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 Theory and Practice of Arts Therapies

THE ARTS THERAPIES: WHOLE PERSON INTEGRATIVE APPROACHES TO

HEALTHCARE

Ilene A. Serlin
 Theory and Practice of Arts Therapies

THEORY AND PRACTICES OF ARTS THERAPIES: WHOLE PERSON

INTEGRATIVE APPROACHES TO HEALTHCARE

Ilene Serlin

This chapter introduces the creative and expressive arts therapies from an

existential perspective that are sees the creative act as a courageous affirmation of life in

face of the void or death. From this affirmation of life comes the healing medicine of

creation. The need to create, communicate, create coherence, and symbolize is a basic

human need.

Thus the artists—in which term I hereafter include

the poets, musicians, dramatists, plastic artists, well as

saints—are a “dew” line, to use McLuhan’s phrase; they

give us a “distinct early warning” of what is happening to

our culture...The artists thus express the spiritual meaning

of their culture.

May, The Courage to Create, p. 17

In a reflection on “The Place of Beauty in Therapy and the Arts,” Swiss

expressive arts therapist Paolo Knill (1995) reminds us that creative acts or works of art

“touch the depth of soul, evoke imagination, engage emotions and serene thought.” Art is

crucial for the healing journey because it touches and also expresses the whole complex

human person, including levels of mind, body and spirit. In Jung’s (1966) essay “On the

Relation of Analytical Psychology to Poetry,” Jung proposed that the origin of a work of

art lies not in the personal unconscious of the artist, but in the collective unconscious,
 Theory and Practice of Arts Therapies

which is the “common heritage of mankind” (p. 80). The humanities connect people

across different cultures and traditions to common challenges of the human condition.

The arts heal in a number of important ways. First, the arts can provide a

diagnostic image of culture and the individual, and provide healing for mental and

physical health. Aristotle observed that there are two instincts basic to human nature: 1)

imitation; and 2) harmony and rhythm, and “even dancing imitates character, emotion,

and action, by rhythmical movement” (Aristotle, 1961, p. 50). Traditional healers were

artists, and many contemporary healing practices draw on aspects of the arts. Studies

show that the artistic endeavor may reduce stress and health complaints, improve immune

function, provide both physical and psychological benefits, and even help people live

longer (Pennebaker, 1999; Kiecolt-Glaser et al.,1985).

Art also provides access to multiple modes of intelligence (Gardner, 1993), thinking,

communicating, and problem solving. Arts expand psychological horizons. Clinical

studies with mood disorders and creativity indicate how different cognitive styles, modes

of representation, and even processes considered in some contexts to be deviant can open

us up to new creative possibilities and untapped powers of the human spirit. For example,

“Outsider art”, a collector’s item, is the expression of those who have been diagnosed as

mentally or emotionally ill and who are often on the outside of society.

Art connects us to the imagination (McNiff, 1992), and bridges the conscious and the

unconscious. It takes us into expanded states of consciousness, helping us understand our

waking reality, mindfulness, altered states and dreamtime. And, in many cultures, art

takes us to the sacred.

 Theory and Practice of Arts Therapies

! Arts promote health. Traditional healers were artists, and contemporary healing

practices draw on the arts. Studies show that the artistic endeavor may reduce stress

and health complaints, improve immune function, provide both physical and

psychological benefits, and even help people live longer. Work by Pennebaker,

Kiecolt-Glaser and others support the many healthy functions of emotional

disclosure and the relationship of different modes of expression to brain function.

! Art provides access to multiple modes of intelligence (Gardner, 1982), thinking,

communicating, and problem-solving. Aesthetic inquiry is a way of knowing

through images, similar in structure to philosophical, psychological or spiritual

inquiry. Art is also a form of expression, and both verbal and non-verbal

communication express outwardly the indwelling of images. It is holistic, draws on

multiple modes of inquiry and learning (Arnheim, 1969), and research (McNiff,

1998).

! Arts expand psychological horizons. Work with mood disorders and creativity

indicate how different cognitive styles, modes of representation, and even processes

that are considered to be deviant in some contexts can open us up to new creative

possibilities and untapped powers of the human spirit.

! Art expands consciousness. Art takes us into expanded states of consciousness,

helping us understand our waking reality, mindfulness, altered states and dreamtime

(Schlitz et al, 2005).

! Art is social. It reflects cultural differences, and it creates community. It reflects

social change, and it effects social change. Art is political, and can be used in

conflict-resolution and in community rituals (Imber/Black, 1992).

 Theory and Practice of Arts Therapies

The Expressive and Creative Arts Therapies

In this section, we will define the arts therapies and take a look at some of the

professions created around the arts in therapy. Should you want additional information,

please contact one of the listed organizations for follow-up.

The expressive and the creative arts therapies have healing as their primary

objective, while the arts are the modality of healing. Expressive and creative arts

therapies have both general organizations and theoretical approaches, and the specific

modalities of art, music, dance, poetry, drama and psychodrama each have their own

associations and practices. Some expressive arts therapists believe that the expressive

therapist should be trained in all modalities and that effective therapy requires an ability

to cross modalities which tracking imagery (see Knill, Barbra, & Fuchs, 1995; Robbins,

1994), while other arts therapists believe that each art form is a discipline that has its own

knowledge base and requires years of practice. The earliest organizations and training

programs represented one discipline, such as the Art Therapy Association. Graduates of

these programs and members of these associations are called “Art Therapists” and they

are certified in “Art Therapy. Other organizations, such as the International Expressive

Arts Therapy Association (IAETA) combine all the arts together. Graduates of this

program are called “Expressive Arts Therapist” and they are certified by the IAETA.

The creative arts therapies also come in a variety of theoretical and philosphical

perspectives, and those will be represented in this volume. For example, a

psychodynamic model for the creative arts therapies is outlined by David Read Johnson

(1998) as a combination of psychoanalytic theory, developmental psychology and object

 Theory and Practice of Arts Therapies

relations theory. In this model, inner states are externalized through the arts media,

conflicts are transformed creatively and then re-integrated into the client’s experience.

Some arts therapist’s decisions about how to practice are based on clinical and theoretical

considerations, while others’ decisions are based on political considerations (for example,

the creative arts therapists work together in some states to lobby for hospital-based

positions. See the National Coalition of Creative Arts Therapies Associations, 2004a).

While all traditions have merit, the clinician learning about the expressive and creative

arts therapies should be familiar with the broad spectrum of theoretical perspectives and

be able to situate each art approach within that spectrum.

In Expressive Therapies, Malchiodi (2005) estimates that 30,000 individuals in

the United States have been formally trained at the graduate level in expressive therapies.

She defines “Expressive therapies” as the “therapeutic use of the arts and play with

children, adolescents, adults, families, and groups” (p. xiv). Noting that individuals have

different expressive styles such as visual or auditory, Malchiodi suggests that therapists’

communication can be enhanced by reaching these clients with an expanded repertoire of

different styles and with a combination of verbal and nonverbal expression. Although

research in the expressive arts therapies is needed, there is already a body of literature on

the use of expressive therapies for assessment of individuals, capacities, and

psychological, psychosocial and cognitive skills (Feder & Feder, 1998). In addition, the

arts therapies are generating their own forms of research that work specifically with

imagery and the creative process (Hervey, L. 2000, McNiff, 1998).

The use of the arts in a therapeutic context has roots in the early 1900’s as music

therapy reached veterans of World War I, and Moreno (1923) used enactment to work
 Theory and Practice of Arts Therapies

through their emotional issues. Art was also used to understand children’s drawings

(Goodenough, 1926) and in sandtray (Lowenfeld, 1969). After World War II, the arts

began to be used with patients who had severe mental illness in psychiatric hospitals like

the Menninger Clinic and St. Elizabeth’s Hospital. Professional organizations were

established with training guidelines, standards and ethics. Recently, the expressive arts

have also been used successfully with people with primarily medical issues. Other

organizations called Arts Medicine (Pratt & Tokuda, 1997) focus on an international

application of the arts in medicine, while some bring the arts into the community (Kaye

& Blee, 1997), and others bring artists from the community to patients’ bedside (Graham-

Pole, 2000). Finally, a recent trend shows other expressive arts therapists working within

the new field of alternative and complementary medicine, bringing the arts into

integrative healthcare (Goodill, 2005; Serlin et al, 2000).

Art Therapy

One of the earliest art therapists in the United States was Margaret Naumburg (1966),

who brought a psychoanalytic perspective to use art as a way of making unconscious

imagery and symbols conscious. Most art therapists believe that art is a “form of visual

language through which people can express thoughts and feelings that they cannot put

into words,” and “,,,a way to communicate experiences that are difficult to verbalize,

such as physical or sexual abuse, trauma, grief, and other complex emotional

experiences” (Malchiodi, p. 17). Various theoretical approaches to art therapy include

psychoanalytic, archetypal, object relations, humanistic, cognitive-behavioral, and

developmental, while the American Art Therapy Association recent survey showed that
 Theory and Practice of Arts Therapies

most art therapists consider themselves to be psychoanalytic (Elkins & Stovall, 2000).

Theorists of psychoanalytic art therapy include:

1) Naumburg (1966), who believed that spontaneous drawings represent and project

unconscious thoughts and feelings.

2) Kramer (2001), who proposes that art expressions sublimate anger and negative

emotions.

3) Levick (1969), who suggested that art expressions identify individual defense

mechanisms.

4) Arthur Robbins (1989), who brings a psychoaesthetic experience approach to

depth-oriented treatment.

Other eminent art therapists are Landgarten (1991), Liebman (1990), McNiff (1981,

1986, 1988, 1992), and Wade (1980). Citations to their work can be found in the

references section.

• Humanistic art therapy relies less on interpretation than on the experiential

process of art-making and its power as a transformative and self-

actualizing force (Betensky, 1995; Garai, 2001; Silverstone, 1997). Gestalt

art therapy is an action-oriented approach, and includes theorists Zinker

(1977) and Rhyne (1995).

• A developmental approach to art therapy is used especially among those

art therapists who work with children, and includes psychosexual,

psychosocial and object relations approaches, as well as stages of normal

artistic development.
 Theory and Practice of Arts Therapies

• A soul perspective on art therapy understands psyche in the classical sense

to be an expression of soul. As such, it has its own language that is more

closely related to art than to science. Its therapeutic assumptions are that

the soul has powers of self-healing which art can unleash (McNiff, 1992,

p. 3).

Finally, art therapy is used with children, adults, groups and families. As an “action-

oriented modality” (p. 42), art therapy provides “facilitation of individual’s discovery of

personal meaning for their art expressions” and “,,,a variety of avenues for children

adults, families and groups to overcome emotional distress, reframe problems, resolve

conflicts, achieve insights, change behaviors, and increase an overall sense of well-being”

(pp. 42-43).

Music Therapy

Music therapy is defined as: “the prescribed use of music by a qualified person to

effect positive change in psychological, physical, cognitive, or social functioning of

individuals with health or educational problems” (Forinash, p. 46). It has ancient and

global roots: Joseph Moreno (1995) shows how what he calls “ethnomusic therapy” has

been an important part of the practices of traditional healers. Successful with post-World

War II veterans, music therapy’s first training program began in 1944, and in 1950 the

American Music Therapy Association (AMTA) was founded. There are estimated to be

15,000 music therapists around the world (Grocke, 2002). They practice in approximately

six major areas, including education, medical, healing, psychotherapeutic, recreational,

and ecological (Bruscia, 1998). Their approaches range from psychodynamic (Benenzon

music therapy), behavioral, biomedical, humanistic or transpersonal (Nordoff-Robbins

 Theory and Practice of Arts Therapies

music therapy and Bonny method). Their methods include improvisation, recreative

experiences, composition experiences, and receptive experiences, and they can practice

as auxiliary therapists, augmentative, intensive, and primary therapists (Alvin, 1975;

Bruscia, 1998; Hodges, 1996; Levin, 1969). Major schools of music therapy are:

• Behavioral music therapy—uses music to change behavior, using positive and

differential reinforcement.

• Developmental music therapy—uses music to reach blocked developmental

goals.

• Music psychotherapy—to music to facilitate self-awareness, emotional

expression and healing.

• Medical music therapy—is used in medical settings to help patients work with

the emotional issues that accompany medical treatment (Adridge, 1992, 1998;

Spintge & Droh, 1996).

• Humanistic music therapy—uses music to bring self-actualization and personal

meaning (Campbell, 1991).

Dance/Movement Therapy

The American Dance Therapy Association defines dance therapy as: the

psychotherapeutic use of movement as a process which furthers the emotional, cognitive,

physical and social integration of the individual” (Loman, p. 68). Dance therapists work

in a variety of settings with individuals and groups to help their clients express

themselves, “…encourages new behaviors and symbolically communicates hidden

 Theory and Practice of Arts Therapies

emotions, releases anxiety, and serves as a vehicle to integrate body, mind, and spirit” (p.

68).

Dance therapy has roots in ancient healing practices (Serlin, 1993). It became a

profession in the United States through the work of a number of creative dancers who

found that they could reach patients others could not by communicating non-verbally

with them. Marian Chace is described as “key to the successful beginnings and

development of dance therapy as a recognized and validated form of psychotherapy”

(Thomas, 1994, p. 128) and her students founded the American Dance Therapy

Association (Dyrud, 1970; Sandel et al, 1993). Early pioneers who give depth to the

theory include: Trudy Schoop (Schoop, 1974) Blanche Evans (1991), Janet Adler

(1996), Valerie Hunt, Judith Kestenberg (1975), Mary Whitehouse, Liljan Espenak

(Espenak, 1969) Elizabeth Polk (Ederer-Schwartz, 1991), Alma Hawkins (Hawkins,

1991) Irmgard Bartenieff and Anna Halprin (Serlin, 1996). Isadora Duncan as the

archetype and “Creative Source of Dance Therapy” is discussed by Miriam Berger

(Berger, 1992), and a history of the founding and development of the American Dance

Therapy Association is given by Beth Kalish (1973) and Elissa White (1973). What all

these approaches share is a fundamental belief that 1) Health comes from an integration

of mind, body and spirit, 2) Psychological and/or physical illness comes from a problem

with this integration, and 3) Change can come through a movement intervention.

The following are the major approaches:

• Chace approach (Chace, 1993): uses rhythmic bodily action to mirror clients’

actions and establish a relationship.

 Theory and Practice of Arts Therapies

• Depth approach: either Freudian or Jungian based, uses movement to reach

unconscious symbols carried in the body. Modalities include: psychoanalytic

(Siegel, 1995), Jungian (Chodorow, 1991), authentic movement (Adler, 2002,

Whitehouse, 1986), and depth/existential (Serlin, 1977, 2000).

• Developmental approach: works with developmental stages in movement and

helps clients work through blocks (Lomen, 1998).

• Medical Dance/Movement Therapy: uses movement to work with people with

physical or life-threatening illnesses that have a psychological component

(Goodill, S. 2005).

Dance/movement therapy has its own assessment tools, used to interpret

nonverbal behaviors. These include Laban Movement Analysis, Kestenberg’s Movement

Profile, Espenak’s movement diagnostic tests, Davis’s Movement Psychodiagnostic

Inventory (see Rothstein, 1970), and Kalish-Weiss’s Body Movement Scale for Autistic

and Other Atypical Children. Major principles in dance therapy include: non-verbal

mirroring and attunement, containment, developmental sequencing and re-experiencing

and working through of bodily-held blocks and issues. Because dance/movement therapy

is action-oriented and spontaneous, it is creative and works with mind, body and spirit.

Drama Therapy and Psychodrama

Drama therapy and psychodrama rely on an innate human sense of story,

narrative, and the ability to create one’s life. Drama as healing was also used in early

shamanic healing practices, but it has been used as a psychotherapeutic modality in the

20th century. The founder of psychodrama was Jacob Moreno (1889-1974), a Viennese
 Theory and Practice of Arts Therapies

psychiatrist who used dramatic enactment to replay problematic incidents in his patients’

lives in the context of a supportive group (Moreno, 1923). Current leaders of

psychodrama include Renee Emunah (1994), David Read Johnson (1998), and Robert

Landy (2005). While psychodrama therapy and drama therapy are similar, they differ in

that drama therapists may work with fictional narratives and are closer to theatre, while

psychodrama uses the personal experiences of the protagonist as narrative. In

psychodrama, the protagonists may play roles that include the psychosomatic,

psychodramatic, social and cultural. Techniques include doubling and role reversal.

Finally, psychodrama and drama therapy have been very effective with children, and with

victims of natural and man-made disasters.

Poetry Therapy

Poetry therapy uses the language of poetry to evoke central images of the clients’

existence. According to the National Coalition of Creative Arts Therapies Associations,

its goals include: 1) Developing an understanding of oneself and others through poetry

and other forms of literature, 2) Promoting creativity, self-expression, and greater self-

esteem, 3) Strengthening interpersonal and communication skills, 4) Expressing

overwhelming emotions and releasing tension, and 5) Promoting change and increasing

coping skills and adaptive functions (National Coalition of Creative Arts Therapies

Associations, 2004). It was established as a field by Jack Leedy, whose edited works in

1969 and 1973 gave rise to the Association for Poetry Therapy organization and the

National Association for Poetry Therapy in 1981.

 Theory and Practice of Arts Therapies

Poetry therapists assess the language development of the client and look for meaning

in the rhythms and feelings of words, as well as in their signification (Lerner, 1994).

Using words, poetry therapists help their clients discover their inner feelings and reframe

their realities, They use metaphors to bring new perspectives and “maintain vitality in the

face of our existential limitations of finiteness, aloneness, vulnerability, and mortality.

Loss shadows every change. Nearly every poem—except some few that bespeak the

philosophy of nihilism—affirms life in the face of death” (Gorelick, p. 123).

Approaches to poetry therapy include psychoanalytic, interpersonal, behavioral/cognitive,

systems/metacommunication school, and humanistic/expressive (Gorelick, p. 124-125).

All client populations are served, as well as a broad range of clinical issues. Poetry

therapists work in major hospitals, in community settings, and in private practice. While

there are formal university training programs in poetry therapy, qualified mental health

professionals can study with an approved mentor in poetry therapy and work toward

certification as a Registered Poetry Therapist or Certified Poetry Therapist. Stages of a

poetry therapeutic process involve: recognition or absorption of the material; examination

or exploration of responses; juxtaposition, or putting responses in context, and

application to the self (Gorelick, p. 128). Ironically, while poetry therapy is one of the

newest expressive therapies, archetypally it comes from the birth of human experience.

Expressive Therapies

Expressive therapists believe that imagery can be expressed in any modality, and

that it acquires its meaning by moving through art, movement, poetry, story, and

whatever else moves the image toward understanding. The therapist is trained in a variety

of modalities and how to creatively address presenting problems. Excellent training in

 Theory and Practice of Arts Therapies

degree programs or certificate programs can be found at Lesley University, California

Institute for Integral Studies, and Tamalpa Institute. Recommended readings include

Principles and Practice of Expressive Arts Therapy by Knill, Levine & Levine (2005).

Conclusion

The creative and expressive arts therapies are increasingly useful for mind/body

health. They work effectively with groups in a wide variety of settings, and can be

powerful in settings involving trauma and natural and man-made disasters. They can also

be valuable to healing at the bedside, in medical clinics and interdisciplinary treatment

teams. Arts therapists are trained to identify and build on people’s innate strengths,

creativity and resourcefulness, skills desperately needed at this point in history.

TOOL KIT FOR CHANGE

Role and Perspective of the Healthcare Professional

1) The arts unite ancient healing practices and contemporary medical technology,

using multiple modes of intelligence.

2) Arts can reduce stress and health complaints, improve immune function,

provide both physical and psychological benefits, and even help people live

longer. They can provide a diagnostic image of culture and the individual.

3) Arts therapies work effectively with groups in a wide variety of settings. They

work with infants, children, adolescents, adults and the elderly, and work with a

wide range of emotional and physical challenges.

 Theory and Practice of Arts Therapies

Role and Perspective of the Participant

1) Art awakens the imagination and life-force

2) The arts therapies can address human anxieties, issues of grief and loss, and

natural and man-made disasters.

3) The act of creation is a courageous affirmation of life in face of the void or death.

Interconnection: The Global Perspective

1) The humanities connect people across different cultures and traditions to common

aspects of the human condition.

2) The arts speak many languages and can communicate with many cultures.

3) The arts connect us to nature and to larger forces around us.

 Theory and Practice of Arts Therapies

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 Theory and Practice of Arts Therapies

Naumburg, M. (1966). Dynamically-oriented art therapy: Its principles and practice.

New York: Grune & Stratton.

National Coalition of Creative Arts Therapies Associations. (2004). Poetry therapy.

Available online at www.nccata.org/poetry.html.

National Coalition of Creative Arts Therapies Associations. (2004a). National Coalition

of Creative Arts Therapies Associations [Online]. Available at www.nccata.org/.

Pratt, R. & Tokuda, Y. (1997). Arts Medicine. St, Louis, MO: MMB Music, Inc.

Robbins, A. (1989). The psychoaesthetic experience: An approach to depth-

oriented treatment. New York: Human Sciences Press.

Robbins, A. (1994). A multi-modal approach to creative art therapy. Bristol, PA:

Jessica Kingsley Publishers.

Rothstein, M.D. (1970). Movement characteristics of hospitalized psychiatric patients. In

American Dance Therapy Association Proceedings. Columbia, MD: American

Dance Therapy Association.

Rhyne, J. (1995). The Gestalt art experience. Chicago: Magnolia Street.

Sandel, S., Chaiklin, S., & Lohn, A. (1993). Foundations of Dance/movement therapy:

The Life and Work of Marian Chace. Columbia, MD: Marian Chace Memorial

Fund of the American Dance Therapy Association.

Schlitz, M., Amorok, T. & Micozzi, M., (2005). Consciousness and healing: Integral

Approaches to Mind/Body Medicine,. St. Louis, MO: Elsevier.

Schoop, T. (1974). Won’t you join the dance? A dancer’s essay into the treatment of

psychosis. Palo Alto, CA: National Press Books.

 Theory and Practice of Arts Therapies

Serlin, I.A.; Classen, C., Frances, B. & Angell, K. (2000). Symposium: Support groups

for women with breast cancer. The Arts in Psychotherapy. 27, No. 2, 123-138.

Serlin I. (1993). Root images of healing in dance therapy. American Dance Therapy

Journal, 15, No. 2, Fall/Winter, 65-75.

Serlin, I.A., (1996). Interview with Anna Halprin. American Journal of Dance Therapy,

18, No. 2, Fall/Winter. 115-123.

Siegel, E. (1995). Psychoanalytic dance therapy: The bridge between psyche and soma.

In American Journal of Dance Therapy, 17, No. 2,. Fall/Winter, 115–128.

Silverstone, L. (1997). Art therapy-the person-centered way: Art and the development of

the person. Book review by Vivien Abrams in The Arts in Psychotherapy 389 –

390.

Spintge, R. & Droh, R. (Eds.). (1996) MusicMedicine. St. Louis, MO. MMB Music, Inc.

Wadeson, H. (1980). Art psychotherapy. New York: John Wiley & Sons.

White, E. Q. (1973). An historical perspective of the registry. Dance Therapy in

Dimension: Depth and Diversity, Proceedings of the Eighth Annual Conference.

American Dance Therapy Association. 253–261.

Whitehouse, M. (1986). C. G. Jung and dance therapy: Two major principles. In P.

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Dubuque, IA; Kendall/Hunt. 61-85.

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 Theory and Practice of Arts Therapies

Resources

American Art Therapy Association. 1202 Allanson Road, Mundelein, Ill. 60060 (847)

949-6064.

American Dance Therapy Association. 2000 Century Plaza, Columbia, MD 21044. (410)

997 – 4040. http://www.adta.org American Journal of Dance Therapy. New

York: Human Sciences Press.

Hospital Audiences, Inc. 220 W. 42nd. St., New York, NY 10036.

http://www.hospitalaudiences.org

International Journal of Arts Medicine. MMB Music, Inc. (good resource for creative

arts therapy materials). Contemporary Arts Building. 3526 Washington Ave., St.

Louis, Mo. 63103 – 1019. Email:Mmbmusic@mmbmusic.com

Society for the Arts in Healthcare. 45 Lyme Rd., Suite 304 Hanover, NH 03755 – 1223.

(603) 643 – 2325. HealthArts@aol,com. Publishes a newsletter listing events,

resources, and sponsors a yearly interdisciplinary conference.

Stern’s Book Service (they carry many creative arts therapy books). 2004 W. Roscoe St.,
 Theory and Practice of Arts Therapies

Chicago, Il. 60618. (773) 883-5100 University of California Extension, Center for

Media and Independent Learning.Creative arts therapy videotapes for rent or

purchase. 2000 Center Street. Fourth Fl.

Berkeley, CA 94704. (510) 642–0460.

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