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Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP)


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“We use our minds not to discover facts but to hide them.” Antonio Damasio“Art makes the invisible visible.” Paul KleeIn this article I propose an art therapy trauma protocol (ATTP) designed to address the non-verbal core of traumatic memory. Trauma theorists [van der Kolk, B.A. (2003). Frontiers in trauma treatment. Presented at the R. Cassidy Seminars, St. Louis, MO 2004; Steele, W. & Raider, M. (2001). Structured Sensory Intervention for Traumatized Children, Adolescents and Parents-Strategies to Alleviate Trauma. New York: The Edwin Mellen Press] have endorsed alternative treatment methods such as eye movement desensitization reprocessing (EMDR), body-based psychotherapy, and expressive arts therapy as an alternative to verbal psychotherapy. Following an overview of the role of memory and emotions in trauma and theories of art making and brain function, I describe a protocol that has had success in integrating the cognitive, emotional and physiological levels of trauma drawing on EMDR, McNamee's bilateral art and Michelle Cassou's method of painting. A one-session example serves to illustrate its use.
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The Arts in Psychotherapy 34 (2007) 22–35
Accessing traumatic memory through art making:
An art therapy trauma protocol (ATTP)
Savneet Talwar, MA, ATR-BC, LPC
Creative Community Arts Studio, 332 Lincoln Ave., Takoma Park, MD 20912, United States
“We use our minds not to discover facts but to hide them.” Antonio Damasio
“Art makes the invisible visible.” Paul Klee
In this article I propose an art therapy trauma protocol (ATTP) designed to address the non-verbal core of traumatic memory.
Trauma theorists [van der Kolk, B.A. (2003). Frontiers in trauma treatment. Presented at the R. Cassidy Seminars, St. Louis,
MO 2004; Steele, W. & Raider, M. (2001). Structured Sensory Intervention for Traumatized Children, Adolescents and Parents-
Strategies to Alleviate Trauma. New York: The Edwin Mellen Press] have endorsed alternative treatment methods such as eye
movement desensitization reprocessing (EMDR), body-based psychotherapy, and expressive arts therapy as an alternative to verbal
psychotherapy. Following an overview of the role of memory and emotions in trauma and theories of art making and brain function,
I describe a protocol that has had success in integrating the cognitive, emotional and physiological levels of trauma drawing on
EMDR, McNamee’s bilateral art and Michelle Cassou’s method of painting. A one-session example serves to illustrate its use.
© 2006 Elsevier Inc. All rights reserved.
Keywords: Art therapy; Emotions; Memory; Neurobiology; Creativity; Creative arts therapy; Art therapy trauma protocol; Trauma; PTSD
In this article I propose an art therapy trauma protocol designed to address the non-verbal core of traumatic memory.
Recent developments in neurobiology have shown that memory is an active and constructive process, and that “the
mind constantly re-assembles old impressions and attaches them to new information” (van der Kolk, 2002, p. 2). Most
memory researchers “deny that the mind is capable of precisely reproducing the imprints of prior experience,” (p.
2) including precisely recalling memories of smells, images or sensations. Individuals diagnosed with post-traumatic
stress disorder (PTSD), however, report exact sensations, memories and emotions related to the trauma, and sometimes
do so months or even years later. Individuals with PTSD symptoms experience a lack of control, as if they were
involuntarily reliving the trauma, even when they may be aware of the disproportionate nature of their reactions. One
of the primary challenges for the psychotherapeutic process is regulating the sensory imprints associated with trauma.
In recent years, advances in neurobiology and psychotherapy have informed the practice of art therapy, which has
increasingly been utilized when verbal psychotherapy has failed to help clients. Numerous therapists have reported the
benefits of creative arts therapies in their settings (Chapman, Morabito, & Ladakakos, 2001;Brett & Ostroff, 1985;
Howard, 1990;Klorer, 2000;Rankin & Taucher, 2003;Yates & Pawley, 1987, among others), although few controlled
studies have been published. Researchers in the field of art therapy have begun to pay attention to neurobiology and
Tel.: +1 301 920 2224; fax: +1 866 829 9807.
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S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35 23
its relationship to art making and its implications for art therapists (Chapman et al., 2001; Klorer, 2005; Lusebrink,
2004; McNamee, 2004). Chapman et al. (2001) published a study with pediatric trauma patients. They reported that
although the clinical trial did not indicate significant differences in the reduction of PTSD, there was evidence that
children receiving art therapy did show reduction in acute stress symptoms. A recent study, however, conducted at
Thomas Jefferson University, Philadelphia, provides data on improvement of the quality of life (Monti et al., 2005),
and emphasizes the connection between the body–mind and creativity, illustrating the efficacy of art therapy.
In trauma treatment it is not the verbal account of the event that is important, but the non-verbal memory of the
fragmented sensory and emotional elements of the traumatic experience (van der Kolk, 2003). Art therapy has long
been recognized as a method that constitutes a primary process (Kramer, 1958; Levick, 1975; Naumburg, 1966; Rubin,
1984;Ulman and Dachinger, 1975) that taps into the non-verbal realm of imagery (Cohen & Riley, 2000). Successful
art therapy can serve to integrate right and left brain functions that, in turn, help integrate experiences (McNamee,
2003, 2004, 2005), especially on a non-verbal level. In the first part of this article I define “trauma,” and review current
research into how it acts to subvert, or is a subversion of, normal brain functions that integrate experience and memory.
In the second, I survey current thinking on the subject of art making and creativity and how they may involve specific
areas and functions of the brain; this is a topic for which considerably more research is needed, so mine is necessarily
only an overview of an emerging field. In the third part I describe the art therapy trauma protocol (ATTP), give a
one-session example, and relate the technique to the issues raised in parts one and two.
Current views of trauma and brain function
Affect regulation, according to Omaha (2004), is the foundation for an adaptable healthy human, whereas affect
dysregulation is the basis for clinical intervention. “Affects are genetically hard-wired, physiological building blocks
from which feelings, emotions, and moods are constructed” (Omaha, 2004, p. 4). The individual’s self-organization
depends on his or her affect and emotion regulation. In the course of our lives, most of us will be exposed to one or
more adverse life events, which may include directly experiencing trauma or indirectly witnessing a traumatic event.
According to the nature of the event, its impact will ultimately be determined by each individual’s ability to cope and
regulate affect in the distressing situation. Greenwald (2005) argues that individuals who experience a traumatic event
deal with their trauma in two ways. One is the adaptive method, in which the individual processes the stressful event in
a supportive environment by moving through the normal stages of grief and loss. The other is the non-adaptive method;
here the event is pushed behind a wall in order to seek emotional and affective relief from the distress it causes.
Walled off memories due to trauma retain their power and freshness on an affective level, even years after the event.
Trauma creates a state of heightened physiological arousal initiated by a sensory experience, whether sounds, images,
sensation of touch, smell or, in rare cases, taste (Rothschild, 2000; van der Kolk, 1994). Memories of the trauma can
also trigger or sustain the arousal response (Steel & Raider, 2001). The effects of trauma on the body and the mind
are well documented, and are defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV,
2000). One of the major symptoms characterizing trauma is PTSD, which is “persistent increased arousal” in the
autonomic nervous system. This is called “somatic memory” (Rothschild, 2000; van der Kolk, 1994).
The primary issue in treating trauma clients is that certain sensory experiences related to the traumatic memory do
not fade over time. Theorists (van der Kolk & van der Hart, 1991;van der Kolk & Fisler, 1995;van der Kolk, Hopper
& Osterman, 2001;van der Kolk, 2003) argue that the effects of trauma persist for months, years or even decades
after the event has occurred. “Particularly emotions, images, sensations, and muscular reactions related to trauma may
become deeply imprinted on people’s minds and the traumatic imprints seem to be re-experienced without applicable
transformation” (van der Kolk, 2003, p. 2). It is the failure to transform and integrate these sensory imprints related to
the trauma that keeps traumatized individuals at an increased level of hyper-vigilance, a cognitive state that prevents
the individual from feeling a sense of psychological well-being and physical safety. We thus confront a particular form
of memory dysfunction.
Memory consists of the storage, categorization and recall of information under appropriate circumstances
(Rothschild, 2000). In the last decade, a growing body of research has established the importance of the limbic
system for understanding emotions and memory and their relationship to trauma (for example: Nadel & Jacobs, 1996;
Rothschild, 2000). Known as the “the seat of emotions,” the limbic system guides the reactions and behaviors neces-
sary for self-preservation and, ultimately, survival of the species. According to Rothschild (2000), the two areas of the
limbic system central to the storage and retrieval of memory are the amygdala and the hippocampus. The amygdala is
24 S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35
most clearly implicated in the evaluation of emotional meaning related “to highly charged emotional memories such as
terror and horror, becoming active both during and while remembering a traumatic incident” (p. 12). The hippocampus
creates the cognitive map of the experience, “putting our memories into their proper perspective and place in our life’s
time line” (p. 12). It functions by, first, comparing the events of present experience with events from the past and,
second, determining whether and how the events are associated. When placed in perspective, the event becomes an
experience with a beginning, middle and end. As a result, the traumatic event is prevented from occupying its proper
place in the individual’s life history (Nadel & Jacobs, 1996;van der Kolk, 1994; Rothschild, 2000). It continues to
invade the present, affecting the integration of the traumatic experiences and memory.
According to Rothschild (2000), experiences are sorted out through a staged memory system in which the main
categories are “explicit” and “implicit” memory. Each of these memory systems distinguishes the types of information
to be stored and how they are to be retrieved. Explicit memory is generally what we mean by the word “memory,” also
called “declarative memory;” it comprises facts, concepts and ideas, and engages the left side of the brain. Words in
the form of oral and written language are necessary for both storage and retrieval of explicit memory. When clients in
art therapy describe the contents of their drawings, giving facts and opinions about family and intimate relationships,
they are calling on explicit memories. This memory system has engaged the hippocampus to create the cognitive map
of events; it furthermore serves in executing complex operations, in solving problems, and in performing tasks step
by step. Explicit memory enables the telling of one’s story, narrating events, associating meaning with experience,
and constructing a chronology of events. Implicit memory bypasses language and thought. It is a direct response from
internal states that are automatic and operate unconsciously. Implicit memory, also called “nondeclarative memory,”
involves the storage and recall of learned procedures and behaviors. Bicycle riding, doodling, drawing or writing,
all things that we perform without thinking and which have become second nature to our everyday living, involve
implicit memories. While performing such tasks the explicit memory remains engaged in identifying the facts, creating
a cognitive map of the time or place of the event (Rothschild, 2000; van der Kolk, 1994).
For the trauma patient, “implicit memories not linked to explicit memories can be troublesome. It appears to be the
case that traumatic memories are more easily recorded in implicit memory” (Rothschild, 2000, p. 31). Levine (1992
cited in Wylies, 2004) argues that PTDS is a highly activated, incomplete, biological response to threat, frozen in time,
and that trauma gets “locked” in the body. Neuroimaging studies of traumatized patients show that dissociation occurs
when patients are asked to remember their traumatic experience. The left frontal cortex – particularly the Broca’s
area, which is responsible for speech – remains inactive. At the same time, the right hemisphere – particularly the
area around the amygdala, associated with emotional and automatic arousal – lights up (Rauch et al., 1994; Bremner
et al., 1992). From these observations it has been inferred that the imprint of trauma does not reside in the verbal,
analytical regions of the brain. Instead, it affects the limbic system and non-verbal region of the brain, which are only
marginally employed in thinking and cognition. van der Kolk (2003) states that “when people relive their traumatic
experiences, the frontal lobes become impaired and, as a result, they have trouble thinking and speaking. They are
no longer capable of communicating to either themselves or to others precisely what’s going on” (Wylies, 2004,
p. 39).
Current PTSD research shows that traumatic experiences interfere with temporal lobe function (Brinbaum, Gobeske,
Auerbach, Taylor, & Arnsten, 1999) and language, which is associated with the Broca’s area (Rauch et al., 1994). van
der Kolk (2002) further suggests that the
“subcortical regions of the brain, the primitive parts are not under conscious control and have no linguistic
representation, have a different way of remembering than the higher levels of the brain, located in the prefrontal
cortex. Under ordinary conditions these memory systems are harmoniously integrated, while, under conditions
of intense arousal, the limbic system and brain stem may produce emotions and sensations that contradict one’s
attitudes and beliefs” (p. 5).
A recent neuroimaging study (Lebedev et al., 2004) suggests that the “dorsolateral prefrontal cortex plays an
important role in aspects of attention and other functions instead of, or in addition to, maintenance memory” (p.
e365), supporting extensive neuropsychology research that points to a general role of the prefrontal cortex on the
maintenance of memory. Similarly, neuroimaging researchers (Bremner, Southwick, Johnson, Yehuda, & Charney,
1993;Bremner, 2001; Rauch et al., 1994) have stressed the importance of the frontal lobes, especially the prefrontal
cortex, in PTSD patients processing traumatic memory. The expression of the traumatic memories, however, can be
modified by feedback from the prefrontal cortex (van der Kolk, 1994).
S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35 25
The frontal lobe is the part of the brain that is involved in planning, organizing, problem solving, selective attention,
personality and a variety of “higher cognitive functions,” including behavior and emotions. The anterior (front) portion
of the frontal lobe, called the prefrontal cortex, is also known as the seat of executive function, due to its ability
to differentiate between conflicting thoughts, determining good and bad, better and best, same and different, future
consequences of current activities, working towards a defined goal, predictions of outcomes, expectations based on
action and social control (Long, 2006). Traumatized individuals are unable to modulate the incoming stimulation,
which interferes with the amygdala and hippocampal functions, bypassing the prefrontal cortex that would normally
assist with the cognitive evaluation of the experience. Studies have shown that trauma sufferers process their trauma
from the bottom up – body to mind—and not top down – mind to body (van der Kolk, 2002, see also Ogden & Minton,
2000). In order to treat trauma effectively therapists must move beyond words and language to integrate the cognitive,
emotional and affective memory.
Theories of art making and brain function
In all its forms – literature, music, painting, sculpture, film, dance or theater – art represents the mind of its creator.
This is no less true in treatment of psychological and neurological disorders than it is in the analysis of established artists
or exceptional ones such as Willem de Kooning and Pablo Picasso (Ziadel, 2005). The major areas of clinical research
in creativity have centered on neurological disorders, especially with frontotemporal dementia (FTD), stroke and aging
(Miller, Cummings, & Mishkin, 1998;Ziadel, 2005). Although researchers had identified the right hemisphere of the
brain as the creative hemisphere, Ziadel (2005) suggests that there is no evidence to support the view that creativity (in
art or music) uniquely resides in one hemisphere. She argues that locating creativity in the right hemisphere is an “old
notion, originally formulated only as a working hypothesis in left–right hemisphere research” (p. xvi). A consensus
among researchers using the neuropsychological evidence from artists with brain damage holds that some assignment
of functions to the right and left hemispheres remains valid, but the factor relevant here is the function of the prefrontal
cortex. They agree that brain damage may severely impair language ability while artistic skills are minimally affected
or not affected at all. Bogousslavsky (2005) states that brain activity shows that when carrying out an art task – a
“complex combination of sensory, cognitive and motor activities – immediately emphasizes the holistic functioning
of the brain in creativity, while it shows that specific, focal brain lesions may alter or disrupt the process” (p. 106).
Bogousslavsky studied the connection between changes in artistic styles and brain lesions. He suggests that a link
exists between increased creativity and decreased frontal lobe functioning in FTD cases of non-artistic individuals
embarking on artistic careers. He further argues that the brain’s frontal-anterior subcortical loops are activated during
the execution of artwork. In the case of abstract painter Willem de Kooning, he notes that even though the artist’s late
works, created during his time of senile dementia, reveal a progressive simplification, they nonetheless maintain a high
level of sophistication. Implicit in this observation is the argument that in his late works de Kooning is drawing upon
the non-verbal hemisphere of the brain; in other words: creativity may be maintained even while the neurology of an
individual is being transformed or degraded through dementia.
Ziadel (2005) reports, based on her research on neurological patients, that both left and right hemispheres are
involved simultaneously in the production of visual art. When observing the production of art with a specialized
tracking device, Ziadel found that most often artists worked the tilt, shape, size, form and height of the elements in
relationship to the theme of a picture. In some rare cases she found that the artist, rather than starting from the global
contours of the subject (associated with the right hemisphere), started with the details first, working his way outwards.
Similar observations were made in the case of two autistic savant artists (Nadia and EC) who had exceptional artistic
skills in rendering realistic figure drawings. On the basis of her observations, Ziadel (2005) affirms the significant
roles played by both the right and left hemispheres in the production of visual art. McNamee (2004) designed the
“Bilateral Art” protocol and argues from her observations with clients that art therapy involves both left and right brain
functions, and integrates both verbal and non-verbal processes. She describes bilateral art as a process of using “both
hands in an effort to stimulate memories and experiences that reside in both sides of the brain” (p. 232). This process
of creating facilitates the integration of experiences. The rationale for her work comes from the seminal publications
of Ganzzaniga (1998) and Kandel (1985), who made contributions to cognition studies as well as to an understanding
of the interactions between the right and left hemispheres.
The research cited has positive implications for art therapists in the relationship between brain and creativity.
Although the relationship between creativity and the brain has not been fully defined, it is reasonable to assume
26 S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35
that creativity involves multiple brain regions. Ziadel along with other researchers points in the direction of “skill
preservation” (p. 19) in the event of brain damage or sensory compromise and its relationship between creativity and
frontal lobe activity (Bogousslavsky, 2005; Ziadel, 2005). Although research has not yielded any precise explanation
for art production after the onset of FTD or dementia, Ziadel (2005) suggests that “cognitive abstraction can be viewed
as a type of invariant human ability that survives extensive neuroanatomical damage” (p. 85). Bogousslavsky (2005)
explains this as the “function of the frontal lobe structure, which is based on the ‘extraction–abstraction processes”’
(p. 106). He argues that a particular relationship is established between the sensory and prefrontal cortices after
neuroanatomical damage, which Ziadel (2005) also supports. The view proposed here is that the automatic skills
and procedures required in everyday life have shared components with artistic skills. The “shared skills are somehow
resistant to brain damage, possibly due to repeated use, over-practice, and redundant representation in the brain” (Ziadel,
2005, p. 82). This means that localized brain damage may not necessarily prevent the individual from art expression. For
example, a dementia patient unable to communicate with his caretaker by means of words communicated effectively
through drawings, transferring the skill of communicating to abstract cognition (Ziadel, 2005). Extraction–abstraction
interactions necessitate the integration of internal representations, which are generated and maintained through frontal
lobe activity (Bogousslavsky, 2005).
The studies in neuropsychology, art and PTSD that I have cited present significant findings for art therapists engaged
in accessing traumatic memory through image making. In light of neuropsychology research on creativity, neuroimag-
ining research on trauma and current art therapy studies, it is possible to infer that art making involves the brain’s
hemispheres in accessing memories and processing emotions. The left hemisphere is responsible for language, speech,
analytical thinking and sequential processing, including confabulation, the process of creating narrative (McNamee,
2004, 2005). A confabulation may be based in fact or be a complete construction of the imagination. In an art therapy
session the left hemisphere offers an explanation to the right hemispheric output in the form of a created image. The
right hemisphere deals with visual motor activities, intuition, emotions, body, sensory, automatic skills and the proce-
dures involved in what we call creativity (Bogousslavsky, 2005). It is directly linked to the subcortical regions of the
brain, such as the brain stem. It is the non-verbal, creative aspect that is evoked when clients are asked to draw in an
art therapy session.
During an art therapy session, it is not uncommon for a client to put into pictures a speechless terror that can-
not be put into words. It is the trauma that is frozen in the somatic memory (van der Kolk, 2003). Siegel (1999)
published research on the effects of early childhood abuse on the developing brain, and Klorer (2005) draws on his
ideas when she argues that the right hemisphere of the brain controls the sensorimotor perception, integration and
social-emotional input. She points out that art making and creative processes tap into the sensorimotor perception.
In doing so they activate the amygdala in the limbic system, which is responsible for the social emotional input that
links with the prefrontal cortex for integrating and planning, activating the physiological, emotional and cognitive
The integration of traumatic experiences is dependent upon the bilateral stimulation of the frontal lobes, espe-
cially within the prefrontal cortex. Non-verbal expressive therapies such as art, dance, music, poetry and drama
all activate the subcortical regions of the brain and access preverbal memories. Each of these creative arts modal-
ities is a “powerful tool” (Meekums, 1999, p. 257), but each will stimulate the left and right hemispheres and
the recall of emotional/traumatic material in a different way. While implicit memory can be accessed through
all expressive therapies, each modality is highly specialized in its training and how it addresses and integrates
emotional material. Table 1 charts the memory activation during trauma and its intersection with different expres-
sive therapies. Dance and drama work directly with the body through movement, activating the right hemisphere
and limbic material, while art and music activate non-verbal material through kinesthetic and sensory pathways
(Lusebrink, 2004). The goal of each of these modalities is to “lead people to emotions and feelings that have long
been forgotten” (Klorer, 2005, p. 218). To process traumatic memories successfully, each of the modalities must
employ an approach that integrates the cognitive, emotional and physiological memory towards positive adaptive
An art therapy trauma protocol (ATTP), its practice and theoretical basis
The proposed ATTP is designed to address the non-verbal, somatic memory of traumatized clients using right- and
left-brain methods based on a positive adaptive functioning model. This protocol is influenced by Shaprio’s (2001) Eye
S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35 27
Table 1
Memory activation during trauma and expressive therapies
Adapted and modified from Rothschild, 2000.
Movement Desensitization and Reprocessing (EMDR), McNamee’s (2003) bilateral art protocol and Cassou’s (2001)
Point Zero method of painting.
The foundation of EMDR treatment lies in Shaprio’s (2001) adaptive information processing system (AIPS),
which proposes that each individual has the innate ability to construct adaptive resolutions to negative experiences
and to integrate positive and negative emotional schemata. Trauma, she believes, blocks the normal adaptive functions
that AIPS will automatically restore. The EMDR protocol asks the client to identify specific traumatic memories;
these memories may include images associated with the event, the emotions and affective memory. The client
identifies the negative self-representation or the negative cognition associated with the traumatic memory; he or she
then identifies the desired, positive self-representation or the positive cognition for that memory. After the negative
cognition is located in the body as a sensation, the client is asked to concentrate on the disturbing traumatic memory.
While keeping the negative cognition and physiological sensation in mind, the client moves the eyes rapidly from
side to side. The goal of the eye movement is to stimulate both hemispheres of the brain. After each set of 10 to
20 eye movements the client reports what new images, memories or sequence of events has emerged. The client
continues to work through the memory until the reprocessing is complete, and recall of the traumatic event no longer
prompts feelings of disturbance (Chemtob, Tolin, van der Kolk, & Pitman, 2000). Although EMDR continues to gain
28 S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35
popularity as a method of treatment, it has generated some controversy as a way of treating trauma (Devilly, Spence,
& Rapee, 1998;Dunn, Schwartz, Hatfield, & Weigele, 1996;Pittman, Orr, Altman, Longpre, Poire, & Macklin,
McNamee (2003) was also influenced by EMDR. She, however, modified the works of Cartwright (1999) on
neurologically based artwork and developed a bilateral art protocol in an effort to stimulate the memories of experiences
that reside in both sides of the brain. McNamee describes detailed steps for the use of her bilateral protocol. She uses
one sheet of paper that is divided into two sections to represent the left and right sides of the brain. On it the client
draws two images identifying the conflicting emotion, situation or belief. The client is instructed to choose the hand
that is most connected to the conflicting element of experience and make an image of it. After the first drawing is
complete McNamee moves the materials to the client’s other hand and has the client draw the opposing element of
experience. She has modified this procedure by having clients trace over the drawing, in any manner they wish, with
their opposite hand to promote bilateral stimulation.
Clients in the ATTP use both hands to process traumatic memory, but the conceptualization of the process, including
use of art materials, differs from McNamee’s. Cassou’s (2001) Point Zero method of painting has been modified to
assist clients in processing and integrating experiences. Cassou explains that her goal with participants is to gain a deep
understanding of creativity by dissolving creative blocks and self questioning, to achieve healing. The use of negative
and positive cognition, scaling the negative cognition and locating the cognitive emotion in the body are adapted from
Shaprio’s (2001) EMDR methodology. The process of painting with dominant and non-dominant hand, use of paints
and use of cognitive interweaves to facilitate the art process come from my art therapy training and clinical practice.
The major difference between the EMDR protocol and the ATTP is what constitutes a target memory. In EMDR the
target memory must be an event on a life events list. This requires the client to have sufficient recollection of the event
to be able to talk about it. Clients come to art therapy, however, because they find that images reflect or express their
state of being more clearly and directly than words. The visual image captures their somatic memory and stands as a
testimony to their felt experiences.
The ATTP is a method to target specific traumatic memories in a larger theoretical framework. The ATTP train-
ing (Talwar & Kaiser, 2006) teaches participants to use a combination of client-centered and cognitive behavioral
approaches in which the ATTP protocol addresses the affective distress experienced by the client. A client-centered
approach emphasizes the experiences, feelings and values of the client, while recognizing that perceptions of reality
vary from individual to individual. The cognitive behavioral approach refers to the client’s ability to change his or her
self perception, while advancing towards positive adaptive functioning (Shaprio, 2001).
After a detailed evaluation of the client’s history is obtained, the ATTP becomes the framework to prepare the
client for trauma work. The client is assisted in exploring ways of problem-solving specific to him or her. This
leads to an understanding of their affective responses and accessing images of safety. Through this process the
client begins to develop an understanding of the underlying negative feelings and self-perceptions, and the affective
responses evoked by these emotions. Clients are encouraged to keep affective logs to become aware of their affective
regulation outside of the therapy session. Learning to cue into their negative cognitions and accessing images of
safety and positive cognition outside of the therapy sessions, the client begins to develop a sense of mastery and self
confidence over their affect regulations and emotions. Rating the validity of positive cognition (VoC), while indicating
how true the cognition feels at that present moment, promotes cognitive functioning while lowering the client’s
This protocol has been employed only with adult clients. Modified versions have been used in supervision and with
children and adolescents, but issues surrounding treatment with children and adolescents lie outside the scope of this
Materials and procedure
In this method, a large sheet (22 ×29) of Bristol board is taped on the wall or easel. The participant paints while
standing and the workspace is arranged to permit full use of the body. The tempera paints are laid out in open jars on
a table in a variety of colors ranging through a continuum from white to black. The space should allow the participant
to walk back and forth between the painting and the paint jars (Fig. 1).
The walking back and forth is particularly important in creating a process that flows. The flow, in turn, allows
proprioception and suspension (Bohm, 1996; Lark, 2005), which encourage dual processing or bilateral stimulation
S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35 29
Fig. 1. Layout of materials for session with client.
(Omaha, 2004; Shaprio, 2001). Engaging in the creative process, making decisions and letting the image emerge with
the client activate the mind and body. Suspension occurs each time the client makes the decision to move from verbal
language to the visual, kinesthetic and sensory language, brush to paint, paint to image, intended to activate dual
processing of the left and right hemispheres of the brain. Observing one’s intention and action through the creative
process promotes self-perception, or what Bohm (1996) and Rothschild (2000) call “proprioception.” In this work,
Fig. 2. Client A’s first image with dominant hand.
30 S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35
“The point of suspension is to help make proprioception possible, to create a mirror so that you can see the results of
your thoughts” (p. 25).
After the client has verbalized a memory of a traumatic event, presenting the facts and events of the memory, he/she
is instructed to:
Phase 1
Suspend all thoughts and associations and begin painting. When the client is finished, he/she is asked to put into
words the dominant emotion associated with the painting or element of the painting. The client typically represents
either literally or metaphorically the earlier conversation or incident reported verbally.
Phase 2
The client is then asked to identify the negative self-representation or the negative cognition (“I am not valuable,
“I am not loved” or “I am a bad person”) along with the alternate, desired, positive self-representation or the positive
cognition (“I am a valuable human being,” “I am loved” or “I am a good person”) for each memory. The client rates
the validity of positive cognition to indicate how true the cognition feels to the client at the present moment on a scale
of 1 to 7, where 1 represents completely false and 7 represents completely true. The positive cognition is typically low.
The negative cognition is then located in the body as a sensation. The client, painting with the non-dominant hand,
is asked to concentrate on the disturbing traumatic memory, while keeping the negative cognition and physiological
sensation in mind. The client paints the new images and memories as they emerge on a new sheet of paper.
Fig. 3. Client A’s second picture with non dominant hand.
S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35 31
Phase 3
The client continues painting, switching between dominant and non-dominant hand and using a new sheet of paper
each time. The client thus works through the memory until there are no longer any feelings of disturbance at the recall
of the traumatic event.
Session with client A
Awas a 58-year-old woman who worked in the field of mental health. She had participated in verbal psychotherapy,
examining various aspects of her life and identifying areas of early childhood trauma for several years. At the same
time Ahad utilized art as a modality of expression and attended various art workshops. She was extremely articulate
and used intellectualization as a primary defense when explaining her art and areas of pain in her life. She was aware,
however, that talk therapy has been inadequate as a way to address her issues of trauma. She sought art therapy to reach
the non-verbal, somatic memory, stating, “I need to work with the image; words are not enough.”
In one session, Ahad a flat affect and facial expression. Her shoulders were hunched over in a depressed body
posture. She spoke of being stuck in a dead-end relationship with one of her own clients and struggled with her
projective identification. Her client was blaming her for preferring another client, being partial towards her in group
therapy sessions. In individual sessions, the client was blaming her for not being “good enough,” rejecting Ain her
role as a therapist. This situation had brought up old memories of rejection and inadequacy from A’s early experiences
Fig. 4. Client A’s third image with dominant hand.
32 S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35
Fig. 5. Client A’s fourth image with non-dominant hand.
with her own family, especially with her mother. The intensity of the feeling was present in the level of disturbance
in her affect, which was depressed with low energy. Ahad struggled to find various ways to work with this client, but
was feeling helpless to make sense of the situation. A, who was also a storyteller, narrated the Russian fairytale of
Alionushka and Ivanuska as a metaphor for her current situation. When asked to paint she created a scene from the
story; in it Alionushka is tied up at the bottom of the ocean (Fig. 2). She was most struck by the image of Alionushka
and choose to focus on her in the painting. She identified the negative cognition for Alionushka as “feeling trapped.
When asked to identify the positive cognition or the desired state of being, she said that Alionushka “would like to feel
whole and free again.” The VoC on a scale of 1 to 7, where 1 is completely false and 7 completely true, was 1. She
located the sensation of “feeling trapped” in her chest.
She then painted with her non-dominant hand (Fig. 3). After a few quick brush strokes she said that she was done.
She looked at the painting and stated, “she turns up again” (referring to a sorceress that had appeared in her earlier
paintings). She moved to her dominant hand (Fig. 4) and replicated the swirling lines with the image of the sorceress
showing up again. She layered paint with a wide sumi brush, tracing out the figure of the sorceress in red and blue.
When she was finished she sated, “this is messy business.
She then moved to her non-dominant hand and painted a solid blue surface with the wide sumi brush (Fig. 5). When
she was done, I suggested that she add a color she had not used or a color she disliked in order to introduce the polarity
between her positive and negative cognition through materials and emotions.
The cognitive interweaves led her to add pink patches on the sides of the paper and she then stopped. I suggested
that she use a finer brush to further push the cognitive polarity through the materials she was using. Changing materials
immediately shifted the image process, and a woman and baby emerged from the edges. After she finished, she moved
to her dominant hand and tried to continue with the fine brush, but stated, “This brush feels too small.
She returned to the wide brush and painted a green surface and began to work paint with a plastic knife (Fig. 6). She
moved to the smaller brush and the image of the horse appeared in an open field. While painting this image, Abegan
S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35 33
Fig. 6. Client A’s fifth image with dominant hand.
to smile, her body seemed lighter; standing upright, she stated, “I don’t need to say anything, but I have hope for my
client. I am free and this horse will lead her to wholeness.” She rated her VoC as 7.
Although Areached her intended positive cognition there seems to be an element of fusion between herself and her
client in the last statement. In this session the horse represented the symbol for freedom, strength and wholeness for
A.Meekums (1999) observed in her research with victims of child sexual abuse that “shifts appeared to be associated
with a shift in self-perception from child to adult self, from victim to assertive survivor, enabling a new integration of
the child and adult selves” (p. 256). The shift that occurred here was a movement towards an adaptive functioning of
the self, whereby Awas able to shift her self perception from “feeling trapped” to “feeling free,” both for herself and
her client.
Projective identification is a defense in which the individual gets caught in the anger and devaluation of another
individual without being able to separate the self from other. The situation for Awas reminiscent of an earlier rela-
tionship, in this case, that with her mother. To deal with the complexity of projective identification it is imperative that
the individual be able to reach a place of empathy for the self and other. In my opinion, the last statement made by A
not only shifted her self-perception from victim to survivor, but also enabled her to change her perception of her own
client. By having empathy for herself, she in turn was able to have “hope” for her client. This new perspective provided
her with greater clarity about her relationship with her client and the residual memory of her mother.
The ATTP described grew out of my clinical practice. Although no research study has been undertaken, clients
report positive results in processing speechless traumatic memories. This article has focused exclusively on processing
somatic memory. Addressing the full spectrum of trauma treatment lies outside the scope of the paper. During the
therapeutic sessions the therapist must carefully evaluate the client’s readiness to confront a specific event or somatic
34 S. Talwar / The Arts in Psychotherapy 34 (2007) 22–35
memory. Considerable time must be spent getting the client ready through emotional and cognitive processing and by
creating an awareness of the somatic memory on the affective and emotional level.
The type of processing described gives the client tools to create sensory awareness, which promotes affect and
emotional regulation. The process of creating the image helps the client to observe his/her thoughts and actions while
becoming aware of the sensorimotor experience, promoting propriception. The walking back and forth allows for
activation between left and right brain process. In creating the image, left brain processes, of deciding between colors,
brushes, and sequential decisions using analytical thinking, alternate with right brain processes, activating the spatial,
visual motor, emotions, and sensory regions. During this process, the mediating limbic structures, the hippocampus
and amygdala, are creating a sequence of events and assigning the events their emotional significance. The bilateral
stimulation through art making, engages the integrating and planning functions of the prefrontal cortex as the memory
is assigned a narrative of beginning, middle and an end by the hippocampus, using left brain functions. The ATTP is
a method that has an integrative approach offering a positive adaptive functioning model, but successfully using this
method depends on each individual’s internal self representation. Omaha (2004) emphasizes the importance of the
therapeutic relationship in strengthening internal representation of the individual. I concur with him that restructuring
early developmental milestones to increase ego strength and internal representations is imperative before processing
the trauma blocks.
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... At times, it may be appropriate to dialogue with these images in active imagination to apprehend their meanings (McNiff, 2004;Shamdasani, 2009). Art therapies operate under the premise that creative activities, such as story-writing and visual arts, offer opportunities to appraise and express painful memories that may be otherwise overwhelming due to their emotional charge (Talwar, 2006). The creator has a degree of control over the distance between ego and potentially troubling unconscious contents to safely accrue insight rather than defaulting to less sophisticated defensive responses (i.e., avoidance; Slayton, D'Archer & Kaplan, 2011). ...
... Meanwhile, when participants utilized the task as an opportunity to document their personal histories like a diary (frequently including painful memories), their interpretations were shorter and had limited depth. This speaks to the hypothesis that creative activity provides indirect access to difficult emotions, while a direct and unprepared encounter with the emotional charge of the experience may bring about refusal to engage (Ellenberger, 1980(Ellenberger, /1971Slayton, D'Archer, & Kaplan, 2011;Talwar, 2006). There were no cases in which participants interpreted literal autobiographical content in a sophisticated manner. ...
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This article describes the development and testing of a novel creative and reflective writing task. Following the rationale of sand-tray and play therapies, participants were asked to meaningfully incorporate four objects from a randomly generated matrix of options into a creative short story. They then composed a second story that incorporated four possessions from home associated with important memories. Afterwards, participants produced interpretive statements or reflections on what the stories meant to them. An exploratory qualitative study was conducted based on narrative data from 15 young adult participants in Canada. Our goals were to: (a) explore the extent to which object familiarity was associated with qualitative differences in stories and interpretations, and (b) investigate for connections between features of participants’ stories and depth of interpretation. Analysis of creative stories resulted in a scheme of four response categories with ten subcategories. Participants’ interpretations of their own stories were coded based on self-described sources of inspiration, such as critical life episodes or popular media. Results are accompanied with excerpts of participants’ stories and reflections, and percentage comparisons are reported. Findings are presented in dialogue with established interpretive frameworks originating in depth psychology. Manipulation of object familiarity resulted in demonstrable differences at the levels of word length, point of view, narrative forms and features, self-disclosure, and reflection. Use of familiar objects in such a task appears to be a largely untapped resource that shows promise as a route to insight.
... Numerous studies have documented the value of artbased interventions with survivors of natural disasters and have analysed the ethical and cross-cultural considerations these entail (Hass-Cohen, Clyde Findlay, Carr, & Vanderlan, 2014;Hollingsbee, 2019;Kapitan, 2015;Malchiodi, 2008;Orr, 2007;Potash & Kalmanowitz, 2012;Talwar, 2007). Art therapists involved in international relief work often state that it is crucial to balance the urgent need for assistance with ethical attunement to the local community and its specific responses to trauma (Kapitan, 2015;Potash et al., 2017). ...
This study focuses on an arts-based mental health and psychosocial support (MHPSS) intervention in the form of TOT (training of trainers) conducted under the auspices of IsraAID in the aftermath of the Yolanda typhoon in the Philippines in 2013. Interviews were conducted with 10 female education and healthcare professionals, who also made drawings of their experiences. The goal was to better understand how they evaluated the training program, both for themselves and their communities. Analysis of the interviews and drawings, based on the principles of Consensual Qualitative Research (CQR), identified three main domains: (1) Supportive and inhibiting factors for participants in the training course; (2) Supportive and inhibiting factors with respect to the participants’ implementation of the training goals in their local communities; (3) Perceptions of the benefits of the training program for the participants and their communities. The discussion centers on the value of the creative process, the importance of the group in the training course and in the context of multiculturalism, and the impact these factors in interventions applying the TOT model.
... 59 3.47 Cohen et al., 1988 Exploratory study in which a series of diagnostic drawings (DDS) was administered to 239 psychiatric hospitalized patients with a diagnosis of dysthymia, depression or schizophrenia with the objective of evaluating the link between the patients' disease based on the psychiatric diagnoses and how it is expressed in the drawings. 52 1.53 Talwar, 2007 This article, following an overview of the role of memory and emotions in trauma and theories of art creation and brain function, proposes an art therapy protocol, designed to address the non-verbal core of traumatic memory, which has been successful in integrating the cognitive, emotional and physiological levels of trauma. 51 3.4 ...
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Aim: Despite the increase in international research in art therapy, few studies have been developed with a bibliometric approach which describe the situation regarding this area of knowledge. Thus, the aim of this study is to describe and contextualize international scientific production in the visual arts modality in the context of artistic therapies, to offer a broader and more in-depth vision of the structure of this area of knowledge through of a bibliometric analysis of the publications indexed in the core collection of the Web of Science. Methods: This is a retrospective, exploratory and descriptive, cross-sectional study to analyze the bibliographic data retrieved from the databases of the core collection. The analysis parameters included the data corresponding to the production according to type of document, country, journal, and institution. In addition, the main lines of research were located and classified and the subject matter of the most cited articles in each of them was summarized. Four periods were selected, between 1994 and 2020, to facilitate the thematic analysis and offer an evolutionary perspective of art therapy research. Results: A total of 563 works were published, in 250 journals, in the 63 years between 1958, when the first document was published, and April 2021. The annual growth rate was 7.3% with a mean average of 8.7 publications per year, and 83.13% of the published works were articles. A total of 1,269 authors from 56 countries were counted. The mean number of citations per document was 5.6 and the mean number of citations per document and year was 0.6. The main research domains were psychology and/or rehabilitation and the highest production on this topic was concentrated in only three journals. In general, a high degree of variability was observed in the study topics and numerous theoretical and methodological articles. The most used visual arts modalities were in the main drawing, painting and photography. Conclusion: This work did not find previous existence of any bibliometric analysis on the international scientific production in art therapy. In general terms, there has been a substantial growth in the number of publications on the subject over the last decade. However, this research area does not appear to have peaked, but, on the contrary, is still growing and progressing despite its long history in clinical practice.
... Looking at military PTSD specifically, research has shown that the hippocampus, part of the limbic system involved in declarative memory, can shrink by up to 26% (Gurvits et al., 1996). By engaging non-verbal and verbal parts of the brain hippocampal activity may perhaps be restored and integration of declarative and non-declarative memory systems fostered (Avrahami, 2005;Gantt and Tinnin, 2009;Lusebrink, 2004;Talwar, 2007). Smith (2016) used a systematic review to summarise hypothesised mechanisms of change in art therapy for veterans. ...
Background A proportion of veterans experience post-traumatic stress disorder (PTSD). Research has shown reduced effectiveness of commonly offered psychotherapies in military personnel. Some research suggested the usefulness of art therapy for veterans with PTSD, but its mechanism of operation has been unclear. The current project aimed to establish participants’ perceptions of any impact of group art therapy and some of the perceived mechanisms of change. Method In a grounded theory design, single semi-structured interviews were conducted with nine veterans who had received group art therapy, two art therapists, and a veteran's wife. Interviews were transcribed and analysed. Findings Theorised categories included (a) art therapy group as “the family”, (b) “the gentle conductor”, (c) trust, (d) doing the work, (e) art therapy as "a communication tool", (f) "points of recognition", (g) "making things concrete", and (h) "not a cure". Limitations Shortcomings included a homogenous sample who all attended art therapy alongside other interventions, reliance on subjective and unmeasured symptom change, and researcher effects related to qualitative methodology. Conclusion The developed grounded theory is consistent with existing evidence and neuropsychological theory. Group art therapy may enable some veterans to prepare for verbal-only therapy, by offering a safe space in which to approach non-verbal traumatic and trauma-related contextual material in a controlled way. Artworks may provide a bridge to facilitate communication of experiences within subsequent verbal therapy and with loved-ones. It is suggested to replicate the project at different sites. Elements of the developed theory may be investigated further to establish its transferability.
This chapter explores how art therapy can help people recover from trauma. The chapter begins by defining trauma and examining why trauma is important to study. We learn about the different forms of trauma and how trauma is diagnosed. Four specific clusters of symptoms are discussed as well as how trauma affects the brain. Specific ways to prepare for trauma work are reviewed. Research evidence on art therapy interventions for trauma is provided and the chapter describes specific ways that art therapy is integrated into trauma treatment and work with children and adolescents. The second half of the chapter explores art therapy in response to disaster and tragedy. We explore art therapy interventions through psychology and art therapy first aid and learn about several real-life case examples. The chapter concludes with a discussion about the importance of self-care when working with clients with trauma.
We designed a qualitative study to explore and identify outcomes of participants’ experience of a workshop aiming to raise awareness of vicarious trauma (VT) and introduce the practice of response art (RA) for self-care. The workshop was designed and implemented in the winter of 2018. It was facilitated by an art therapist. Seven psychotherapists who work with refugees and asylum claimants attended the event. During the workshop, they received theoretical information about VT and RA, were initiated to the practice of RA, and offered a RA kit to take home. All participants took part in three semi-structured interviews over the two months following the workshop. The data collected from the follow-up interviews was submitted to a thematic analysis to gain an understanding of participants’ experience of the workshop and of RA as well as to elucidate enduring outcomes of the workshop and post-workshop RA experiences. Results suggest the experience was pleasant and beneficial to participants. Knowledge acquisition, the normalization of one’s experience of vicarious trauma, and increased and new awareness of oneself and others, to name a few, were reported by participants as outcomes of the workshop and of RA. The need for practical knowledge consolidation through follow-up workshops was also strongly advised by participants. Recommendations for professional development endeavors bridging VT and RA based on our findings are discussed.
The Kamishibai theatre is a traditional Japanese method of storytelling using illustrated boards successively taken out of a small wooden chest used as a screen. Although the method has a significant educational and therapeutic potential, researchers devote little attention to it, focusing mainly on its connection with developing language competency and promotion of reading. However, the Kamishibai theatre constitutes an excellent form of working with children with intellectual disability, as we try to demonstrate in this article. The article is devoted to the issues of using Kamishibai theatre in working with children with intellectual disabilities and the role the teacher plays in implementing this stimulation method. Considerations made are based on the results of two previous scientific projects oriented around the epiphanies and key experiences in the biographies of educators and the impact of various forms of communication within the Kamishibai theatre method on the perception of the content presented to children with intellectual disabilities. The article presents the results of our research, supplements the analysis with the indications regarding the role of the teacher conducting art therapy classes and an in-depth reflection on the predispositions a teacher should possess.
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Considering the physical, and psychological impacts and challenges brought about the coronavirus disease 2019 (COVID-19), art therapy (AT) provides opportunities to promote human health and well-being. There are few systematic analysis studies in the fields of AT, which can provide content and direction for the potential value and impact of AT. Therefore, this paper aims to critically analyze the published work in the field of AT from the perspective of promoting health and well-being, and provides insights into current research status, hotspots, limitations, and future development trends of AT. This paper adopts a mixed method of quantitative and qualitative analysis including bibliometric analysis and keyword co-occurrence analysis. The results indicate that: (1) the current studies on AT are mostly related to research and therapeutic methods, types of AT, research populations and diseases, and evaluation of therapeutic effect of AT. The research method of AT mainly adopts qualitative research, among which creative arts therapy and group AT are common types of AT, and its main research populations are children, veterans, and adolescents. AT-aided diseases are trauma, depression, psychosis, dementia, and cancer. In addition, the therapeutic methods are mainly related to psychotherapy, drama, music, and dance/movement. Further, computer systems are an important evaluation tool in the research of AT; (2) the future development trend of AT-aided health and well-being based on research hotspots, could be focused on children, schizophrenia, well-being, mental health, palliative care, veterans, and the elderly within the context of addressing COVID-19 challenges; and (3) future AT-aided health and well-being could pay more attention to innovate and integrate the therapeutic methods of behavior, movement, and technology, such as virtual reality and remote supervision.
Background Few studies have investigated brain responses to different art media. Investigations into brain processes during art making have highlighted important structures. Neuroimaging tools have been used to investigate activation of brain areas whilst artmaking, but not in a therapeutic setting. This review highlights recent advancements in this area and encourages researchers to be the first to apply this in the UK. Aim To understand how the principles of neuroscience are currently informing the literature to explain the effects of art media in art therapy practice. Methods Review of published peer-reviewed research between years 2000 and 2020 on neuroscience and art therapy. Results Findings were summarised into categories discussing psychological/neurobiological issues, art media, neuroimaging technology, and models posited. Forty-six studies were found; majority discussed the structure and function of the brain to explain art therapy processes. The Expressive Therapies Continuum (ETC) model theorised that media properties stimulate different levels of visual and cognitive processing. The novel Mobile Brain/Body Imaging (MoBI) neuroimaging technology may be used as a means of quantifying data. Conclusion Significant progress has been made in attempting to explain brain responses during the art therapy process. However empirical data is needed to prove theoretical models. The use of neuroimaging has started this process to lead research into evidence-based practice. Implications for practice/further research Evidencing the ground-breaking ETC model, using neuroimaging and MoBI technology is needed through close collaboration between transdisciplinary departments. Art therapists should be encouraged to use the ETC to inform art therapy assessment, planning and treatment. Plain-language summary Neuroscience is the study of the brain and its processes, and recently technology has been available to researchers to examine brain processes in detail. This systematic narrative review explores recent literature that uses the principles of neuroscience to investigate the effects of art therapy, with a specific interest in art media. A systematic narrative review is when the findings of the study rely on the use of words to summarise the data. Art media is an important part of art therapy, as it is through artistic expressions that the client communicates their inner troubles. Different art media has been shown to elicit different feelings and behavioural responses in clients. However, research showing brain responses to different art media is limited. This study highlights ways in which further research in this field can take place. Results show that significant advancements have already been made that identify important structures and functions of the brain accessed during art therapy. Important models which incorporate neuroscience principles and theorise the art therapy process are highlighted. A significant model is the Expressive Therapies Continuum. This model explains how the brain processes information when different art media is used. However empirical data is needed to substantiate the theory behind this model. The use of neuroimaging technology is one way to achieve this. Therefore, this paper encourages transdisciplinary research to further investigate the effects different art media has on the brain during the art therapy process.
The significance of art in human existence has long been a source of puzzlement, fascination, and mystery. in Neuropsychology of Art, Dahlia W. Zaidel explores the brain regions and neuronal systems that support artistic creativity, talent, and appreciation.
This paper explores the process of eight months in which Martha was involved in psychotherapy. Several days following the sixth psychotherapy session, Martha created this book entitled “Spontaneous.” It consisted of ten line drawings done with marker. This book was created without any conscious direction or thought, and the meaning was obscure to the client. However, the meaning became clearer as the psychotherapy process unfolded. “Spontaneous” was like a map, outlining the process which Martha needed to complete in order to resolve the issues of being sexually abused.