Art as Therapy within Occupational

Therapy in M.ental Health Settings:

a Review of the literature
Chris Lloyd and Vanessa Papas

There is a lack of literature and research supporting the use of art as therapy in occupational
therapy. In spite of this, art as a therapeutic modality is a frequently used tool. In an attempt to
define the rationale for using art in therapy, this paper reviews selected literature to gain an
understanding of the historical use of art and the current status of art used by occupational
therapists in mental health settings.

Introduction (1986) highlighted the importance for occupational therapists

to develop an understanding of underlying dynamics relevant
The occupational therapy profession has traditionally em-
in activities. There is a long association of occupational thera-
ployed the therapeutic use of activities in working with a vari-
pists with art as a therapeutic modality in mental health
ety of client groups. The choice of activities depends upon the
(Gillette 1963). The reasons for the use of art as a therapeu-
identified client needs. An activity frequently used in mental
tic medium has changed greatly over the years.
health settings is art. Friedman (1952) described the value of
Historically, projective techniques have been used by psy-
art as follows: 'Due to its flexibility, art as a medium in therapy
chologists and others for personality assessment and/or analy-
adapts itself well to the treatment programme, and provides
sis of unconscious conflicts as might be revealed in a client's
for the patient a mode of expression variable enough to meet
artwork (Rabin 1981). In the late 1950s, occupational thera-
his needs, immediate and ultimate' (p64).
pists were challenged to use projective testing in their clients'
In developing programmes that best meet the identified
creative activities (Gillette 1963). Occupational therapists with
needs of clients, a sound rationale is required for the use of
a knowledge of psychodynamic and projective theory began to
selected activities. Establishing the aims and goals of the
explore media from this perspective.
group treatment is critical in planning a therapy programme
The first of the occupational therapy assessments was the
(Finley 1993). Not only must the therapist have confidence in
Azima Battery (Gillette 1963, Cramer-Azima 1982). The
the choice of activity, but the client must be provided with a
Azimas used the triad of pencil drawings, finger paints and
supportive, pleasant and constructive experience (Yalom
ceramic clay as the media for the artwork to contribute to
1983). There has been an increasing emphasis on account-
diagnostic information and as a guide for appropriate treat-
ability and consumer outcomes (Queensland Health 1994)
ment planning (Gillette 1963, Cramer-Azima 1982). The
which the therapist needs to take into account when design-
Azima battery was elaborated upon by Shoemyen (1970) to
ing and implementing a therapy programme. The question this
include mosaic tile, finger painting, sculpture and clay model-
raises is how best to evaluate the programme and whether or
ling.
not it is effective in addressing the clients' needs. While art is
The diagnostic test battery developed by Androes et al
frequently used within various treatment facilities, there is lit-
(1965) contained tasks of drawing, painting, woodwork and
tle documentation throughout recent occupational therapy lit-
leatherwork. This tool provided the opportunity to obseNe
erature relating to art programmes, reasons for use of art or
clients in a variety of situations and to gain additional informa-
therapeutic outcomes.
tion regarding the client's rehabilitation programme and the
This paper reviews the historical use of art and the current
dynamics of his or her illness. Other projective techniques
literature on reports of occupational therapists using art in
developed by occupational therapists have included:
mental health settings.
• The Fidler Diagnostic Battery, which was designed to pro-
vide information that contributed towards diagnosis and
A review of the historical use of art treatment planning (Fidler and Fidler 1964)
To determine the historical use of art in occupational therapy, • The Magazine Picture Collage, which assessed some of the
the available occupational therapy literature at the university symptomatology operating in the dynamic structure of the
library was reviewed. Activities are the major therapeutic mea- client's personality (Buck and Provancher 1972, Lerner
sures used in occupational therapy. According to Hopkins et al and Ross 1977)
(1978, pl00), 'activities are primary agents for learning and • Variations of the Draw-a-Person test, which provided infor-
development and an essential source of satisfaction', Levens mation for treatment planning in the areas of cognitive per-

Chris lloyd, MOccThy,Senior Occupational Therapist, Integrated Mental Health Services, Gold Coast Hospital, 108 Nerang Street, Southport,
Queensland 4215, Australia, and Postgraduate Student and Senior Clinical Lecturer, Department of Occupational Therapy, University of
Queensland,St Lucia, Queensland4072, Australia.
Vanessa Papas, BA, BOccThy,formerly Occupational Therapist, Integrated Mental Health Services, Gold Coast Hospital, 108 Nerang Street,
Southport, Queensland 4215, Australia.

British Journal of Occupational Therapy, January 1999, 62(1) 31

 formance, affect and mood, insight, motivation and situa-
tional components (Sheffer and Harlock 1980).
Of interest is the Draw-a-Person test. This test can be
administered in a group setting and addresses performance
areas such as self-care, work and play which are important for
occupational therapists to evaluate. Sheffer and Harlock
(1980) defined self-care as the ability to take the responsibili-
ty needed to promote one's health, independence and social
interaction; work as the ability to engage in activities that
accomplished some useful purpose for self and others; and
playas voluntarily pursuing activities with the expectation of
enjoyment.
According to Tiffany (1978), these techniques have proved
to be empirically useful and there have been some attempts
to standardise them. A common problem in many projective
evaluations is the lack of standardisation. Most of these tests
do not have an objective method for scoring the results and
contain limited reliability and validity information. These tools
need to be analysed for reliability and validity. Tiffany (1978)
suggested that the validation of information gained in projec-
tive techniques should be sought in other obseNation and
evaluation methods.
The material obtained through the use of art was thought
to be useful as diagnostic material (Vogel et al 1950,
Bendroth and Southam 1973, Malcolm 1975, Alleyne 1980);
for planning and developing occupational therapy programmes
(Messner 1951, Friedman 1953, Llorens and Young 1960);
and for detecting change in psychodynamic patterns, that is,
the uncovering and working through of defences, the uncover-
ing and working through of drives, the uncovering of conflicts
and emergence of insight, and the uncovering and working
through of transference (Wittkower and Johnston 1958).
The tendency in occupational therapy at this time was to
use projective techniques to identify deep, underlying person-
ality traits and structures, such as self-image, spontaneity,
suggestibility, use of ego defence mechanisms and uncon-
scious conflicts (Alima et al 1957, Sheffer and Harlock
1980). Weinroth (1955) found that a rich source of informa-
tion about clients was gained while engaging in art activities.
According to Zwerling (1979), the creative arts therapies
evoke responses more directly and immediately than any of
the more traditional verbal therapies.
Over time, occupational therapists changed their focus
from art as a projective medium to art as a means to develop
the therapeutic relationship and promote communication, or
therapeutic movement (Alleyne 1980). Creative activity facili-
tated the expression of feeling by the client and the collection
of information by the therapist, and provided the opportunity
to work together through the material (Alleyne 1980). Art is
an alternative channel of communication whereby clients can
express fears in images and use the images as a bridge
between themselves and the therapist to discuss these
images and what they mean (Naumburg 1966, Gray 1978).
Creative activities can also stimulate and structure ideas. The
emphasis is on the value of the activity and the communica-
tion it stimulates and not on the later analysis of the finished
product (Willson 1983).
More recent reports on the use of art have emphasised the
difference between art therapy and using art as therapy. In art
therapy the focus is on therapy where, according to Oster and
Gould (1987), the therapist looks for symbols in images and
attempts to help clients become more aware of their inner
selves. Clients are then assisted to integrate their newly dis-
covered inner selves with their outer realities in the anticipa-
tion that generalisations to the everyday interpersonal behav-
iours outside the therapeutic experience can take place.
According to Willson (1983), when using the arts within thera-
py, the focus is on the value of the activity and the communi-
catiol1 it stimulates. It has also been suggested that when art
32
skills and the quality of the end product are the focus, the
therapeutic aspects of art become the creativity and the
sense of personal accomplishment it brings (Leary 1994).
A review of the current use of art
To determine how art is used in occupational therapy, a review
was carried out of the American Journal of Occupational
Therapy, the British Journal of Occupational Therapy, the
Canadian Journal of Occupational Therapy, the Australian
Occupational Therapy Journal, the New Zealand Journal of
Occupational Therapy, Occupational Therapy in Mental Health,
the Occupational Therapy Journal of Research and
Occupational Therapy in Health Care for the period 1984-
1994. These journals were selected on the basis of their
availability at the university library. A decision was made to
review only the occupational therapy literature and not the lit-
erature from the discipline of art therapy. This decision was
based upon the need to define the rationale for the use of art
by occupational therapists in a mental health setting prior to
deciding whether or not to include the use of art in the thera-
py programmes being offered. Only 16 published papers were
retrieved. Of these papers, six were research articles and 10
were descriptive articles; this distinction was based upon the
stated purpose of the papers as outlined in the abstract.
Research articles
The research articles covered a diverse range of topics from
test instruments to promoting options and choices for clients.
The House-Tree-Person (H-T-P) test, which is an instrument
with a well-standardised system of administration, has been
examined with an acute psychiatric inpatient popUlation
(Polatajko and Kaiserman 1986). The purpose of this study
was to determine if the H-T·P test was a valid and efficient
method for identifying a problem list for occupational therapy.
A comparative study using blind procedures was conducted.
Each subject was administered the H-T-P test by a research
officer and concurrently but independently the occupational
therapist administered the occupational therapy assessment.
The H-T·P data were used to develop an occupational therapy
problem list and to select occupational therapy strategies.
Polatajko and Kaiserman (1986) suggested that the H-T-P
was a valuable screening tool for use in an acute care psychi-
atric setting where the occupational therapist is required to
come to an early decision regarding client inteNention. In
addition, they found that therapists reported gaining greater
insight into their clients' problems. Polatajko and Kaiserman
(1986) concluded that the H-T-P was a more efficient method
of evaluation than the occupational therapy assessment which
consisted of three parts, that is, inteNiew, concrete task (tile
trivet) and abstract task (collage).
Castilla and Klyczek (1993) examined the Kinetic Person
Drawing (KPD) task of the Bay Area Functional Performance
Evaluation (BAFPE) in an adult psychiatric day treatment pro-
gramme. Correlations between this projective drawing test and
measures of functional performance were used to determine if
the results of this projective test were associated with an indi-
vidual's functional performance. The authors concluded that
the results showed that the KPD was not a valid measure of
functional performance when used alone. At present, none of
the projective tests developed specifically for use in occupa-
tional therapy have any evidence of their reliability and validity
as assessment tools.
Group work using art and discussion for the assessment of
acutely disturbed adult psychiatric clients was examined by
Crouch (1987), who considered that there had been limited
research into the effectiveness of group techniques in the
assessment and treatment of clients. The effectiveness of
groups for assessment was determined by comparing the
British Journal of Occupational Therapy, January 1999, 62(1)
 occupational therapy assessments with those made by other
professionals in the health care team. Crouch (1987) found
that the short-term assessment of clients by occupational
therapists during group work did not differ significantly from
those of other members of the team. She concluded from
these results that short-term assessments of clients during
these types of group work were effective. She considered that
the broader implications of this study reinforced the effective-
ness of the occupational therapist's contribution to the multi-
disciplinary team. Crouch (1987) felt that the major advan-
tage that an occupational therapist had in the assessment of
any client was the access to the observation of activities used
in the assessment process itself. Heine and Steiner (1986)
proposed using standardised water-colour paintings as an
adjunct instrument for longitudinal monitoring of changes in
mood states. They found this to be significant in identifying
client progress not reflected by other criteria. They cautioned,
however, that since this study was piloted on only a small
sample, further study was warranted.
Froehlich and Nelson (1986) compared the affective
meanings of life review discussion groups to life review activity
groups. They found a positive response with incorporating life
review into verbal or activity groups using painting and col-
lages with elderly women from an urban subsidised housing
project. Froehlich and Nelson (1986) urged systematic investi-
gation of the health-promoting characteristics of activities.
One research article looked at the provision of options and
the encouragement of choices for clients with mental illness
from a residential facility (LaMore and Nelson 1993). This
study examined whether giving adults with mental illness
options at the beginning of an art actiVity would motivate
them more than when not given options. The clients painted
significantly more if given options and the opportunities for
choice than if they were not given choices. LaMore and
Nelson (1993) stated that choice, interest, preference, mean-
ing, purpose and performance in occupation were central to
occupational therapy knowledge. This finding is important in
highlighting the need for therapists to pay attention to provid-
ing opportunities for options and choices and with fostering
independence for clients seen in therapy.
Descriptive articles
The descriptive articles focused predominantly on using art to
help different client groups to express themselves. With an
unemployed depressed male, projective drawings were used
to enable the person to express his feelings; the translation of
these feelings and images into verbal form served to alter the
cognitive processing of the individual (Centoni and Tallant
1986). Brock (1991) discussed the therapeutic use of clay for
the assessment and treatment of clients in a psychiatric day
unit. The group provided clients with the opportunity to gain
self-awareness through self-expression and interacting with
others. Projective techniques, incorporating using a collection
of stencils, were used to assist emotionally disturbed children
to express their thoughts and feelings (Fraenkel and Tallant
1987). This modality was found to be particularly useful in
treating children with limited verbal communication.
Frye (1990) described using art as an initial activity in an
attempt to engage clients with multiple personality and disso-
ciative disorders in meaningful activity. She found that these
clients often avoided structured therapy groups but were more
responsive to expressive arts. Based on her clinical observa-
tions, Frye (1990) proposed a progressive model for viewing
clients' art. She suggested that this would provide clarity and
direction for both the therapist and the client in working
towards recovery. In working with clients with anorexia, the
approach concentrated on the process of painting rather than
the end product. The emphasis was on creating a non-threat-
British Journal of Occupational Therapy, January 1999, 62(1)
ening atmosphere by centring discussions on the paintings
(Conroy et aI1986).
Art has also been used to assist adult neurotic clients to
explore emotions and self-perceptions in order to build up a
sense of continuous identity so that clients reach a satisfacto-
ry integration of both their internal and external worlds
(Temple 1988). Spontaneous imagery and the scribble tech-
nique were used to increase effective communication, se/f-
disclosure and changes in attitude and behaviour with a vio-
lent offender (Lloyd and Campbell 1986-87). These tech-
niques were found to be useful in assisting the individual who
has difficulty in verbalising his or her thoughts and feelings.
What these articles shared in common was the use of art to
increase communication, the working through of material and
engagement in the therapeutic process.
Patrick and Winship (1994) raised the issue concerning
the disposal of a created piece when art has been used as a
medium for therapy. They suggested that, although disposal is
an important and meaningful event, it is often left undis-
cussed. Patrick and Winship (1994) considered that dis-
cussing disposal with the client would provide valuable materi-
al to examine. They urged further research into what happens
to the created piece after the therapeutic alliance has ceased.
An interesting variation on the use of art was described by
Busuttil (1990). In this paper, clients' artworks were used to
hold art exhibitions as a link towards community understand-
ing, acceptance and tolerance of people with a mental illness.
The use of an art exhibition promoted recognition and se/f-
esteem, and contributed towards overcoming barriers of stig-
ma (Busuttil 1990).
Finally, Hughes (1989) described her work in a psychiatric
day hospital. Art was employed to facilitate clients' self-
expression, creativity, insight and progress in therapy. Hughes
(1989) developed guidelines for using art in therapy, an art
exercise battery and method of observation. She highlighted a
number of considerations to make effective use of art in ther-
apy. These included the concept of creativity, the available
resources, the media to be used, the methods chosen and
the form of evaluation (Hughes 1989). The art exercise bat-
tery was designed for clients with depression, bipolar affective
disorder, personality disorder and eating disorders who were
undergoing short-term group therapy. Hughes (1989) suggest-
ed that it had limited use in other fields without modification.
The Hughes Behaviour Categories and Observation Sheet was
found to be a useful evaluation method, although a second
therapist was needed as observer (Hughes 1989).
Discussion
The occupational therapy literature has reported the use of art
with diverse client groups in a variety of mental health settings.
The focus of using art in therapy has changed greatly over the
years. Earlier reports placed greater emphasis on the pSYChody-
namic aspects of art and the development of projective tech-
niques. Later reports have promoted the use of art to develop
the therapeutic relationship, self-awareness and communication.
There is disparate material assembled under the rubric of
art as therapy, ranging from group collages on one hand to
structured individual tests on the other. This is suggestive of a
field which is in the very early stages of scientific research,
where it is very difficult to make comparisons of widely differ-
ent phenomena. With this being the case, informative data
can be gained using qualitative methodology. The themes evi-
dent in the articles reviewed centred around using the process
of art activities to gain information about the client, the thera-
peutic relationship, promoting communication, and enhancing
self-expression and self-awareness.
It appears that the use of art in mental health settings has
declined in popularity since the mid-1980s, judging by the
33
limited number of papers published in this area. The reason
for this is unclear. There are, however, a number of current
occupational therapy debates which may well influence the
choice of art as a therapeutic medium. With the development
of art therapy as a profession, occupational therapists may be
more reluctant to use art as therapy unless they have addi-
tional training. It may also have something to do with the fact
that there is a limited amount of research information avail-
able that validates the use of art in mental health settings. In
addition, there currently appears to be a greater emphasis on
using psycho-education and other more verbal techniques in
mental health rather than the creative therapies which come
from psychoanalytical theory. Furthermore, there is the current
emphasis on accountability and consumer outcomes. Perhaps
the tension inherent in using art as a working-through phe-
nomenon does not fit well with declining resources, with the
need to show the effectiveness of the media used or with the
changing nature and venues of occupational therapy. Most of
the papers reviewed are from the inpatient or day-patient sta-
tus, whereas today occupational therapy has shifted to take
on a community focus which is not reflected in these papers.
Then there is the debate over what constitutes therapeutic
change: is it the process or the activity? This may influence
occupational therapists in placing greater emphasis on the
group process rather than on the use of activity.
The debate between the use of art as a means of carrying
out diagnostic tests and the effectiveness of art activities in
developing communication is an interesting one. Many of the
earlier diagnostic tests, such as the Azima Battery, the Fidler
Diagnostic Battery and the Magazine Picture Collage, are not
mentioned in recent occupational therapy literature. Variations
of the Draw-a-Person test continue to be used. Oster and
Gould (1987) highlighted the importance of using drawings as
a useful and non-threatening approach to gain needed infor-
mation about the individual through observation of both the
client and the end product. The research evidence to support
the validity and reliability of the variations of the Draw-a-
Person test is scant, although there is a well-standardised
system of administration. It has been suggested that there
has been a loss of interest in projective \echniques in general
owing to the difficulty in establishing rigorous evidence of the
reliability and validity of such tests (Polatajko and Kaiserman
1986). It has been interesting to note that, although a num-
ber of the authors of the papers reviewed suggested further
areas of research that could be conducted, none of them has
published additional papers relating to his or her suggestions
and nor has this been taken up by other occupational ther-
apists.
A greater number of the papers reviewed emphasised using
art activities in developing communication and self-awareness
than on its usefulness as a diagnostic tool. This reflects the
change in focus from the use of art as a projective technique
to art as a means of developing the therapeutic relationship
and promoting communication and self-awareness. Possible
limitations of the use of art were rarely addressed in the arti-
cles reviewed. The limitations that were mentioned related to
the clients' level of disturbance and it was suggested that
involvement in arts activity takes place once clients had sta-
bilised. An uncritical stance found in the literature under
review was evident.
Based on the literature review, the use of art as an activity
in mental health settings can, the authors believe, be a valu-
able medium for occupational therapists. Art can be used to
assist clients to gain an understanding of themselves and to
communicate with others, and as a means of personal expres-
sion and accomplishment. In addition, art can be used by
occupational therapists to gain valuable data about clients,
both through observation of clients while engaged in their art-
work and from their final production.
34
It appears from the occupational therapy literature that
there is a need for research into the use of art by occupation-
al therapists as a therapeutic medium. Further work into the
reliability and validity of the existing projective assessment
tools is debatable given the difficulty in obtaining rigorous evi-
dence. It would also be of interest to determine the value that
occupational therapists place on the use of art and the rea-
sons for using art in working with persons with a mental ill-
ness. Research findings in these areas will assist occupational
therapists in making informed choices about the types of arts
media to use, the purpose for which the arts are being used
and whether the stated goals of treatment are being met
when using art as a therapeutic modality.
Conclusion
The use of art has been widely employed in mental health set-
tings by occupational therapists. Current trends from the liter-
ature indicate that art is being used by occupational thera-
pists in the assessment of clients, promoting the therapeutic
relationship and enhancing communication and self-expres-
sion. The use of art by occupational therapists is a field of
study which is in the early stages of scientific research. There
is limited research data supporting the use of art as a thera-
peutic medium or of tools to evaluate the effectiveness of art
programmes used by occupational therapists. Further re-
search into the validity and reliability of diagnostic test batter-
ies developed by occupational therapists does not appear to
be warranted given the lack of interest in this area in recent
times. Research efforts would appear to be better directed
towards examining why occupational therapists use art, its
effectiveness in gaining information about clients and its
effectiveness in promoting communication. Given the fact that
art is a frequently used therapeutic modality and the shift
towards increased accountability and consumer outcomes,
further research into the use of art is warranted.
Acknowledgement
This article is based, in part, on a paper which was presented at the
Australian Association of Occupational Therapists 18th Federal and
Inaugural Pacific Rim Conference, Hobart.
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the utilisation of time in the tasks of care management, use
of traditional core skillS, and administration, together with
direct versus indirect client contact time was returned by a
further eight participants.
The quantitative information received was analysed using
Minitab and represented in bar charts, figures and tables. The
qualitative material was studied for content and described
thematically in tables and verbatim responses. The statistical
results from the task and time analysis were calculated and
presented in figures and tables. The data strongly suggest that
care management is largely an administrative and organisa-
tional process which has resulted in a substantial decrease in
client contact time.
The recommendations include better administrative and
financial support to field workers and a reduction in the
bureaucratic procedures of care management. Additionally, it
is suggested that improved professional supervision, and the
allocation of clients with complex or multiple disabilities to
occupational therapists for care management, would raise the
profile of occupational therapy. The development and use of
alternative agencies employing occupational therapists in the
community for the provision of speCific disability services
together with more effective use of community care workers
could increase client contact time and improve job satisfac-
tion by facilitating improved service delivery and reduced wait-
ing lists.
35