Contributors xix

Private practice in Art Terapy and Counseling. Author, Expressive Terapy

with Troubled Children (2000).
Lukasz M. Konopka AM, PhD, ECNS, BCIA-EEG Senior Executive Director-
Spectrum for Integrative Neuroscience, McHenry IL. Department of Psychia-
try LUMC, Marywood IL.
Kerry Kruk MS, LPC, CSAC, ATR-BC Human Rights Coordinator, Dept. of
Human Services—Continuous Quality Improvement Division, City of Vir-
ginia Beach. Adjunct faculty, Eastern Virginia Medical School, Graduate Art
Terapy and Counseling, Norfolk VA.
Vija B. Lusebrink PhD, ATR, HLM Professor Emerita, University of Louisville,
Louisville KY. Author, Imagery and Visual Expression in Terapy (2009).
Emily Nolan DAT, ATR-BC, LPC Assistant Professor, Art Terapy, Mount Mary
University, Milwaukee WI. Private practice, Bloom: Center for Art and Inte-
grated Terapies.
Tally Tripp MA, MSW, LCSW, ATR-BC, CTT Assistant Professor, Art Terapy,
George Washington University, Washington DC. Director, George Wash-
ington University Art Terapy Clinic. Private practice, Art Terapy and
Psychotherapy.
1 Introduction
Juliet L. King

Always try the problem that matters most to you.

Andrew Wiles, mathematician

The mind operates in binaries, where emotion tends to overrule reason and
vice versa, initially limiting the capacity for language and the ability to express
oneself completely. It is in our very nature to operate in polarities in that the
basic component of the brain, the neuron, functions this way too. A neuron is
either on or it is off; neurons either combine to create a pattern of activation
or they do not. This is the truth shown by scientific facts: either—or, yes—no,
on—off, is—isn’t. Due to a consistent information flow, however, the excitability
of the neuron is variable, and the potential to create action is ongoing and
limitless.
There are three primary goals for developing and publishing this textbook.
The first is to provide an accessible framework for how the disciplines of art
therapy, science, and medicine complement one another and contribute to the
field of traumatology. Although complex and varied, human responses to trau-
matic experiences of any kind are natural, subjective, informed by the processes
of evolution, and have a biological basis, all of which are axiomatic in contem-
porary trauma treatment. An introductory chapter describes an overview of brain
processes, providing the reader with a common language to understand how
neuronal mechanisms are involved in clinical treatment, and in further chapters
leading clinicians explain how they combine principles of neuroscience with the
practice of art therapy.
The second goal is an invitation to medical and healthcare professionals to
further discuss the synthesis of neuroscience and art therapy in the building
of theory and the development of research designs that enhance biological,
psychological, social, and spiritual health. This is the focus of the concluding
chapter, which offers additional methods of understanding neuroscience related
to art therapy practice and highlights the use of neuroimaging as a tool to gather
and test the crucial questions we must answer: How does art therapy work? What
are the mechanisms involved? Can we quantify these, and what are the best ways
to do this?
DOI: 10.4324/9781003196242-1
2 Juliet L. King
The third goal for this volume is to contribute to the development of a
revolutionized definition of art therapy itself, one that is necessary for the
evolution and survival of the profession.

There is only one thing stronger than all the armies in the world, and that is
an idea whose time has come.
(Victor Hugo, poet and author (n.d.))

Those in clinical and academic practice continue to perceive the profession as

a dichotomy of art-as-art versus art psychotherapy. Well-established authors on
the subject have explained the history of this division and the current movement
toward a definition of an inclusion that exists on a continuum (Hinz, 2009; Junge,
2014; Ulman, 2001; Wadeson, 2010). While such a dichotomy may have been
necessary in the past, and is certainly understandable, it is no longer useful and
has no factual or scientific basis. I am pleased to see that there is currently a special
issue call for papers asking “Is there a Need to Redefine Art Therapy?” from Art
Therapy: Journal of the American Art Therapy Association, which seeks to examine
the historical definition of art therapy from a contemporary perspective.
This is an important and timely call, and I suspect that the submissions will
include consideration of the polarities that once defined our most noble
profession as parallel to those of hard science and soft science. Most interesting
questions usually do not have simple yes and no answers, and the hard science
that has traditionally defined neuroscience is based on what can be seen under
a microscope. The more indirect methods of the so-called soft science of
psychology are concerned with large and complex issues that require sophisti-
cated but often less clear-cut approaches (Pigliucci, 2010). What we can readily
observe, measure, and test has been considered to be science; thus, less under-
stood phenomena of ambiguous psychological processes are considered soft.
However, the brain does not distinguish the processes of scientific invention and
the making of art, which are in fact found to be similar (Konopka, 2014, p. 73).
This functional similarity helps to conceptualize the replacement of a dichot-
omized perception of hard and soft sciences, and of art-as and art psychotherapy,
within one continuum of what we know we can explain on one end (the left)
and what is more difficult to capture on the other (the right). Investigating this
continuum does not require a microscope when naming the cytoarchitecture of
its structure, but it does require imagination as we learn how to bridge these
operations through the relationships of its components.
To consider the intricacies that take place in the process of any therapeutic
discipline through an objective lens is not only mainstream best practice but also
an ethical and professional responsibility. Perhaps there is a sense that this type
of inquiry reduces the magic from the many complexities involved in therapeutic
practice and art-making in general. This is an unnecessary bias, in that the concept
of magic encompasses unlimited definitions, all of which depend upon the way
it is considered. For example, Anna Freud thought defense mechanisms relied
on “magical operations” (Combs, 2013), resiliency can be considered a type of
“ordinary magic” (Masten, 2001), and linguistic scholars have determined that
 Introduction 3
imagination evolves from the root word magic (Cheak, 2004). Since the beginning
of time, human beings have sought to understand themselves and assign meaning
to their lives that informs the capacity to be open minded, to live nondefensively
with the question of how to live (Lear, 1998). I interpret Lear’s work in reference
to a philosophical and psychological capacity that is ingrained in the training of
the art therapist and that can be applied in a wide range of dimensions. Humans
can be curious, flexible, and creative as we tolerate the ambiguity inherent in
human relationships and the process of healing.
To imply that science detracts from any type of relational experience is
outdated and counterintuitive to our roots in art and medicine. As the prolific
and everlasting neurologist Oliver Sacks (1973, 255) said:

We rationalize, we dissimilate, we pretend: we pretend that modern science

is a rational science, all facts, no nonsense, and just what it seems. But we have
only to tap its glossy veneer for it to split wide open, and reveal to us its roots
and foundations, its old dark heart of metaphysics, mysticism, magic and myth.
Medicine is the oldest of the arts, and the oldest of the sciences: would we not
expect it to spring from the deepest knowledge and feelings we have?

Exploring the unconscious in the context of the therapeutic relationship

allows access to this deepest knowledge and is bedrock of art therapist training.
There is so much about humanity that is unknown, and much of the rhetoric is
untrue. Applying a scientific understanding to processes less known creates
more questions than answers and, like the medicines of art,” . . . are not confined
within fixed borders” (McNiff, 2004, p. 5). The unconscious is where many of
our capacities are born, and as Carl Jung (1957) said, “That’s the beauty of it!”
The beauty is that we only have glimpses into this realm, and regardless of any
theoretical orientation, it is well known that aspects of this great universe such
as memories, perceptions, judgment, affect, and motivations are not always
consciously accessible (Schedler, 2010).
In his healing work as a neurologist and psychiatrist, Freud (1992) provided
us with a “Royal Road” to explore dreams as the most direct representation of
the unconscious. Medical training in the twenty-first century is highly special-
ized, and physicians are not taught to understand representative unconscious as
it relates to physical symptoms. For example, when a patient consults a sleep
specialist to resolve an issue of somnambulism, the neurologist is trained to treat
the symptom at the cellular and molecular levels in determining the etiology
of the interrupted sleep cycles. Many sleep specialists will report, however,
that patients are often interested in sharing their dreams. Although the dreams
might be interesting, the doctors have no idea what they could mean; therefore,
the expression of the dream or the dream itself is not considered as a part
of treatment. Psychiatry is the branch of medicine that would typically be
more attuned to the unconscious of the patient, but is not clearly embedded
in contemporary medical practice and is often far removed from issues like
sleepwalking. This is a looming gap, where the patients desire to connect
and explain aspects of their condition the best way they know how to a doctor
4 Juliet L. King
who is not prepared to understand. A lack of interpersonal awareness affects the
quality of healthcare and perpetuates a systematic disconnectedness in the
delivery of service. I am not suggesting that sleep specialists become psycho-
analysts, nor am I inferring that physicians do not care about the relationship
that they have with their patients, but this is an opportunity for art therapists
and neurologists to work together in the efforts to legitimize mechanisms of the
unconscious. Doing so will support and enhance relationships between doctors,
therapists, and patients across all medical and healthcare disciplines.
Many aspects of human behavior are difficult to study, and art itself is a
complicated topic that involves innumerable considerations that span the bridge
of understanding. Different forms of expression are connected to brain processes
that include the interconnections of neuroanatomy, neurophysiology, and the
integrity of neurotransmitters, yet finding correspondence between certain
neuronal organization and specific brain functions remains a problem in
neuroscience (Amaducci, Grassi, & Boller, 2002). Defined as “the study of the
neuronal processes that underlie aesthetic behavior” (Skov & Vartanian, 2009,
p. 3), the growing field of neuroaesthetics investigates important connections
between science and art. Pioneer Semir Zeki (1999) claims that art stems from
physiology and focuses on the “biological basis of aesthetic experience” in his
work, seeing that the function of art is an extension of the functions of the brain
(p. 76). Art therapists have studied what is also being explained through neuro-
aesthetics in the development of theory. For example, the Expressive Therapies
Continuum (ETC) (Kagin & Lusebrink, 1978; Lusebrink, 1990, 2004, 2010;
Hinz, 2009) has long led art therapists in understanding the interface of the
multileveled neurologic regions that are involved in creative expression.
Neuroaesthetics supports this theory by reporting that creativity involves several
interconnected systems in the brain, is the result of cognitive flexibility, and
involves memory, sustained attention, and judgment (Dietrich, 2004). There have
been several studies in the field of art therapy that have served to clarify the
impact that art-making has on the brain through the use of neuroimaging
technology (Belkofer & Konopka, 2008; Belkofer, Van Hecke, & Konopka, 2014;
Kruk, Aravich, Deaver, & deBeus, 2014), all of which share a generalized con-
clusion that artistic production is not localized to certain neurological regions
and leads us to see that art is, in fact, all over the brain (Belkofer, 2012). The
exciting complexities that make it difficult to explain and correlate the creative
process with neurological functions point us to the wild terra incognitae that is
ready to be further explored.
Neuroaesthetics does not focus on how the brain and art are applied in a
therapeutic context, yet further investigation of how the physiological and
psychological aspects of aesthetic experience relate to one another is an import-
ant goal that will expand in the future (Chatterjee, 2010). Here is an opportunity
for art therapists to collaborate with neuroaesthetics researchers in developing
a greater understanding of important psychic connections and learn how best
to apply this information in treatment. Lusebrink and Hinz provide an example
of how to do this in chapter 3 through the initial description of the two inter-
acting neural streams responsible for visual information processing, one that
 Introduction 5
identifies what object we look at, and the other that tells us where the object is,
which is also nicely described in the neuroaesthetics literature by Chatterjee
(2014). However, Lusebrink and Hinz break new ground to consolidate this
information and apply it to the treatment of trauma by establishing an emotional
balance that is related to a sense of oneself in space. This supports the interface
of scientists and artists, who Huang (2009) refers to as “coinvestigators of
reality,” sharing the common goal of seeking knowledge (p. 24). Neuroaesthetics
and art therapy help to explain that human behavior and cognition represent
inherent fundamental collections of highest levels of cerebral function. With this
we understand more clearly how the study of human behavior, addressed by
the fields of psychology, psychotherapy, and art therapy, should be based in
neuroscience (R. Pascuzzi, personal communication, June 16, 2015).
When studying brain science it is easy to get lost in technical jargon, wandering
about sulci and gyri in the efforts to navigate the matter. The many types of
neuroscience can also become confusing as they branch out, like synapses, to form
interdisciplinary fields of research and practice. Neuroscience is defined simply
as the study of the nervous system. The main categories of neuroscience are named
as these: developmental, how the brain grows and changes; cognitive, how
language, thought, and memory are understood; molecular and cellular, which
focuses on proteins, genes, and molecules; behavioral, which examines processes
underlying animal and human behavior; and clinical, the study of disease and
health (National Institutes of Health, 2015). These categories are not mutually
exclusive. For example, to understand autism, developmental neuroscience
intertwines with behavioral, also a form of cognitive, in the study of clinical goals,
all of which have molecular and cellular roots!
We are traveling at light speed as we learn about the brain in the context of
the living, and although “we do not have an intellectually satisfactory biological
understanding of any complex mental processes” (Kandel, 1999, p. 612), leaders
in the field of neurobiology, psychiatry, and psychology have propelled a response
to this, which has “helped to redefine our understanding of the neuroscience of
psychotherapy and ushered in a revolution in mental health” (Belkofer & Nolan,
ch. 7) The authors in this text build upon the foundation of psychobiology that
binds neurology and psychotherapy (Cozolino, 2010) and make steps on the
bridge that links the theory, practice, and research of art therapy to all categories
of neuroscience in the collective effort of figuring out the “magic synthesis”
(Arieti, 1976) of what these relationships are.
For example, Klorer (ch. 6), Gantt and Tripp (ch. 4), and Lusebrink and Hinz
(ch. 3) explain the repercussions of damaged attachment systems that are the
result of early childhood and preverbal traumas and show how art therapy
interventions provide potential to re-form these relational attachment patterns
in a context based in clinical neuroscience. Noah Hass-Cohen (ch. 5) provides
a detailed overview of the neurobiology of chronic traumatic symptoms,
autobiographical memory, and creativity and resilience, and then synthesizes this
to explain the working knowledge of the basics of trauma treatment, conditions
of therapy, and development of interventions. This chapter links the molecular
and cellular processes that create biological systems in the identification of how
6 Juliet L. King
to understand the behavior of the people we work with and the best ways to
provide care.
A while back I was describing to a sage mentor a teaching strategy that I wanted
to implement in the classroom, based on some things that I had read recently.
After hearing my description, she suggested I try it and reflected that as I am a
creative arts therapist, I “learn by doing.” The more I work with clients who
have trauma and learned colleagues such as the authors in this book, and the
more I read, write, and speak on the topic, I have come to understand my innate
doing within the context of neurogenesis (the growing of new neurons) and
neuroplasticity (the capacity for neurons to connect and form new pathways),
the processes of which occur throughout the entire life span. The reality that a
person can influence the brain to change its own structure is the most important
shift in understanding the brain beyond what we once knew about its anatomy
and basic component, the neuron (Doidge, 2007). The tenets of art therapy
are underscored with neurobiological principles, and all of the intervention
strategies included in this book are enhanced and further explained with
knowledge of neuroplasticity.
These primary tenets are that 1) the bilateral and multidirectional process of
creativity is healing and life enhancing, 2) the materials and methods utilized
effect self-expression, assist in self-regulation, and are applied in specialized ways,
and 3) the art-making process and the artwork itself are integral components of
treatment that help to understand and elicit verbal and nonverbal communi-
cation within an attuned therapeutic relationship. Explaining these tenets and
their interventions in a neurobiological framework is especially relevant in the
treatment of trauma, in that by definition trauma is a biological and “wordless
event” (P. Isley, personal communication, July 30, 2015). The response that
humans have to any traumatic experience disrupts physical and mental homeo-
stasis. Changes in the sympathetic nervous system, endocrine system, and the
structures of the brain cause responses in cardio, respiratory, and muscular
systems (Solomon & Heide, 2005), and this dysregulation creates myriad phys-
ical and sensory integration problems that, although natural, make it difficult
to identify, understand, and express one’s lived experience in a cohesive and
subjective way. As many systems in the body become disrupted and fragmented,
the capacity to verbally communicate is stifled, which is often seen in clinical
practice as the inability to integrate memories of the traumatic experience(s) with
the verbal processing of such events.

I am paraplegic in my mind.
(Veteran in art therapy treatment)

I had the great fortune of working with OEF/OIF veterans of combat at the
Roudebush VA in Indianapolis, where I joined forces with research psychologist
Dr. Brandi Luedtke in the development and implementation of mindfulness-based
art therapy groups (MBAT). Dr. Luedke brought the mindfulness and I the art
therapy to the implementation of two successful pilot studies that provided services
for veterans of combat, all of who were diagnosed with PTSD and in some cases
 Introduction 7
traumatic brain injury (TBI). We conducted a research study that primarily sought
to show how participants exhibited a decrease in self-reported and clinician
reported PTSD symptoms and depression pre- and post-treatment and an
increase in self-reported mindfulness skills and higher levels of compassion. The
results revealed a statistically significant improvement in total self-compassion
and self-judgment and a trend improvement in the symptom of isolation. There
was also a statistically significant improvement shown through the self-reported
PTSD scale (PCL) in the reexperiencing of symptoms and a trend improvement
in avoidance. The feedback evaluation forms indicated that all 11 participants got
something of positive and lasting value out of the treatment and on the average
rated the importance of the program a 9.5 out of 10. Every participant expressed
an interest in participating in future MBAT groups at the VA if they were
available and shared many personal thoughts about the experience, including that
the groups offered “a new and creative way to talk about feelings associated with
trauma,” and that the program “helped to open new doors for me, identifying
underlying issues that I need to address either individually or in other group
sessions.” The statistical and qualitative data indicated that MBAT was successful
in treating symptoms of PTSD and TBI with veterans, and further remarks from
the group members led me to understand how the tenets of art therapy impact
veterans who are coping with traumatic experiences. Participants stated: “Making
art makes it easier to think . . . It gives us something to do while we’re trying to
talk about things that are hard to talk about . . . ,” and

There seems to be a language barrier we create when confronting issues of

trauma. I think, through art, we basically are constructing a bridge to better
understand our psychological wounds . . . I believe [art therapy] to be an
excellent medium to reach intangible emotions.
(Veteran in art therapy treatment)

This is very important data that hopefully will provide evidence for continued
MBAT programming at the VA, as art therapists face an ongoing challenge
as we work through the politics of an overarching system that only defines
reimbursable care with certain credentials. Amid the political battles that I fight
in the advocacy for art therapy services, I always remember how the most
enlightening experiences with these service members came by way of being
present in their process while they created art and talked about it. Regardless of
the task that was initially presented to the group, common themes of a changed
identity would present as the members expressed narratives of combat and
return from war. The veterans felt that they were different people than they once
were and had difficulty piecing the shattered parts of their experiences together,
which resulted in an overall sense of despair. The artwork created most often
superseded these initial descriptions, as the images that emerged often included
powerful themes of light and dark colors. In viewing the work, we were able to
talk about the dichotomy of color and its placement on the page. This context
sparked conversation of a different nature: another way to see one’s self as
having components of light at the same time as dark.
8 Juliet L. King
I often wondered to myself if the artwork was reflective of the brain, where
the light represented the limbic system and the dark the frontal lobe as the people
maneuvered their own unpredictable terrains together in the group. I would think
about patterns in artwork and patterns of mind and consider how trauma
impacts the ego ideal, and as it hurts us could it also help us? With this vision
I encouraged the group members to talk to one another and talk about their
artwork, to consider the metaphor that a wholeness may exist somewhere within.
Among these recapitulative emotional experiences, initial hopeless discussions
became those of possibility and potential. Working with the veterans helped me
understand more about the experiences of people who have endured multiple
traumas at war and has also given me a perspective for how to conceptualize
possibility in a system that is fragmented and disconnected.
When I presented on this topic to an audience of art therapists, I was surprised
to get the feedback from a working professional that “We don’t deal with the
ego ideal in art therapy with veterans. It is irrelevant.” I believe, after talking
further with her, that she was trying to inform me of some successful approaches
that she uses, and how they do not have such focus. However, it rests with me,
years later, that the quickness with which a colleague would dismiss a philosophy
that I, and my clients, find to be quite pertinent, is a call to action for art
therapists to be flexible and open minded in their philosophies. To find ‘the best
ways’ to help others is resultant of an integrative and team-oriented approach,
entrained within our own and other professions. I urge us all to engage in
conscientious and thoughtful debate, not one those of judgment and exclusion.
It is in the clinical work of the psychotherapist to address the questions of
meaning, and regardless of a diagnosis, the sources of ontological insecurity are
universal and involve a concerted exploration for what it means to be alive. These
themes are difficult to approach for any mind, and regardless of the theoretical
orientation, it will always be important to consider the paradox of traumatic
experiences, the impact they have on the psyche of the individual, and what the
significance of this is in the larger questions of defining meaning and purpose
in the world.

It’s the relationship that heals, the relationship that heals, the relationship
that heals—my professional rosary.
(Irvin Yalom, psychiatrist and psychotherapist,
cited in Feltham, 1999)

Just as an artist needs to learn to paint a representation before communicating

the abstract, a therapist needs to work with patients in order to understand the
most powerful intervention of all: the relationship. All of the contributors to
chapters in this textbook include the therapist-patient relationship as central to
progress in their treatment with trauma survivors. Regardless of the discipline,
it is the therapeutic relationship that provides the template for change, and
empirical research in cognitive science has shown that the most effective
therapists are those who recognize the importance of the relationship in healing
(Schedler, 2010). This therapeutic tenet is understood at the intellectual level in
 Introduction 9
the learning process, but it is only through concentrated work that a clinician
experiences a holistic understanding of what this really means.
Neuroscience has provided art therapy with a developed understanding of the
importance of our work at a fundamental level, and we in turn offer the ability
to embody these essential scientific principles as they are actualized in applied
and thoughtful clinical care. Neuroscience is the clay, offering an inherent
structured medium that art therapists can then sculpt and develop into form as
we forage the liminal space on the way to imago of growth. And just as the
complexities of artistic expression float throughout the whole brain and the
“. . . mainstream of art’s medicine will always flow through the studio” (McNiff,
2004, p. 27), it is through the relationship that we all become whole.

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