective is born in Italy, placing man at the center. With Rembrandt’s chiaroscuro, we see the soul struggling to be brought to light, progressively emerging, layer after layer, to reveal itself, to be grasped consciously. The relationship between work and artist is now intimate and revealing, a tool of investigation culminating in self-portraiture. From this point onward, art increasingly becomes a relationship, revelation, and knowledge, both real and concrete, while simultaneously responding to inner tensions and revealing a therapeutic, transformative element for the creating artist and for those who encounter the work[5]. Initially, the therapeutic aspect was left to the artist, to those with a particular inclination and training, later revealing a connection between genius and madness in the Romantic era.
With the birth of the first psychiatric institutions[6], some psychiatrists noticed patients’ need to express themselves through artistic creations, observing interesting aesthetic and diagnostic outcomes. This led to the first attempts at systematic classification of patients’ creations. Art studios were established in psychiatric institutions. With the spread of psychoanalysis in the early twentieth century, the use of art in therapy began to gain importance, revealing the genuinely therapeutic aspect of artistic creation. From the Bauhaus to Terezin, with Friedl Dicker-Brandeis, artist and educator, art became a therapeutic tool to make the concentration camp experience more humane. The ability to perceive beauty even in critical and desperate situations made a difference; those who, despite their fragility, could turn to a realm of spiritual freedom and inner richness had a better chance of surviving the concentration camp[7]. Knowing how to see beauty and cultivate an aesthetic sense are capacities that make the difference between life and death, as Viktor E. Frankl explains. Beauty indeed has therapeutic capabilities. Also noteworthy is the Closlieu Studio created by Arno Stern to accommodate war orphans, a project that once again highlights the therapeutic aspect of artistic creation[8]. Art therapy now has its own identity, characterized by its dual artistic and therapeutic nature. Detached from purely aesthetic needs typical of art, it reveals its effectiveness in the therapeutic relationship with the patient through the artistic process.
Salutogenesis
Art therapy addresses the vital and healthy part of the patient, a vision that in the medical field leads to the paradigm of salutogenesis, which, unlike pathogenesis, is a model centered on the concept of health and well-being. It was developed by Israeli sociologist and physician Aaron Antonovsky (1923-1994). Pathogenesis investigates the causes of disease, while salutogenesis seeks the causes of health, what allows a person to stay healthy. The central point is not to preserve the individual at all costs from a virus or disease but to enable them to face and overcome traumatic events. In Antonovsky’s research on a group of Holocaust-surviving women who enjoyed great health, it became clear that the important point is not avoiding illness but being able to overcome it by integrating it into an experience.
So what are the requirements for maintaining health? Rudolf Steiner as early as 1920 hoped that medicine would be integrated into a broader context and that the physician would see the patient as part of the whole humanity, an individual embedded in a social fabric composed of various relational, spiritual, and economic aspects. Every individual is influenced by and influences the context in which they live. Connection to a broader vision is itself a salutogenic factor, as it situates the individual in a context, giving meaning to both. Conversely, separation from the social fabric, a fragmented view of existence and how the individual lives separated in the world, promotes disease and is a symptom that can become an illness within a healthy evolutionary path. Disease is thus seen as a separation of a part from the whole, a process that works independently within the biological organism or the social organism—one aspect cannot be considered without the other. Integrity, meaning, and purpose are connected in this broad vision that promotes health. Within this paradigm, which completely overturns the mechanistic view of disease, the ability to transform an experience, no matter how traumatic and painful, naturally emerges as a way to move forward, integrating it. In recent years, this aspect has found a kind of synthesis in the term resilience. In reality, resilience is the ability of a material to absorb impact without breaking. However, a series of steps must follow to bring trauma to transformation and subsequent integration, to metamorphose the experience.
What ultimately promotes health from a preventive perspective? According to Aaron Antonovsky’s research: cultivating a religious sense, spiritual knowledge; cultivating rich, healthy relationships; being secure on a physical level[9].
Art or Therapy?
The relatively recent nature of art therapy makes it difficult to integrate this therapeutic practice within the world of medicine. We have discussed salutogenesis as a new paradigm emerging in medicine as an alternative to pathogenesis, but how does medicine view art as therapy? Science as a whole is based on the empirical method, hence the reproducibility of results following observations in a controlled environment. The result is acquired according to criteria of quantity, weight, and measurement.
This, in general, and with some simplification.
Art therapy, as clinical art therapy, faces a question: “How can the result of an artistic therapeutic process be measured?”
Steiner, with his work on the renewal of the arts, paved the way by highlighting the objectivity of color, the laws underlying form, and placing art therapy tools in a broader context. In Goethe’s theory of colors, we see the sensitive and moral action of color[10], studies that were later taken up and developed by Steiner[11] to objectify certain aspects of art.
In a methodological practice of scientific observation based on the Goethean method and objectively recognized elements such as the essence of color, form, graphic sign, there is—within the artistic therapeutic process—a unique element every time, the individual. Each biography is indeed absolutely unique. Therefore, in art therapy, we find coexisting “scientific” aspects that can be traced to parameters on one hand and entirely unique and unrepeatable aspects, traceable exclusively to the individual, on the other.
Art therapy thus lacks, from the current scientific standpoint, reproducibility. We must take this into account, even though, thanks to some clinical studies such as:
– Harald J. Hamre et al., Anthroposophic Art Therapy in Chronic Disease: A Four-Year Prospective Cohort Study[12];
– Joshua N., Rainbow T. H. Ho, Effects of Clay Art Therapy on Adults Outpatients with Major Depressive Disorder: A Randomized Controlled Trial[13],
one can establish a measurable benefit in practicing art therapy:
– Patients receiving anthroposophic art therapy had long-term reduction of chronic disease symptoms and improvement of quality of life[14].
– The positive results demonstrated that short-term therapeutic clay work treatment guided by art therapy can supplement pharmacological treatment, not only in symptoms reduction, but also in positively strengthening daily functioning (Choi & Park, 2012) and enhancing personal strength, intra-personal and inter-personal connections (Sholt & Gavron, 2006)[15].
In this sense, as both art and therapy, art therapy must meet the dual challenge of following a scientifically acceptable methodology while maintaining the typical aspect of art, which is to be unique and distinctive, respecting the individuality and journey of each patient. This intrinsic polarity in art therapy is what the therapist must grapple with, the epistemological aspect.
Art Therapy and Oncology
In the oncology field, clinical art therapy can contribute by addressing the typical needs of patients facing a critical moment, accompanying them throughthe stages of the disease. If we follow the salutogenic perspective, we must consider not only the body but also the broader context, situating the individual in the whole, a complete picture that requires the patient to address and consider their inner resources to face the illness and the treatment process. With the patient’s consent, the therapeutic path can begin with simple artistic activities, including painting, drawing, and modeling. The patient has the opportunity to express themselves artistically, accompanied by the therapist, allowing the disease process to integrate into the patient’s experience, which brings healing. This practice and artistic therapy for oncology patients should be seen as part of a broader holistic care that combines pharmacological, surgical, and psychological interventions. The art therapist, therefore, works in collaboration with other medical and psychological professionals in an interdisciplinary manner, acting in specific contexts with the full support of the medical team, starting from the analysis of the individual’s situation and diagnosis, to intervene on both the emotional and cognitive levels.
Ultimately, art therapy, within the oncological therapeutic path, must aim to help the individual integrate their experience of illness and treatment, enabling them to continue their life journey as far as possible. A crucial aspect to highlight is the need for training the entire medical and paramedical team to accompany the individual in the therapeutic artistic process.
Art Therapy: A Cure for Life
“Being silent, listening, being present”[18] through the artistic therapeutic process, accompanying the patient, are fundamental elements of the art therapy workshop. “Death and dying” is something individual for each person, but it also has recurring aspects: the involvement of the family, the staff, the caregivers, and the patient’s need to leave a mark. This need is fulfilled through the artistic work that remains as a bridge and a testament. Art therapy, as in the case of J., an 11-year-old girl, accompanied the patient in her final moments, responding to her request to leave a mark through a series of works created a few days before being admitted to hospice. J. had decided to prepare pieces for her siblings and her friends. The artistic work takes on vital importance in the last moments of life, both for the patient and the family, as it is the last tangible trace that remains.
“We cannot help patients in this part of life if we deny that there will be really hard moments”[19], and art therapy has the potential and tools to reach, through the artistic therapeutic process, up to the threshold, addressing the patient’s needs, their fears, emotions, and the awareness that confronts us and the need to engage with the spiritual aspect, without going through words[20].
Differences Between Occupational Therapy and Art Therapy
Occupational therapy, which can be organized within the hospital by setting up an art workshop, differs significantly from art therapy, even though both use artistic tools such as paint, clay, chalk, and all the materials that an occupational therapy workshop typically uses. Beyond this shared aspect—materials—art therapy diverges from an occupational or recreational art workshop because the art therapist conducts a patient assessment, diagnoses, and sets therapeutic goals through an artistic therapeutic path that occurs within an artistic process. The patient has their own medical record where progress and the evolution of the journey are documented. The art therapist, where conditions allow, ideally works in a team with other professionals such as the attending physician, clinical psychologist, nursing staff, social and healthcare workers, and educators.
While an art workshop serves an entertainment function, an art therapy workshop has a therapeutic purpose and can be sought out by anyone wishing to undertake a personal journey, whether they are going through a crisis, illness, stress, or simply wish to stay centered, as a good practice of mindfulness.
Behind the search for health that every patient
seeks with the doctor and the therapist, there is the request:
“Help me find in the therapeutic process
the deepest core of my being because I am not just my illness […]
Help me understand the meaning of my illness
and face it creatively.”
Thus, the illness for the future can be
what the resource of art is for the artist: a task!
—Marianne Altmaier
[1]P. Klee, Creative Credo, in: Paul Klee, Notebooks Volume 1 The thinking eye, Lund Humphries, London, 1969, pag. 76 (trad. italiana: P. Klee, Confessione creatrice e altri scritti, Abscondita, Milano, 2019).
[2] Georges Bataille Lascaux. La nascita dell’arte, Abscondita, Milano, 2020.
[3] Karl Jaspers, Leonardo Filosofo, Abscondita, Milano, 2001.
[4] Häussler, H. G., Il segreto della forma in Michelangelo. Le figure della Sagrestia nuova, Venezia, Edizioni Arcobaleno, 2002.
[5] Steiner, R., Storia dell’arte, specchio di impulsi spirituali, 5 voll., Milano, Editrice Antroposofica, 1991-1997.
[6] Tratto da: <https://lyceum.it/academy/arteterapia-clinica/origini-dellarteterapia/>.
[7] Viktor E. Frankl Uno psicologo nei lager, Edizioni Ares, Milano 2013, pag.72.
[8] Arno Stern da: <https://arnostern.com/it/biografia.htm>.
[9] I rimandi obbligati sono: Antonovsky, A., Health, stress and coping, San Francisco, Jossey-Bass, 1979; Id., Unraveling the mystery of health, San Francisco, Jossey-Bass, 1979. Una esposizione divulgativa del lavoro di Antonovsky e dei tre principi sopraindividuati si può trovare in: Glöcker, M., Salutogenesi: le fonti della salute fisica, psichica e spirituale, in: liberascuola-rudolfsteiner.it <http://www.liberascuola-rudolfsteiner.it/2017/12/30/salutogenesi-le-fonti-della-salute-fisica-psichica-e-spirituale/> (2017)
[10] Goethe, J. W., La teoria dei colori, Milano, Il Saggiatore, 2014, pagg. 189-214.
[11] Steiner, R., L’essenza dei colori, Milano, Editrice Antroposofica, 2013.
[12] In: EXPLORE, Volume 3, Issue 4, July 2007, pagg. 365-371.
[13] In: Journal of affective disorders, Volume 217, 1 August 2017, pagg. 237-245.
[14] Harald J. Hamre et al., Ibidem, Abstract.
[15] Joshua N., Rainbow T. H. Ho, Ibidem, 4.1. Significance of the study.
[16] E. B. Elimimian, L. Elson, R.S.Butler, M.Doll, S. Roshon, C.Kondaki, A.Padgett and Z. A. Naheh A pilot study of improved psychological distress with art therapy in patients with cancer undergoing chemotherapy:
< https://bmccancer.biomedcentral.com/track/pdf/10.1186/s12885-020-07380-5.pdf >
[17] Kristina Geue, Heide Goetze, Marianne Buttstaedt, Evelyn Kleinert, Diana Richer, Susanne Singer An overview of art therapy interventions for cancer patients and the result of research:
< https://www.sciencedirect.com/science/article/abs/pii/S0965229910000373>
[18] Cicely Sunders Vegliate con me hospice un’ispirazione per la cura della vita, Itinerari EDB, Aprile 2008, pag. 44
[19] Ibidem, pag. 41.
[20] Cambridge University Press Art Therapy for terminal cancer patiences in a hospice palliative care unit in Taiwan <https://www.cambridge.org/core/journals/palliative-and-supportive-care>
