Art-based assessments

Art therapists and other professionals use art-based assessments to evaluate emotional, cognitive,
and developmental conditions. There are also many psychological assessments that utilize artmaking
to analyze various types of mental functioning (Betts, 2005). Art therapists and other professionals are
educated to administer and interpret these assessments, most of which rely on simple directives and a
[39]
standardized array of art materials (Malchiodi 1998, 2003; Betts, 2005). The first drawing
assessment for psychological purposes was created in 1906 by German psychiatrist Fritz Mohr
[39]
(Malchiodi 1998). In 1926, researcher Florence Goodenough created a drawing test to measure the
[39]
intelligence in children called the DrawAMan Test (Malchiodi 1998). The key to interpreting the
Draw-A-Man Test was that the more details a child incorporated into the drawing, the MORE intelligent
[39]
they were (Malchiodi, 1998). Goodenough and other researchers realized the test had just as much
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to do with personality as it did intelligence (Malchiodi, 1998). Several other psychiatric art
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assessments were created in the 1940s, and have been used ever since (Malchiodi 1998).
Notwithstanding, many art therapists eschew diagnostic testing and indeed some writers (Hogan
1997) question the validity of therapists making interpretative assumptions. Below are some examples
of art therapy assessments:

The Diagnostic Drawing Series (DDS)

The Diagnostic Drawing Series (DDS) is a three-picture art interview designed by Barry M. Cohen and
Barbara Lesowitz in 1982. It is one of the most commonly taught art therapy assessments and, with
more than 60 DDS studies to date, it is the most researched art therapy tool worldwide. Cohen and
colleagues wrote the DDS Rating Guide that directs mental heath professionals on how to score the
DDS. The Rating Guide for the DDS evaluates the client based on structures within the drawings
[40]
rather than the content.
The Diagnostic Drawing Series is perhaps the most standardized of all art therapy assessments and
relies on both empirical methodology and social science theories. Administers also pay special
attention to the behaviors and behavioral changes of the test-taker. The DDS is designed to be
administered to people aged 13 and over, but there are versions that are geared toward the
[41]
assessment of children.
The test consists of three drawings and the test-taker has fifteen minutes to complete each. The testtaker is given flat-sided chalk pastels, an 18X24 inch sheet of white paper, and the test-taker is should
be seated at a table or desk of appropriate height for the subject.
Administration

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Picture 1Make a picture using these materials

Picture 2Draw a picture of a tree

Picture 3Make a picture of how you are feeling using lines, shapes, and colors.

Interpretation Significant training is required to interpret the results of this assessment. Interpretations
[41]
are made based on:

Color: types, usage, blending, and original use

Lines and Shapes, enclosure of lines and shapes, ground lines, sky lines; quality of lines, length,
space usage

Integration and abstraction

Representation of the image in context: how is the image placing in its environment?

Use of people and/or animals

Inanimate objects

Movement portrayal

How the pastel was used by the test-taker

Placement on the page

Strengths and Weaknesses of the DDS: The DDS is the most researched of all art therapy
assessments and many drawings are archived for reference. Cohen provided a quantifiable
assessment for art therapists to use around the world. The test also has protocol and controls for the
influence of medications and pharmaceutical confounding factors. The DDS is generally considered to
[42]
be a reliable and valid assessment tool. The weaknesses of the test are rooted in the complexity of
interpretation and subsequent lack of true scientific measurement. In general, projective tests tend to
[43]
be much more unreliable than objective tests. The art therapist must have significant training in
[40]
order to appropriately evaluate the test-taker.

The Mandala Assessment Research Instrument (MARI)

In this assessment, a person is asked to select a card from a deck with different mandalas (designs
enclosed in a geometric shape) and then must choose a color from a set of colored cards. The person
is then asked to draw the mandala from the card they choose with an oil pastel of the color of their
choice. The artist is then asked to explain if there were any meanings, experiences, or related
information related to the mandala they drew. This test is based on the beliefs of Joan Kellogg, who
sees a recurring correlation between the images, pattern and shapes in the mandalas that people
draw and the personalities of the artists. This test assesses and gives clues to a person's
psychological progressions and their current psychological condition (Malchiodi 1998). The mandala
originates in Buddhism; its connections with spirituality help us to see links with transpersonal art.

HouseTreePerson (HTP)
Main article: House-Tree-Person test
The House-tree-person test (HTP) is a projective test designed to measure aspects of a
persons personality. The test can also be used to assess brain damage and general mental
functioning. By virtue of being a projective test, the results of the HTP are subjective and open to
[44]
interpretation by the administrator of the exam. HTP was designed by John Buck and was originally
based on the Goodenough scale of intellectual functioning. Buck included both qualitative and
quantitative measurements of intellectual ability in the HTP (V). A 350-page manual was written by
Buck to instruct the test-giver on proper grading of the HTP, which is more subjective than
[44]
quantitative. In contrast with him, Zoltn Vass published a more sophisticated approach, based on
system analysis (SSCA,Seven-Step Configuration Analysis).
Administering the Test: HTP is given to persons above the age of three and takes approximately
150 minutes to complete based on your level of mental functioning. During the first phase, the testtaker is asked to draw the house, tree, and person and the test-giver asks questions each picture.
There are 60 questions originally designed by Buck but art therapists and trained test givers can also
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design their own questions, or ask follow up questions. This phase is done with a crayon. During the
second phase of HTP, the test-taker draws the same pictures with a pencil or pen. Again the test-giver
asks similar questions about the drawings. Note: some mental health professionals only administer
phase one or two and may change the writing instrument as desired. Variations of the test may ask the
[44]
person to draw one person of each sex, or put all drawings on the same page.
Examples of follow up questions:

After the House: Who lives here? Is the occupant happy? What goes on inside the house? What's
it like at night? Do people visit the house? What else do the people in the house want to add to
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the drawing?

After the Tree: What kind of tree is this? How old is the tree? What season is it? Has anyone tried
to cut it down? What else grows nearby? Who waters this tree? Trees need sunshine to live so
[44]
does it get enough sunshine?

After the Person is drawn: who is the person? How old is the person? What do they like and
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dislike doing? Has anyone tried to hurt them? Who looks out for them?

Interpretation of results:
The quantitative measure of intelligence for the House-tree-person has been shown to highly correlate
[44]
with the WAIS and other well-established intelligence tests.
The subjective analysis of the test takers responses and drawings aims to make inferences of
personality traits and past experiences. The subjective nature of this aspect of the HTP, as with other
qualitative tests, has little empirical evidence to support its reliability or validity. This test, however, is
still considered an accurate measure of brain damage and used in the assessment of schizophrenic
[44]
patients also suffering from brain damage.

Road drawing
In this drawing assessment and therapeutic intervention, the patient is asked to draw a road. This is a
projective assessment used to create a graphic representation of the person's "road of life." The road
drawing has the potential to elicit spontaneous imagery that represents the client's origins, the history
of his or her life process, experiences to date, and intent for the future - even from a single drawing
(Hanes, 1995, 1997, 2008). The road's reparative features or its need for "periodic upgrade" can serve
as a metaphor for the client's capacity for change and restoration (Hanes, 1995, 1997, 2008).

Standards of practice in the United States

Board certification, registration, and licensure
In the United States, art therapists may become Registered (ATR), Board Certified (ATR-BC), and, in
some states, licensed as an art therapist, creative arts therapist (LCAT; NY State only), or professional
[46]
or mental health counselor (many states). The ATCB Code of Professional Practice is divided into
five main categories; General Ethical Principles, Independent Practitioner, Eligibility for Credentials,
Standards of Conduct, and Disciplinary Procedures (ATCB 2005). Becoming a registered ATR
requires that one complete a graduate-level program in art therapy from an accredited university, as
well as completion of practicum and an internship, and additional clinical experience post-graduation
[46]
with supervision from a professional clinician.
For more information on how to become licensed, US art therapists should contact the state licensure
board in the state in the US in which they wish to practice. Art therapy students who are preparing for
practice in the field should consult with their academic advisers about what courses are necessary to
meet board certification and/or licensure requirements. Licensure is generally needed to obtain
reimbursement for services as an independent practitioner and in some states, is required by law in
order to practice independently. To receive certification, a significant amount of coursework and
clinical experience is required. Depending on where an art therapist practices geographically,
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certification is not always necessary in becoming a professional art therapist. Typically, the minimum
requirement is a masters degree in art therapy, or a masters degree in related counseling or
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psychology fields, with an art therapy focus. According to The American Art Therapy Association
(AATA), it is imperative that masters program students must successfully take courses in a variety of

studio art disciplines as a means of signifying artistic proficiency. Additionally, students are required to
take at least 48 credit hours at the graduate level in particular psychology related topics, as well as
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successfully partaking in practica and internships.
In countries other than the US, art therapists should contact governmental or regulatory boards that
oversee the practice of mental health or health care professions to identify any specific coursework or
education that is needed. Because art therapy is still considered a developing field, most countries do
not regulate its practice and application.

Post-Masters
In order to apply for an ATR or other registered art therapist certifications, students are required to
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complete 1,000 hours of direct client contact post-graduation from a masters program. After
obtaining an ATR, individuals have the opportunity to apply for Board Certification from the Art
Therapy Credentials Board by passing an examination. Like many psychology-related licensing, art
therapy licenses vary by state, and having a license does not necessarily mean a therapist is
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nationally certified.

General ethical principles

One topic covered in this section describes the responsibility art therapist have to their patients (ATCB
2005). According to the ATCB, art therapists must strive to advance the wellness of their clients,
respect the rights of the client, and make sure they are providing a useful service (2005). They cannot
discriminate against patient whatsoever, and may never desert or neglect patients receiving
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therapy. Art therapist must fully explain to their patients what their expectations of the patients will
be at the outset of the professional relationship between the two. Art therapists should continue
therapy with a patient only if the client is benefiting from the therapy. It's against the principles
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established by the ATCB for art therapist to have patients only for financial reasons.
Another topic of this section discuses the competency and integrity art therapists must possess (ATCB
2005). The ATCB states art therapists must be professionally proficient and must have integrity
(2005). Art therapists must keep updated on new developments in art therapy. They are only
supposed to treat cases in which they are qualified as established by their training, education, and
experience (ATCB 2005). They are not allowed to treat patients currently seeing another therapist
without the other therapist's permission (ATCB 2005). Art therapists must also observe patient
confidentiality (ATCB 2005).
Other topics covered in this section discuss other responsibilities of art therapists. This responsibilities
include, responsibility to students and supervisees, responsibility to research participants,
responsibility to the profession (ATCB 2005). This section also establishes the rules by which art
therapists must follow when making financial arrangements and when they chose to advertise their
service (ATCB 2005)

Independent practitioner
Independent practitioners are art therapists who are practicing independently or responsible for the
service they are providing to paying clients. This section covers the credentials for independent
practitioners.
Independent practitioners must provide a safe and functional environment to conduct art therapy
sessions (ATCB 2005). According to ATCB, "this includes but is not limited to: proper ventilation,
adequate lighting, access to water supply, knowledge of hazards or toxicity of art materials and the
effort need to safeguard the health of clients, storage space for art projects and secured areas for any
hazardous materials, monitored use of sharp objects, allowance for privacy and confidentiality, and

compliance with any other health and safety requirements according to state and federal agencies
which regulate comparable businesses" (2005).
This section also establishes the standards for independent practitioners to follow when dealing with
financial arrangements.. Basically it states that the art therapist must provide a straight forward
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contract to the payer of the therapy sessions. It also states that the art therapist must not deceive
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the payers or exploit clients financially.
The last topics this section sets standards for address treatment planning and documentation (ATCB
2005). Art therapists must provide a treatment plan that assists the patients to reach or maintain the
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highest level of quality of life and functioning. This involves using the clients strengths to help them
reach their goals and address their needs. Art therapists are also required to record and take notes
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that reflect the proceedings of the events of therapy sessions. According to ATCB, the following is
the minimum of which must be documented: the current goals of any treatment plan, verbal content of
art therapy sessions relevant to client behavior and goals, artistic expression relevant to client
behavior and goals, changes (or lack of change) in affect, thought process, and behavior, suicidal or
homicidal intent or ideation (2005) and a summary of the "clients response to treatment and future
treatment recommendations" (2005).

Eligibility for credentials

This section of the ATCB Code of Professional Practice outlines the process by which art therapy
students receive their credentials. It discusses the standards for eligibility and describes the
application process. It also states that the ATCB certificates are the property of the ATCB and that any
art therapist who loses their certificate and still claim to have ATCB credentials can be punished
legally. It also discusses the procedure to follow when accused of wrongdoing related to art therapy.
Lastly, it discusses the wrongdoings related to art therapy that therapists can be convicted for with a
felony or another criminal conviction. These wrongdoings include rape, sexual abuse, assault, battery,
prostitution, or the sale of controlled substances to patients.

Standards of conduct
This section of the ATCB Code of Professional Practice addresses in detail confidentiality, use of
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clients artwork, professional relationships, and grounds for discipline.
Art therapists are not permitted to disclose information about the clients therapy sessions. This
includes all verbal and/or artistic expression occurring within a client-therapist relationship (ATCB
2005). Art therapist are only allowed to release confidential information if they have explicit written
consent by the patient or if the therapist has reason to believe the patient needs immediate help to
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address a severe danger to the patients life. Also, therapists are not allowed to publish or display
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any of the patients work without the expressed written consent of the patient.
The standards of a professional relationship between art therapists and clients are covered in this
section. Within a professional relationship, art therapists are banned from engaging in exploitative
relationships with current and former patients, students, intern's, trainees, supervisors, or co[47]
workers. The ATCB defines an exploitative relationship as anything involving sexual intimacy,
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romance, or borrowing or loaning money. Within professional relationships, therapists are to do
what they feel is best in the clients interest, shall not advance a professional relationship for their own
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benefit, and shall not steer their patients in the wrong direction.
The breaking of any of the standards established in this section is grounds for discipline.

[47]

Disciplinary procedures
The content contained in this section of the ATCB Code of Professional Practice specifically discusses
in legal and technical detail the entire disciplinary procedures for wrongdoings in art therapy (2005).
Main topics covered in this section cover: submission of allegations, procedures of the Disciplinary
Hearing Committees, sanctions, release of information, waivers, reconsideration of eligibility and
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reinstatement of credentials, deadlines, bias, prejudice, and impartiality
While the ATCB oversees disciplinary procedures for art therapists, if an art therapist is licensed, the
state board through which the art therapist is licensed carries out disciplinary action for violations or
unethical practice.

Uses
General Illness
People always search for some escape from illness and it has been found that art is one of the more
common methods. Art and the creative process can aid many illnesses (cancer, heart disease,
influenza, etc.). People can escape the emotional effects of illness through art making and many
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creative methods.
Hospitals have started studying the influence of arts on patient care and found that participants in art
programs have better vitals and less complications sleeping. Artistic influence doesn't need to be
participation in a program, but studies have found that a landscape picture in a hospital room had
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reduced need for narcotic pain killers and less time in recovery at the hospital.
Art therapy has been shown to help students ages 11 to 18 with autism spectrum disorder to increase
their social skills. There was improvement in assertion scores, and hyperactivity scores and
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internalizing behavior (harming oneself) significantly decreased with art therapy sessions
Art classes also can have a therapeutic effect on retired peoples well-being. Retired participants who
regularly took art classes were interviewed about their previous art class participation. They felt that
painting gave a sense of satisfaction and achievement with their many free hours. It also boosted
confidence (from noticing improvement over time in their paintings), productivity, and offered an
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opportunity for participants to be encouraged to discuss art with others.

Cancer diagnosis
Art therapists have conducted studies to understand why some cancer patients turned to art making
as a coping mechanism and a tool to creating a positive identity outside of being a cancer patient.
Women in the study participated in different art programs ranging from pottery and card making to
drawing and painting. The programs helped them regain an identity outside of having cancer,
lessened emotional pain of their on-going fight with cancer, and also giving them hope for the future.
Studies have also shown how the emotional distress of cancer patients has been reduced when
utilizing the creative process. The women made drawings of themselves throughout the treatment
process while also doing yoga and meditating; these actions combined helped to alleviate some
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symptoms
A review of 12 studies investigating the use of art therapy in cancer patients by Wood, Molassiotis,
and Payne (2010) investigated the symptoms of emotional, social, physical, global functioning, and
spiritual controls of cancer patients. They found that art therapy can improve the process of
psychological readjustment to the change, loss, and uncertainty associated with surviving cancer. It
was also suggested that art therapy can provide a sense of meaning making because of the physical
act of creating the art. When given five individual sessions of art therapy once per week, art therapy

was shown to be useful for personal empowerment by helping the cancer patients understand their
own boundaries in relation to the needs of other people. In turn, those who had art therapy treatment
felt more connected to others and found social interaction more enjoyable than individuals who did not
receive art therapy treatment. Furthermore, art therapy improved motivation levels, abilities to discuss
emotional and physical health, general well-being, and increased global quality of life in cancer
[51]
patients.

Disaster relief
Art therapy has been used in a variety of traumatic experiences, including disaster relief and crisis
[52][53][54][55][56]
intervention.
Art therapists have worked with children, adolescents and adults after natural
and manmade disasters, encouraging them to make art in response to their experiences. Some
suggested strategies for working with victims of disaster include: assessing for distress or post
traumatic stress disorder (PTSD), normalizing feelings, modeling coping skills, promoting relaxation
[57][58][59][60]
skills, establishing a social support network, and increasing a sense of security and stability

Bereaved Children
Art therapy and other creative, humanistic intervention strategies are becoming popular methods for
working with life-threatened patient and for working with the family members of patients who dieparticularly bereaved children. Art therapy stimulates the conscious and unconscious expression of the
mourning process in adult and child patients. Children are at greater psychological risk because their
grief is less overt and can occur months or even years after the death. Group therapy is used to
provide social sanction for the expression of that grief and to promote adaptive mourning
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responses.

Incarceration
Art therapy may be a beneficial treatment for incarcerated women. A residential substance abuse
program called New Beginnings in a detention facility has used art therapy as a means of treatment for
incarcerated women. The therapy sessions were weekly and lasted 2 hours. During the first 15
minutes of the art therapy session, the topic of therapy was discussed. The topics were self-esteem,
fear, self-defeating behaviors, treatment goals, barriers for recovery, and self-sabotage. The clients
then worked on an exercise relating to the topic for 45 minutes in tables of four. Exploring deeper
thoughts, positive reinforcement and feedback, confidence building, and clarification of thinking were
encouraged by the art therapist. The clients were resistant at first, claiming I cant draw. However,
they began to share their works and offer insight on other inmates work after one or two sessions.
Group cohesion increased after the inmates began expressing different perspectives on their work and
others. Simple art media was offered, to ensure that the clean-up process and technique of the
materials was not difficult or intimidating. Art therapy in the program was used to help clients recognize
their defense mechanisms that conceal their fear or inadequacy or to create a sense of safety and
peace, increase confidence, express feelings verbally, and identify feelings. Therefore, art therapy can
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be used as a tool in incarceration settings with women for mental health and substance abuse.

Distraction
Distraction from sadness using art therapy may be a better alternative than venting sadness. Two
studies by Drake and Winner (2012) published from the American Psychological Association
compared venting (expressing negative feelings) and distraction (expressing something that is not
related to negative feelings) in one study. To distract oneself, the participants were told to draw
something unrelated to a sad film they had watched. The participants who had vented were told to
draw something related to the film. In study 2, the participants were told to think of a sad event and
were put into the venting, distraction, or sitting conditions. The sitting condition allowed the passage of

time to be evaluated. In study 1, the distraction method in which the participants drew something
unrelated to the sad film significantly improved negative mood compared to the venting condition. In
study 2, the distraction method in which the participants drew a house (something unrelated to the sad
event), had significantly improved negative mood compared to venting (drawing the sad event) or the
sitting condition (sat quietly for 10 minutes). Therefore art therapy could be beneficial to people
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suffering from depressive moods through a way of distraction rather than venting.
Art therapy has also been used to develop problem resolution and emotional regulation skills in
children.

As an approach to problem solving

Congdon (1990) discusses art therapys benefits in terms outside the traditional approaches within the
clinical world of therapists purporting that art therapy should be used not just to help treat mental
[64]
illness but as a tool to help individuals solve problems in day to day to living.