Donna H. Kaiser

Establishing a Research Agenda for Art Therapy: A Delphi Study

Abstract Art therapy in the United States is a young profession that would benefit from an identified research agenda to marshal resources more effectively to address gaps in the knowledge base. This article describes a Delphi study of U.S. art therapy researchers who were surveyed on research priorities for the profession. The research panelists were asked to identify the most important areas of investigation, research questions, methods, and populations or conditions that should be studied. The survey results presented may be used to construct a research agenda for the field so that priorities can be addressed in a more unified, strategic way.

Assessing Attachment with the Bird's Nest Drawing: A Review of the Research

The Birds Nest Drawing (Kaiser, 1996) is an art-based assessment that was developed to assess attachment security. In the past 10 years, several studies have further tested this art therapy directive with various populations. This paper briefly reviews attachment theory, delineates the significant findings from five of the studies, and provides information from four others. Implications for clinical use of the Birds Nest Drawing and need for future research are discussed.

Indicators of Familial Alcoholism in Children's Kinetic Family Drawings

The impact of parental alcoholism on children has long been an interest for clinicians, educators, and the general public. Children of alcoholics are at risk for developing numerous difficulties, including low self-esteem, high impulsivity and hyperactivity, external locus of control, and greater incidence of illness, accidents, somitization, conduct disorder and academic problems. The goal of this study was to attempt to delineate indicators in childrens depictions of family that would suggest the presence of parental alcoholism. Kinetic Family Drawings (KFD) from two groups of children, those with parents identified with alcoholism and those with no known parental alcoholism, were collected. Statistical analysis revealed two of the six items of the evaluation scale—depiction of isolation of self and isolation of other members of the family—were significantly higher in the group of children with substance-abusing parents (t (32) = -3.83, p < .05, and t (32) = -4.25, p < .05, respectively). Implications of these findings for art therapy practice and research are discussed.

What Should Be Published in Art Therapy? What Should Art Therapists Write About?

The call for research demonstrating the efficacy and effectiveness of art therapy has been reiterated over several decades of our profession’s existence (for example, see Gantt, 1998; Kapitan, 2012). This past year, as I have gained experience in my role as editor, I have increasingly recognized a need to publish more practice articles to complement and inform the growing body of research in our profession. Over the past 10 years the number of research articles in this publication has increased dramatically. At the same time, we have seen fewer and fewer of the kinds of case studies frequently published in the earlier literature. Although case studies, as a type of praxis article, can shed light on how individual art therapists work, what is needed now is literature detailing what practicing art therapists do that includes how they conceptualize their day-today work providing art therapy services. In addition to providing valuable information for other practicing art therapists, articles like this also help inform researchers in their development of study designs. Documenting the practice of art therapy as it is performed today, including what art therapists are observing with clients and the concerns they are challenged with daily, will provide researchers with valuable information. Linking practice, research, and theory is increasingly essential to adequately develop our body of literature and all aspects of practice in the field. This issue features two practice articles about art therapy with specific populations that have only occasionally appeared in this journal. Aimee O’Neill and Hilary Moss, in their very interesting work in Ireland, describe a community art therapy group for those with chronic pain, an area that has been explored more in music therapy—Loewy’s (1997) Music Therapy and Pediatric Pain was published almost 20 years ago and research on music therapy and pain is robust (for example, see Bradt et al., 2014). Yet, literature on art therapy and pain is scant. The work of O’Neill and Moss can potentially spur development of similar programs elsewhere and stimulate future art therapy research on this important topic. The time is ripe for this kind of investigation. In the second practice article, Jessica Masino Drass presents a Dialectical Behavior Therapy (DBT) framework that informs her art therapy work with individuals with Borderline Personality Disorder. Although there seem to have been and still probably are many art therapists working with individuals with similar serious treatment concerns such as emotion dysregulation, disturbance of identity, and suicidality, there have been only a few peer-reviewed publications on this topic lately (Heckwolf, Bergland, & Mouratidis, 2014; Huckvale & Learmonth, 2009) and these do not provide specific practice knowledge grounded in a conceptual framework that art therapists will find worthwhile. It is instructive to learn about Drass’ work and how she has incorporated constructs of DBT into art therapy that is informed by contemporary theory and practice from other mental health disciplines. In addition to these instructive articles about practice, four timely and notable research reports provide enlightening results critical to how art therapists practice. Mattye Laurer and Renee van der Vennet present results from a replication of the effects of making art versus sorting of art prints done with a sample of individuals in outpatient treatment for substance abuse. Taking a cue from Bell and Robbins’s (2007) study design used with undergraduates, they found similar reductions in anxiety and negative mood with individuals with significant clinical symptoms. Although the intervention was a free art task, not specifically art therapy, it still holds implications for art therapy practice with clients who need help with improving mood and decreasing anxiety. Elizabeth R. Kimport and Elizabeth Hartzell report a study on the use of clay with individuals in an inpatient setting who have major psychiatric diagnoses. Even though this is a population identified as needing attention in research (Kaiser & Deaver, 2013) there is a dearth of systematic investigation in this area. Their preliminary evidence supports using a structured clay intervention to help with anxiety reduction and adds to previous work on the use of clay in art therapy. Clearly more research is needed on the use of various art media with different populations and it is useful to see investigations on the use of threedimensional and tactile materials such as clay. In a study with individuals who have posttraumatic stress disorder (PTSD) related to a history of childhood sexual abuse, Carol-Lynne J. Becker, a psychologist with the Veterans’ Administration, finds that integrating art interventions with exposure treatment for PTSD appears to enhance reduction of depression and the symptoms associated with PTSD. Though the sample was quite small the results suggest the need for more study in this area especially with the sustained reductions at one month in anger,

Needed: Art Therapy Knowledge and Practice Wisdom to Inform Research

More than ever, the Journal needs articles on art therapy services and programs—knowledge and practice wisdom—a literature on what art therapists are doing in their everyday work. This is necessary not only to disseminate knowledge to other art therapists but also so researchers are alerted to what is critical to study in the context of services they deliver to clients. The content of this issue illustrates these points. This issue of Art Therapy begins with two articles that describe noteworthy art therapy programs—this is exciting to see as practitioners and students often search for information on how art therapy is practiced with specific populations. The first article describes a program for individuals with various physical and neurological disabilities, for which there is little information in the literature. The second, a research article on a group art therapy program for parents, explains the program rationale and interventions providing valuable knowledge to readers who assist parents in helping their children who experience difficulties in educational settings. Next, two research articles, one on individuals’ responses to using different art media and how that relates to attachment and the second on projective drawings, offer thought-provoking conclusions that accent the importance of thinking deeply about the impact of attachment experiences on a person’s art therapy experience and an often-neglected source of loss for many people, the death of a pet. These are followed by a viewpoint advocating for an approach to research that aggregates art therapy practice knowledge, and a brief research report on a study about coloring. This issue leads with a detailed description of an art therapy program for individuals with various kinds of physical and neurological disabilities developed by a group of art therapists in Italy. Luzzatto, Bruno, Cosco, Del Curatolo, Frigenti, and Macchioni explain their framework for developing the program providing essential information on how they conceptualize art therapy to support specific areas for their clients and what they think is beneficial about their approach. The artwork from participants in the program, many of whom had moderate to severe disabilities, is provided and illustrates the kinds of visual images, both moving and provocative, that resulted. There is very little in the literature on art therapy services for individuals with disabilities so this information will be valuable to those art therapists who work with similar persons. The authors also provide material on their program evaluation that orients the reader on how to think about what outcomes are desirable for those with these kinds of disabilities. This is a fine example of the kinds of practice literature that are needed—bravo! Hong Kong art therapists, Lee and Peng, contribute an article on their study of the benefits of group art therapy designed for mothers of children with special educational needs. They explain the justifications for the interventions they use and for the use of multiple kinds of evaluation to discern the ways in which this art therapy program can be helpful to mothers experiencing parenting stress and who want to help their children manage emotional and social challenges that arise from difficulties related to learning. Because the researchers used weekly qualitative in-person evaluations with the mothers they were able to discern some of the positive changes that resulted week-by-week that did not show statistical significance in standardized measures. This is critical because standard measures have their limitations and voices of consumers of art therapy can point to what researchers need to pay closer attention to in future research. Considering the practical significance of findings about the benefit of art therapy services is a step toward understanding how to better help clients as well as how to enhance research designs that evaluate art therapy going forward. Snir, Regev, and Shaashua, art therapy researchers in Israel, contribute an interesting study on individuals’ responses to using one of five different art materials in terms of their scores on the attachment dimensions of avoidance and anxiety. The field of art therapy needs to expand research on responses to art materials and this is an unexpected approach in terms of relating responses to attachment dimensions rather than what is usually encountered: measuring reduction of symptoms such as anxiety, evaluating improvement in areas such as well-being, or studying responses to art media by population group or condition. The findings of this preliminary research suggest that there are associations between attachment anxiety and an individual’s negative response to particular art materials, an intriguing result that should be investigated further and that offers data useful for practice. This is a domain of research, individuals’ responses to art media, that the profession of art therapy needs to seriously consider a priority so that specificity about materials and processes of art therapy are delineated in a way that clinicians can use to create more effective interventions.

Why Art Therapists Should Care About Peer Review

Before the editorial, I want to convey the immeasurable loss the community of art therapists, especially in this country, has experienced with the death of Harriet Wadeson this past January. Her impact on generations of art therapists is incalculable; her influence on the profession is vast though for the most part not visible to the casual observer. Those who knew Harriet, though, are well aware of the range and depth of her contributions. Judith Rubin and Joanne Ramseyer contribute lovely tributes that convey the essence of this bright and energetic art therapy legend. And, Harriet’s stunning cover image of a dragonfly brings to mind the apt symbolism of this magical insect. The dragonfly was viewed with respect and as having protecting powers by North American Indians; it can move quickly by navigating the realm of the heavens through flight but it hatches from still waters before becoming airborne. Her luminous image of this exquisite creature aptly captures her essence—we will all miss her.

What Do Structural Racism and Oppression Have to Do With Scholarship, Research, and Practice in Art Therapy?

The publication of the third issue of the Journal this year, a special issue on Ethics, Law, and Cultural Competence in Art Therapy, has kindled a lot of interest, both positive and negative. The call for papers for that issue was disseminated in August 2016, in response to questions raised by the passage of Tennessee HB 1840 allowing counselors to decline services to clients whose desired goals of therapy or their behaviors, are in conflict with counselors’ beliefs. Since that call for papers, the landscape of daily life has changed for many art therapists, mental health clients, and art therapy students. The unexpected election of Donald Trump, the policies of the Trump/Pence administration, and the decision of the American Art Therapy Association (AATA) to align with Karen Pence and her initiative Healing with the HeART have negatively impacted many providers of art therapy and probably hurt clients they work with, and changed how people outside the field view art therapy. Changes to U.S. immigration policies, the hateful rhetoric of the administration’s alt-right allies, and hostility to LGBTQIA rights have direct negative effects on the mental health of traditionally marginalized individuals. These events have also brought to the forefront the reality of whiteness and white privilege in the individual, social, political, and professional arenas in which art therapists operate. Compared to the rest of society, the profession of art therapy has been and still is primarily constituted of an unusually high percentage of white people (Elkins & Deaver, 2015). This is problematic because as Carr (2016) has noted,

Thirty-Two Years and Counting

It is both a daunting and an exhilarating experience to take on the editorship of Art Therapy in its 32nd year of publication. Daunting because I follow so many exemplary editors who have indelibly made remarkable contributions. Exhilarating because the quality of submissions reflects a level of engagement in research endeavors never before seen in our profession. Previous editors Gary Barlow, Linda Gantt, Cathy Malchiodi, Francis Kaplan, Frances Anderson, and Lynn Kapitan have all made worthy contributions that have made this journal the international scholarly publication it is recognized as today. Lynn Kapitan deserves exceptional praise for her management and coordination of multiple transitions during her tenure. These have brought Art Therapy into the 21st century with its own website, searchable online content of all back issues, a web-based submission and review system, inclusion of the Journal in the EbscoHost database that allows worldwide dissemination of art therapy scholarship, and the successful transition to publisher Taylor & Francis with its international presence and ability to market the Journal more strategically. This is an exciting time for the Journal and for our profession. There is an increasing international awareness of the value and benefit of art therapy services, programs to educate and train art therapists are growing in size and scope around the world, and research about art therapy is rapidly increasing. As the official journal of the American Art Therapy Association, Art Therapy has an important role to play in supporting and promoting these trends. Namely, the Journal can continue serving as the premier destination for publication of research on art therapy. At this juncture, we encourage the submission of more practice-based manuscripts to expand the dialogue among art therapy practitioners and to bring knowledge about their valuable work with targeted populations into the body of literature of the profession. Featuring both practice and research forges a necessary link between the two that enriches both. The articles in this issue fulfill the aims of expanding research with implications for working with targeted populations that have been identified by art therapy researchers as important to study (Kaiser & Deaver, 2013). The first, “Art Making as a Mental Health Recovery Tool for Change and Coping” by Theresa Van Lith, is a qualitative study of what is one of the most critical topics of study for art therapy—what consumers with persistent mental health concerns experience as a result of participation in art therapy. Strengths of the study are notable for qualitative research in art therapy: the participation of real-life consumers of art therapy, extensive researcher engagement with 12 participants over the course of a year, interview focus on reflections about the artwork created during the study, and participant validation of themes that evolved during data analysis. Van Lith concluded that for these individuals art therapy was both a mechanism of change for achieving a connection with an authentic self and also a useful tool for day-to-day coping and problem solving. I find it intriguing that the theme involving connecting with the inner self, which participants described as concurrent with immersion in the creative process, is consistent with recent literature that emphasizes that “owning your self” (van der Kolk, 2014, p. 203) is a principal development that occurs during trauma recovery. It is fascinating that what consumers of art therapy identify as curative echoes what experts judge as critical for therapeutic change. In the next article, “Recognizing Emotions: Testing an Intervention for Children With Autism Spectrum Disorders,” Donna Abely Richard, William More, and Stephen P. Joy describe their research on a three-dimensional art therapy intervention designed to facilitate recognition of facial emotions and thus promote the ability for social interaction. Further, the authors provide preliminary findings regarding the intervention’s effectiveness with young children with autism spectrum disorder. Providing services for those with autism spectrum disorder is a growing area of practice in art therapy and our literature needs both practice-based literature and research to investigate this topic in more depth. Although this pilot study did not show any statistical significance between the experimental and control groups, effect sizes showed a small difference in improvement for the experimental group, suggesting that the intervention has promise. Coauthors Jennifer E. Drake and Adeline Hodge contribute a pilot study that builds on previous research in psychology with implications for art therapy: “Drawing Versus Writing: The Role of Preference in Regulating Short-Term Affect.” Most art therapists are familiar with the work of Pennebaker and colleagues (see, e.g., Pennebaker & Francis, 1996) on the benefits of expressive writing. Since his work, others have compared writing to drawing to test their comparative benefits. Pizarro (2004) demonstrated that following a negative mood induction, drawing a still life was more effective at improving mood in the short-term than either drawing or writing about a negative mood. Others have shown that short-term mood is improved more effectively when the emotion regulation goal is distraction rather than

Introduction to the Issue

Don Jones, artist and art therapist, passed away this January. He was an early president of the American Art Therapy Association and is considered to be one of its founders. This wise and inspirational man has influenced generations of art therapists in ways that most of us do not recognize today. A moving tribute to Don by Bruce and Catherine Moon in this issue offers a sense of his impact on the lives of numerous generations of art therapists. He will be sorely missed even as his work is carried forward by those he has mentored over decades. Also in this issue are several thought-provoking articles about art therapy research and practice. The first is a randomized controlled trial by Nora E. Stinley, Deborah O. Norris, and Pamela S. Hinds on the use of mandalas created on an iPad to manage the pain and anxiety that pediatric patients experience during needle sticks. Their results demonstrate that the intervention was feasible, the treatment group demonstrated significantly fewer stress behaviors, and anxiety decreased for children who created mandalas. This represents important preliminary evidence for the benefits of art making for managing acute pain that is a noteworthy contribution to the body of knowledge on art therapy. Next, an art intervention for improving the behavior of a child with autism using a single-case experimental design is contributed by Nai-Cheng Kuo and Joshua B. Plavnick. Art therapists working with this population may be inspired by this strategy that can be helpful for increasing the involvement of children with autism in large-group instructional settings. The one-on-one art task instruction the authors describe occurred prior to group instruction and produced decreased levels of off-task behavior when compared to baseline conditions. The results support previous antecedent-based interventions by demonstrating the effectiveness of an individualized art task as a procedure for reducing problem behavior. Next, the 2013 survey of American Art Therapy Association members by David E. Elkins and Sarah P. Deaver provides current data on demographics and art therapy practice as compared with previous member surveys over a span of 15 years. Although many variables examined over this time have not changed substantially, the authors found certain trends that are important for the association and educators to consider for meeting future challenges in the workplace. Interesting trends over time are seen in increased salaries and work hours, more members with various state licenses, more “art therapist” job titles, and slightly more doctoral and postgraduate degrees. Michal Bat Or presents an exploratory qualitative study of mothers’ experiences of separateness representations as portrayed in clay sculptures of themselves with their children. Using the sculptures and then interviews about the mothers’ experiences of creating the form and the meaning of the work, the researcher compared this data with a continuum constructed to indicate low to high separateness in terms of autonomy, grounding, and the mothers’ awareness of separateness from their children and from their own mothers. Bat Or points to the value of this task in that discussing it with the therapist can help develop greater awareness and promote a mother’s increased ability to recognize separateness experiences. The first brief report in this issue, by Caroline Peterson, describes a new and innovative mindfulness-based art therapy program: “Walkabout: Looking In, Looking Out.” She details the work she has been doing in palliative care that builds upon her practice and research on mindfulness-based art therapy. Readers will find her chronicle of the development of this program compelling and useful both in its framework integrating walkabouts and art therapy and use of art media. In the second brief report Tami Gavron and Ofra Mayseless describe their research on the Joint Painting Procedure (JPP) that explores assessing qualities of the relationship between parents and children as reported by mothers. Their description of the JPP will be of interest to art therapists who work with parents and children together as it provides a framework for evaluating formal elements of the painting and the behaviors of parent and child during the JPP assessment. They found moderate associations between three of their scales and each partner’s perception of the relationship, mothers’ perceptions of their psychological boundaries with their children, and mothers’ reports of their children’s home and school adjustment. Gavron and Mayseless emphasize the clinical usefulness of their preliminary findings. Finally, a viewpoint by Girija Kaimal and Carol Ann L. Blank affirms the value of conducting program evaluation in the arts therapies for both researchers and clinicians. The authors highlight the fact that program evaluation research is a way for arts therapists to undertake systematic study of their services, to access client perspectives that can help improve future services, and to document outcomes that may be potentially valuable for obtaining grant funds. They urge arts therapists to consider partnering with academicians to conduct program evaluation and then describe three examples of such partnership projects.

Assessment in Art Therapy

I was excited by the opportunity to review this book because I have given a great deal of thought about what and how to teach students about art therapy assessment, and I have been curious about the ways in which art therapists use assessment in their daily practice. I also have devoted much of my attention professionally to the development of an art therapy assessment; thus, this book has personal and professional significance to me. Gilroy, Tipple, and Brown are experienced art therapists who teach and practice in the United Kingdom. They have attempted to describe the varied contemporary practices of art therapy assessment in three main sections in this book: “Sitting Beside,” “Snapshots From the Field,” and “A More Distant Calculation.” The first section sets out to introduce “different aspects of context, relationship and art making” (p. 5) and contains material that seems primarily to reflect the British art therapy approach (althoughU.S. art therapists Henley and McNiff are included). The second section contains short practice-based reports by both U.S. and British art therapists that describe how they conduct assessments. The final section has five chapters that describe the development and use of art-based assessments, written by art therapists from both the United States and the United Kingdom. “Sitting beside” refers to an assessment point of view that primarily informs British art therapists. Based in psychodynamic theory, this view is aimed most often at determining a client’s ability to engage with art in a therapeutic context, and is directed toward formulating the client’s concerns. In this section of the book, the emphasis is on empathy and subjectivity. In contrast “a more distant calculation” is the phrase the authors chose to characterize a perspective on art therapy assessment that they seem to suggest is more typical of the approach in theUnited States. This approach is considered objective and aimed toward making a diagnosis. My response to this distinction ranged from being pleased that the authors positioned assessment in this way to promote understanding of these differences, to shock at such a dichotomous way of looking at assessment approaches. My reaction led me to wonder how art therapists in other countries might read this account and where they might place themselves in these very disparate categories. As a U.S. art therapist, I learned art therapy assessment from the “distance” approach—not a term I find palatable. With experience, however, I moved away from such a stance and use first contact with clients for assessment by inviting them to look at their images with me. Together we observe and discover what the images might mean to them. Assessment became the initial step in getting to know the person, understanding the individual through a shared construction of the meaning of imagery created, and using the assessment artwork as an opening to the therapeutic conversation. The authors of Assessment in Art Therapy initially appear to privilege “sitting beside” over “more distant calculation,” but also seem to support a more scientific approach. As Gilroy writes in the first chapter “What’s best for whom?” these two views are manifested in “clinical assessment, one suggesting an empathic response and the other a more distant calculation” (p. 11). She presents the tension between these subjective and objective perspectives and implies a need to acknowledge the ends of the spectrum while also considering the need for an evidence base for art therapy assessment. Gilroy identifies the need for sound psychometrics that can be used to make recommendations about practice and policy. She explains that there is a lack of assessment research evidence in the UK at present, and also that art therapists possess much tacit knowledge based on their clinical experience. She challenges British art therapists to convey this knowledge explicitly and clearly so that it can be adequately studied. This first chapter is nicely organized and the author supplements her narrative with boxes that summarize key points. I found the most interesting information contained in the summary box on “Suitability for art therapy: individual, group, open studio” (p. 22). Art therapists in the UK must determine who is suitable for art therapy because the National Health Service limits the number of clients that can use the services. The middle section of the book, “Snapshots From the Field,” offers several short reports in which art therapists describe what they actually do in their assessments. These range from Etherington’s description of assessment with a boy with autism in her private practice to Liebmann’s account of her approach to assessing adults who are receiving community mental health services to determine their suitability for art therapy. I particularly like certain individual chapters: Gantt’s work stands out in terms of cogently contrasting the art therapy and psychology systems of assessment and Betts’s well-argued challenge for art therapy is to expand assessment