THE BENEFITS OF ART THERAPY WITH CHILDREN AFFECTED
BY ACUTE TRAUMA

By

ALEXA MORRISON

A THESIS SUBMITTED IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
BACHELOR OF INTERDISCIPLINARY STUDIES

We accept this thesis as conforming to the required standards:
_________________________________________
Reid Webster (Ph.D.), Thesis Supervisor, Dept. Psychology
_________________________________________
Terryl Atkins (M.F.A.), Dept. Visual and Performing Arts
__________________________________________
Patrick Walton (Ph.D.), Dept. Education and Social Work
__________________________________________
Mark Rowell Wallin (Ph.D.), Co-ordinator, Interdisciplinary Studies

Dated this 20th day of March, 2017, in Kamloops, British Columbia, Canada

ABSTRACT
There are differing opinions whether art therapy has a positive effect on people’s lives;
limitations inherent in most studies undermine the potential validity of this claim.
Demonstrating that art therapy has positive affects has been hindered by the paucity of welldesigned empirical studies in this area. Despite the perceived limitation of art therapy, it remains
a useful tool to aid in the enhancement of a child's life. Art expression allows children to process
the distressing event in a way that is more easily communicated compared to relying solely on
their verbal skills. Art therapy is commonly used when treating victims of trauma, which implies
that there is something about this type of therapy that allows for further insight into their
recovery. This specific type of therapeutic process provides an opportunity for children to view
the trauma in a new way. It is often seen as a way for children to reframe and integrate the
traumatic experience as a way to help them cope with the traumatic event. Rather than having
therapy and art stand in isolation from one another, I highlight the importance that the integration
that these two disciplines bring towards helping children. Reviewing the literature on this subject
has not only given me a better understanding of the process, but it has also given some insight
into the types of concerns that are involved with working with children, such as the nature of the
trauma, the different types of trauma that may be treated, and the ethics of working with
children.

Thesis Supervisor: Assistant Professor Reid Webster

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ACKNOWLEDGEMENTS
I would like to thank my thesis supervisor, Reid Webster, for his continued patience and
encouragement throughout my research and writing of this thesis. His knowledge and guidance
made this project possible for me. I am grateful and appreciative for the time that he has
committed to my work since the beginning of this process. I would also like to thank the rest of
my thesis committee, Terryl Atkins (M.F.A.), and Patrick Walton (Ph.D.), for their assistance.
Finally, I would like to express my gratitude to Mark Wallin (P.H.D.) for his continued support
and advice along the way.

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TABLE OF CONTENTS
ABSTRACT……………………………………………………………………………………...ii
ACKNOWLEDGEMENTS…………………………………………………………………… iii
LIST OF FIGURES……………………………………………………………………………...v
INTRODUCTION……………………………………………………………………………….1
CASE STUDY……………………………………………………………………………………9
ART THERAPY……………………………………………………………………………......10
TRAUMA AND TREATMENT……………………………………………………………….14
PROBLEMS WITH STUDIES………………………………………………………………...16
FUTURE DEVELOPMENT…………………………………………………………………...20
CONCLUSION…………………………………………………………………………………22
REFERENCES………………………………………………………………………………….24
ADDITIONAL REFERENCES……………………………………………………………….26

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LIST OF FIGURES
Figure 1. Drawing by a 14-year-old Traumatized by Violence (Kuban, 2015) …………………10
Figure 2. Pre-Treatment Post-Treatment Research Design……………………………………...18
Figure 3. Controlled Study Research Design…………………………………………………....22

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INTRODUCTION
Art is often described as a diverse technique that is used to express one’s thoughts and
ideas. It is appreciated for the presence and beauty that it holds. Art has the ability to address
social and political issues that are particularly important to the artist. It allows us to be able to
use our imaginations to express our thoughts, desires, and conflicts that may arise within our
lives. Art is often viewed as indefinable and immeasurable because of its multiple forms, which
has given it a sense of mystery within society (Dissanayake, 1988).
There are many different techniques that can be used. For example, painterly, linear,
sculpture and gestural mark making are a few of the ways that artists use materials to express
their imaginative thoughts and ideas in a unique way1. Often the way the artist represents these
ideas allows the public to view something that is familiar (objects, people, or places), in a new
way. The flexibility of materials gives the individuals creative control to explore any avenues
that may be of interest to them. There is a breadth of mediums that can be used so that artists are
able to articulate their ideas in the most effective ways possible. The different ways that artists
can express their thoughts and ideas encompass the various senses, in concrete material form or
time-based performative ways, and may be interactive. Additionally, because of the
extensiveness of materials that are available it has allowed the production of art to be part of
humanity since approximately 35,000 BCE (before common era) (Aubert et al., 2014). It has told
stories throughout time, expressed religious thoughts and ideas, and expanded our knowledge of
everyday things, such as relationships, routines, or objects. Art has allowed humanity to use

1 Painterly refers to the quality of line with which a person uses to express the natural

characteristics of the marks. Gestural is much less controllable as to meaning and can embody
quick, without forethought movements within the quality of the line and can be very expressive.
In contrast, a person may also use linear lines that are more orderly and geometric.
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visual language as a way to creatively express these thoughts and ideas in an alternative way and
this is part of what has contributed to the long lasting influence that it has had on humanity
throughout our history.
Art has been a universal characteristic, or behavior throughout humankind, which is why
it can be used in a broad way to reach a vast number of people (Dissaniyake, 1988). The use of
images has been part of human practice since homo sapiens were drawing animals and people on
cave walls. The purpose of the drawings is not clear, but it is believed that they were a form of
communication and depicted different ceremonies. What is believed by some anthropologists and
archaeologists is that cave paintings also communicated ideas of hunting and gathering, which
lend credence to the argument that drawing and other forms of art can be used as a form of selfexpression (Aubert et al., 2014). They often used rich red and yellow colours from ochre, or
charcoal, to draw on rocks and the walls/ceilings of caves, such as in the Lascaux caves in
France and the Chauvet caves (Bourges, 2014). Creating visual images to express ourselves is
something that connects us to other people because art can be seen as a means of
communication, and the creation of visual imagery can impact our thoughts and memories. The
creative process can also connect us to different senses throughout our body, such as touch,
smell, sight, and even sound, and our senses play a large part in triggering our memories to allow
us to express them in a visual context. Even though images were used very early on, art did not
begin to be considered as a useful therapeutic technique until approximately 1910.
Art therapy was introduced into traditional therapy at that time by therapists who had a
background in art; their art background set them apart from other therapists as it allowed them to
see the value art held in regard to healing which they felt allowed for a better understanding of
one’s self (Hussain, 2010). Dissanayake (1988) discusses how art can be viewed as adaptive and

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desirable; it allows for an unselfconscious experience that can create a connection between
external and internal reality. Margaret Naumberg was one of the first psychotherapists in the
U.S.A. to use art in her practice to assist in the diagnoses and treatment of patients. She
employed art with psychiatric patients using insights from Sigmund Freud’s psychoanalytic
method and his analysis of dream imagery (Hussain, 2010). She saw art in a similar way as
Freud viewed dreams, as a means to make the unconscious, conscious and a way to integrate
with ego consciousness. Edith Kramer shared Naumburg’s psychoanalytic belief in art as
therapy. Kramer, who trained as an artist under Friedl Dicker in the Bauhaus tradition 2, taught art
to the children of political refugees in Prague in the 1930’s (Malchiodi, 2014). She was also a
political refugee, but escaped Nazi expansion in Europe. She worked with disturbed children and
began teaching art classes to refugees of Nazi Germany; she felt that being able to transfer
memories and thoughts into images was a useful tool to allow the victims of traumatic events to
aid in coping with the trauma (Hussain, 2010). Both Naumburg and Kramer were very influential
in the development of art in therapy, but used it in different ways to approach the process.
Although they had a strong interest in Freud’s psychoanalytic theory, Naumburg used a
dynamic-oriented approach that focused on the child developing spontaneous scribbles into
imagery, whereas Kramer had the child draw specific images and scenes. Their interpretations
also varied; Naumburg believed that only the client could reveal what the drawing meant
whereas Kramer found that the drawings could be interpreted by the art therapist (Hussain,
2010). In the end, they both undeniably saw the value in what they were doing and the benefits
of using art when dealing with disturbed children who were suffering from mental issues, or
children who were refugees dealing with issues of displacement and anger. Naumburg and
2

The Bauhaus was a very influential and modernist German art school. It began operating
around 1919, and combined the use of crafts and fine arts.
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Kramer believed that by incorporating art with therapy, one would be able to use visual creativity
and the malleable materials to express one’s self, thereby integrating the unconscious memories
with conscious memories.
Art therapy was first officially recognized as a discipline in the 1940’s in America and
Europe (Hussain, 2010). By combining techniques from psychology and the use of visual arts, it
provided practices to better help people understand their experiences more completely and to
heal. By introducing aspects of psychological processes into the therapeutic art process, it
allowed therapists to develop new ways to assess children who were struggling with mental
disorders.
The initial research on art therapy focused on children who were suffering from many
different issues, such as feelings of loss, anger, anxiety, displacement, and depression. To be able
to develop a more effective therapeutic process, therapists began to view projective tests, using
drawing, as useful tools for diagnosis, and for developing further insights into their patients
(Rabin, 1986). The projective tests used drawn imagery as an expressive technique. Therapists
employed projective techniques, such as the House-Tree-Person, in which children were asked to
draw the best pictures they could of a house, a tree, and a person. They could also have the child
draw pictures of familiar images (people or homes), and then look for noticeable differences
within the drawings that appeared to be unusual in comparison to a “healthy” child’s depiction of
that image. These tests further evolved to incorporate techniques that allowed the patient to
express themselves in more fluid and natural ways. The different projective tests were believed
to bring repressed memories to the surface. The use of these tools provided therapists with ways
to help children reveal information that they were struggling to articulate.

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The field of art therapy progressed to examine the healthy and unhealthy developmental
processes of children. Rhoda Kellogg developed an “encyclopedia” based on two million
children’s drawings from across the world that referenced the different developmental levels of
the children (Sourkes, 1991). This “encyclopedia” was a reference that permitted them to be able
to see what their drawings were expected to look like and gave them something to which they
could compare other drawings. By looking at children’s development and the content that they
drew during these different developmental stages, they were able to examine the irregularities
that were expressed by the child, such as drawings of dark evil images/figures or drawings of
themselves that showed them expressing negative emotions. Furthermore, the evolution of
learning about the importance that creative art processes can have when assessing and treating
children affected by trauma has allowed for further understanding within the development of art
therapy.
Art therapy is a therapeutic process that incorporates the use of creative outlets to
facilitate diagnosis and to help the clients better understand their traumatic experience. Davis
(1989) discusses some of the common benefits that he recognizes within art therapy practice, and
states that, “[a]rt can be used to focus on well-being and wholeness, as well as to help develop
and build new skills. The use of art also facilitates self-nurturing and promotes healing” (p. 273).
The coping mechanisms that art therapy introduces to the client bring several positive attributes
to the client’s healing that may have not been brought to the surface otherwise. One of the
characteristics of art therapy that allows it to be a beneficial therapeutic technique for children is
its ability in accessing trauma without relying on the subjects’ verbal skills, and how it allows
children to retain partial control over their healing process. As noted by Pifalo (2007), “[b]ecause
of the visual nature of traumatic memories, an image-based therapy may offer the most efficient

5

means of accessing, processing, and integrating these split-off fragments that otherwise may
continue to result in flashbacks and nightmares” (p. 171).
The expanding literature within the field of art therapy, particularly with children,
examines how different types of trauma (natural disasters, domestic violence, and sexual abuse),
lead to the development of Posttraumatic Stress Disorder (PTSD). According to Van Westrhenen
(2014) symptoms of PTSD include, “overwhelming feelings of re-experiencing the traumatic
event (e.g., nightmares and intrusive thoughts), avoidance of trauma stimuli, negative alterations
in cognition and mood” (p. 527). PTSD symptoms often involve involuntary intrusive thoughts,
recurring flashback of the traumatic events, and intense psychological distress for the person
affected (Piotrowski, 2017). Children can frequently become aggressive towards others, and
avoidant of places or people that remind them of their trauma. Art therapy can be seen as a
vehicle by which visual memories are accessed in a visual/tactile way; it is believed to bring
more effective healing for the patient. The sense of touch that is involved when using tactile
materials can bring the overwhelming memories to the surface, which allows them to realize
many new thoughts and emotions with which they are dealing. With the use of different
materials, such as pencils, crayons, markers, or paint, for example, they are able to work through
their trauma, heal, and develop better ways of coping.
There is also evidence to suggest that art therapy will continue to help children after
therapy concludes. Being able to work through their trauma and learn new ways to cope with
issues that might present themselves once therapy has been completed allows them to avoid
further negative effects that could be caused by their experience, and understand their emotions.
According to Meshcheryakova (2012), art can be a form of self-nurturing which children can
employ to soothe themselves when they are feeling insecure or uneasy about any future

6

relationships or situations they may encounter. There are many different types of mediums,
including, but not limited to, drawing, painting, or manipulating clay that can allow them to work
through their traumatic experience, and allow them to improve their emotional and physical wellbeing. The client is able to have input into the medium that they are the most captivated by, as
well as have some control over the process that they choose to take to find catharsis from their
traumatic memories. For example, if they feel that drawing with crayons for one session will
help them to express their conflicts more effectively then they can do so, which then could
evolve into working with paints in future sessions. The qualitative difference between the
materials can also be intimidating for the child because a particular medium may seem too out of
control, or messy. They may be fearful of working with that particular medium (e.g., clay or
paint), but the use of that material may be crucial for catharsis of their trauma. Nevertheless,
these decisions are ultimately decided by the art therapist who remains as the stable force that
guides the child appropriately towards materials that will bring them relief, compared to using
materials that will increase the child’s symptoms. For example, the use of paint can awaken
additional trauma within them because of the messy disposition that it can entail. The features of
this medium can emulate bodily functions, such as blood, that could cause a traumatic reaction
for the child (T. Atkins, personal communication, August 17, 2016). The ability to have some
control of their progress gives them a strong sense of self and achievement; this is often
something that is distorted when they have experienced trauma, or are struggling with issues in
their lives.
Once they begin the sessions they are able to have one-on-one sessions, or they can
participate in group therapy. With group therapy they are able to feel a sense of community and
support from the rest of the group, which allows them to feel less alone in their experience.

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Backos’ (1999) article discusses female sexual abuse survivors who all participated in group
therapy with other survivors to overcome their sexual abuse trauma. Being able to see that they
are not the only ones who have experienced this specific type of trauma can help them to feel
less alone when going through the healing process. The girls began their session with a
discussion of their present feelings, and they all drew mandalas that revealed emotional
instability (Backos, 1999). Mandalas have highly projective properties. They are often given to
patients as a blank circle and they are asked to fill it in based on the definition of a task (Sourkes,
1991). For example, they could be asked to base their mandala on the question of, “How they are
feeling now.” The girls who suffered from sexual abuse were all experiencing a variety of
feelings and the group sessions gave them a tool for catharsis and healing (Backos, 1999).
The art that the clients create is not always about the quality of their finished product but
can also be about the process they undergo while creating their art work. The finished product at
the end of therapy is valued because of the satisfaction that it brings to the child. The therapist
examines the use of colours the client uses, whether they are colourful or monochromatic shades.
The purpose and reason behind their choice of the colours and materials can vary from person to
person depending on the trauma symptoms that they are experiencing and their individual
differences. For example, it has been recognized that children suffering from anxiety often draw
dark chaotic images that express the feelings that they are experiencing (Wadeson, 1989). Not
only do therapists look at the variety of colour, or lack thereof, but they consider the location of
the images and the order in which elements were placed. The distinct differences between each
piece of art are important, but the therapist continues to use reliable formulas for analysis and
interpretation.

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Another focus of the clients’ art work that is acknowledged as important to the
therapeutic process is the content they choose to create as well as the therapist’s observations
while they are going through the different therapeutic procedures. Some examples of these
procedures could be drawing a place that makes them feel safe, unsafe, happy, or angry
depending on the direction that the art therapist feels is suitable for the child. Whether it is
creating different types of pictures, scribbles, paint strokes, or other types of mark making, the
details in the picture are what express the distress that the child may be experiencing.
Art therapy is able to help with different issues from the sequelae of trauma, including
anxiety, obsessive thoughts, or aggression. The variety of strategies that art therapists are able to
employ, can allow art therapy to be very beneficial for a wide variety of individuals. Mallay
(2002) expresses this benefit of art therapy when she writes:
Art therapy allows the use of creative materials to describe feelings and situations.
Exercises are goal-oriented, require no artistic skill, and help to process feelings and
concepts without having to ‘say’ all the words. Art therapy is ideal when sensory, verbal
or cognitive abilities are affected because it does not rely on verbal output. (p. 159)
These features allow it to reach cross culturally because of the lack of reliance on verbal
language in the same way that talk therapy does. The pictures that are drawn in therapy can be
very detailed, or simply consist of different types of mark making, such as gestural or more
considered lines. The fluidity of not having to rely on the final product being a masterpiece
opens the door to having art therapy be available to a majority of people. These features are
important because it is capable of helping those who are willing to express themselves in a visual
way.

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The effectiveness of art therapy, however, has not been empirically established compared
to other types of traditional therapeutic approaches. Art therapy’s lack of recognition compared
to other therapies/treatments (e.g., Cognitive Behavioral Therapy (CBT)), comes from the lack of
empirical research examining the effectiveness of art therapy as a therapeutic modality. Yet, one
of its main benefits is that, compared to traditional therapy, art therapy does not exclusively rely
on verbal abilities because of the imagistic and tactile nature of the therapeutic process. It uses
aspects from visual arts (drawing, sculpting, and using their imagination to tell their experience
in a new way) and psychology (looking at how trauma affects cognition, behavior, and conscious
and unconscious thought) to aid in helping people with a variety of ailments to cope and better
themselves. For example, it is often used with patients who are suffering from PTSD, depression,
and anxiety. Being able to see the traumatic experience in a new way and reformat the clients’
understanding of the trauma allows them to be able to better cope with their traumatic memories
on a daily basis. Despite the fact that art therapy does not have as much value in our society
compared to other therapies, it brings a unique successful methodological approach to the realm
of therapy. The mental disorders that were previously stated affect many cultures, which ensures
that the importance that art therapy is able to be effective cross-culturally once cultural
differences are factored into the approach.
CASE STUDY
Within the recent literature there have been many different case studies that have
examined how art therapy techniques are able to aid in trauma recovery. Figure 1 is an example
of a case study that used art therapy to assist in the recovery of a young boy who experienced
trauma and discusses the benefits of the therapeutic process.

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Figure 1. A 14-year-old boy traumatized by violence.

Kuban (2015) discussed some examples of drawings by children; for example, Figure 1
was completed by a 14-year-old boy who witnessed neighborhood violence. This particular
drawing was referred to as his “focus box” to remind him of what to focus on for his future to
avoid these violent situations from his past. Being aware of his background and history is what
brings a broader understanding of his visual representations of his trauma. Backos and Pagon
(1999) state that, “[w]hen designing a group for adolescent sexual abuse survivors, one must be
aware of not only issues surrounding the sexual trauma, but also issues pertinent to the
developmental stage” (p. 127). By understanding and being able to acknowledge the differences
within the stages of children, the therapist is able to view the child’s situation and recognize
issues that may pertain to that developmental area. Also, the importance of learning the different
stages can assist with group therapy and being able to place children into groups that are the
most beneficial for them.

ART THERAPY
Art therapy began with the desire to better assess the mental issues and personality of
children, as well as to help with the assessment of disturbances within the child. There was a

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need to advance therapy techniques for children because of the issues they have articulating their
anxieties and fears associated with their trauma. Most children, developmentally, do not have the
verbal skills to be able to express themselves accurately and efficiently (Naumburg, 1950). Art is
often something that gets left behind once children develop further into their adolescent years
and because of this, it becomes a very important aspect that is missing from their life. The
incorporation of visual expression, without any reservations, brings new perspectives and allows
for growth within the aspect of knowledge and healing into their consciousness. Incorporating
the process of visual creation into therapy gives children a safe place to express their emotional,
mental, and physical distress. Therefore, when different art techniques were incorporated to
assist with personality testing and the testing of behavior disorders in children, it opened a new
way of viewing the therapeutic process. The evolution of therapists recognizing the value in
creativity and allowing it to be used to help traumatized individuals demonstrates the powerful
ability that art has to encourage the healing of different types of trauma.
Art therapy can assist with chronic and acute trauma. Chronic trauma usually consists of
a traumatic moment happening repeatedly. For instance, witnessing abuse in one’s life, whether
it is physical, mental, or sexual, can all be forms of this type of trauma because of the recurring
nature of these events. In comparison, acute trauma is something that is not recurring, so it
usually happens as a single event. Witnessing a natural disaster or an act of terrorism are both
examples of trauma that can affect one’s mental state with one single event. During the horrific
events of the Sandy Hook Elementary school shooting, 9/11, and Hurricane Katrina, many
children and families suffered from immense pain and suffering. Hurricane Katrina survivors
were dealing with issues of displacement and grief because of the loss of their homes and
families, as well as having to process the unpredictable event (Looman, 2006). In all three cases

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of trauma, art therapy was used to help the traumatized children cope with the loss and pain they
were faced with by giving them an outlet that did not primarily rely on verbal communication.
The therapeutic process provided the children with the tools to express their feelings/memories
of their experiences, and for the art therapists to address the many issues that developed as a
result. For example, many of the children suffered from symptoms of anger, anxiety, depression,
obsessive thoughts, paralyzing fear, and the loss of control in their lives (Looman, 2006).
Malchiodi (1998; cited by Looman, 2006) notes that, “[t]he trauma of a natural disaster is a line
of demarcation distinguishing a time of relative safety and a time of distress, fear, anxiety, and
other concerns associated with experiencing the trauma” (p. 137). Experiencing disasters that
result in displacement can cause symptoms of PTSD to arise, which can hinder the child’s
thought process and development. Trauma can come in many different forms and is able to cause
a great deal of anger, anxiety, and depression as a result. Pifalo (2007) discusses the benefits of
art therapy when used with sexually abused children, such as assisting in the understanding of
the child’s traumatic narrative. Johnson (1987; cited by Pifalo, 2007) states:
Traumatized children and adults often suffer from intrusive thoughts regarding
their experiences and often relive the events as if they were continuingly
occurring in the present. The traumatic moment becomes encoded as an abnormal
form of memory that often breaks spontaneously into consciousness both as a
flashback during waking hours and as a nightmare during sleep. The traumatic
memories have a number of unusual qualities. They are not encoded like ordinary
memories into a linear narrative that can be easily assimilated into an ongoing life
story. Instead, they often remain as fragments that can emerge as a whole when
stimulated by similar sensory input known as triggers. It is likely that during times

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of overwhelming stimulation, as in the moments of child sexual abuse, the highly
developed cognitive system is bypassed and the event is recorded in a more
visual, photographic form. (p. 170)
Conveying this point is important because it highlights some of the ideas that allow art
therapy to be able to be differentiated from other forms of therapy, notably talk therapy. When
looking at trauma and how it impacts memory, it is apparent that addressing traumatic memories
in a visual way can benefit the organization of the traumatic narrative that can be difficult for the
child to understand. For example, acute trauma can cause confusion for the child because they
have difficulties understanding that these types of events will usually happen once in a life time.
By reformatting their understanding of the event they can proceed with their life and not be
anxiously waiting for the same traumatic incident to happen again.
As adults, we are able to understand that when a traumatic event happens in our lives it is
unlikely to happen again. These types of understandings about life are something that happens
with our development and knowledge of the world. In the case study, F, a young 10-year-old boy
who was hit by a car that drove through a restaurant window while he was eating, suffered from
physical injuries as well as PTSD (Mallay, 2002). Following the trauma, he began suffering from
hallucinations, lack of sleep, and feelings of anger and frustration. In this specific example, one
of his main struggles was dealing with the fear of the trauma happening again; in this case the
therapist used different drawing exercises to address his anger and fears that he was experiencing
as a result (Mallay, 2002).

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Using different exercises, such as “The Kinetic Family Drawing”3, the child can reformat
and acknowledge the experience that can help the child become more confident in understanding
how and why these types of incidents can happen. Specific types of trauma (e.g., domestic abuse,
natural disaster) have different trauma reactions (e.g., flashbacks, nightmares). The experience of
each trauma is indicative of how the therapist aids in alleviating the trauma reactions during
treatment.
Art therapy permits different ways of addressing the trauma while creating distance from
the intense affect that is associated with the disaster (Orr, 2007). In many cases, art therapy can
be more effective for children compared to traditional talk therapies because it can be easier for
children to express themselves visually. Pifalo (2007) states that:
Sexually abused children already have had their boundaries violated so they need the
structure, distance, and protection provided by art therapy. The art medium has the
capacity to create distance and contain powerful emotions. The art product reduces the
vulnerability of the child by empowering him or her to control the level of exposure with
which to cope at any given time. (p. 172)
The level of exposure that the child is faced with during the therapy sessions is partially
controlled by what the child feels that they want to articulate creatively. Thus, helping to reduce
their vulnerability and increase their sense of control. Being able to recognize how different
types of trauma are processed (e.g., sexual abuse) affects the way that the PTSD symptoms are
treated. The visual aspect of art therapy brings a visual/tactile way of gathering the information
that was experienced during the trauma.
3 The Kinetic Family Drawing is a diagnostic tool to determine the child’s self-concept. This is

determined by asking the child to draw a picture of their family while each member is doing an
activity. This allows the therapist to better understand their view of themselves within the family
dynamic.
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TRAUMA AND TREATMENT
There is a large range of different types of trauma that one can experience, and each type
of trauma, whether it is acute or chronic, can cause a variety of symptoms that can be unique to
each person. Children who have experienced either types of trauma can experience feelings of
loss, fear, anxiety, depression, displacement, confusion and anger, among others. With such a
large range of symptoms, it is important to be aware of how to properly treat them so the child is
not re-traumatized. Art therapy, if used correctly, can be altered to fit children individually to
best suit their experience and symptoms. With that, it is extremely important to be aware of the
issues that can be caused by inaccurately treating a child in therapy.
When dealing with children, it is essential to understand the process of working with
them so that you can help with their recovery in a constructive way. If the therapist is not aware
of the implications of incorrectly administering treatment to children, then it can exacerbate or
intensify the psychological trauma for them which can carry on throughout their lives. One of the
issues that Mallay (2002) discusses is that, “[i]t is important to view artwork within the client’s
context, and be aware of developmental, environmental and other influences, before any
impression is formed about a client’s expressive therapeutic output. Perceptions from artwork
should be verified with the client if possible so the evaluations are contextual” (p. 164). The
different developmental stages are exclusive to each child, and can affect their treatment and
how they are processing the trauma. If this issue is not taken into consideration, then the therapist
could develop an inaccurate perception of what the child has created. By being able to learn
about each individual child, it will ensure for a more accurate and effective therapeutic
experience.

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The relationship between the therapist and child can become quite strong and important
in the healing process. Often, this relationship is the only thing that is constant and stable within
their lives since the trauma, especially, as stated earlier, with refugees and cases where they have
been displaced from their homes and families. The use of the artwork develops rapport between
the client and therapist because the art work acts as an intermediary between them (Waller,
2006). In this process, transference can develop with children becoming attached to the
practitioner, or countertransference, where the practitioner treats the children as their own.
Transference can make the termination of the therapy a very complex moment for the child who
has a history of loss of attachment from someone. Termination that is handled properly can help
children manage the ability to enter and leave relationships in a way that does not disrupt their
lives with previous traumatic responses, and for this to occur, they should help the child prepare
for the time when treatment comes to an end (Meshcheryakova, 2012). If transference develops
between them and it is not resolved in an appropriate way, the children can develop problems
coping with the loss or change of something in their life. In contrast to transference they can also
go the opposite way and develop resistance towards the entire therapeutic experience. Sometimes
this can be a result of being influenced by the parents because they might be fearful that their
child is being exposed to the trauma again and being put into more distress because of the
therapy (Davis, 1989). Parents intuitively want to protect their children from sadness and pain, so
they are cautious when it comes to opening up the conversation about difficult situations that
have previously caused the child stress. Being aware of these potential situations, as well as
having a background in art, can bring a more thorough understanding of any issues that may
arise during the therapeutic process.

17

PROBLEMS WITH STUDIES
When reviewing the literature within the field of art therapy, and whether art therapy is
successful, the evidence is largely anecdotal rather than empirical, and as such there is little
objective evidence to support the claim that art therapy can effectively treat children who have
experienced trauma. Much of the literature focuses on case studies; case studies provide little
evidence about the outcomes that are associated with art therapy because of the issues that
researchers can encounter due to their subjective nature (Reynolds, 2000).
The studies reviewed examine children between the ages of 3-17 years suffering from
symptoms of PTSD caused by acute trauma. Most of the research involves case-studies, a
process in which the art therapist examines the progress of one client over time; if the child
improves, then the therapist concludes that art therapy caused the change. There are several
problems with this form of research. First, in case studies, the therapists are hardly unbiased
observers; they clearly have a vested interest in demonstrating the effectiveness of their
treatment procedures which can skew their perceptions and judgements. Second, case studies
lack internal validity. Internal validity is the confidence one has that it was the treatment (e.g., art
therapy), per se, and not some other uncontrolled factors or variables that could account for the
observed results (i.e., the reduction or elimination of symptoms).
Threats to internal validity operating in these case studies that preclude causal
conclusions include maturation, statistical regression to the mean, and history, among others.
Maturation reflects changes occurring over time (i.e., during treatment) due to normal
developmental process operating within the child; these normal emotional and cognitive changes,
rather than art therapy, could account for the observed improvements seen in case studies.
Statistical regression to the mean could be operating if the therapist selects a client on the basis

18

of extreme symptoms of PTSD/anxiety. In this instance, there is only one direction for client
movement (i.e., change in severity of symptoms) and that is towards the mean (i.e., the
symptoms become less severe). Again, this lack of internal validity would prevent one from
concluding that it was the process of art therapy that lead to the decrease or resolution of the
symptoms. History as a threat to internal validity refers to unanticipated events occurring during
the treatment period that could account for the observed improvement. For example, starting the
child on medication that targets the trauma symptoms would make it impossible to determine
whether the medication, or the art therapy, or a combination of both might be responsible for any
observed improvements.
There have been a limited number of studies that have moved beyond the case study
approach. A common research design is the one-group pretest-post-test design (see Figure 2). In
this approach, measures of the participants’ symptoms are obtained prior to the commencement
of art therapy, and then again at its conclusion; here the researcher looks for a decrease in the
number or severity of symptoms at post-treatment in comparison to pretreatment to demonstrate
that a change or improvement has occurred. This research design, however, is open to the same
criticisms levied against case studies; it does not eliminate competing explanations (e.g.,
maturation, statistical regression to the mean, history, etc.) for the observed improvement in
symptoms that these children might demonstrate following art therapy.

19

Pretreatment

Participants

measure
symptoms

Post-treatment

Art Therapy

meaure
symptoms

Figure 2.
To demonstrate that art therapy is an effective treatment method for children who have
experienced trauma, this field needs to incorporate well-designed empirical research methods
that have been employed to examine the effectiveness of other therapeutic approaches. In this
venture, researchers must employ objective, reliable, and valid measures of the trauma
symptoms. They must operationally define what constitutes “art therapy”; they must clearly
define how art therapy will be conducted and how many sessions will be provided. They must
also include comparison groups, usually a well-established treatment approach (sometimes
referred to as the treatment–as-usual, (TAU)), such as cognitive-behavioral treatment, for
example, and a wait-list control group. The well-established treatment approach would provide a
standard to which art therapy can be compared and would allow the researchers to answer the
question: Is art therapy as effective, more effective, or less effective, than the standard treatment
approach for children presenting with trauma symptoms? The inclusion of a wait-list control
group is vital to eliminate threats to internal validity; for example, it would control for changes
that occur simply through the passage of time (e.g., maturation). Random assignment of
participants to the treatment conditions is one final element that must be included in any welldesigned study. Random assignment is a crucial control procedure in which each participant has
an equal opportunity to be assigned to any one of the proposed groups (the art therapy group, the

20

treatment as usual group, and the wait-list control group). This key procedure means that the
groups would be functionally equivalent at the outset of the study, prior to the introduction of the
treatments. If we are confident that the groups are equivalent at the commencement of the study
(i.e., no significant differences on pretreatment measures or any other individual differences),
then we are in a much stronger position to conclude that any changes in trauma symptoms were
caused by of the treatment conditions and not to uncontrolled factors such as selection
differences that would provide competing explanations for the observed findings; this would
allow us to more confidently conclude that art therapy, and no other competing variables, was
solely responsible for reduction or elimination of the trauma symptoms.
Some of the studies do not clarify the goals and methods that were employed during the
therapy, which would benefit future art therapists’ knowledge of what is most effective to treat
children of different ages, gender, culture and trauma. In the absence of well-designed studies,
we cannot conclude, at this time, the validity and significance that art therapy effectively
resolves trauma based problems with children.

FUTURE DEVELOPMENT
After reviewing the literature on art therapy, it is apparent that the studies lack reliability
and validity. They are unable to validate the benefits of art therapy because the studies do not
demonstrate that it is specifically art therapy that is giving the patients relief from their mental
symptoms. Most studies appear to be lacking statistically sufficient evidence to successfully
support the field of art therapy. Pifalo’s (2007) study looked at the use of art therapy with
sexually abused children and adolescents. The children were divided into three groups depending
on their age, and they participated in art therapy sessions once a week for 10 weeks. Using a

21

variety of mediums (drawing, painting, and clay), he was able to see an overall reduction in
clinical symptomatology across all scales when comparing the pretest and posttest scores from
the Trauma Symptom Checklist for Children (TSCC) (Pifalo, 2007). Even though there was a
reduction in symptoms, the study had limitations due to the small sample size. When a study is
conducted with a small sample size it causes issues because it is not efficient and does not
control for Type I (false positive) or Type II (false negative) errors. A Type I error is made when
we conclude that the treatment was effective even though the data is not actually present within
the study and a Type II error is reporting that no effect has occurred within the study and missing
the accurate data from the study (Ioannidis, 2013). To be able to provide appropriate data for this
population, Pifalo (2007) suggests using a more rigorous research design with a larger sample
size and incorporating a control group that has no history of sexual abuse. With stronger designs
it will result in clearer results of how art therapy can better support children affected by trauma.
An example of a future potential study that could be conducted to accurately demonstrate
the effectiveness of art therapy is shown in Figure 3 (below). The study would begin by
gathering a large sample of children and randomly assigning them to one of three different
groups. By randomly assigning them to one of three groups, it allows for each child to have an
equal chance to be put into any one of the groups. Children have differences from one another
and random assignment allows for individual differences to be equally distributed amongst the
groups, and eliminates the risk of selection bias within the study. Each group would then
participate in either art therapy sessions, cognitive behavior therapy, or no therapy at all (waitlist
control group). The sample would consist of children who all have similar anxiety symptoms and
they would all be tested for their level of anxiety before beginning treatment. Treatment could
last for 4 months, for example, while the children attend a session once a week. After treatment

22

has been completed they would then be tested for their anxiety symptoms again in the post-test
period. The pre-test and post-test results of each group would be compared to one another; their
results would be evaluated on whether their symptoms were reduced, remained the same, or
increased. A well designed controlled experimental design, would demonstrate that the
independent variable (treatment: Art Therapy or CBT) was the cause of the results, and no
outside factors contributed to the reduction of symptoms. Ideally, they would then be tested
again for a follow-up after some time has passed to see if the observed improvement continued
or changed in any way. Often this can create some issues with studies because conducting
follow-up studies take time and people can drop out of studies, or move away. For example, Rita
Rosner’s study on interventions for bereaved children and adolescents, discusses the threats that
can accompany controlled studies, and a common issue identified is that participants drop out
before the study has finished (2010). Dropout rates can be caused by the study being too time
consuming and the participants losing interest in the study, or the participants moving away and
are no longer available. Even though there could be potential issues with the follow-up treatment,
Figure 3 allows you to create a controlled study, which would then permit you to be able to see if
the anxiety symptoms decreased as a result of art therapy on its own, compared to having other
contributing factors. There was a quantitative systematic review that used a similar research
approach comparing art therapy to other therapeutic approaches. The study had some limitations,
but the results of the study showed that art therapy had statistically significant positive effects
(Lesley, 2015).

23

Figure 3.
CONCLUSION
In conclusion, there needs to be further exploration regarding the effectiveness of art
therapy with children expressing PTSD symptoms as a result of acute trauma. It is apparent that
there needs to be more research examining the benefits and outcomes of using art therapy to help
with the healing process of trauma symptoms. Yet, what is believed to be beneficial about art
therapy is the ability to access trauma memories with the use of different artistic mediums, and
not relying solely on verbal communication. The ability to use visual methods to access
information is especially useful when dealing with children because they do not have the ability
to articulate their feelings exactly as they might be experiencing them. In previous cases it was
observed by Pifalo (2007) that, “[t]he child-friendly atmosphere of an art therapy environment
and the presence of colorful art materials may help in reassuring children that this experience
will be different from forensic interviews, medical exams, or encounters with law enforcement”

24

(p. 171). There remains something to be said about the relationship of art and psychology and its
ability to aid with the healing of trauma victims. These qualities that are apparent in art therapy
are what assists with overcoming the different types of trauma and the symptoms that accompany
them. The unique qualities that art therapy encapsulates is what gives it the ability to not only
help the child in the present, but to also give them the tools to be able to cope in difficult
situations in the most effective way possible.

25

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