Tilburg University College

Art Therapy and Depression

To what extent does art therapy treat depression compared to other forms of therapy?

Supervisor Second Reader Lieke Wijnia David Janssens

Created by Anique van Gorp 2003279

June 15, 2019

Abstract

Art therapy is a relatively new form of therapy that integrates the fields of psychology and creative arts. This form of therapy aims to unravel people’s unconscious desires through arts – drawing, clay, music – in order to treat patients from any kind of illness they are facing. Research has shown that even though art therapy is known to be an increasing popular substitute for other forms of therapy, it is still questioned how exactly art therapy assists in the healing process of its patients, and what it is that makes this treatment more effective than other forms of therapy. To answer these questions, the purpose of this thesis will be to explore the effectiveness of art therapy in relation to depression. I have chosen to focus on depression as a medical illness because it is a critical mental illness that is often overrated, and experts are still seeking answers on how to treat depression. Moreover, as a personal reason, depression is something that I have faced, and am still facing, for the last couple of years.

To investigate art therapy and its effectiveness in treating depression compared to other forms of therapy, primary and secondary research will be conducted to collect relevant and valuable data. Analysis of primary and secondary research completed in this thesis shows that there are many theories on the question of what makes art therapy different from other forms of therapy and why it is considered to be a more effective form of therapy. This is because art therapy has a different name and different way of dealing with its patients in every place of the world. Ultimately, even though there is a variety of experts claiming to know the potential healing effect of art therapy, despite this variety, in this thesis I argue that art therapy is a valuable therapeutic method for treating depression and deserving of more future research.

Acknowledgements

I would like to thank various people for their input and assistance to this thesis. First of all, I would like to thank Ms. Wijnia for her guidance and constructive feedback. Her assistance and willingness to invest time in this project is greatly appreciated. Moreover, I would also like to thank Mr. Janssens for putting in time to act as a second reader to this thesis.

Furthermore, I would also like to thank the following people for their contribution to this thesis; Ms. Sam for sharing her insightful knowledge on art therapy, Ms. Diepstraten for her enthusiastic contribution and assistance, and, finally, Mr. Oostelbos for sharing his work experience on depression, and thereby bringing extensive value to this project.

Table of Contents

Abstract ...... 2

Acknowledgements ...... 3

1. Introduction ...... 5

2. The Evolution of Art Therapy ...... 9 1. Historical Development...... 9 2. Current manifestations ...... 11

3. The Effectiveness of Art therapy in Treating Depression (compared to other forms of therapy) ...... 14 1. Philosophical and Psychological perspectives ...... 14 2. Primary Research and comparative findings ...... 19

4. The Healing Effects of Art Therapy ...... 25 1. Philosophical and psychological perspectives ...... 25 2. Primary research and comparative findings ...... 33

5. Conclusion...... 36

Citations ...... 38

Appendix...... 44 Appendix 1: Fragments of interview with Ingemarie Sam (29/11/18) ...... 44 Appendix 1.1 ...... 44 Appendix 1.2 ...... 44 Appendix 1.3 ...... 44 Appendix 2: Fragments of interview with Arja Diepstraten and Peter Oostelbos (06/03/19) ...... 45 Appendix 2.1 ...... 45 Appendix 2.2 ...... 45 Appendix 2.3 ...... 46

1. Introduction

Throughout history, art has proven to have the ability of treating numerous pathological states. According to famous philosophers such as Aristotle (384-322 BC) and Pythagoras of Samos (570- 495 BC), art has therapeutic abilities (Troll, 2001, p. 265). For example, Aristotle, an ancient Greek philosopher, believed that art appeals to the emotions and imitates human interactivity, life and nature (Stanfield, 2015). In life people do not always understand what is happening around them. There are still so many things that the human mind cannot understand. Art has the ability to make us understand our surroundings. Imitating an object of nature or the unknown in art, according to Aristotle, bring us closer to our definition of perfection and understanding. This brings out a whole new reality to the painter and observer of the art piece. Moreover, according to Pythagoras, an ancient Greek philosopher, music that is ordered by numbers “represents the harmony of the cosmos and […] the compositions of universe and man” (Brooke, 2006, p. 169). Therefore, Pythagoras argues that music which is “ruled by the same mathematical laws that operate in the visible and invisible world” brings back harmony into the soul (Brooke, 2006, p. 169). From both arguments, it can be observed that many different art forms exist that may be therapeutic to an individual. Before continuing the discussion of the concept of art and its therapeutic abilities, it is important to narrow down what is meant by ‘art’.

The concept of art and its meaning has continually challenged philosophers. What is art? When can something be considered a work of art? Should art be forbidden or allowed in society? Can art be therapeutic? Art is a broad concept and its implications are still challenged today. In this thesis, I want to analyze the creation and reflection of one’s art on the basis of drawings and paintings in a therapeutic setting. Therefore, art such as music, poetry or acting will be ruled out in this thesis.

Art therapy is a relatively new form of therapy which differs from other forms of therapy. According to Elinor Ulman, professor of art therapy at George Washington University, art therapy is a combination of both ‘art’ and ‘therapy’ (Rubin, 2009, p. 25). According to Ulman, one has to define art and therapy separately to be able to define art therapy as a whole. Ulman defines therapy as “procedures designed to assist favorable changes in personality or in living that will outlast the session itself” (Rubin, 2009, p. 25). Moreover, art is defined as “the meeting ground of the inner and outer world” (Rubin, 2009, p. 25). This definition of art

attempts to convey the message that by creating or spectating art, one can learn to understand how things are viewed from the artist’s perspective (the outside world) and adapt these views in one’s own understanding of the world (inner world). By looking at these two definitions as different concepts, the definition of art therapy from the British Association of Art Therapists’ (BAAT) proves to be most appropriate for this essay. According to BAAT, the aim of art therapy is to “…enable a client to effect change and growth on a personal level through the use of art materials in a safe and facilitating environment” (Hogan, 2014, p. 9). This definition proves to be most appropriate, because it an explanation of why art therapy is different from other forms of therapy. Art therapy uses art materials and a safe environment to bring about progress within the individual. This ‘safe environment’ is different in art therapy than other forms of therapy, because the space is “an assembly of possibility, an enactment, and a territory that contributes significance to artworks” (Whitaker, 2017). It is a space where the therapist and patient can use the whole environment for creating different forms of artworks and it is an environment especially designed to express the patient’s creativity and to make him or her comfortable with expressing that creativity. Furthermore, the art therapy’s environment can set the “tone for art therapy’s production and can animate exploration” (Whitaker, 2017). This means that if the patient is normally not comfortable with expressing or showing his art work and emotions, the environment will assist with that. Therefore, the type of setting that is chosen for an art therapy environment is essential, because the environment is an important contribution to the healing process of the patient. Finally, modern medical research has proven that art has the ability to heal certain pathological states, such as depression. It is important to note that art has a role in treating depression, but that it does not necessarily imply a solution.

Art therapy has the capability of treating depression. People that have depression often have a difficult time describing their depression. Also, the level of depression varies with each person, and therefore it is hard to describe how much impact it has on a person’s life. Personally, I agree with Meredith Friedson, a Licensed Clinical Psychologist, who argues that depression can best be described as the loss of meaning. This loss of meaning can take part in many forms. For instance, it can take form in the “loss of identity” or the “loss of relationships” (Friedson, 2017, xix). Also, according to a study on Predicting the Role of the Meaning in Life on Depression […], having a poor meaning in life is associated to several mental health problems such as depression, suicide and helplessness (Garcia-Alandete, 2014, p. 1546). Officially, The National Institute of Mental Health (NIH) defines depression as a

“common but serious mood disorder (The National Institute of Mental Health, 2018). Many people will experience depression in their lifetime, but it must not be taken lightly. For instance, according to the American Foundation for Suicide Prevention, “suicide, [mostly caused by depression or stress] is the second leading cause of death” in 2017 for those between the age of 15 and 34 who live in the United States (American Foundation for Suicide Prevention, 2017). Furthermore, depression consists of several symptoms such as feelings of hopelessness, increasingly feeling tired, being more pessimistic, weight changes, etc. (The National Institute of Mental Health, 2018). Additionally, there are many different forms of depression, including seasonal affective disorder (feeling increasingly depressive during winter) or psychotic depression (someone with depression and some form of psychosis) (The National Institute of Mental Health, 2018). There are many forms and levels of depression to be considered, but for the scope of this thesis I will focus on the concept of depression as a whole. Ultimately, drawing from the above presented perspectives, in this thesis depression is regarded as a problematic mental health disorder that must be dealt with in a serious and cautious manner. As art therapy is thought to have the ability to treat and heal depressed people, it is important to pose the following question, namely, what exactly is the healing effect in the process of art therapy that treats depression?

To heal someone, through therapeutic means, is to treat an individual’s imbalanced or damaged health. There are many theories on what the healing effect in art therapy is and what it exactly entails. For example, Glenda Needs, an art therapist, claims that art itself has the capacity to heal (Needs, 2015). According to her, art is an unexplainable “significant mood regulator” (Needs, 2015). Therefore, Needs argues that the creation of art is a healing process in art therapy. Yet, she does not know how and why making art is a healing process. Therefore, the question remains: what is the healing effect in art therapy? Edith Kramer (1916-2014), psychoanalytic theorist and art therapist, claims that art therapy “has the force to […] amplify the development of the meaning to facilitate the psychic organization of the individual” so that the individual can manage himself in stressful conditions without collecting any damage (Ceausu, 2018, p. 209). However, again, this observation also does not pinpoint what the healing effects that assist in these developments of meaning in the individual are. Ultimately, the identification of the healing factors in art therapy and its treatment in depression is complex and remains a topic of discussion among therapists until this very day.

The main focus of this thesis will be on identifying the healing effects of art therapy, mainly what exactly in art therapy contributes to the treatment of depression, and comparing the effectiveness of treatment of art therapy in relation to depression with other types of therapy. Therefore, my research question for this thesis is,

To what extent does art therapy treat depression compared to other forms of therapy?

Throughout my thesis, I will explore how art therapy developed and why it proves to be a useful treatment for depression. In chapter 2, I will trace the historical development, and the present manifestation of art therapy and how it gradually grew out to be an effective treatment for depression. Next, in chapter 3, I will discuss why art therapy is considered to be a more effective treatment for depression than other forms of therapy. Firstly, in this chapter, I will discuss several philosophers and their views on what makes art therapy effective when it comes down to treating depression. Secondly, I will analyze data gathered from two art therapists and a coach on depression and discuss their views based on the interviews I have done with them. In this chapter, the interviews and qualitative research aim to show the theories and opinions of those qualified in the fields of art therapy and depression. In chapter 4, I identify the healing effects of art therapy in relation to its treatment of depression. This chapter considers the arguments of several philosophers and results of primary data collection that I conducted throughout my research. Ultimately, it seems that every art therapist has his or her own theory on how to treat patients with depression. Cultural and geographical differences affect these different styles of treatment in art therapy. Due to the fact that there are many forms of art therapy, it is difficult to establish an ultimate conclusion on art therapy and its effectiveness in treating depression compared to other forms of therapy. However, overall, figures and theories in this thesis show that forms of art therapy contribute positively to the patient’s treatment in facing his or her depression.

2. The Evolution of Art Therapy

1. Historical Development

Even though art therapy is a fairly new concept, throughout history art has always been used as a communication tool. When people could not talk or write yet, they used drawings as a way of communicating with each other. For instance, the first cave painting ever found was in the El Castillo cave in Cantabria, in Spain, 400,000 years ago (NIMH, 2018). The purpose of the cave drawings is still highly debated but researchers theorize that they were used for religious ceremonies or to communicate with others who lived in the same area. Moving on from this time period, art was used as a tool for self-expression and symbolism. It was not until the 1940s that the use of art was developed into a discipline that is different from its original use (NIMH, 2018). Researchers and scientists now realized that creating and inspecting art has the capability to calm or treat patients with specific mental or physical issues.

The term ‘art therapy’ was coined by Adrian Hill, a British art therapist and author, in 1942 (Hogan, 2001, p. 25). However, as mentioned before, the methods of creating images and using art in therapy were already used before the term came into existence. Therapists started to use artistic practices for therapeutic purposes when they saw it was helpful in “the context of moral treatment, psychoanalysis, and […] part of experiments in modern art” (Hogan, 2001, p. 25). Depending on how treatment in art therapy is conducted, as it will always differ as explained in the next section, it is used to treat patients with a variety of illnesses and conditions, such as head tumors, cancer, depression, and trauma.

Officially, Withymead is the first official art therapy community, which was founded by Irene Champerowne in 1942 in Britain (Hogan, 2015, p. 39). The organization was found after the bombardment of Exeter (Hogan, 2015, p. 39). It has been argued that this community was the most crucial organization in the advancement of art in the field of therapy. The reason for this is that art therapy was never properly introduced before. Therefore, the main aim of the people within the organization of Withymead was to recruit potential art therapists and assist patients who came to them and were thought to need help. Moreover, professionals in the field of any kind of therapy were also welcome to undergo an “informal art therapy training” (Hogan, 2015, p. 39). Professionals sought assistance either because they were eager to learn

about this new form of therapy or they were keener on broadening their horizons due to the aftermath of the bombings. Many victims of the bombardment were assigned therapy, leading to numerous calls on therapists in Britain. Ultimately, an important feature of Withymead was the aim of providing friendly and open relationships between therapists and patients. Such relationships are necessary for the confidence and treatment of the patient.

In secondary literature, the most prominent book that exists on the topic of the history of art therapy is Becoming a Profession (2013) by Dianne Waller. There is a large amount of literature on art therapy in general, yet all of them draw from this book. It explores the historical development of art therapy in Britain from 1940 till 1982 and how it came into existence. Art therapy arose in English-speaking and European countries in the mid-20th century. Even though art therapy arose from the work experience and ideas of individuals from different countries, in Britain the definition was coined and further developed by an organization called The British Association of Art Therapists (BAAT) (B., 2019). BAAT is still an active organization today and they represent art therapists in the UK (B., 2019). They promote the field of art therapy and provide “support and advice to its members” (B., 2019). Therefore, based on this information, Waller’s book is used as the main exploration of the historical development of art therapy.

Art therapy emerged from the fields of psychoanalysis and art academics (Waller, 2013, ch. 8). There are many theoretical and practical models that derived from the concept of art therapy. Hill’s model, which described the process of creating art to be a pleasing and entertaining activity, focuses on the creativity and relaxation processes of art therapy (Waller, 2013, ch. 8). For example, Hill had one particular patient, a Canadian airman who was near the end of his life. Hill encouraged him to try watercolor painting. The relaxation and stimulation that this created for the airman, contributed to an extended life for him (Hill, 1945, p. 59). Moreover, Hill addresses that even if individuals all have a different range of artistic abilities, the creation of one’s own art can increase the confidence in one’s abilities (Hill, 1945, p. 35). Secondly, Irene Champernowne’s model, which attempts to resurface communication of unconscious conflicts through image making, focuses more on the relationship between the mind and art through art therapy (Waller, 2013, ch. 8). According to Waller, Champernowne is one of the intellectual leaders in the history of art therapy (Waller, 2013, ch. 8). Even though she never referred to herself as an art therapist, she combined her analytical psychology with a model of art making. She followed the steps that she used in her

therapy in the context of art therapy. According to Waller, the only thing that she did different in her sessions, was that she asked her patients to bring their work instead of making their work in the sessions (Waller, 2013, ch. 8). There are many more models in the world that have their own definition of what art therapy is and does which will be explained later on throughout the thesis. This also depends on the cultural background and time frame that people come from. Art therapy is still a new form of therapy, and therefore many models, forms and ideas of what art therapy exactly is still different in every country, as will be explored in the next chapter.

2. Current manifestations

Nowadays, art therapy is used to treat many different mental illnesses. Scientists discovered that creating art, reflecting on art and talking about it with a therapist heals and calms, in some ways, the human mind and body. I will explore various manifestations of art therapy, ranging between Asia, the United States and Scandinavia.

Art therapy is a form of therapy that is conducted differently all over the world. For instance, in parts of Asia, art has always been visible in its folk myths, costumes, decoration, and religions (Kalmanowitz, 2012, p. 28). For example, Buddhist art, which was introduced in the Indian subcontinent, portrayed the life of Gautuma Buddha (c. 563/480 – 483 – 400 BCE) (Baroni, 2002). The Buddha was known for being a monk, philosophical teacher and the religious founder of Buddhism (Boeree, 2000). Buddhist art, and the religion itself, quickly spread quickly through the Asian continents. As such, art was an essential part of Buddhist religion. Another example is art that was introduced in the Song Dynasty (960 CE – 1279 CE) in China (Boundless, n.d.). Art was an important part of the social life of the Song Dynasty. Many people traded art, communicated through their art works, and viewed art works. Art in the Song Dynasty brought people together which turned the social life of its people into a vibrant community (Boundless, n.d.). Therefore, the whole concept of understanding and creating art is more apparent in some of the Asian traditions and cultures than any other type of art (for example singing, dancing or creating music). People connect through art, and therefore, art brings people together.

In the United States, art therapy is thought to be formed in the Northeast of the country by Margaret Naumburg and Edith Kramer (Jung, 2010, p. 5). Margaret Naumburg, author one of the first theoreticians of art therapy, called her work “dynamically oriented art therapy” in 1940 (Jung, 2010, p. 5). Dynamically oriented therapy focuses on the unconscious. It attempts, through the use of images and art, to derive one’s thoughts, feelings and emotions (Naumburg, 1966). More will be discussed about dynamically oriented therapy in chapter 4.1 where the healing effects of therapy will be identified through theories of several expert philosophers and psychologists. Edith Kramer, also a theoretician of art therapy, published her first work in 1958, called Art Therapy in a Children’s Community (Kramer, 1958). It was not until the 1960s that the interests in art therapy started to grow in the United States. Art therapists emerged from different disciplines such as “art, psychiatry, and from art education” (Jung, 2010, p. 6). From there on, psychiatrists also began to realize the power of art. For example, psychologists such as Tarmo Pasto, began to collect drawings from psychiatric patients (Jung, 2010, p. 7). Tarmo Pasto realized that the art created by these patients was not dimmed by their mental illnesses. Through these examples, people realized that art therapy had a positive impact on treating, to some extent, certain mental disabilities.

Line Kossolapow, author of Communication European Arts Therapy (2005), claims that almost all countries in Europe have contributed to the development of art therapy. All these different methods that these European countries have developed themselves in the field of art therapy has contributed to the overall image of art therapy in Europe. For example, Kossolapow states that in Norway art therapy has been used in a cancer hospital. Art therapy had a positive effect on the patients, because they could be “active, creative and expressive” despite their illnesses (Kossolapow, 2005, p. 71). Astri Aakrann Ziesler, an art therapist in the department of rehabilitation in the hospital, claimed that a young woman with a tumor was taught, through art therapy, to cope with her illness (Kossolapow, 2005, p. 71). Finland has contributed to the field of therapy by using art therapy in education to teach teenagers with learning difficulties (Kossolapow, 2005, p. 97). In Finland it was quite rare to combine art therapy with its educational system. Nevertheless, the result of this experiment? The participants “grew in their self-identity and developed their social relationships” (Kossolapow, 2005, p. 100). Both examples show that art therapy has developed and benefitted from differently motivated ideas and experiments. Nowadays, art therapists still try to examine to what extent art therapy has an effect on its patients. This can be seen in the European organization called the European Consortium for Arts Therapies Education

(ECArTE). ECArTE is a non-profit organization, founded in 1991, that represents the development of Art Therapy in Europe (E., 2019). It offers education for art therapists. Ultimately, the development of art therapy in Europe seems fragmented but, through organizations such as ECArTE, seems to manage art therapists and their treatments.

In her book, Kossolapow states that many more countries influenced the way art therapy is seen today. These examples show that art therapy is not a “colorless and neutral” concept and that it is hard to universalize it, because there are so many processes developed in art therapy by different organizations and individuals from different places (Kossolapow, 2005, xix). Therefore, nowadays, art therapy is not a concept that can be defined as a universal concept. Every state, country or continent has a different way of conducting art therapy. For instance, in the UK, art therapists have to register with the Health Care Profession Council (HCPC) (Sigal, n.d.). HCPC regulates healthcare professions in the UK. According to the HCPC official website, people must be registered with the HCPC in order to be able to work in the UK (HCPC, 2018). Potential art therapists must show that they meet HCPC’s standard requirements in order to maintain their state registration (Sigal, n.d.). Another example is the American Art Therapy Association situated in the United States (AATA). The AATA is committed to support, “both at the state and national levels”, art therapists and their clients (AATA, 2017). Furthermore, the AATA state that they “appropriate regulations of art therapy” (AATA, 2017). Therefore, the AATA is not only an association that promotes the field of art therapy but also ensures that every patient in the US receives valuable treatment and not one that could potentially harm the patient in any way. These examples show that professional treatments in art therapy are not the same in every state or country, and therefore not universal.

3. The Effectiveness of Art therapy in Treating Depression (compared to other forms of therapy)

1. Philosophical and Psychological perspectives

In this section, I will first discuss the ideas of three scholars, namely philosopher John Dewey (1859-1952), philosopher Christina Blomdahl, and psychologist Kevin R. Cavazos, and evaluate their arguments on why art therapy is considered to be more effective in treating depression than other forms of therapy. I will start off this section with John Dewey, because the main principle of art therapy has evolved around his philosophical theories and findings. Dewey is not necessarily involved in the therapeutic processes of art therapy, but his theories give a relevant insight on why art therapy can be considered to be more effective than other forms of therapy. Next, I will evaluate some of Christina Blomdahl’s reasons that she lists in her experiment on why art therapy is more effective in treating depression. I am discussing Blomdahl’s experimental reasonings, because her findings are a modern outlook on art therapy, as opposed to Dewey’s outlook. Finally, I will discuss the same viewpoints from Kevin Cavazos’s essay on the ‘Therapists’ perspective on the Effectiveness of Art Therapy’. His essay includes many academic resources and neuroscience-based reasoning on why art therapy is becoming increasingly popular when it comes down to treating depression. After this, I will discuss some figures that indicate whether art therapy is, in fact, more effective in treating depression than other forms of therapy. There are many philosophers and psychologists that claim that art therapy is the most efficient way to heal people from depression, but what are such claims based on? By using figures and data from recent experiments conducted by academic researches, I aim to find out whether art therapy can be considered a most effective option to treat depression. The rising popularity of art therapy gives form to a new era of healing and understanding mental health issues such as depression. This is illustrated by an experiment conducted by Lesley Uttley. In this experiment she observed that art therapy is proven to be a more effective treatment for people with depression than other forms of therapy. This section is concluded with Gretchen Graves’ thesis study on the effect that art therapy has on certain mental illnesses. It is important to conclude this section with both Uttley’s experiment and Graves’ thesis study, because Dewey, Blomdahl, and Cavazos’ theories can be applied as reasonable arguments to the outcome of their experiments and thesis.

Maxine Jung gives relevant insights in ‘The Modern History of Art Therapy in the United States’ on why John Dewey (1859-1952), American philosopher and psychologist, has provided an incentive to art therapy. Dewey is known for his “contributions to liberal- democratic theory” and his theory of art and experience (Dewey, 1993, xiv). Firstly, Dewey believes that art is the most important tool of communication (Dewey, 2005, ch. 4). Art is the most essential form of communication, because it learns people “about each other’s similarities and differences”, it breaks barriers of understanding, and it defines the aspects of a community (Mattern, 1999, p. 54). As will be demonstrated in chapter 4.1, communication is an important element of art therapy, because the patient needs to communicate his or her issues to the therapist and communicating one’s issues through art is one step forward to regaining one’s mental health. Secondly, Dewey’s philosophy stated that Progressive Education, a practical educational movement that initiated in the late 19th century, should focus on the ‘whole child’ (Jung, 2010, p. 25). Progressive Education stresses the importance of “learning through doing” (Jung, 2010, p. 25). One learns more about oneself and one’s environment through doing things. Therefore, the Progressive Education movement and Dewey both agree that a classroom should imitate a democratic community where the child can live a life rather than constantly attempting to gain intellectual information. This means that art is considered to be important for the education of the child. It also means that creating art is a necessary step for the self-development of the child. Then, how does this all connect to depression? A patient with depression needs to be in an environment and people who he/she can trust (a democratic community). Patients that face depression need to learn how to live a life again where they feel safe, and this can only be done in a safe environment. By learning through creating art and putting patients in a democratic or safe environment where they can rehabilitate, patients will slowly trust and feel safe again. Next, a more modern viewpoint on the effectiveness of art therapy in the treatment of depression will be discussed.

Blomdahl gives several reasons in her journal article, A Realist Review of Art Therapy for Clients with Depression, why art therapy is considered to be more effective for treating depression than other forms of therapies. Blomdahl’s article reviews other experts who have investigated art therapy and its effectiveness in treating depression. Firstly, she observes that art therapy provides several tools for self-exploration of the individual. Self-exploration assists the individual by increasing awareness of what is happening with (internal) and around (external) oneself. It also assists the individual in increasing “awareness of what affects [him/her] and of response patters occurring in everyday life” (Gunnarson, 2009, p. 167). The

therapist can increase the self-awareness of the patient in several ways. For example, one can create images with the TTM (Three Theme Method). According to Birgitta Gunnarson, TTM is a therapeutic art intervention designed for patients that want to focus on individual development (Gunnarsson, 2015). TTM “develops strategies [for the patient] to become an actor in his or her everyday life” (Gunnarsson, 2015). Ultimately, patients will engage in conscious self-exploration by bringing together mindfulness exercises with art exercises. Secondly, Blomdahl observes how art therapy is a form of self-expression. The patient can use any color and draw anything he or she likes. Art therapy gives away a sense of freedom and peace in the individual that can be developed through making one’s own choices when it comes to creating things. Moreover, expressing one’s unconscious thoughts in drawings, through the use of different colors and symbols, helps the individual to tell his or her story (Trombetta, 2007). Thirdly, she identifies symbolic thinking as an important part of art therapy. Through symbolic thinking, the patient has the ability to think in pictures and symbols. (Blomdahl, 2013, p. 328). Therefore, art can communicate things that the patient is unable to say in speech. Artistic creations, through symbolic thinking, also gives rise to unconscious emotions. Furthermore, by analyzing the art creations of the patient, the therapist will a better idea on how to deal with the patient’s feelings. Lastly, another important part of art therapy is sensory stimulation. Sensory stimulation allows patients to “explore materials with a mindful approach” (Blomdahl, 2013, p. 328). Stimulation through the senses allows patients to delve into their emotional reactions in reaction to the painting materials. By using the senses, one can stimulate certain emotions or different parts of the body (i.e. the brain or mind).

Cavazos discusses in his article, called ‘Therapists’ perspective on the Effectiveness of Art Therapy’, the effectiveness of art therapy in dealing with adolescent depression. He gives several reasons why art therapy is a better way to deal with depression than other forms of therapy. Firstly, art therapy is an effective form of treatment for patients with depression, because “traditionally artists have been known to derive their inspiration from their emotions” (Cavazos, 2012, p. 41). Therefore, it can be easier to convey these emotions through artistic expressions than, for example, through verbal expressions. When given the assignment to draw how one feels, one puts all efforts and emotions in that drawing. This is sometimes harder to do through verbal expression, because language and speech can be more damaging, when facing certain mental health issues, to the brain than art (Zaidel, 2014). Nevertheless, verbalization in art therapy is less damaging, because talking about structural information

takes less effort than respond to semantic information (Koroscik, 1983, p. 23). Semantic information is processed within the individual while responding to structural information, for example a drawing, is portrayed in the outside world. It is easier to verbalize something that oneself has drawn and is portrayed right in front of you. Secondly, art therapy is a healing force for the mind and body (Cavazos, 2012, p. 41). It can be considered a healing force, because “the creative process helps release brain chemicals that fight depression” (Cavazos, 2012, p. 41). Girja Kaimal, assistant professor in the College of Nursing and Health Professions, created a group that used functional near-infrared spectroscopy (fNIRS) technology (Brexel, 2017). fNIRS is used to measure brain activity. In the group they used fNIRS to “measure blood flows” in the brain in reaction to the participants completing a variety of art-related projects (Brexel, 2017). In Kaimal’s experiment, it was concluded that scribbling initiated more brain activity in artists than in non-artists, but “free-drawing was observed to be about the same for artists and non-artists” (Brexel, 2017). Therefore, when a patient starts to draw, his or her brain activities start to increase, which, in turn, creates an easier access to unconscious emotions and memories.

Next, I will discuss Timothy Puetz’s research article Effects of Creative Arts Therapies on Psychological Symptoms and Quality of Life in Patients with Cancer, published in 2013. The objective of Puetz’s research was to evaluate the effects of art therapy on the quality of life and psychological symptoms of cancer patients during and after their treatment.

Figure 1 (Puetz, 2013, p. 966).

Figure 1 shows that art therapy can decrease mental cancer-related symptoms such as pain, quality of life, anxiety, depression, and fatigue among cancer patients after they have received their treatment. However, in most cancer-related symptoms, these figures are greatly diminished during follow-up assessments. This means that art therapy does not work as a long-term treatment. Ching-Teng’s study on ‘Positive Effects of Art Therapy on Depression...’ seems to agree with this statement. In Ching-Teng’s experiment she mentions that art therapy showed positive effects in improving depression of older adults that live in nursing homes (Teng, 2019, p. 324). However, she also mentions that by “incorporating artistic activities into social work care [might] help develop long-term care into a more […] innovative direction” (Teng, 2019, p. 324). Therefore, both studies conclude that art therapy is not effective for long-term treatment. For this to be solved, it would mean that there needs to be an increased amount of follow-up therapy sessions planned for it to be effective for its patients. Or, as stated by Ching-Teng, the patient must surround him/herself with more artistic activities.

Furthermore, a thesis study done by Gretchen Graves on Group Art Therapy for Patients with TBI supports the statement that art therapy is more effective in dealing with patients with depression than any other form of therapy (i.e. psychotherapy) (Graves, 2006).

Figure 2 (Graves, 2006).

The above graph shows the positive effect art therapy has on depressed patients with brain injuries. The research results indicate a 66% improvement among patients with depression. This means, based on the above-mentioned sources, that art therapy is considered highly

effective when it comes down to short-term treatments. One has to bear in mind that these cases are affiliated with extreme forms of depression. This means that every patient does not just deal with depression but also pain and anxiety because they are extremely ill. Therefore, these experiments are not valid when it comes down to measuring all forms of depression.

Art therapy uses a form of psychotherapy and visual and sensory functions to assist the patient to “move easily into brain function” (Giacco, 2009). Psychotherapy is a form of therapy that uses dialogue. Therefore, there are no visual, sensory or motor functions involved. From an experiment conducted by Lesley Uttley, psychologist and lecturer at University of Sheffield, it was concluded that art therapy had more positive effects on the treatments of its patients than other patients undergoing treatment from other forms of therapy. In her experiment she compared how effective treatment was with patients with mental health issues in art therapy to treatment in psychotherapy (talking therapy). In Uttley’s experiment, “art therapy was associated with significant positive changes relative to the control group in mental health symptoms in 7 of the 11 studies” (Uttley, 2015). However, even though art therapy was associated with more positive effects than psychotherapy, psychotherapy proved, to some extent, to be more cost-effective. This means that psychotherapy produced more value than the price paid by the customer. However, this does not mean art therapy did not prove to be cost-effective as well. Art therapy still proved to be cost-effective but, as concluded in the experiment, there was not enough evidence to make a well-proven comparison between the cost-effectiveness of group psychotherapy and group art therapy (Uttley, 2015).

2. Primary Research and comparative findings

During my research I interviewed two art therapists, Ingemarie Sam and Arja Diepstraten, and a coaching expert, Peter Oostelbos, specialized in the field of depression. These experts were selected for an interview, because they are knowledgeable and specialized in both fields of art therapy and depression. Firstly, in this section, I will discuss Oostelbos and Diepstraten’s views on art therapy. I will examine why they think art therapy is more effective in treating depression compared to other forms of therapy. Oostelbos is a coaching expert focusing on those who are depressed and are looking for assistance to overcome or reduce their depression through therapy. Oostelbos faced depression himself after he faced a burnout in 2004. He was

no longer happy with the work that he had completed and struggled to find meaning in his life. Instead, he wanted to help other people who struggle to live with their depression. His partner, Arja Diepstraten is an art therapist, and coordinator of quality of care at Stichting Olijf. Stichting Olijf is a network that supports women with gynecological cancer. I will combine their views in this section, because I conducted a double-interview with them. Moreover, by diving more into Oostelbos’ views on how to treat depression, a correlation or relation might be found between how Oostelbos treats his patients and how art therapists, represented by Diepstraten, treat patients in an art therapeutic setting. Secondly, I will explain Sam’s arguments on why she considers art therapy to be a better form of self-expression than other forms of therapy. The relation between art and self-expression is essential to the context of research question of this thesis, because through oneself, through one’s personal acts, one creates his own vision and puts it into the world. Sam is trained and works as art therapist, in addition to her job as program manager at Tilburg University. Furthermore, she recently completed a master’s degree in art education at Fontys University of Applied Sciences in Tilburg. Lastly, I will compare and contrast the findings from the interviews with the literature research completed in the previous section. This section presented the philosophical and psychological views on art therapy and its effectiveness in treating depression compared to other forms of therapy. It is important to contrast and compare both sections, because the previous section focused more on the historical development and facts of art therapy, whereas this section shows topical perspectives on how art therapy is conducted in the field. I will also use Matthew Johnstone’s book on depression called I had a black dog: His name was depression to depict why art is an efficient way to confront oneself with depression. In addition to the practitioners’ points of view, this book reflects the patient’s perspective.

Diepstraten believes that an individual has different moods or personalities at different times (Appendix 2.1). Art therapy can help patients in finding who they are and what they are feeling at an exact moment. In our interview, Diepstraten gave the example of a black mouse (Appendix 2.1). A person can feel like a black mouse when he is put under pressure at work by his boss. This means that the person is constantly facing stressful situations and is under constant anxiety. This can lead to depression. Art therapy can be useful in this matter as it attempts to let the patient discover who she or he is. This is done through drawing. If the patient draws, for example, something inferior and small, like a black mouse, it could show what the patient is feeling or who he or she is. The drawing can stand symbol for who the patient is and can show part of the depression that lies within the patient. Oostelbos builds up

on this example. He mentioned that one has to imagine what his depression looks like to learn to live with it (Appendix 2.2). Therefore, Oostelbos argues, that art therapy is an efficient way to express that imagination through art (Appendix 2.2). If one attempts to draw his depression, it is much clearer to the patient and to the art therapist what the patient is dealing with. In a way, the patient has a confrontation with himself which is an important part of the healing process. These are some approaches that make art therapy distinct from other forms of therapy. Through verbal therapy alone, the patient cannot show what his depression looks like. The depression cannot be expressed in reality, only through words. This, in turn, is sometimes not enough.

When a patient encounters issues while creating a work of art, it mirrors their problems in how they cope with things in their lives. Sam discusses in our interview that there are many ways to cope with a problem, for instance, through different therapy settings (Appendix 1.3). However, in art therapy, the most efficient way to cope with a problem is by making a work of art in a therapeutic session. Sam provided the example of a patient with a perfectionist attitude (Appendix 1.3). The patient only wants to create the most beautiful drawings otherwise he is left unsatisfied. To counter the perfectionist attitude of the patient, the art therapist should put a time limit on the creation of the drawing or the art therapist can, when having a good relationship with the patient, ‘accidentally’ put a stain on the finished drawing of the patient. By trying those things in art therapy, the patient will learn that “the world does not end when there is [a] stain on their drawing” (Appendix 1.3). This reflects back to how the patient copes with things in real life. They learn that they do not always have to be perfectionistic in every act that they perform. For instance, Sam gave the example of a patient who is a perfectionist. However, we can also apply this to a patient who deals with depression. For instance, as mentioned before by Diepstraten, the art therapist has the ability to view whether the patient is depressed from the perspective of the drawing that he or she has created. This is also connected, as Sam mentions, to the attitude while creating that particular drawing (Appendix 1.3). Ultimately, Sam and Diepstraten argue that both the attitude towards creating art and the creation of art itself are factors that contribute to the development and identification of depression. These factors are not necessarily present in other forms of therapy, for instance, in verbal therapy one can only use his voice to communicate his issues. Yet, the argument is, one needs to express issues through external factors such as artistic materials.

Dewey’s arguments reflect Oostelbos’ and Diepstraten’s views on the importance of communication in art therapy are very similar. Dewey, whose ideas were mentioned before in section 3.1, argues that art is a form of communication because it breaks certain barriers of self-understanding. One can see, in the art that one creates, something about onself that might not have been realized before. Meanwhile, Diepstraten believes that the art created in art therapy, symbolizes the creators personhood and emotions. The patient creates an artwork that embodies his or her own emotions. No one criticizes the patients drawing. The drawing is a form of self-expression. Therefore, both agree that art is a form of expression of oneself that cannot be expressed the same way in other forms of therapy. Dewey and Diepstraten’s views also complement Cavazos’ observation that “traditionally artists have been known to derive their inspiration from their emotions” (Cavazos, 2012, p. 41). This argument goes in line with Oostelbos’ view when he mentioned that patients feel better when they face an image of how their depression looks like. Drawing one’s depression is not only an outlet of emotions, but also an important confrontation for the patient.

The confrontation with ‘the self’ or depression is reflected in Matthew Johnstone’s book I had a black dog: His name was depression. In this book he depicted his depression as a black dog. Below you will find some images that he created for his book. Afterwards, I will elaborate on the origins of the story and how the black dog and the black mouse, mentioned before by Diepstraten, are related to one another.

Figure 3. (Johnstone, 2012)

Figure 4. (Johnstone 2012)

Figure 5. (Johnstone, 2012)

The Black Dog book was inspired by Winston Churchill (1874-1965) (Johnstone, 2012). Churchill was known to portray his depression as a black dog. In a letter sent to his wife on 11 July 1911, he reported that the wife of his cousin “had been cured of depression by a doctor in

Germany” (Daniels, 2018). In this letter one can notice that he refers to his depression as a black dog. The letter mentions the following,

“I think this man might be useful to me – If my black dog returns. He seems quite away from me now – it is such a relief” (Daniels, 2018).

Therefore, Matthew Johnstone’s aim of the book must have been to promote how one can see and deal with one’s depression. It can be viewed as a metaphoric image to depression. Not many people understand what depression is and what it looks like. This book gives the reader a clear view what people deal with in their life when they are confronted with depression.

The illustrations in Johnstone’s book each display a different size and form of the black dog. Figure 3 and 4 depict the depression of the man in the images in a negative light. The man is heavily influenced by his depression or in this case, ‘the black dog’. However, Figure 5 (which is one of the last images portrayed in the book), shows that the man has finally learned to control his depression. This idea, of drawing one’s depression and illustrating it through art, is a unique way to confront one’s depression. Therefore, art therapy is not only an outlet of emotions but also allows one to have a harsh confrontation with one’s inner self. This is done through the use of treatments through art which makes art therapy different from other forms of therapy.

Moreover, the black mouse described earlier on by Diepstraten is an example of the black dog illustrated by Johnstone. Both use animals to depict depression. According to Eva Meijer (1980-), philosopher and author of The Role of Language in Interspecies Politics, “animals have their own language and cultures” even though human beings often do not take into consideration the language, social and political relations of animals (CoteBoudreau, 2018). This is a valid reason why human often identify their depression with that of animals. People with depression feel unheard by others and do not believe that their opinions bring any value to society. It can be argued that Johnstone has brought the ‘black mouse’ example by Diepstraten into reality. Art has enabled Johnstone and his readers to realize that one can confront his depression through his own creativity. Ultimately, depicting one’s depression through art can help a patient with overcoming that depression. As figure 5 depicts, one needs to learn with his depression or be able to control it and art shows that one can do exactly that.

Ultimately, the views of the art therapists and philosophers from section 3.1 are very similar to the views of the interviewees discussed in this section. I figure that the views are similar because art therapy was introduced not so long ago, only in the 1940. Therefore, the variety of views is not that large just yet. Moreover, it seems that the most common argument in all cases is that art enables one to see oneself through an artistic inner self as discussed in the black dog example. Humans are creative beings, and no matter what the drawing looks like, it will always represent some form of emotion that is felt at that moment. This is exactly what makes art therapy effective in treating depression. Not only does it also include verbal and artistic expression, as opposed to other forms of therapy, but it is also a confrontation of oneself with reality.

4. The Healing Effects of Art Therapy

1. Philosophical and psychological perspectives

This chapter attempts to identify the healing effects of art therapy and whether these healing effects are helpful when treating depression. In order to approach this topic, I will first discuss several philosophers, psychologists, and art therapists and analyze their views on the healing effects of art therapy. In the philosophical approach I will discuss three philosophers; Carl Jung, Margaret Naumburg, and Edith Kramer. I will put more focus on Carl Jung and briefly describe Naumburg and Kramer’s theories. Jung paved the theoretical way, which was then further developed by Naumburg and Kramer. Moreover, Jung was also one of the first psychiatrists to claim the potential healing effects of art therapy. He further developed these into his theories. By investigating their theories, it will become clearer what is meant by “healing” factors. And finally, to conclude this section, I will apply the theories of the above- named figures to the drawings and case of a 7-year old depressed boy called Joe. This case was supervised under Rita Simon (1921-2008). It is necessary to conclude this section with Joe’s case, because applying the theories of the above-named figures will confirm that their theories contribute to the healing effects of art therapy.

Carl Gustav Jung (1875-1961), a Swiss psychiatrist whose work was highly influential in the fields of philosophy and psychiatry, claimed that the function of creating art was to contain emotions related to trauma, depression or anxiety (Malchiodi, 2006, p. 134). He also believed that art therapy could be used to “heal” a person.

Jung’s theory had a big impact on art therapy. The Jungian theory differs from Sigmund Freud’s (1856-1939) theory of personality, because it speculates that the mind of the unconscious consists of two levels: the personal and collective level (Granot, 2018, p. 3). Freud and Jung were both interested in the ‘unconscious’ but had different visions as to what the unconscious meant. Jung believed that Freud’s theory on the unconscious was “too limited and overly negative” (Therapy, 2014). The Jungian theory claims that the personal unconscious level consists of traces of a person’s “repressed memories and conflicts” (Granot, 2018, p. 3). Meanwhile, the collective unconscious level dives into the deeper layers of the human psyche. This level contains the “storehouse of a whole spiritual heritage of humankind’s evolution” (Sharma, 1997, p. 173). This means that in the collective unconscious one can find a complicated series of networks of universal primitive and prehistorical memories (Jung, 1969, p. 42). These series of networks, Jung called ‘archetypes’ (Jung, 1969, p. 42). He defined archetypes as universal images that come from the collective unconscious and which are the psychic equivalent of the instinct (Feist, 2009). One example of an archetype is the ‘Self’. The ‘Self’ is also one of the most important archetypes in the Jungian theory. The ‘Self’ is a “movement towards self-realization” as it is an archetype “of centre and wholeness in the service of individuation” (Granot, 2018, p. 4). The ‘Self’ expresses the unity of the person’s character as a whole.

Jung’s theory is relevant to the understanding of the development of art therapy. Firstly, his thoughts on the personal and collective unconscious, and the process of individuation were included in the first edition of the book Approaches to Art Therapy (Rubin, 1987). Secondly, Jung believed that in some way the mind could heal itself independently with the help of symbolic solutions (Granot, 2018, p. 4). Symbolic solutions are answers and resolutions that the one seeks within oneself rather than seeking these solutions “with the patient’s actions in the external world” (Storr, 2013). After Jung’s theory was put in the Approaches to Art Therapy, many other experts, including Joy Schaverien (1943-), a Jungian psychoanalyst and professor in art psychotherapy, and Edith Wallace (1909-2004), student of Jung, included Jung’s views in their own approaches to art therapy. For example, Schaverien used the

Jungian theory to analyze what role the image plays in art therapeutic settings (Schaverien, 2000, p. 55), and Wallace applied it to the method of active imagination (Wallace, 2001, p. 95). All of these examples contribute to the identification of healing effects in art therapy. They contribute to the development and recognition of healing effects of art therapy, because Jung was one the first to realize that there is a connection between the unconscious and art therapy. Even though Jung was not necessary an art therapist himself, he paved the way for art therapists. Experts such as Schaverien, Wallace, and many others built on Jung’s theories.

The Jungian form of therapy promotes the healing effect by giving priority to the importance of the “positive therapeutic dyad” (Green, 2005, p. 75). The therapeutic dyad focuses on the relationship between the patient and art therapist. The therapist should remain neutral and refrain from any criticism to the patient. A positive therapeutic dyad gives form to the self- healing archetype which is, according to Jung, entrenched in children’s psyches (Allan, 1988). When the self-healing archetype unravels itself, children will act out certain thoughts, for example through making drawings, that are related to their inner struggles (Allan, 1988). Therapists specialized in Jungian therapy aid to a child’s inner healing by going through their inner struggles (Kalsched, 1996). Therefore, Jungian art therapy contributes positively to the self-healing of the child. The methods and healing effects that the Jungian art approach has on children will be discussed more extensively later in this chapter.

Here, I will shortly discuss Nora Swan-Foster’s introductory manual on Jungian Art Therapy. In this novel, Gail, a former patient of a Jungian art therapy experiment facing depression and constant anger, created a drawing (figure 6) showing a “natural flow of regressed psychic energy” (Swan-Foster, 2018, ch. 4). This novel is of relevance here, because it perfectly illustrates the importance of the Jungian theory through art.

Figure 6 (Swan-Foster, 2018, ch. 4)

This drawing depicts Gail’s dream. Gail sits in between both of her deceased loved ones. The image that she depicted from her dream was a necessary step for Gail to reconnect herself to “her deep emotions of love” in a time where she was struggling to cope with being always angry and sad in the end of her marriage (Swan-Foster, 2018, ch. 4). According to Swan- Foster, “the unconscious offered a touching image of protected space that reminded her of authentic love and support” (Swan-foster, 2018, ch. 4). By connecting to her inner-self and bringing out the emotions of love and happiness, she got reminded that emotions such as hate, and sadness do not dominate her life. She is reminded that she is allowed to be happy as well.

Moreover, as mentioned before, the Jungian art approach in art therapy contributes positively to the well-being of children. This is because children strive for wholeness and are still in the phase where they are trying to find themselves. They try to find their personality and who they are, according to Jung, through symbolic identification (Jung, 1963). Children create symbols unconsciously in, for instance, their dreams or drawings. According to John A.B. Allan, a Jungian art therapist, children show their understanding of the world through visual methods (Allan, 1988). This is done, because the “symbolic function of play with […] children bridges the gap between concrete experience and abstract thought” (Green, 2005, p. 75). Ultimately, through closing this gap, Jungian art therapists are able to analyze and rate the symbolic complexes within the child. And the child will come to a closer understanding of his or her own emotional distress. Moreover, the relation between the art therapist and the child is also important. If there is no trust between the two, then the child will not be comfortable, and therefore, not draw from their unconscious emotions.

These examples show that the healing effect in Jungian art therapy focuses on the re- connection between the self and the unconscious. In a way, this approach to art therapy could also be called ‘spiritual’. This approach in art therapy can be called ‘spiritual’. Because, as Jung mentions, “the needful thing is not to know the truth, but to experience it” (Cicovacki, 2002, p. 204). Therefore, in this approach, the truth needs to be experienced. One can know the truth but that does not necessary bring any meaning to the patient. When one has experienced the truth, one will heal. Therefore, the relations between the spiritual and experiencing the truth is important. It is essential to find our way to the inner and irrational experience. Other art therapists, such as Shaun Mcniff (1946-), currently the leading figure in the fields of art therapy (McNiff, 2015), seem to agree with Jung. Mcniff mentions in Art as Medicine, that one cannot just view a painting as having a cause and effect relationship (McNiff, 1992, part 1). It is important to see a patient’s drawing as “part of the soul’s nature”, as it is “essential to the eco-system of the soul (McNiff, 1992, part 1).

Margaret Naumburg (1890-1983) was an American artist, educator, and one of the most influential theoreticians in the field of art therapy (Rubin, 2001). Just like Jung she also followed Freud’s theories. However, she appropriated his theories. She believed that one could derive unconscious emotions through the creation of images. Therefore, from her philosophical and psychological theories, she created a separate field of art therapy, called ‘dynamically oriented art therapy’ (Maxine, 2010, p. 34).

In dynamically oriented therapy, one’s most important thoughts and feelings are “derived from the unconscious” through the expression of images (Naumburg, 1966). According to Naumburg, images say more than words. Images and drawings are used to facilitate inner conflicts through symbolic forms. Naumburg believed that communication through symbols could bypass the difficulties of speech. It is not always easy for one to talk about his or her fears or emotions From Naumburg’s own experience, she observed that patients that entered her therapies with speech difficulties, were more willing to talk after they created their own drawings (Naumburg, 1987). Communication through symbols speeds up “the process of verbalization”, because “patients could learn to freely associate in words to the spontaneous images they had created” (Tobin, 2015, p. 3). This also results in the greater independence of the patient from the therapist. The patient plays an active role in interpreting its own art instead of receiving instructions and interpretation from the therapist (Tobin, 2015, p. 6). The

patient learns to stand up and speak for him or herself. Therefore, Naumburg believes that the combination of verbalization and symbolic communication is most essential in art therapy.

Ultimately, dynamically oriented therapy is similar to Jungian art therapy. Both stress the importance of the transference between the unconscious and the art that is created by the patient. However, Naumburg puts more emphasis on the importance of interaction in the communication between the patient and therapist.

Edith Kramer (1916-2014), art therapist and social realist painter, took a different approach to art therapy (Malchiodi, 2014). Just like Naumburg, she also followed Freud’s work. She agreed with Freud that sublimation is an effective method to deal with the “threat of unconscious drives by making constructive use of their potentially destructive power” (Tobin, 2015, p. 6). Sublimation is a type of defense mechanism where unacceptable desires or feelings are turned into socially acceptable attitudes in society. However, she did not agree with Freud that “verbalization and transference” are necessary to deal with the threat of the unconscious drives, because sublimation is already the end goal (Tobin, 2015, p. 6). Moreover, Kramer was a firm believer in the healing effects of creative work. She believed that art therapy can guide the development of a mature ego defense which in turn helps patients to cope with the unconscious conflict in their lives.

Ultimately, the three experts believe that the creation of art is a necessary step for one to deal with the threat of unconscious emotions. The theories that they formulated draw from Freud’s theory. However, instead of creating art, Freud believed that verbalization is the most important step to deal with the unconscious. Jung, Naumburg, and Kramer dismiss this idea. Jung and Naumburg continue to stress the importance of interaction between the patient and therapist. According to both, the creation of a patient’s drawing is the most important part of the healing process, because it enables a patient to reflect on their unconscious conflicts. When these conflicts have come out in the open (through the drawings), then it is easier to interact and talk about these emotions. The unconscious has turned to the conscious, and verbalization is easier when the patient understands his or her own unconscious emotions. Through art, the therapist can get a better understanding of the patient’s emotional turmoil as well. Meanwhile, Kramer does not believe that verbalization is an essential part of art therapy. According to her, art therapy should focus on the production (and evaluation) of the art itself.

Next, I will give an example of a drawing of a 7-year-old depressed boy called Joe, who underwent art therapy under the watchful eye of Rita Simon (1921-2008). Simon is known for her devoted contribution to the field of art therapy and her critique on the Freudian and Jungian psychotherapies (Schupbach, 2009). Joe got depressed and suffered mood swings, because his parents got divorced. Simon believed that through investigating Joe’s case, and particularly his drawings, she could get behind the potential healing effects of art therapy. In this case we will see whether or not we can apply the above theories to a contemporary real- life example.

Figure 7. (Simon, 2005, 25).

The drawing shown in Figure 7 represents a house, displaying the exterior and interior of the house. However, the house seems to be split into two different houses. This can be seen from the perspective that the house has two different roofs, and two different compartments (the side on the left with two windows and the side on the right with stairs, and also two windows). Therefore, this drawing represents the divorce of his parents. They will live separately from now on. Though the full realization has not been set that they will have to live in two separate houses instead of separately in one house. This drawing shows the confusion and inner conflicts that Joe faces.

Figure 8. (Simon, 2005, p. 26).

The words written in his drawing (figure 8) are, according to Simon, “the vehicle he needed” to transfer his drawings into a conversation (Simon, 2005, p. 27). The drawings themselves represent Joe’s inner conflicts. Figure 8 also represents two houses that are very different from each other. These houses represent the new differences between his mother and father, and the realization that they are now living under separate roofs. The character in the middle of the picture seems more complex. It seems that the character is unable to speak as almost its whole body is scribbled down. It can only see because only the eyes are visible. In my opinion, this character represents Joe, because he has no say in the divorce of his parents and he can only watch as his parents drift further away from each other.

In conclusion, Joe’s drawings represent, to a large extent, his repressed and unconscious emotions. To prove the validity of this statement, it is important to connect Joe’s case to the theories discussed above. Firstly, Jung was one of the first art therapists to theorize that art is the most efficient way to realize the inner struggles of a child. This is quite apparent in Joe’s case. Before Joe drew these pictures, he did not know how to communicate his feelings towards the outside world. It was through his drawings that he, himself, could express his unconscious emotions. Secondly, much like Jung, Naumburg believes that communicating

one’s thoughts through symbols speeds up the verbalization process. This is quite apparent in Joe’s second drawing where he starts to write words around his drawings. He attempts to verbalize his thoughts through his drawing. R.M. Simon seems to agree with Naumburg when he writes that “these words provided the vehicle he needed to transfer the […] activity of drawing into thoughts capable of being verbalized” (Simon, 2005, p. 27). Therefore, Naumburg’s theory seems to be correct. The creation of symbols is a necessary step and has an important healing effect on the patient, because when the patient seems to draw freely in a thoughtless way, ideas occur from the unconscious state of mind. Thirdly, Kramer argues that verbalization does not have an important role in the healing process of the patient. Yet, even if R.M. Simon believes that creativity has led him to create drawings in which he could heal himself, verbalization is still an important part of the healing process that comes after the creativity part.

2. Primary research and comparative findings

In this section I will further elaborate on the views of Ingemarie Sam and Arja Diepstraten, both art therapists, and Peter Oostelbos, a coach on depression. In this chapter, I will further develop into the discussion of the healing effects of art therapy. Based on the interviews conducted during my research, I will attempt to answer the following question, namely, what types of healing effects are identified in art therapy? To answer this question, I will predominantly explore Sam and Diepstraten’s views on what it is in art therapy that determines the healing effects when it comes to treating mental health issues such as depression. The interview conducted with Oostelbos is not further discussed, because he is not specialized in the field of art therapy as such. Lastly, after discussing Sam and Diepstraten’s views on this matter, I will compare and contrast the views in this section with the findings in the sections above, where the views of several philosophers and art therapists on the topic of the healing effects in art therapy were discussed. It is important to examine whether art therapists today still identify the same healing effects identified by philosophers, historians, and psychologists before them.

In Sam’s thesis, titled Art Lessons for Life written in 2015, and during my interview with Sam, she defines the therapeutic effect as a sum of responses to any kind of treatment which are thought to have a positive or favorable effect (Sam, 2015, p. 22). This is similar to how I have defined the notion of the healing effect. The healing effect in this thesis is defined as

healing one’s damaged health under therapeutic means. One of the therapeutic effects, which Sam mentions to be essential in art therapy, is the verbal conversations done after giving the patient time to create a piece of art (Appendix 1.2). In this verbal conversation the therapist attempts to talk about the process of creating the drawing. Verbal conversation in art therapy is important, according to Sam, because it is a process where the patient can express his or her emotions. By referring back to the process of creating this particular drawing, the art therapist can indicate what type of emotions the patient is feeling. Secondly, Sam argues that a therapeutic effect can also be found through the creation of drawings alone (Appendix 1.1). In our interview, Sam gave an example of a patient “without much confidence” (Appendix 1.1). The patient is unable to draw a flower, because he thinks all the flowers that he creates are ugly. The patient does not have the standard that he wants to meet (Appendix 1.1). As a solution, the art therapist could ask the patient to draw the flower in the ugliest possible way possible. Then, the patient will realize that the flower that he initially had to create was not ugly at all. Sam states that, “the therapy is not in words, but the therapy is in drawings” (Appendix 1.1). Therefore, Sam believes that there are two ways that you could think together, the patient and art therapist, about the work of art that has been created. Through reflection, there potentially is a therapeutic resolve. Alternatively, this therapeutic effect can also be established through a new assignment that is not done through reflection or conversation, but by creating something different.

Verbalization, arguably, contributes to the healing effect within art therapy. As discussed in section 4.1, Jung and Naumburg also agree that verbalization in art therapy is an important part of the healing process of the individual. Sam develops this thought further, about the healing effect of verbalization, as she mentions that interaction between the therapist and patient enables the patient to express his or her emotions. Meanwhile, Jung and Naumburg believe that the expression of one’s emotions is a part of the artistic dimension in art therapy. Even though they state that verbalization is a part of the process of emotional outlet, they do not think that is as important. I would argue that the healing effect and importance of verbalization depends on the patient in question. Some can address their unconscious emotions through art alone. Others need the help of the therapist to do this. Nevertheless, it is necessary to include this process in art therapy, because this is exactly what makes art therapy more efficient and different from other form of therapies. At the very least, verbalization seems to be a helpful addition to the healing process of patients.

The connection between the artistic materials and the individual can also be considered to have a healing effect on a patient with depression. According to Diepstraten, an important healing factor is bodily connection. She takes the example of a young immigrant girl who was all over the place and did not seem to be happy (Appendix 2.3). It seemed as if she was missing something in her life. Diepstraten goes on to say that through therapeutic means, not specifically art therapy though, she found out that the young child was seeking for bodily contact (Appendix 2.3). She wanted to be held by someone. This was the healing effect for the child. Having bodily contact with someone can give one the feeling that she is not alone. However, bodily contact, especially with children, is usually forbidden in any kind of therapy. And if it is allowed, the consent of the patient is necessary. This is also the case for adults. As an alternative, an art therapist can use material connection to offer patients any kind of comfort. Art materials include any type of materials that can be used to create art with. This includes materials such as paint brushes, paint, crayons, etc. In a way, the connection that one can experience while using materials can be the same as experiencing bodily contact with someone. For instance, Diepstraten gives the example of using clay to create art in an art therapy session (Appendix 2.3). Clay is warm, soft and wet. The effect that clay has on a patient’s touch can evoke certain feelings, for instance, comfort or happiness or perhaps a happy thought of a past event. The connection that one feels with art materials can be substituted for bodily contact. There are negative and positive sides to using art materials as a substitute for bodily contact. For instance, if a patient finds an increasing solace through his connection with art materials, then how will he learn to connect with other people? Moreover, the patient might develop a materialistic point of view further in life and avoid bodily contact with others. On the positive side, if one feels more connected to the materials used to create things with, the patient will learn to develop a relation or healing effect with other materials as well. The patient will learn to independently heal or better himself through the use of materials. Ultimately, there are negative and positive sides to calling this line of reasoning as indicating a ‘healing effect’ in art therapy. However, art therapy is about creating art and finding oneself through the creation of one’s artwork. According to Diepstraten, no patient should expect any kind of bodily contact in art therapy, unless permitted and discussed beforehand between the patient and art therapist (Appendix 2.3). Therefore, the connection that one feels when connecting with either art or art supplies assists the patient with his or her healing experience. Ultimately, in the framework of this thesis, it is considered the source of a potential healing effect.

Diepsraten’s view on the healing effect being the connection between oneself and materials are not often discussed in secondary literature. Also, no comparisons could be made with any of the philosophers discussed beforehand. Jung, Naumburg, and Kramer all believe there is a connection between one’s unconscious emotions and art. But none of their works mention a connection between one’s unconscious emotions and the art materials used to create art. According to Nono Orbach, art therapist and multidisciplinary artist, “materials [in art therapy] are rarely mentioned in their own right, for their own inherent qualities”, because, first of all, writing about art materials and their spiritual facets is more difficult than writing about finished artworks in terms of their colors or content (Orbach, 2003, p. 2). Secondly, focusing on the spiritual assets of the artwork itself is more straightforward to the general public and patients. Therefore, as a solution, art therapists should put more focus and research into the potential healing effect of art materials. This way patients will get an increasing understanding of expressing their feelings, through the use of art materials, in their artworks. It will help them to deal with illnesses they are facing.

5. Conclusion

Throughout this thesis, views of art therapists, philosophers, and psychologists have been discussed on the field of art therapy and its effectiveness in treating depression compared to other forms of therapy. Though popular, art therapy and its effectiveness in treating depressed patients is still a hot debate today. Art therapy is operated differently almost in every culture or country in the world. It is not a universalized form of therapy. However, there are associations everywhere that control licensed art therapists and oversee whether their treatment suffice the state’s or country’s requirements for art therapy. Ultimately, even though treatments in art therapy are not universal or the same in every part of the globe, art therapy still has the capability, through right guidance and therapeutic methods, to heal patients that suffer from depression.

Art therapy is a relatively new form of therapy and its healing effects, as to what this form of therapy can heal, remain a topic of discussion until this very day. Philosophers such as Junge, Naumburg, and Kramer argue that art can communicate one’s inner struggle. A struggle that one cannot always necessary communicate through words. From this perspective, art therapy is considered to be an efficient way to treat patients who are troubled. This also includes patients who struggle with forms of depression. Depression can come into a person’s life in

any form. There are different forms of depression and, therefore, there will also be different ways in how people cope with depression. Art therapy is an efficient method to cope with one’s depression when the patients wants to confront his depression. In an art therapeutic setting, patients are able to visualize their depression, and therefore the patient is forced to confront his or her problems. That is why, according to the discussed philosophers, art therapy is so important. Humans are creative beings, and when confronted with tools of creativity, individual struggles can be depicted and explored.

Furthermore, I have extensively explored the discussion on whether art therapy is considered to be a better treatment for patients with depression compared to other forms of therapy. Other forms of therapy, such as psychotherapy, have been around for a longer time and people tend to trust these forms of therapy more than art therapy. However, art therapy is becoming increasingly popular due to its creative process of dealing with the patient’s unconscious. According to Cavazos, humans are creative beings and this creativity can lead to an outlet of emotions. These emotions can be positive, negative or neutral. Verbalization, according to Cavazos, is also a way to show one’s emotions but it is more damaging to those who face depression, because it takes less effort. Of course, then there is also the question on why verbalization remains included in the treatment of art therapy. This is because verbalizing about images takes less effort than discussing semantic information. Patients see their art and their emotions conveyed through their artworks. Therefore, it seemingly becomes easier to talk about their issues after they have drawn their feelings outside their inner world.

Ultimately, it is important to mention that there are not many books published on the history or healing effects of art therapy. There are still discussions going on today on what exactly in art therapy it is that treats or heals people with, for instance, depression. What makes it so different from conversational therapy? Why does one need art to heal himself? What is the relation between art and mental health illnesses? Or is it not about art at all? These are still questioned asked today. I aim for this thesis to contribute to this discussion, by making clear that there are many professional and educational opinions on what makes art therapy different from other forms of therapy and why it is a popular new form of therapy that contributes to the betterment of one’s mental illness.

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Appendix

Appendix 1: Fragments of interview with Ingemarie Sam (29/11/18)

Appendix 1.1 A: What makes art therapy different from regular therapy? I: “There are 2 main differences. This is already a bit art therapeutical. For instance, I draw a flower. What we could do together is, in an art therapeutic session, is looking at this and bringing back in words the process that I went through by making this (a verbal part of art therapy). An example is when a patient says, ‘I don’t have much confidence’, and he doesn’t like his painting and says that it is ‘awful’, ‘I cannot draw at all’. The therapist asks, well if you think this is ugly, then try to make a flower that is very ugly so you don’t have this standard you want to meet. Then the therapy is not in words, not verbal anymore, but the therapy is in drawings. After the patient draw this really ugly flower, the patient could look at his work and realize that his previous drawing isn’t that ugly at all. You can think together about the work of art that has been made in the session, but you could also, through reflection, find a therapeutic resolve. But it could also be through a new assignment that this therapy is done. So not by reflection or conversation but through something different. To work through something.”

Appendix 1.2 A: Do older people get treated differently in art therapy than younger people? S: “…You have people who are very perfectionistic. When someone draws a lot, it could also be that the expression of emotions in the drawings is blocked because he/she wants to create this perfect drawing. People who are older can reflect on the drawing that they have made, because it is not only by pencil that people make 2-dimensional piece of art. You can also use other art materials.”

Appendix 1.3 A: What is the key in art therapy? S: “Art therapy is the learning through doing things. It is not only through visual arts but also through dancing and making music. When you encounter problems while creating a work of art, it is most of the time the way you cope with such problems is a copy of the way you cope with the rest of your life. You can try different things to cope with the problem in a work of art and therapeutic session. And then you bring this new way of behaving yourself, of coping with things, into the rest of your life. For example, when someone is very perfectionistic, he/she wants to make beautiful things. What you could ask someone, is to make something that is not beautiful or to make it very quickly so that she cannot put a lot of time to make it perfect. The therapist could even make a big stain on the patient’s drawing. Then, by trying those things in therapy, someone learns that the world doesn’t end when there is this stain on the drawing. First of all, what is very important is when you do a harsh thing like that, you need to have a good relationship between the patient and therapist. A safe environment is key to do things like that. Otherwise someone is going to be very upset and then he/she stops the therapy immediately. First of all, you start as a therapist and make sure that the patient is at ease with you. Then you can also start explaining what you are going to do (with an adult).”

Appendix 2: Fragments of interview with Arja Diepstraten and Peter Oostelbos (06/03/19)

Appendix 2.1 D: (34:15) Wat je vaak ziet is dat je in situaties verschillende manieren reageert. Dat kun je ook zien alsof je verschillende persoonlijkheden hebt. In een bepaalde situatie kun jij je helemaal los en vrij voelen. Maar in een andere situatie, een werk situatie (wanneer je een autoritaire baas hebt bijvoorbeeld, kun jij je een grijze muis voelen. Je voelt dat jij je stem niet goed naar voren kunt zetten. Dus dan kun je een figuurtje maken van de grijze muis. Op die manier kun je eigenlijk bij jezelf nagaan in alle details, wie ben ik in die situatie? Het kan dus zijn dat een van die figuurtjes voor jou wel symbool staat daar waar de depressie op ligt. Bij de grijze muis ontstaat die depressie en dat figuurtje is waar jij je niet van waarde voelt, niet gezien wordt, en niet het gevoel hebt dat jij het waard bent om hier te zijn.

English translation: D: What you often see is that you react different ways in different situations. You can also look at it as having different personalities. In a certain situation you can feel completely free. But in another situation, a work situation (when you have an authoritarian boss, for example, you can feel like a gray mouse. You feel that you cannot put your voice forward properly. So, then you can make a figure of the gray mouse. In this way you can actually check yourself, and ask, who am I in this situation? So, it may be that one of those figures is a symbol for you and identifies best with your depression.

Appendix 2.2 O: (32:00) Ik heb heel erg naar mezelf gekeken. Er is mijn depressie en er is Peter. Wie is Peter en wat is de depressie? En hoe houdt peter zich tot die depressie? En daardoor heb ik mezelf beter leren kennen maar ook mijn depressie. En zo heb ik ook geleerd hoe de depressie tot stand is gekomen. Ik kwam ook te geloven dat ik goed ben zoals ik ben met of zonder depressie. Ik ben goed zoals ik ben. Die depressie is er ook en dat is lastig maar dat maakt mij niet minder. Als je dat al kunt zeggen dan ben je al een eind op weg naar acceptatie en leven met. Dan is het probleem nog niet opgelost maar het wordt wat minder zwaar. Je kunt er van een ander perspectief naar kijken. Eerst was het dat ik een was met mijn depressie en nu kan ik er van een afstandje naar kijken. En daar kom je weer bij mijn vrouw ’s (Diepstraten) werk terecht. Je kunt je inbeelden hoe je depressie er uit ziet (bijvoorbeeld een zwart gat) en op papier zetten. Je kunt daar een vorm aan geven.

English translation: I looked a lot at myself. There is my depression and there is Peter. Who is Peter and what is the depression? And how does Peter relate to that depression? By thinking about these questions, I got to know myself better but also my depression. And so, I also learned how the depression came about. I also came to believe that I am good the way I am with or without depression. I'm fine the way I am. That depression is also there and that is difficult but that does not make me less valuable. If you can already say that then you are already well on your way to acceptance and living with depression. Then the problem is not yet resolved, but it becomes less heavy. You can look at it from a different perspective. First it was that I was one with my depression and now I can look at it from a distance. This is related to my wife’s job. You can imagine how your depression looks like and put it on paper. You can shape your depression.

Appendix 2.3 D: Als jij gezien wordt voor wie je bent, dat hersteld al een hele hoop. Als ik kijk naar een vluchteling kind van 9/10 jaar, ze stuiterde alle kanten op en ze was een ramp op school. Toen ontdekte ik dat het kind liefst om der arm genomen werd en dingen benoemen in de ruimte. Samen kijken, samen benoemen was belangrijk voor haar. Op een gegeven moment ontstaat zoiets. Dan vraag je jezelf, in welke lichaamsfase zit dat kind eigenlijk? Ze kan wel 10 jaar zijn maar in haar ontwikkeling is ze misschien 2 jaar. Ze kan ook op een gegeven moment zeggen dat ze niet meer om de arm genomen wilt worden. In een therapeutische setting ziet het er wel raar uit als je een kind op je laat liggen of omhelst. Maar voor dat kind hielp dat wel. Bij kinderen is het wel wat makkelijker om ze te omhelzen in een werkomgeving. Maar ik kan me haast voorstellen dat een volwassene kerel ook wel een omhelzing wilt. Hoe doe je het dan bij een volwassene om toch dat gevoel te krijgen?

O: Officieel is lichamelijk contact met een cliënt en therapeut verboden. Het kan en mag maar je moet daar voorzichtig mee zijn. Van tevoren moet je ook aan de cliënt vragen of je ze wel mag aanraken.

Je ziet dat in die aanraking dat daar in vaak tekort zit. Aanraking hoeft niet alleen maar lichamelijk te gebeuren. Het kan ook door materiaal. Dan loop je dus wat minder risico dan menselijke aanraking. Maar menselijke aanraking is desondanks niet met materiaal te vervangen. Het andere puntje van het materiaal is dat het appel waarde heeft. Als je kleit dan is het nat, warm en zacht. Dus dan kan je al bepaald gevoelens opwekken bij iemand. Die gevoelens kunnen positief en negatief zijn. Sommige mensen vinden klei juist heel vies.

English translation: D: If you are seen for who you are, that will restore a lot. When I look at a refugee child of 9/10 years old, she bounced in all directions and was a disaster at school. Then I discovered that the child preferred to be embraced and to name things that she saw in space. Looking together, embracing each other, and naming things together was important to her. At some point such a thing arises. Then you ask yourself, which body phase is that child actually in? She may be 10 years old but in her bodily development, she may be 2 years old. She can also say at a given moment that she no longer wants to be embraced. In a therapeutic setting, it may look strange if you let a child lie on you or embrace you. But that did help for that particular child. It is easier to embrace children in a work environment. But I can almost imagine that an adult guy also wants a hug. How do you do it with an adult to get that feeling?

O: Officially, physical contact with a client and therapist is prohibited. It is possible and allowed, but you have to be careful with that. You must also ask the client in advance if you can touch them.

D: Touch does not only have to be physical. It can also be done through materials. Then you run a little less risk than human touch. But human touch can nevertheless not be replaced with materials. The other tip of the material it has “appel waarde”. If you use clay; it is wet, warm and soft. So then you can already generate certain feelings in someone. Those feeling can be positive and negative. Some people think clay is very dirty.