The psychopathology of everyday art: a quantitative Study - World ...

The psychopathology of everyday art: 

a quantitative study 

by 

Suzanne Hacking 

November 1999 

A dissertation submitted 

in fulfilment for the degree of 

Doctor of Philosophy 

Department of Psychiatry 

School of Postgraduate Medicine 

University of Keele 

i

Abstract 

Analysis of psychiatric artwork has been largely based on its content or verbal reports of its meaning. This 

thesis presents an alternative approach to psychopathology of paintings, in the development of a new 

instrument, the Descriptive Assessment for Psychiatric Artwork (DAPA). This thesis reports the 

steps taken to validate the DAPA: through examination of the literature, initial study, reliability study and 

the main comparison of 86 patients with disabling psychiatric disorder and controls. 

The surface distribution of 12 operationally defined characteristics of paintings was recorded: 10 

formal (red, yellow, green, brown, blue, black, intensity, painted and drawn line, and space covered by 

media) and 2 content characteristics (subjective emotional tone and dominant form) using a grid of twenty 

rectangles placed over the picture. These scores were collapsed to produce average scores for each painting. 

All paintings within subject were also collapsed to produce a subject profile of 12 continuous scales. 

Reliability assessment between six independent raters and the author were excellent. Intraclass 

correlations were 0.86-0.99 and Cronbach's alpha 0.91-0.99. 

Design: Subjects were classified using ICD-10 diagnostic classifications for research (depression, 

schizophrenia, personality disorder, substance abuse). 1-way ANOVAs were performed with post-hoc 

comparisons using the Duncan procedure. Discriminant analysis predicted patient/control classification 

and controlled interactions between variables. 

Results: ANOVA showed highly significant differences (p

Table of Contents 

Page Number 

Chapter One: Introduction 

1. Organisation of thesis 

1 

2. The argument for another art assessment 2 

Chapter Two: Literature Review 

1. Is there a way through the jungle? What kind of literature is 

relevant to this study? 

Literature search methods and exclusion criteria 30 

Impressionistic and theoretical studies 35 

Artists: Are they special cases? 42 

2. Research Studies 

Case and series studies 47 

Expression of feelings 49 

Changes or signs in content or form of artwork 54 

Therapeutic Relationship 63 

Summary of case studies 65 

Controlled studies 69 

Analysis 71 

Summary 87 

Validity analysis of the literature 88 

Summary and conclusion 93 

Reliability analysis of the literature 95 

Summary of reliability study 136 

3. Conclusion and Summary 141 

Chapter Three: Positive Thinking: What are the common 

psychiatric characteristics of paintings? 

Meta Analysis of reliable studies identified by the literature 143 

Conclusion for meta analysis 158 

Summary of findings from the common results 158 

Chapter Four: The Descriptive Assessment for Psychiatric Art 

The ideal characteristics for a new test: Development of the DAPA 162 

The DAPA test 

Illustration of scoring procedure and rating guide 171-2 

Methods Section 173 

1. The Main Study 173 

Sample 174 

Instruments 178 

iv

Analyses 182 

Procedures 189 

2. Reliability Study 193 

3. Study 1 206 

Chapter Five: Results Section 

1. Results of the statistical tests 

Preparation of the data 217 

Comparison of groups 

221 

2. Interpretation of the figures 

Specific differences from the ANOVA 223 

Discriminant analysis 236 

3. Subordinate analyses 241 

Chapter Six: Discussion 245 

1. Expectations and anomalies 

Colour 250 

Structure 262 

Conclusion and summary from discussion of the results 273 

2. Relation of results from Study 1 to Study 2 278 

3. Discriminatory power between controls and patients 284 

(i) Is the DAPA a better assessment than the other tests 

reviewed in Chapter 2? 284 

(ii) Which variables discriminate between patients and 

controls? 286 

Strengths and weaknesses of the study 288 

Effectiveness of the DAPA 291 

Chapter Seven: Conclusion 293 

Is the DAPA better than other art assessments? 299 

Where do we go from here? 300 

The future for measures of Psychopathology 302 

Appendices 

Descriptions of terms from analyses of the literature Appendix 

1 

Tables of data relating to the Chapters 2 and 5 Appendix 2 

Table of authorities Appendix 3 

Development of the instrument (the DAPA) Appendix 4 

Permission and informed consent for experiments with patients Appendix 5 

Bibliography 

v

List of Illustrations, Figures and Tables 

Chapter 2. 

Impressionistic studies 

Table 1: Analysis of 253 impressionistic and theoretical papers by diagnoses 

according to the theory of art value to therapy. 37 

Table 2a: Environmental description for 253 impressionistic and theoretical papers 

according to explanation of art therapeutic value. 39 

Table 2b: Commonly claimed benefits for 253 impressionistic and theoretical papers 

according to explanation of art therapeutic value. 40 

Table 3: Summaries of impressionistic studies of or about artists. Appendix 2 

Case studies 

Table 1: Diagnostic groups for case studies by levels of benefit where the primary 

purpose of artmaking was the expression of feelings. 

51 

Table 2: Descriptions of 67 case studies showing consistency of the research by 

levels of benefit from expression of feelings. 52 

Table 3: Chi square results for association between method of study, form of 

expression and benefits for 67 studies which claimed 'expression of 

feelings' as the main benefit for the use of art with psychiatric patients. 

53 

Table 4: Summaries of papers reporting changes or signs in the theme/content of 

the artwork. Appendix 2 

Table 5: Summaries of papers reporting general signs of psychiatric disturbance. 

Appendix 2 

Table 6: Summaries of papers reporting changes or signs in the form of the 

artwork. Appendix 2 

Table 7: Summaries of papers reporting the most important feature of art therapy 

was the therapeutic relationship. Appendix 2 

Table 8: Summaries of papers reporting behaviour changes for case studies. 

Appendix 2 

Contingency tables for Chi square calculation to indicate association between method of 

study, form of expression and benefits for categorised commonalities of the 67 

'expression of feelings as main benefit for art therapy' studies: 

crosstabulation 1: Orientation by method of study. Appendix 2 

crosstabulation 2: Orientation by form of expression. Appendix 2 

crosstabulation 3: Orientation by benefit. Appendix 2 

crosstabulation 4: Method of study by benefit. Appendix 2 

crosstabulation 5: Form of expression by method of study. Appendix 2 

crosstabulation 6: Form of expression by benefit. Appendix 2 

Controlled Studies 

vi

Table 1: Descriptive statistics for 51 controlled studies. 73 

Table 2: Frequency and percentage of demographic variables for 51 

controlled studies by levels of result. 73 

Table 3a: Diagnostic groups 1-4. Frequency and percentage for 

whole study. 75 

Table 3b: Diagnostic group 1. Frequency and percentage by levels of result. 75 

Table 4: t-tests performed to compare the means of ordinal demographic 

variables by year of study. 76 

Table 5: Non-parametric tests performed to compare the ranks of categorical study 

variables by year of study. 76 

Table 6: Significant variables identified from the Mann-Whitney non-parametric 

association test. Frequency and percentage for Group 1, early studies 

1973-1977; Group 2, late studies 1992-1996. Changes in methods and 

measurements. 78 

Table 7: Frequency and percentage of test variables for whole sample of 

controlled studies by results. 79 

Table 8a: Analysis of variance compared 5 demographic variables 

by 7 study factors. 83 

Table 8b: Analysis of variance performed to compare the means of 5 

ordinal demographic variables by 7 study factors. 84 

Table 9: Frequency and percentage for measurement form by no. of 

criterion measures. 85 

Table 10: Frequency and percentage for test derivation and results by 

no. of judges. 86 

Validity Analysis 

Table 1: Frequency and percentage of criterion variables for 70 studies 

by result. 91 

Table 2: Diagnostic groups for 70 studies with criterion measures. Frequency 

and percentage by levels of result. 92 

Table 3: Non parametric test to show differences between study factors for 

findings of association and non-association of art-test with criterion 

measure. Mann-Whitney U-Wilcoxian Rank Sum Test. 

92 

Reliability Analysis 

Table 1: Reliability statistics and discriminating variables for category of 

theme. 105 


content. 107 

Table 3: Reliability statistics and discriminating variables for category of body 

detail in picture. 110 


vii

quality. 113 


line quality. 115 


shape. 118 


colour. 120 


reality 123 


space. 126 

Table 10: Reliability statistics and discriminating variables for category of energy. 

128 

Table 11: Reliability statistics and discriminating variables for category of pictorial 

detail. 130 


complexity. 132 


control. 

133 


composition. 134 

Chapter 3 

Meta Analysis 

Table 1: Results of the aggregated combination of all variables from tabulated areas 

for patients and any type of control 155 

Table 2: All variables for 11 studies from the tabulated 15 different areas of 

drawing measurement. 155 

Table 3: Aggregated results for patients/all controls by form or content 

variables. 157 

Chapter 4 

Development of the DAPA 

Table 1: The simplified positive findings from case and control studies reviewed 

relating to content of picture. 164 

Table 2: Table of expected characteristics from the literature. 169 

Methods 

Table 1: Demographics for all experimental groups. 175 

Table 2: Category definition of case assignment to 4 types: Affective disorder, 

Schizophrenia, Personality Disorder, Substance Abuse. 190 

Table 3: 21 patients who were excluded from the study. 190 

viii

Reliability Study 

Tables showing scores given by 6 raters and author for 7 pictures, no. of exact 

agreements, mean rating for 6 raters and difference to score 7. 

Figures showing plot of differences in interrater score with author score for Mean 

Raters+Author plotted against average, Rater score+author score/2 

Table/figure 1: Red Appendix 2 

Table/figure 2: Yellow Appendix 2 

Table/figure 3: Orange Appendix 2 

Table/figure 4: Purple Appendix 2 

Table/figure 5: Green Appendix 2 

Table/figure 6: Blue Appendix 2 

Table/figure 7: Brown Appendix 2 

Table/figure 8: White Appendix 2 

Table/figure 9: Black Appendix 2 

Table/figure 10: Intensity Appendix 2 

Table/figure 11: Painted Line Appendix 2 

Table/figure 12: Drawn Line Appendix 2 

Table/figure 13: Space Appendix 2 

Table/figure 14: Emotional Tone Appendix 2 

Table/figure 15: Form Appendix 2 

Table 16: Standard deviation of the differences between the mean of the 6 trainee 

raters and the author ratings over 7 paintings. 198 

Table 17: Means and standard deviations of rater scores for each variable over the 

sample of 7 pictures. 202 

Table 18: Ordering of DAPA variables for reliability. 201 

Table 19: Inter-rater reliability showing Cronbach Alpha score for internal 

consistency of scores between raters; and correlation coefficient for linear 

association between scores of raters. 202 

Study 1 

Table 1: Demographics for experimental groups. 207 

Table 2: Diagnosis: Assignment to type. 211 

Table 3: Multiple ranges: group means significantly different at the 5% level. 

Duncan procedure. 214 

Chapter 5 

Results 

Boxplots, spreadplots and tables showing distribution for each diagnostic group against 

whole population for variables from the DAPA test with heterogeneous distribution 

before transformation. 

Table, boxplot and spreadplot 1a (red). Appendix 2 

Table, boxplot and spreadplot 1b (yellow). Appendix 2 

Table, boxplot and spreadplot 1c (orange). Appendix 2 

Table, boxplot and spreadplot 1d (purple). Appendix 2 

ix

Table, boxplot and spreadplot 1e (brown). Appendix 2 

Table, boxplot and spreadplot 1f (white). Appendix 2 

Table, boxplot and spreadplot 1g (painted line). Appendix 2 

Table, boxplot and spreadplot 1h (drawn line). Appendix 2 

Table, boxplot and spreadplot 1i (form). Appendix 2 

Boxplots, spreadplots and tables for variables which were kept in their original state 

because they showed homogeneity in their distribution from the Levene test, or the 

transformation did not improve their distribution pattern. 

Table, boxplot and spreadplot 2a (green). Appendix 2 

Table, boxplot and spreadplot 2b (blue). Appendix 2 

Table, boxplot and spreadplot 2c (black). Appendix 2 

Table, boxplot and spreadplot 2d (intensity). 

Appendix 2 

Table, boxplot and spreadplot 2e (space). Appendix 2 

Table, boxplot and spreadplot 2f (emotional tone). Appendix 2 

Mean scores for variables from the DAPA test showing distribution norms of over 109 

subjects after transformation. 

Table, boxplot and spreadplot 3a (red). Appendix 2 

Table, boxplot and spreadplot 3b (yellow). Appendix 2 

Table, boxplot and spreadplot 3c (brown). Appendix 2 

Table, boxplot and spreadplot 3d (painted line). Appendix 2 

Table, boxplot and spreadplot 3e (drawn line). Appendix 2 

Table, boxplot and spreadplot 3f (form). Appendix 2 

Table 4: Projected transformations for data based on computations designed to 

verify the assumptions of the ANOVA test. 218 

Table 5: Transformed data based on computations designed to verify the ANOVA 

test. 218 

Figures 6, standard differences from mean of each diagnostic group. 

6a, plot of red Appendix 2 

6b, plot of yellow Appendix 2 

6c, green Appendix 2 

6d, blue Appendix 2 

6e, brown Appendix 2 

6f, black Appendix 2 

6g, intensity Appendix 2 

6h, painted line Appendix 2 

6i, drawn line Appendix 2 

6j, space Appendix 2 

6k, emotional tone Appendix 2 

6l, dominant form Appendix 2 

Figures 7, standard differences from mean of diagnostic groups: abnormal distribution. 

x

7a, orange Appendix 2 

7b, purple Appendix 2 

7c, white Appendix 2 

Table 8: Results of analysis of variance for the purpose of identifying diagnostic 

grouping variables between 4 groups of psychiatric patients and one 

control group on 13 formal measures of their paintings. 222 

Table 9: Main Analysis: multiple comparisons, Duncan procedure. 222 

Specific Differences for each variable 

Figures showing confidence intervals and means by diagnostic type for DAPA variables: 

Figure 10a, red 224 

Figure 10b, yellow 225 

Figure 10c, green 226 

Figure 10d, blue 226 

Figure 10e, brown 227 

Figure 10f, black 228 

Figure 10g, intensity 229 

Figure 10h, painted line 230 

Figure 10i, drawn line 231 

Figure 10j, space 232 

Figure 10k, subjective emotional tone 234 

Figure 10l, dominant form 235 

Table 11: Discriminant analysis to classify controls or patients. Classification 

functions from the first sample are used to classify the second sample. 

Repeated 5 times with different partitions of the data set. 238 

Table 12: t-test results for significant differences between means of variables 

measured from paintings by patients against non-patients as though they 

were independent. 239 

Table 13a: Separate effect size for each variable from the DAPA test. 240 

Table 13b: Separate effect size for each variable from the DAPA test. 240 

Table 14: Results of 2-way ANOVA: diagnostic groups by number of paintings 

from each patient. 

242 

Table 15: Correlations between number of pictures within each group with each 

variable. 243 

Table 16: Correlation for DAPA variables measured from the paintings of 

schizophrenics - a) Colours b) structure. Appendix 2 

Table 17: Correlation for DAPA variables measured from the paintings of substance 

abusers - a) Colours b) structure. Appendix 2 


depressives - a) Colours b) structure. Appendix 2 

xi

Table 19: Correlation for DAPA variables measured from the paintings of controls 

- a) Colours b) structure. Appendix 2 


personality disorder - a) Colours b) structure. 

Appendix 2 

Chapter 6 

Discussion 

Table 1: Summary table of results. 249 

Table 2: Interpretations of the use of colour in artistic production, taken from 

S.P.Amos. 251 

Figures 3a-e: Map of associations between colour variables measured between 

diagnostic groups from the results of the DAPA test. 

252 

Figures 4a-e: Map of association of structural variables measured between diagnostic 

groups using the DAPA test. 262 

Illustration: example of use of grid system with marked score for 'red'. 171 

xii

List of Abbreviations 

Am. Assn. Art Therapists American Association of Art Therapists (AAAT) 

Am. American 

Am. Educational Research J. American Educational Research Journal 

Am. J. Art Therapy 

Am. J. Psychotherapy American Journal of Psychotherapy 

Art Psychotherapy The Arts in Psychotherapy 

B. J. Psychiatry British Journal of Psychiatry 

Bull. Art Therapy Bulletin of Art Therapy 

British Assn. Art Therapists (BAAT) British Association of Art Therapists 

Canadian Psychol. Canadian Psychologist 

CDAT Comparitive Description of Artwork Test 

DAPA Descriptive Assessment for Psychiatric Artwork 

DAP Draw-A-Person (used in drawing tests) 

DDS Diagnostic Drawing Series 

HFD Human Figure Drawing 

HTP House-Tree-Person (used in drawing tests) 

Int. International 

J. Journal 

J. of the Am. Academy of Psychoanalysis Journal of the American Academy of 

Psychoanalysis 

J. Am. Psychoanalytic Assessment Journal of American Psychoanalytic Assessment 

J. Clin. Psychol. Journal of Clinical Psychology. 

J. Exp.l Psychol. Journal of Experimental Psychology 

J. Gen. Psychol. Journal of General Psychology. 

J. Nervous Mental Dis. Journal of Nervous and Mental Disease 

J. Pers. Assess. Journal of Personality Assessment 

J. Sch. Psychol. Journal of School Psychology 

Percep. Motor Skills Perceptual and Motor Skills 

Psycholog. Bull. Psyhological Bulletin 

Psychol. Mon. Psychological Monographs. 

WHO World Health Organisation 

xiii

Acknowledgements, thanks and foreword 

This thesis comes as a culmination of questions that have arisen, mostly unformulated, 

over many years of involvement in art, which started casually through community 

projects, continued during a degree in Fine Art, and subsequent professional involvement 

with mental health groups. During the last decade, I touched on the same sort of question 

under the auspices of academic psychology during my MA., but finally the opportunity 

to research through psychiatry has led me to approach the subject from a far different 

angle than I had originally envisiaged. I have not become a multidisciplinary expert, I 

have tried to understand what I have applied, but no doubt shortcomings can be found 

in it. The course of this research, however, has changed me. It has given me new and 

useful skills, and thought structures, but it has also taken away some aspects I was not 

fully aware of; I am still synthesising the widely different contexts it covered. 

I am aware this thesis may read as an attack on the profession of art therapists, 

although this is far from the intention. It is a sad picture of art therapy research that 

emerges, and I have related its failings rather than the clinical achievements of this 

dedicated profession for which I have the greatest respect and whose research work is 

often constrained by lack of funding and low status. 

This research was made possible by the interest and generous help and 

encouragement I have received from some who gave their valuable time and went out of 

their way to assist this novice. I should like to record outstanding debts of gratitude to 

Dr. David Martin Foreman, Senior Lecturer, Psychiatry Dept. School of Postgraduate 

Medicine at the University of Keele, who supervised this research through the depths of 

depression to its highlights and whose unfailing encouragement, useful comments, 

criticism and suggestions most motivated me over the six years it took. I would like to 

specially thank also Mike Fletcher, Head of Dept., School of Computing, Staffordshire 

University, who provided specialist knowledge and supervised the application of the 

discriminant analysis technique and who kindly checked over the first draft of the results 

section. 

I thank these Consultant psychiatrists from N. Staffs. Hospitals, who allowed me 

access to their patients: Dr. K. Bloore, Dr. K. Barrett, Dr. F. MacMillan, Dr. J. Crisp, 

Dr. Ward, D. Gee, Dr. Slade, Dr. J. Boardman, Dr. Myers and special thanks to Dr. K. 

Barrett, Clinical Director, Bucknall Hospital and Senior Lecturer in Psychiatry, Post 

Graduate School of Medicine, Keele University whose interest, encouragement and 

supervision of the initial stages for the first DAPA study was instrumental in 

development of the test theory. 

John Belcher of the Dept. of Mathematics, Keele University did his best to 

instruct me in basic statistics in the early stages of this research; Professor Terry Shave, 

of the Dept. of Fine Art at Staffordshire University allowed me to recruit his students 

as test-raters; Dr. Linda Gantt, of Alexandria sent me her Ph.D thesis from the USA and 

provided some useful contacts. 

Finally, without the unceasing support and encouragement of my partner David, 

I should never have been able to finish what has seemed at times an impossible task, 

14

especially since the birth of our daughter Ellie 3 years ago. His support, love and 

understanding is my greatest resource. 

Chapter One: Introduction 

Organisation of thesis: The first three chapters introduce the background to the study, 

the need for systematic assessment of painted artwork and the development of a novel 

approach to the assessment of drawing categories. Chapter one provides an overview, 

points out that conventional interpretive evaluative methods do not identify what is 

specifically psychiatric about artwork produced by patients and reveals the neglect of 

formal measures. Chapter two reviews the development of assessment of psychiatric 

artwork over the past 20 years in two sections. Section 1 introduces a number of popular 

views about how art therapy works and Section 2 concentrates on the information from 

case studies and controlled studies; common findings, conclusions and changes in 

assessment methods. These results are then critically discussed with particular reference 

to methodology. In chapter three a meta-analysis is performed on studies from the 

review to identify which groups of variables are central to reliable and systematic 

assessments of psychiatric paintings. The summary gathers the knowledge from the 

literature review to show the kinds of measurement which have the best repeatability and 

validity for new instruments. 

Chapter 4 describes the development of a novel instrument, the Descriptive 

Assessment for Psychiatric Art (the DAPA) and introduces the steps taken to validate 

it: the main experiment, inter-rater reliability and the initial study. Chapters 5 presents 

the results of the main study. Chapter 6 considers the support for and discrepancies 

from the DAPA results with previous work. Finally, Chapter seven summarises and 

15

concludes on the effectiveness of the instrument with some thoughts on how the 

approach exemplified by the DAPA extends previous practice in this field. 

Introduction 

The Argument for Another Art Assessment 

It has long been remarked upon that people with mental illness can sometimes produce 

quite surprisingly communicative and highly organised art, the explanation of which has 

had a number of theoretical approaches 1 . The general task has been to describe and 

explain the phenomena of psychotic art in relation to the behaviour and experience of 

mental illness. This issue has been discussed within many disciplines, without producing 

final solutions, but the psychological aspects have been, to some extent detached and 

investigated on an empirical level. The subject is too complex to be handled as a whole 

and it has been divided into many different problems for research. MacGregor (1989) and 

Waller (1991) have made recent extensive reviews of the history of ideas in the field of 

psychiatric art 2 . These two sources alone provide a comprehensive historical 

background, but Winner 3 adds a useful analytical framework and the diversity of 

1 

For summaries see Tessa Dalley and Caroline Case (1992), Handbook of Art Therapy , London: 

Routledge, probably gives the most readable account of the diversity of theoretical approaches; T. Dalley 

and A. Gilroy, eds. (1989), Pictures at an Exhibition , London: Routledge, explores the range of 

psychoanalytic explanations thought to be related to psychopathology in art; Marion Liebmann (1990), 

Art in Practice , London: Tavistock, describes the variety of art therapy practised with different client 

groups in one area; and V. Lusebrink (1990), Imagery and Visual Expression in Therapy , New York: 

Plenum, identifies most of the different practical approaches to art therapy. 

2 

Diane Waller's (1991) Ph.D. based Becoming a Profession: the history of art therapy 1940-1982 , London: 

Routledge, gives a useful and informative in-depth study of the roots of current theoretical practice. John 

Monroe MacGregor (1989), The Discovery of the Art of the Insane , New Jersey and Oxford: Princetown 

University Press, also developed from his Ph.D. research, provides a detailed interdisciplinary history of 

the earlier empirical and case studies, personalities and work of insane artists. 

3 

Ellen Winner (1982) Invented Worl ds: the psychology of the arts , Cambridge, Mass: Harvard U.P. 

16

contributors to the exploration of emotion through art have been comprehensively 

discussed elsewhere 4 . The foci of investigation fall between two domains, closely 

interrelated: those describing the process of creation and therapeutic benefit and those 

describing the product. 

This chapter introduces a number of popular views about the explanation and 

investigation of pictures produced by psychiatric patients. When we talk about art 

therapy, we refer to a belief that art is somehow expressive in itself or even healing 5 . Art 

therapists are not united in their subscription to any explanatory theory but most agree 

on these principles: disturbed people, particularly schizophrenics, produce artwork 

which is communicative in a way that their language is not; the thoughts or feelings of the 

patient are literally re-presented in concrete form; connections are made cognitively or 

visually which approximate insight experiences; the paintings are described as powerful 

and disturbing, often filled with bizarre imagery. These features have been related to the 

artist's mental or emotional state. The commonly understood advantage in using art with 

people who may not be able to fully express themselves in language is that as the painting 

4 

see, for example: Tessa Dalley (1984), Art as Therapy , London: Tavistock; T. Dalley et al. (1987), eds., 

Images of Art Therapy , London: Tavistock, giving a range of perspectives on the therapeutic aspects of 

art; Joy Schaverien (1992) gives a very readable psychoanalytic breakdown of the relationship of affect and 

transference and the development of the therapeutic relationship, The Revealing Image: analytical art 

psychotherapy in theory and pra ctice , London: Routledge. 

5 

Joan Woddis (1992) comments on the belief of many art therapists in a "mythology concerning the 

intrinsic healing properties of the art-making process" (Art Therapy: new problems, new solutions in Diane 

Waller and Andrea Gilroy, eds., Art Therapy: A Handbook , Bristol: O.U.P. p.39). For example, to use 

a standard text on art therapy, Dalley and Case (1992, Handbook, op.cit. p.54) acknowledge the split 

between art therapists on this issue and also on the relevance of psychoanalytic theory. Whilst Dalley 

generally emphasises the vital importance of the therapist in access to the image, elements of the healing 

function of art do enter pervade into her writing: She explains her personal view of the function of the art 

therapist as "providing a setting in which healing can occur". Another 'setting' argument: "The activity 

of painting sets up a relationship between client and the paper, which can be exclusive of the therapist, but 

the therapist... holds the safety of the scene, like the mother ever attentive to her infant" (p.59). Recent 

papers which offer this view as an explanation for the therapeutic process are reviewed in Chapter 2. 

17

or drawing progresses, relationships and reinforcement develop between the parts of the 

composition, which can be monitored by the therapist, or manipulated to produce 

specific reactions, as with a conversation. 

This overview does not provide a historical survey, which would both step 

outside the conceptual boundary of this thesis and require more space. The background 

is only discussed as far as it affects this thesis. It introduces two kinds of assessment 

which informed the study of psychiatric art: case studies, which are split into four areas; 

and projective testing. Although limited, this background is important here because many 

of the assumptions underlying the theoretical base used to analyse content, especially in 

impressionistic studies, hark back to speculations that were published at the turn of the 

century but have been subject to serious criticism ever since 6 ; for example, the confusion 

of relations between insanity and artistic creativity. This section also introduces a few 

of the terms and jargon commonly used in studies of art but not all of them since many 

are based on theoretical assumptions which do not concern this study 7 . 

6 

But not from writers on psychopathological art. D. Waller (1991) op.cit. gives an account of the 

development of current theory but there is little personal comment. Most writers on art therapy rather than 

tackle arguments try to embrace a range of apparent contradictions by modifying or integrating theory; 

Waller explains "art therapy is a term which has been used to describe a collection of diverse practices, held 

together fundamentally by their practitioners' belief in the healing value of image-making", Waller and 

Gilroy (1992) introduction, op.cit. Dalley and Case (1992), Handbook, op.cit. write that art activity is 

both a conscious process (p.51, 98) and an unconscious process (p.64), point out that images are complex 

and take time to understand both for the therapist and the artist and need discussion (p.52, 64) and Dalley 

goes on to interpret a series of paintings left by a client who never spoke to her (p.118). Notable 

exceptions are David Maclagan (1989) who includes acerbic comments in his articles concerned with the 

relation of verbal psychotherapy to the image produced, see for example, The Aesthetic Dimension of Art 

Therapy: luxury or necessity, Inscape , Spring: 10-13; John Birchtnell (1981) Is Art Therapeutic?, Inscape , 

V(I).p.10 and J. Champernowe (1971), Art and Therapy: an uneasy partnership? Am. J. Art Therapy , 

April, X(3):131-143 which gives the bones of the arguments. 

7 Dalley and Case (1992) op.cit., p.60-3 gives a useful glossary and explanation of the main analytic terms 

and interpretations, but there is no generally agreed standardisation. 

18

Another reason that little time is spent here is because before the 1950s concept 

change in psychiatry, there was a totally different approach to diagnosis so we can't 

really be sure that previous descriptions are comparable with today's psychiatric 

categorisations. Institutionalisation may have accounted for much of the previous 

findings of global differences between patients and controls. During the late 1960s, 

psychiatric diagnostic criteria was standardised between the U.S. and the U.K., especially 

in operational definitions of specific categories. 

The need for more research in art assessment 

The two most commonly recognised uses of art with psychiatric patients other than as 

a diversionary activity, are in therapy for expression of emotional issues and for 

psychological assessment, as an aid to diagnosis or treatment. There is pressure on art- 

therapy to control and assess its therapeutic input for the latter two categories if art 

activity is not to be relegated to the first. The descriptive literature points to obvious and 

felt benefits from clients' experience of art therapy, but there is a marked paucity of 

criticism of the theoretical bases of the practices and a lack of investigative research into 

the contribution of the artwork to psychopathology 8 . 

Investigation into the psychopathology of art: the background 

8 

Recognised by the majority of contemporary writers in this field, for example: David Edwards (1987), 

Evaluation in Art Therapy, in Derek Milne, ed., Evaluation in Mental Health Practice , Beckingham: 

Croom Helm, pp.53-69; Andrea Gilroy (1992) Research in Art Therapy, in Waller and Gilroy, Handbook, 

op.cit. pp.229-247; Shaun McNiff (1986), Freedom of Research and Artistic Inquiry, Arts in 

Psychotherapy , V.13: 279-84; comments from Linda Gantt and Gladys Agell (1994) in, R. Goodman, 

G. Agell, L. Gantt and K. Williams, 'Are there Doctors in the House? Does Art Therapy Need a Cure?' 

Am. J. Art Therapy , V.33, p.3-13. 

19

The link between genius as a product of madness and creativity, which was first 

proposed by Lombroso, Italian psychiatrist and criminologist, in 1891 9 , has survived in 

popular culture and to some extent in learned circles, as have two articles written by Paul- 

Max Simon (1876 and 1888) 10 . Lombroso and Simon separately describe the use of 

characteristic features as a means of psychiatric diagnosis. Simon's conclusions, from 

clinical observation, were based on only 14 creative individuals and Lombroso's offer only 

his own speculations. Nevertheless they were a great influence on the psychiatric 

approach to art of the late 19th century. MacGregor describes the refinement of Simon's 

work in the more systematic experimental approach of Fritz Mohr (1874-1966), derived 

from the school of Kraepelin (1856-1926) 11 . Mohr's methods were adopted by students 

of the subject 12 and led to the development of standardised tests on the one hand, and on 

the other hand, the descriptive case study. Both methods subsequently developed 

separately, each strand evolving its own literature, techniques and theory. Prinzhorn 

(1886-1933), a psychiatrist as well as an art historian, studied the Heidelberg collection 

of psychiatric art. His book, Artistry of the Mentally Ill (1922) 13 presents and does not 

interpret the work of particularly talented but selected individuals, commenting on the 

9 

Cesare Lombroso (1891), Man of Genius , London: Scott. 

10 see MacGregor (1989) op.cit., Chapter 7, pp.103-115 for a description. 

11 

Emil Kraepelin discussed the drawings of dementia praecox patients (his own category for schizophrenia) 

in his Lehrbuch der Psychiatrie (1883) distinguishing several subtypes, although his involvement with 

patient art was rather superficial (MacGregor (1989, op.cit.):188-9). 

12 Although he never got further than descriptive studies himself. Most of his followers contributed little 

to his original findings with a few notable exceptions (e.g. Herman Rorschach, 1884-1922 and Karl 

Jaspers, 1883-1969). 

13 

Hans Prinzhorn (1922), Artistry of the Mentally Ill , Berlin: Springer Verlag. 

20

style and communication value. Prinzhorn ridiculed the diagnostic use of drawings: 

"Anyone unable to make a diagnosis without the drawings will certainly not have an 

easier time with them" (p.3). This work is still held as the most complete treatment of 

the field at the time, but there is no doubt that some of his 'schizophrenics' would not be 

so diagnosed today. By the turn of the century, psychiatry 14 acknowledged the 

systematic drawing test as a useful aid to diagnosis. Illustrated case studies with 

attempts to link characteristics from drawing and painting to psychiatric symptoms were 

published, although with few exceptions these were poor quality: their material was 

selective, they confused observation and interpretation, were unreliable in their 

reporting 15 . By mid-century, there were hundreds of descriptive case studies, some book 

length 16 . Speculative attempts to relate psychiatric symptoms to images were mostly 

discredited when the confounding influences of intelligence, art experience, skill in 

patients were demonstrated to influence raters' judgement of normality in the 1970s 17 , 

14 

Macgregor (1989, op.cit., pp.243-244) describes the interest of Karl Jaspers in the comparison of 

aesthetics in paintings by artists with a mental illness with those of psychiatric patients from the Prinzhorn 

collection, (K. Jaspers, Strindberg un d Van Gogh ); Henri F. Ellenberger (1970), The Discovery of the 

Unconscious - The History and Evolution of Dynamic Psychiatry , Harmondsworth: Penguin Press, gives 

a good account of the gradual medical recognition that drawings by the mentally ill functioned as 

externalisation of their delusional preoccupations and that specifically disturbance of speech was related 

to disturbance of pictorial rendering. 

15 

A. Anastasi & J. Foley (1941), A Survey of the literature on artistic behavior in the abnormal: 1. 

Historical & Theoretical Background, J. of Gen. Psychol. , V.25:111-142; for later criticism of the 

substandard quality of much of the research material of the past, see: S. Russell-Lacy, V. Robinson, J. 

Benson, J. Cranage (1979), An Experimental Study of Pictures Produced by Acute Schizophrenic 

Subjects, British Journal of Psychiatry , V.134:195-200; Harriet Wadeson (1980), Art Psychotherapy, 

New 

York: Wiley; Cathy Malchiodi (1993), Introduction to special issue on Art Therapy and Professionalism, 

Is there a crisis in Art Therapy Education? Art Therapy , V.10(3):122. 

16 

Artist, A. Hill (1945), Art Versus Illness , and (1951) Painting out Illness , London: Allen Unwin. 

Books now considered minor classics by psychiatrists: R. Pickford (1967), Studies in Psychiatric A rt 

London, Tavistock; F. Reitman (1950) Psychotic Art , London: R and KP, and J. H. Plokker (1964), 

Artistic Self-Expression in Mental Disease , London; Littlebrown, while E. Cunningham-Dax (1953), made 

a more objective and controlled study, Experimental Stu dies in Psychiatric Art , London: Faber Faber. 

17 R. Langevin, M. Raine, D. Day and K. Waxer (1975), Art experience, intelligence and formal features 

21

again by a multidisciplinary team who tested different diagnostic groups against non- 

patients in 1979 18 and more recent studies have confirmed these findings 19 . 

Art Therapy and Psychoanalytic Interpretation 

It is not really possible to discuss this section generally, so it is necessarily limited in 

scope because of the enormous complexity of the understanding of psychoanalytic 

theory and also because of the limited application to this thesis. Nevertheless, some 

aspects of the contribution of psychoanalysis to art therapy research must be 

summarised, since the bulk of the literature reviewed in this thesis, and hence the 

direction and questions come from therapists, whose formal training includes some 

breakdown of psychoanalytic theory 20 , trying to share the sense of the imagery they face 

in their clinical practice. 

in psychotics' paintings, Arts in Psychotherapy , Fall V.2(2):149-158; Frank A. Johnson and Roger P. 

Greenberg (1978), Quality of Drawing as a factor in the interpretation of figure drawings, Journal of 

Personality Assessment , V.42(5):489-495; R. Cressen (1975), Artistic quality of drawing and judges 

evaluations of the DAP, Journal of Personality Assessent , V.39:132-137. 

18 S. Russell-Lacy et al (1979, op.cit.). 

19 

M. Miljkovitch and G.M. Irvine (1982), Comparison of drawing performances of schizophrenics, other 

psychiatric patients, and normal schoolchildren on a draw-a-village task, Arts in Psychotherapy , V.9:203- 

16; G.C. Cupchik and R.J. Gebotys (1988), The search for meaning in art: interpretive styles and 

judgement of quality, Visual Arts Research , V.14:138-50; J. Sims, R.H. Dona and B. Bolton (1983), The 

validity of the DAP as an anxiety measure, J. Pers. Assess ment , V.47:250-7; see review by F.F. Kaplan 

(1991), Drawing assessment and artistic skill, Art Psychotherapy , V.18:347-52. 

20 

The qualification for art therapists in Britain is an art degree and a postgraduate one year training course, 

which may not even include experience of personal therapy, in art therapy run by specialist centres, so 

much of their information is simplistic and self-taught; recent application of psychoanalytic theory to art 

therapy is covered in a special issue devoted to transference and countertransference in the creative arts 

therapies, Arts in Psychotherapy (1992) V.19(15). 

22

Others have given summaries of the immense influence of Freud and Jung on art 

evaluation 21 , both need no introduction here. Freud never used drawings in his work, but 

his model of the artist as a borderline psychiatric case became the public view of the 

'unconscious made visible' of the artist's work. Freud's deconstruction of the work of 

Leonardo and Michelangelo 22 was probably his influential contribution to the technique 

of interpretation 23 . Jung painted and sculpted and encouraged his patients to do the same 

"in order to escape the censure of the unconscious mind" 24 . He rejected Freud's negative 

view of phantasy as a source of unconscious or as sublimations of infantile conflicts. He 

made a distinction between personal and collective unconscious, and based his 

interpretations and assumptions concerning archetypes 25 and universal symbols 26 on a 

21 

MacGregor (1989) op.cit., pp.245-270 gives a perspective of Freud and Jung's limited involvement in 

true psychotic art and the development of method and theory from Kris; Joy Schaverien (1992) op.cit., 

takes particular aspects from psychoanalysis to develop her own methods for art therapy and evaluation, 

but gives a very clear explanation of transference and counter transference; Ellenberger (1970) op.cit., 

shows the development from the theories of Freud to today's 'dynamic psychiatry'; Waller (1991) op.cit., 

presents a perspective of the synthesis of methods in psychoanalysis for 

interpretation of art in therapy in Britain from 1940, and Maxine Borrowsky Junge and Paige Pateracki 

Asawa (1994), A History of Art Therapy in the United States , Mundelein: Am. Art Therapy Assn., review 

the art therapy literature which summarises the contributions of first and second generation art therapists 

in America but is generally less theoretically orientated. For a more in-depth analysis of psychoanalytic 

methods in art, E. Kris (1964), Psychoanalytic Explorations in Art , New York: Intl. U. P., and R. 

Wollheim (1964), Art and its Objects Cambridge (reprint 1980): Writers Readers, probably give the most 

understandable explanations. Books on art therapy generally are too simplistic and use a synthesis of 

different methods with no overall context. 

22 

Laurie Schneider Adams (1993) Art and Psychoanalysis , New York: Harper Collins gives a perspective 

on Sigmund Freud (1910), Leonardo Da Vinci - a memory of his childhood, Art and Literature, Pelican 

Freud Library , V.XIV, Harmondsworth: Penguin, mostly derived from his childhood memories and 

speculations on the infancy of Leonardo. It was in The Moses of Michelangelo, ibid., (1914) that he 

explored expression in the artwork. 

23 But he made a number of assumptions based on faulty translation of Italian histories. 

24 

C.G. Jung and R. Wilhelm (1931), The Secret of the Golden Flower , London: Macmillan, p.94; 

Schaverien (1992), op.cit., gives a good description of the concept of the 'unconscious' and its application 

to modern day art therapy pp.22-25. 

25 

Archetypes in art; inherited unconscious images that are component parts of the 'collective unconscious' 

shared by all. 

26 Universal symbol: a symbol that is assumed to represent the same referent universally. Such symbols 

23

theoretical foundation relating art products to innate and inherited personal and universal 

potentialities. 

Psychoanalytic interpretation of content has thrown the only major light on 

access to art and artists through their paintings. There have been accusations of obscurity 

due to the metaphoric language. However, there has been limited involvement with true 

psychotic art, and more concentration on the psychoanalysis of the artist. Followers 

who did involve themselves have largely abandoned Freud's categorisation of primary 

(primitive) and secondary (rational) processes and derived their methods from dream 

analysis techniques with theoretical excerpts from Jung. 

The psychiatrist, Schilder, working with the artist, Levine, in 1942, describes the 

development of this thesis for art therapy: 

Drawings which are offered during the analysis can be handled in the 

same way as dream material irrespective of whether they have contents in 

the common sense or whether they are to be classified as abstract art. The 

drawing corresponds to the manifest content of a dream and also abstract 

forms are basically the expression of human problems and conflicts. The 

material at hand allows the conclusion that in abstract forms particularly, 

primitive and important drives make their appearance. Their study is 

therefore revealing, not only from the point of view of art but also from the 

point of view of therapy 27 . 

reflect basic components of the human psyche. 

27 

Paul Schilder (1942) Mind: perception and thought in their constructive aspects , Oxford U.P reprint 

1981, p.10. 

24

Simplistically, art is understood to access the unconscious processes between two 

people, and the theory is based around the process of projective identification, sometimes 

with the image and sometimes with the therapist. The purpose of the analysis is to 

mediate. Bringing the unconscious in a controlled way to consciousness is deemed to 

release the emotions (catharsis): universal images may be interpreted as archetypal 

symbols, i.e. they often mean the same things to different people. 

A number of prominent analysts were seriously involved with art besides 

Winnicott 28 ; Ernst Kris, the Freudian psychoanalyst and art historian, contributed a 

study of a psychotic sculptor 29 and developed the crucial explanation of the creative 

process as "regression in the service of the ego" 30 . No analyst has succeeded in 

penetrating the world of the psychotic artist and the image as far as Marion Milner, 

whose book In The Hands of The Living God (1969) detailed her work (1943-1959) with 

Susan, a schizophrenic girl, which has had a great influence on the theoretical 

development of art therapy 31 . Milner wrote this book as an inditement on insensitive 

treatment of patients in hospital, of the isolation of the schizoid and the need to make 

contact. She described the tendency for some patients to produce spontaneous drawings, 

28 

for others see: H. F. Ellenberger (1968), The Concept of Creative Illness, Psychoanalytic Review , 55, 

pp.442-56; MacGregor 1989, op.cit. gives a very detailed analysis; D.W. Winnicott (1971), Playing and 

Reality London: Tavistock. 

29 Ernst Kris (1952), study of Messerschmidt, a psychotic artist (trans. chap 4), in 

explorations , op.cit. p.128-50. 

25 

Psychoanalytic 

30 

R. Shafer (1958) Regression in the service of the ego: the relevance of a psychoanalytic concept for 

personality assessment in G. Lindzey (ed.), Assessment of Human Motives , London: Grove Press, pp.119- 

148, explores in more detail the idea presented by Kris (1952, op.cit) that creation or enjoyment of the arts 

involves a controlled use of the capacity to shift quickly from mature cognitive activity to less mature 

forms. 

31 

for example, authors who acknowledge her influence: Dalley and Case (1992) op.cit.; Schaverien (1992) 

op.cit.; Waller and Gilroy (1992) op.cit.

the content of which was seemingly dependent on the pathological depths of the patient, 

and the more contact the patient had, the more the need to draw diminished 32 . Among 

other influential case studies was that of a woman who could draw but not speak about 

her painful emotional experiences, by the Australian psychiatrist, Meares 33 , and another 

by Jungian psychiatrist, Baynes 34 , paralleling the clinical techniques of therapeutic art 

practice in the 1940-50s. Recent traditional psychoanalytic works have not departed 

from this type of careful in-depth study 35 and there is further promise of development 

from new theoretical structures, such as from the writings of Lacan 36 . 

The overriding agreement in all serious psychoanalytic writing is that it is time- 

consuming, particularly in the development of a relationship, and there can be few 

immediate results, but this important qualification is disregarded by many art therapy 

perspectives of these techniques 37 , another qualification from psychoanalytic literature, 

32 An observation which has generally been ignored by her later followers. 

33 

Ainslie Meares (1958), The Door of Serenity . 

34 

H. G. Baynes (1940), Mythology of the Soul London: Tindall Cox. 

35 

A recent example is the 20 year analysis of a female patient "recovering a hidden artistic talent" and the 

discussion of theories arising from the paintings; Margaret I. Little (1997), Miss Alice M. and her Dragon , 

New York: Binghampton. 

36 Lacan's esoteric ideas have made a massive impact on most aspects of psychoanalysis, especially his 

reinterpretations of Freud. When it is possible to assess how Lacan's later view of the image, as a separate 

category, fits in with his theory of signifiers, it may offer much to the study of psychopathology through 

systems other than language, J. Lacan (1988) The Topic of the Imaginary, in J.A. Miller (ed.), The 

Seminar of Jacques Lacan , Book 1 (trans. Forrester), Cambridge U.P.; Bruce Fink (1995), The Lacanian 

Subject , Oxford: Princeton U.P. 

37 see these examples from collected essays edited by well-respected art-therapy authors and lecturers (who 

do not expound these views themselves): Sheila McClelland (1992), Brief Art Therapy in Acute States: 

a process oriented approach, in Waller and Gilroy op.cit., pp.189-207, The author claims to draw on the 

work of Dr. Mindell on process science and psychological interventions in psychiatry and the personal 

construct work of G.A. Kelly (1955). She interprets many of the typical features of work presented by 

psychotic and neurotic referrals and recommends 1. rapid establishment of rapport, 2. maintaining a focus, 

3. Active assertive therapist style and 4. anticipating the ending, but qualifies that considerable training 

is needed. This method is described as "a minimal intervention as it aims to draw forth what is already 

26

neglected as a matter of course now for art-therapy 'referrals', is that the art must elicit 

spontaneously from the patient 38 . MacGregor makes the point that he discusses little 

of the contribution of art therapists to the history of investigation of the image making 

of psychotic individuals, "The interference of individuals with minimal training in either 

psychiatry or psychotherapy cannot be seen as an advantage" 39 , although he goes on to 

point out that a full psychoanalytic training with art skills makes a valuable contribution 

to the therapeutic milieu, giving the example of Margaret Naumberg, psychoanalyst and 

generally acknowledged as the inventor of American psychodynamic art therapy 40 . 

Demonstrations of the therapeutic ineffectiveness of psychoanalytic treatment 

have led to a loss of confidence in the theory, but it at least offers a framework of 

happening"; Paola Luzzatto (1989), Drinking problems and short-term art therapy: working with images 

of withdrawal and clinging, in Andrea Gilroy and Tessa Dalley, eds., op.cit., pp.207-219 discusses 

treatment of 2 patients who were also attending group therapy, through interpretation "linking behaviour 

and feelings - past and present" and confrontation "allowing, or even encouraging, the exploration of 

alternative ways of defence" in only 11 hours of art therapy by "stimulating free associations to the image". 

She assumes transference to the imagery and supports her views with a variety of noncontextual references, 

assumes a therapeutic relationship, and none of the interpretations of imagery or counselling relates to the 

patient's drinking, but to "underlying problems". She discusses the anger of her second patient who "had 

art therapy chosen for him". The images were recognised by the patients as symbolic of their own attitude. 

38 

Margaret Naumberg (1947) Studies of the free art expression of behaviour disturbed children as a means 

of diagnosis and therapy , New York: J.Nervous Mental Dis. Monographs, Cooleridge Foundn.; (1950) 

Schizophrenic Art, Its meaning in Psychotherapy New York: Grune Stratton; Art Therapy: its scope and 

function in E.F. Hammer, ed. (1958), Clinical Applications of Projective D rawing , Springfield: Thomas; 

(1966) Dynamically Orientated Art Therapy: Its Principles and Practices New 

York: Grune Stratton; and Marion Milner 1969, op.cit., were both very specific that the patient should 

come spontaneously to art and not be given standard exercises. 

39 MacGregor (1989), op.cit. p.311. 

40 

Margaret Naumburg, (1947, 1950, 1958, 1966, op.cit.); Kris was particularly conscious of the 

psychoanalytically orientated form of art therapy developed by Naumburg and refers to it as providing 

detailed case material "I believe that future students of this question will be strongly impelled to draw on 

the material so carefully presented by Naumburg. In no other similar publication of which I know is there 

for instance, an equal opportunity to compare graphic and verbal productions of one patient", Kris (1953), 

Review of Schizophrenic Art, by Margaret Naumberg Psychoanalytic Quarterly V.22: 98-101. Kris also 

makes reference to H.G. Baynes (1940) op.cit. as providing an example of the Jungian approach to the 

same problem. 

27

approach. Some of the major criticisms of psychoanalytic theory 41 would more than 

equally apply to their art derivatives: the metaphorical language, vague theoretical 

concepts and the assumed correspondence between concept and behaviour. Farrell 42 

notes that belief and attitude towards psychoanalytic interpretation of art depend on 

previous disposition and training and the weight attached to Freudian theories. Freud 

himself admitted much about the weakness of psychoanalytic methods and serious 

criticisms have been made at all levels 43 . Art therapy is not psychoanalysis, but some 

techniques have been absorbed, albeit sometimes in a non-contextual and piecemeal way. 

Dalley recognises that art therapists are not agreed as to what actually constitutes art 

therapy 44 . Most art therapy explanations of how psychoanalytic interpretation and 

theory applies to art therapy are necessarily abbreviated to fit in with the general context 

of a book or a paper for clinical practice. They give the impression of confusion, 

subjectivity, lack of context and provide a synthesis of sometimes incompatible theory 45 . 

41 

Ernst Nagel (1959), Methodological issues in psychoanalytic theory, in S. Hook, ed., Psychoanalysis: 

Scientific Method and Philosophy: A symposium , London: Grove Press, pp.38-56; Brian Anthony Farrell 

(1981), The Standing of Psychoanalys is , Oxford (originally 1955): OUP 

42 Farrell (1955/1981) op.cit. p.82-84 and Freudian theory p.71. 

43 

For a review see H. J. Eysenck (1961), The Effects of Psychotherapy, in H. J. Eysenck, ed., Handbook 

of Abnormal Psychology , London: Basic Books, pp.697-725. 

44 

Diane Waller and Tessa Dalley (1992), Art Therapy: a theoretical perspective, in Waller and Gilroy 

op.cit. p.1. 

45 

For example, Dalley and Case (1992) op.cit. Chapter 4 provides simplistic combinations of theories 

from different analysts working at different times. Quotes from art historian, Peter Fuller ( Art and 

Psychoanalysis , 1980), relating to artists, support their deconstruction of Freud and others; The published 

papers are discussed in more detail in Chapter 2; There are numerous examples of confusing language but 

even the more respected practitioners are culpable Schaverien (1992), op.cit. in attempting to explain her 

methods of analytical art psychotherapy uses psychoanalytic terms, mixed with her own derivatives, states 

that "mythical thought processes are evident within the pictures" (p.41) and speaks of "sympathetic magic" 

as a technique and explanation. Further explanation by association to psychoanalysis: "In analytical art 

psychotherapy as in psychoanalysis, the scientific and the mythical modes of thought are both of 

28

Many art therapists are deeply uncomfortable about the use made of psychoanalytic 

techniques 46 . Criticism of the application does not necessarily imply the theoretical 

assumptions are invalid, but that these hypotheses require proof of their relevance. 

Neither Freud, Jung, nor others have ever produced sufficient evidence. 

concern."; By Jung (1946, op.cit. p.12) "The patient, by bringing an activated unconscious to bear on the 

doctor constellates the corrupting unconscious material in him, owing to the inductive effect which always 

emanates from projection in greater or lesser degree. Doctor and patient thus find themselves in a 

relationship founded on mutual unconsciousness." This image from Dalley and Case (1992, usually clear) 

on how the client takes an active part in the therapy "The healthy part of the client aids the sick part, 

feeding it and, in doing so, feeds itself". 

46 

Dalley and Case (1992) op.cit., p.53-54; J. Champernowne (1971), Art and Therapy: an uneasy 

partnership. op.cit.; Shaverien (1992) op.cit., develops her own theories about the role of the image as 

reflective of the art therapy process. R.W. Moore (1983), Art Therapy with Substance Abusers: a review 

of the literature, The Arts in Psychotherapy, 

V.10:251-60 identified 20 papers with a range of orientations, 

all using structured sessions dominated by art techniques rather than psychotherapeutic. Many art 

therapists have adopted systemised protocols of assessment such as the DDS (B.M. Cohen, J. Hammer, 

S. Singer (1988) The Diagnostic Drawing Series (DDS): a systematic approach to art therapy evaluation 

and research, Arts in Psychotherapy V.15(1):11-21) in direct opposition to recommended principles from 

Naumberg and lending support to her unease about the relationship between Freudian analysis and art 

therapy (Naumberg 1966, op.cit.); David Maclagan aired concerns that some therapeutic methods were 

incompatible with pictorial imagery, that therapy is assumed to be inherent in the process of creating the 

pictorial image and that the verbal discourse takes place in a different and more explicit frame of mind 

(1989) op.cit. this argument, p.10. Maclagan is not arguing against psychoanalysis but is suspicious of 

attempts to decode the picture. He goes on to state that "If there is an 'art' in this analytic work, then it 

is all to often a devious, detective art, concerned with un-doing what the pictorial image is composed of 

and weaving into it a web of its own devising"; Janet Lee Bachant and Elliot Adler (1997) Transference: 

Co-constructed or brought to the interaction? J. Am. Ps ychoanalytic Assessment , V.45(4):1097-1120 

detail the evolution of the transference controversy. 

29

Gestalt Analysis 

Rudolph Arnheim has been a seminal influence on the development of art therapy 47 . His 

was also the monumental figure who presented the most comprehensive and unifying 

framework for perceptual, emotional, expressive and cognitive-development for the 

interpretation of the visual arts, Gestalt theory. The principles of Gestalt, therefore, 

pervade much present day thinking about the assessment of artworks by art therapy 

clients 48 and must therefore be mentioned. 

The meaning of visual data was seen at three distinctive and individual levels: the 

representational and recognisable; in symbol systems; and the abstract understructure, 

the form of everything we see 49 . Any visual event is a form with content but the content 

is highly influenced by the significance of the constituent parts, such as colour, tone, 

texture, dimension, proportion and their compositional relationships to meaning. 

47 

see The Arts in Psychotherapy 1994, V.21(4) passim. Shaun McNiff and Bruce Moon, two prolific and 

influential recent authors of art therapy texts and discussions, acknowledge their debt to Arnheim as do 

others (McNiff, Celebrating the Life and Work of Rudolf Arnheim, p.247-8, and Rudolf Arnheim: A 

Clinician of Images, p.249-260; Moon, What Kind of Art Therapy, p.295-298). Arnheim himself gives 

an interesting brief perspective on his interest in expression, The Thoughts That Made Me Move, p.245-6. 

Arnheim has been on the editorial board of the journal, The Arts in Psychotherapy since the 1970s. 

48 

see Dalley and Case, 1992, op.cit. Chapter 6, traces the development of psychoanalytic understanding 

(from the point of view of art therapy) to the theories of A. Ehrenzweig (1967, The Hidden Order of Art ), 

dealing with the unconscious structure of the work, actually at odds with the surface constructions of 

Gestalt theory but are here integrated and seen as the predecessors of writers such as Adrian Stokes, painter 

and aesthetician, with such statements as: "Stokes saw the work of art itself as an individual separate 

object, differentiated, yet made of undifferentiated material" (p.133). The influence of Arnheim can be seen 

in much of the description of assessment of art therapy, for example, in the reasons for rejection of 

molecular analysis for the global assessment of the whole picture (for example in Wadeson, 1980 op.cit.) 

and in descriptions of how the client experiences art in therapy. A recent example of the new 'empathetic' 

research approach appears in the description of a client's experience of art therapy: Judith Quail and R.W. 

Peavy (1994) A phenomenological research study of a client's experience in art therapy, Arts in 

Psychotherapy , V.21(1): 45-57. 

49 

Donis A. Dondis (1973), A Primer of Visual Literacy Cambridge: MIT Press, p.13. 

30

This is not all, however, there is also an emotional reaction, especially to art, of 

the kind described by Ralph Ross 50 , which, 

Yields an experience of the kind we call aesthetic, an experience most of us 

have in the presence of beauty, which gives deep satisfactions. Exactly 

why we have these satisfactions has puzzled philosophers for centuries, 

but it seems clear that they depend somehow on the qualities and 

organization of a work of art including its meanings, not on meanings in 

isolation. 

Sensing and interpreting were seen to be only a part of the total process of 

perception, varying with expectations, desires and emotional attitudes. Gestalt was 

always a theoretical model and many of its wider precepts have since been challenged 51 . 

Very few of Arnheim's hypotheses were ever subjected to experimental proof, partly 

because most of the theory is untestable 52 . 

Criticism of Gestalt theory began early in its development and continued 53 . The 

main focus has been that the definition of a criterion for a true Gestalt is the 

unpredictability of its effect from a knowledge of its parts and their relations. This idea 

is important to this thesis, because it offers the explanation that a picture is more than 

the sum of its constituents and so to the belief that pictures can only be assessed on a 

50 

Ralph Ross (1963) Symbol Systems and Civilisation , New York: Harcourt Brace. 

51 

For a quick summary of the criticism and experiments on the Gestalt position see James Hogg (1969), 

Some Psychological Theories and the Visual Arts, in Hogg, ed., Psychology and the Visual Arts , 

Harmondsworth: Penguin, p.78-81. 

52 J. Hogg (1969), op.cit. makes the point that to appeal for direct evidence in order to evaluate Arnheim's 

work would be to miss the point that he has set out to establish a way of looking at the psychological 

experience of art not a body of experimental detail. 

53 

But most attacks were on the theory of perception: E. Nagel (1952), Wholes, Sums and Organic Unities, 

in D. Lerner, ed., Parts and Wholes: The Hayden Colloquium on Scientific Method and Concept , reprint 

1963, London: Macmillan; B. Petermann (1932), The Gestalt Theory and the Problem of Configuration , 

London: Kegan Paul. Arnheim writes from an analytic perspective on art and adopts the Gestalt 

assumption of inherent constructs which may be modified by training and experience. 

31

molar level and not by individual elements. Thus we can also look to this literature for 

an answer. It is this very independence of the whole from its parts that Gestalt is 

initially attempting to explain 54 . But, because the effects of a complex system cannot be 

predicted from its parts, it does not mean that the appropriate relations cannot be 

found 55 . 

Projective testing 

The projective drawing test has evolved from the search for emotional and 

psychiatric 'indicators', inferred from the acknowledged unreliability in scoring on 

intelligence measures in psychiatric populations. Psychoanalytic writings describe how 

traits and emotions from the disturbed person are ascribed to another (projection). 

Projection accompanies a refusal to acknowledge the projected feelings (denial). It 

functions as a defence mechanism 56 to protect the individual from repressed anxiety and 

conflicts. A projective test is NOT designed to probe the unconscious, but to provide 

a forum where desires, needs, beliefs and attitudes are revealed which may not be 

consciously known. It systematically assigns emotional, symbolic or expressive value 

to particular ways of marking a painting, or to particular images. The advantage of 

projective tests over the unstructured single case method is in their systematic 

54 The Gestalt concept "has become the explanatory principle from which as a primary given fact, the 

phenomena may be deduced", Petermann (1932) op.cit., p.49. 

55 

Nagel (1952), op.cit. p.140 comments on criterion from Kohler, 1924, who proposes the same argument, 

paraphrased by Hogg (1969), loc.cit. 

56 Mary Levens (1989), Working with defence mechanisms in art therapy, in Gilroy and Dalley, op.cit. 

p.143-6 gives a good description of defence mechanisms. 

32

application to large numbers. Projective tests are claimed to detect hurt, anxiety, 

depression and psychiatric disturbance 57 , however, individual interpretation of the 

elements by the therapist is essential, since operational definitions are often ambiguous 

or non-existent. 

The projective art test assumes that a given drawing represents the self and that 

dysfunction in perception of the self will reflect in dysfunction of that representation. 

This externalising function of drawing is very important clinically as it presents a way 

of communicating outside language. Most projective art tests use the human figure. The 

draw-a-person test 58 is a popular intelligence test for IQ or ability measures in normal 

children. It uses a friendly medium which is well understood by a child, is not dependent 

on language skill and the drawing is rated by a total sum of the recognisable parts of a 

figure. Although developed for children, it is regularly used for adult psychiatric patients, 

for which population it is yet to prove reliable, since although it correlates highly with 

other developmental tests, it consistently over or under estimates individual scores in 

normal populations 59 . 

57 

see Abell et al, (1994) op.cit. for a review; K.G. Aikman, R.W. Belter and A.J. Finch (1992) Human 

Figure Drawings: Validity in assessing intellectual level and academic achievement, J.Clin Psychol. , 

V.48(1):114-120) tested 216 child and adolescent psychiatric patients and found more than half 

misclassified. Goodenough herself provides an appendix chapter speculating on the distortions expected 

in psychiatric populations (1926, op.cit.). 

58 

see D. Harris (1963), Children's drawings as measures of intellectual maturity , New York: Harcourt 

Brace, p.12-36 for a review of the early descriptive and developmental studies; the best known is the 

Goodenough-Harris Draw-a-man scale, (F.L. Goodenough and D.B. Harris (1963), The Goodenough-Harris 

Drawing Test , New York: Harcourt, Brace, which revised and extended studies by Florence Goodenough 

(1926) Measurement of Intelli gence by Drawings , New York: Harcourt Brace. 

59 

S.C. Abell, A.M. Heiberg and J.E. Johnson (1994), Cognitive Evaluation of Young Adults by Means 

of Human Figure Drawings: an empirical validation of 2 methods, J. Clin. Psychol. , V.50(6):900-5; for 

a review see L. Slansky, M. Short-Degraff (1989), Validity and Reliability issues with Human Figure 

Drawing Assessments, Physical and Occupational Therapy in Paediatrics , V.9(3):127-142; and G.H. 

Fabry, and J.E. Bertinetti (1990), A Construct Validation Study of the Human Figure Drawing Test, 

33

Attempts to lists characteristics of clinical significance have produced no 

consensus of agreement between studies 60 . When attributes of the picture which are 

supposed to accompany symptoms are examined, the question of what kind of 

accompaniment is still at issue. Projective tests do not have answers, they collect 

information. For example, the interpretation of a subject's projection onto the highly 

ambiguous stimuli of inkblots (the Rorschach Test) is said to reveal deep unconscious 

needs and personality factors. The prototype of the projective approach is the landmark 

work of Machover (1949) 61 , which stresses the significance of isolated signs and details 

in human figure drawings. The usefulness of this method has been challenged by the 

failure of validation, reliability and validity in objective studies, and that it is by no means 

certain what they measure, how they work, or if indeed they do work 62 . Later authors 

have adopted a more clinical intuitive stance 63 . Wadeson 64 had doubts, as a few other 

Perceptual and Motor Skills , V.70:465-466, give modest support for validation but do not recommend 

its use in isolation. 

60 

Harriet Wadeson and William T. Carpenter (1976), A Comparative Study of Art Expression of 

Schizophrenic, Unipolar Depressive, and Bipolar Manic-Depressive Patients, J. Nervous Mental Dis. , May 

V.162(5):334-344. Found characteristics of different diagnostic groups of patients unrelatable to table 

expectations derived from the literature. Wadeson later commented that there was as much evidence for 

as against these characteristics (1980 op.cit.) For recent studies, refer to Chapter 2. 

61 

K. Machover (1949), Personality 

10th ed., Charles C. Thomas. 

Projection in the Drawing of the Human Figure , Springfield IL: 1978 

62 

Sophia Kahill (1984) Human Figure Drawing in Adults: an update of the empirical evidence 1967-1982, 

Canadian Psychol. V.25(4):269-292 noted some improvements in research methods but had nothing to 

add to previous reviews "While it is obvious that figure drawings are not meaningless, establishing what 

it is they mean with any precision or predictability is difficult" (p.288). 

63 

G.D. Oster and P. Gould (1987), Using Drawings in Assessment and Therapy: a guide for mental health 

professionals , New York: Brunner Mazel, describes a drawing protocol; E. Koppitz (1983), Projective 

Drawings in Children and Adults, Sch. Psychol. Review , V.12:421-427. provides informal projective 

scoring scores which depend on experience/insight of administrator; recent example of Silver: Rawley 

Silver and Joanne Ellison (1992), Identifying and Assessing Self-Images in Drawings by Delinquent 

Adolescents, Arts in Psychotherapy , V.22(4):339-352. 

64 

Harriet Wadeson (1987), The Dynamics of Art Psychotherapy , New York: Wiley. 

34

writers who have published detailed discussion of formal research and its problems 65 , 

over the relevance of quantitative methodology for assessing the qualitative idiographic 

insights provided by interpretation of the productions from projective testing. After a 

career of scientific investigation into the psychopathology of art, Wadeson challenged the 

received wisdom about what constituted 'schizophrenic' or 'depressed' drawings. She 

contended that, 

Although the graphic and sculptural characteristics can provide 

information about the art therapy client's state, patients of the same 

diagnosis may exhibit different graphic or sculptural characteristics" ... 

"There is no such thing as a 'schizophrenic picture'. There are confused 

looking pictures, fragmented organization, bizarre representations 66 . 

Wadeson offered a set of twelve drawings for readers to test their skills to decide if the 

artist was psychotic. She implies difficulties. 

Few researchers have taken note of criticisms in reviews of projective tests 67 . 

Despite the lack of experimental validation 68 , the standardised procedures from projective 

65 

H. Wadeson (1978), Some uses of art therapy data in research, Am. J. Art Therapy , V.18(1):11-18; Bruce 

Males (1979), Is it right to carry out scientific research into art therapy? Therapy V.3:5; Males (1980) Art 

Therapy: Investigations and implications, Inscape , 4(2):13-15; T. Dalley (1980), Assessing the therapeutic 

effects of art: an illustrated case study, Arts in Psychotherapy , V.7:11-17; David Edwards (1987) 

Evaluation op.cit.; Sean McNiff (1986), Freedom of research op.cit.; McNiff (1987) Research and 

Scholarship in the creative arts therapies, Arts in Psychotherapy , V.14:285-92 arguing against 

inappropriate methods for the subject; Andrea Gilroy (1992), Research in Art Therapy, in Waller and 

Gilroy, op.cit., pp.229-247; Michael Franklin and Rosalie Plitsky (1992), The problem of interpretation: 

implications and strategies for the field of art therapy, Arts in Psychotherapy , V.19(3):163-175. 

66 Wadeson (1987), op.cit. p.93. 

67 

Generally, A. Anastasi and B. Foley's (1941) 4 article survey of the literature, condemned the poor 

quality of research: empirical tests were badly reported, lacking in basic information; associations of 

characteristics were idiosyncratic, unreplicated, used extreme groups and results were often contradictory 

or uninterpretable (A survey of the literature on artistic behaviour in the abnormal IV, experimental 

investigations, J. Gen. Psychol. V.23:187-237). Qualitative variation not differences were noted across 

groups especially in writing in (p.193). Research on spontaneous work (Section III, 

35 

Psychological 

Monographs , V.52(6):1-71) revealed "ambiguous ill defined mentalistic concepts which add much 

confusion to the problem. It is difficult in certain studies to draw the line between observation and 

interpretation" (p.64); In 1968, C.H. Swenson, Empirical Evaluations of Human Figure Drawings,

tests are still popular in assessment, diagnosis and treatment decisions, probably because 

of what Swenson (1968) 69 described as "a random partial reward schedule" due to the 

occasional case where projective drawings gave an indication of a client's problem, 

although clinical caution in their interpretation seems rare 70 . There have been very few 

empirical studies, reflected in the lack of confidence in statistical approaches, and these 

mostly still lack methodological validity 71 . The focus has been to isolate the diagnostic 

content through association of symbols or identify 'markers' 72 . However, some studies 

show naive raters can globally categorise pictures of patients and non-patients through 

'intuitive' feelings of abnormality 73 and can be reliable. Thus it seems that there is 

Psychological Bulletin , V.70:20-44, advised researchers attend to characteristics of the work rather than 

unrelated hypotheses and criticised interpretive assumptions. Hammer (1968, op.cit.) and others after 

made similar recommendations, but Cathy Malchiodi (1994) op.cit. was able to make virtually the same 

criticisms describing the term 'assessment' as a misnomer, most tests as directives, and that few interrater 

studies, reliable and valid scoring systems were available. 

68 

E.F. Hammer (1968) op.cit., Clinical Application of projective drawings; Swenson's eight year reviews 

of research (C.H. Swenson, Empirical Evaluations of Human Figure Drawings, Psychological Bulletin 

1957, V.54:431-466, and 1968 op.cit.) concluded that "Machover's hypotheses concerning the DAP have 

seldom been supported by the research" and more recent publications have nothing to add: Scott (1981) 

Measuring Intelligence with the Goodenough-Harris Drawing test, Psychol. Bull. V.89:483-505; Kahill 

(1984), op.cit.; Abell (1994), op.cit. 

69 Swenson (1968) op.cit. p.370. 

70 

Most writers acknowledge the appropriate uses for the DAP are with body image disorders, such as this 

example: Sandy K. Reuven (1998), Reversal of a body image disorder (Macrosomatognosia) in Parkinson's 

disease by treatment with AC pulsed electromagnetic fields, Intl. J. of Neuroscience 1998, V.93:1-2. 

Abuses of the process continue, for example, the use of the Goodenough-Harris Draw-a-Man test, as 

developmental indicator for adult psychiatric populations, despite the lack of research evidence for it, 

general admonition (inc. the authors) and numerous studies condemning the practise as unreliable. 

71 The claim by the authors of the Diagnostic Drawing Series, a standardised evaluation from 3 pictures, 

to have demonstrated replicable differences between patients (B. Cohen et al., 1988, op.cit.) is discredited 

at length in the reliability analysis, Chapter 2 of this thesis. 

72 

Recent studies (over the last 22 years), both empirical and other are discussed in the literature review, 

Chapter 2. 

73 

Bernard I. Levy and Elinor Ulman (1967), Judging Psychopathology from Paintings, J. Abnormal 

Psychol. , V.72(2):182-7; Ulman and Levy (1968), An Experimental Approach to the Judgement of 

Psychopathology from Paintings, Bull. Art Therapy , V.8(1):3-12; Ulman and Levy (1973), Art Therapists 

as Diagnosticians, Am. J. Art Therapy , V.13:35-8. These articles reprinted three times (1975, 1984 and 

36

something recognisable about the artwork which has not been isolated. Projective testing 

approaches continue to be developed 74 , and recently there have been encouraging 

developments based on more rigidly defined formal criteria with children 75 . 

The research contribution of Art Therapy to assessment issues 

Wadeson's (1976) table of psychiatric characteristics of art from the previous literature 

had little empirical basis 76 . Gantt and Schmal's (1974) annotated bibliography of art 

therapy literature over 33 years 77 listed 1175 items from English and foreign language 

sources: only 39 were classified as 'research' and not all dealt with art therapy. There was 

little attempt at replication, reliability, and definition of terms. Linda Gantt and J. 

Howie's (1979, unpublished) chart of correspondences between characteristics of the 

artwork of patients and the DSM111 seemed to offer an alternative framework for 

1992) show that from 55 judges of varying backgrounds, some art or psychiatry related, all predicted 

patient status better than chance; Linda Gantt (1990) tested 6 art therapy graduates on 30 pictures between 

6 DSMIIIR groups and attained the same results: A Validity Study of the Formal Elements Art Therapy 

Scale (F EATS) for diagnostic information in patients' drawings , Unpublished Doctoral Dissertation, U. 

Pittsburgh, Pensylvania, U.S.A. 

74 

For the main projective tests in use today, see D. Arrington (1992), Art-based assessment procedures and 

instruments used in research, in H. Wadeson, A Guide to Conducting Art Therapy Research , Mundelein, 

IL: Am. Art Therapy Assn., pp.157-178. 

75 

Micheal S. Trevisan (1996), Review of the Draw A Person: Screening Procedure for Emotional 

Disturbance, Measurement and Evaluation Counselling and Development V.28(4):225-8. Reviews the 

DAP:SPED by J. Naglieri and S.I. Pfeiffer (1992) Performance of disruptive behaviour disordered and 

normal samples of the DAP:SPED, Psychological Assessment , V.4(2):156-159 with a complex and 

comprehensive projective approach to assess 55 items of emotional disturbance in children. 

76 Wadeson and Carpenter (1976), Comparative Study op.cit. were unable to relate characteristics of 

different diagnostic groups of patients to a table derived from general analysis of expectations from the 

literature. 

77 L. Gantt and M. Schmal (1974), Art Therapy, A Bibliography (1940-73) (George Washington University 

and National Institute of Mental Health (NIMH), U.S.A (unpublished). 

37

investigation of artwork, but few have taken up this challenge 78 . Moore's review of 392 

papers from 1974-1980 79 found only 69 claimed to deal with research, although some 

were speculations and suggestions for research possibilities. The bulk of the literature, 

even in the 1990s has been concerned with techniques of therapy. There have been no 

recent comprehensive reviews (to my knowledge) to bring us up to date 80 . The spate of 

books in the 1970-80s were illustrated, focused on case material and theoretical positions 

and had little to say about research or diagnostic questions and the '90s 'cookbooks' of 

techniques and theories 81 advocate feminist 82 , phenomenological, empathetic and 

qualitative approaches using case studies 83 . The phenomenological type of investigation 

78 Chart of pictorial characteristics equating to diagnostic symptomatology related to DSMIII categories 

(1979), NIMH unpublished. Linda Gantt advises that the chart is now out of date and the work must be 

redone (personal correspondence, 1994). 

79 

R. Moore (1981), Art Therapy in Mental Health , Rockville MD: NIMH. 

80 Diane Waller's review takes us only to 1982. 

81 

Such as Bruce Moon's (1992) rather evangelical Essentials of art therapy training and practice , 

Springfield, IL: Thomas; Leah Bartal and Nira Ne'eman (1993), The Metaphoric Body: Guide to 

Expressive Th erapy Through Images and Archetypes , London: J. Kingsley; Waller and Gilroy (1992), 

Handbook, op.cit. 

82 

Shirley Riley (1997), Conflicts in Treatment Issues of Liberation, Connection and Culture: Art Therapy 

for Women and their Families, Art Therapy , V.14(2):102-8 on women's need to be heard and access to 

communication in male dominated treatment systems; Franklin and Plitsky (1992) problems of 

interpretation, op.cit. 

83 

see for example discussion of propriety of empirical research, advocating separate systems of empathetic, 

understanding research and diagnosis on the basis that problems of art therapy clients are 'essentially 

creative': Borrowsky Junge and Linesch (1993), Our Own Voices op.cit.; Linda Gantt (1986), 'Systematic 

investigation of art works: some research models drawn from neighbouring fields, Am. J. Art Therapy , 

V.24(4):111-18 arguing inadequate training of art therapists for empirical research therefore more rigour 

in appropriate methods; Andrea Gilroy (1992), Research in Art Therapy, in Waller and Gilroy, Handbook, 

op.cit. pp.229-247 cites many more advocates for phenomenological research; Helen Payne, ed. (1993), 

Handbook of Inquiry in the Art Therapies: One River, Many Currents , London: Kingsley, passim; David 

Aldridge (1994), Single-Case Research Designs for 

the Creative Art Therapist, Arts in Psychotherapy , V.21(5):333-342; Herman Smitskamp (1995), The 

Problem of Professional Diagnosis in the Arts Therapies, Arts in Psychotherapy, 

V.22(3):181-187; Rosalie 

H. Politsky (1995), Towards a Typology of Research in the Creative Arts Therapies, Arts in 

Psychotherapy , V.22(4):307-314; Cathy Malchiode (1993), crisis, op.cit. 

2 recent examples of these processes: Quail and Peavy (1994), phenomenological study, op.cit. use 'the 

verbal descriptions of the client as the main source of data'. These retrospective impressions of a group 

38

is thought to generate more appropriate information than empirical techniques for 

psychotherapy, and fits in with a general trend of more integrated approaches suggested 

by the new breed of recent books 84 . However, studies based on these precepts present 

a deluge of unanalysed information in which it is difficult to distinguish a purpose or 

research value. 

The problems of the approach to psychiatric pictures 

Single case descriptive methods, projective tests and indeed most descriptions or 

interpretations of psychiatric paintings have in common an approach typical of art 

criticism to the paintings, which has been applied without consideration of the 

assumptions the language implies. One of the most obvious assumptions is the conscious 

and serious intention of the artist 85 . This approach cannot cope with involuntary 

experience were stimulated by interviews about selected drawings and relate change in the client to the art 

process. Quail feels that this validates and confirms the value of art-therapy; Debra Linesch (1994), 

Interpretation in Art Therapy Research and Practice: The Hermeneutic Circle, The Arts in Psychotherapy , 

V.21(3):185-195 applies a model of interaction to a case study of an abused girl. 

84 

for example: Frederick J. Leger (1998), Beyond the therapeutic relationship: behavioral, biological and 

cognitive foundations of psychotherapy , New York: Haworth, attempts to integrates and unite multifarious 

psychotherapies and discusses scientific difficulties; Arthur Robbins et al.(1998), Therapeutic Presence: 

Bridging Expression and Form , London: Kingsley, explores nontraditional interactions; and articles: 

Herman M. Adler (1997), Towards a Multimodal Communication Theory of Art Therapy: the vicarious 

coprocession, Am J. of Psychotherapy , V.51(1):54-66, supports common therapeutic processes of music, 

art and other events; Sarah G. Banker, The Power of Art and Story: women therapists create their own fairy 

tales, in A. Robbins, Therapeutic Presence op.cit., explains how symbolic presences open up multiple 

solutions for expression; G.L. Engels (1977), The Need for a New Medical Model: a challenge for 

Biomedicine, Science , April 8, V.196(4286):129-37, discusses the out-of-date medical model of disease 

and the new personal rather than illness focus; Ruth Cohn Balletino (1998), The Need for a New Ethical 

Model in Medicine: a challenge for conventional, alternative and complementary practitioners, Advances , 

V.14(1):6-16 joins the debate and introduces suggestions for a new ethics code for new boundaries. 

85 Gilroy and Dalley (1989) Pictures at an Exhibition, op.cit. is a synthesis of essays dealing with art 

therapy of mental patients, and psychoanalytic examination of the work of artists, using the same kind of 

language and treatment of the subjects, and assuming an active creative process. Recent example of use 

of language and aesthetic analysis to artwork of mental illness in Dalley and Case (1992), op.cit. Ch. 6, 

Development of psychoanalytic understanding p.119-145; Art and Psychoanalysis p.71-96. 

39

expressions of a disordered psyche. Therefore conventional methods of art criticism are 

not sufficient to identify the psychiatric components of artwork produced by patients. 

The madman is not an artist and neither is art a cure for madness 86 . 

86 

John Birchtnell (1981) op.cit. recognises (but does not subscribe to) the belief by art therapists that 

making of art is in itself therapeutic; Refer back to introduction to ch.1 for examples of this theory; Shaun 

McNiff, a prolific author on art therapy, has described the art therapist as "One who works with the 

supernatural, a technician of the sacred, a master of ecstacy, mystic healer, priest and artist" (1979 - From 

shamanism to art therapy, Art Psychotherapy V.6(3):155-61). 

40

The problems of secondary sources as data 

Most research still relies on clinical observation of case studies and they comprise the 

major part of the published literature. These reports suggest that the art produced by the 

patient changes with improvement in the patient, and more contraversially that the act 

of making the art promotes change in the patient. The generally accepted solution to the 

recognised influence of the interpreter on the interpretation has been to have the patient 

provide a verbal explanation of the picture 87 . So far, serious methodological difficulties 

have not been recognised or addressed and reliable evidence for interpretive accounts is 

not available 88 . 

Presently, the measures which are used to assess art in therapy assess the 

therapist's or the client's opinions of the psychotherapeutic process, or attempt to 

correlate verbal interpretations with the visual products. The transformation to a verbal 

explanation is useful, because the language of psychiatric diagnosis helps place the 

elements of the picture in a clinical framework. However this transformation loses its 

visual integrity of form as it places the emphasis on what the patient tells us, or even 

what the therapist tells us, with a focus on interpretation of a covert message. In this 

respect it loses the integrity of psychiatric diagnosis, in which form is implicit 89 . This 

way of thinking about art has not been shown to be wrong, but it is difficult to test the 

truth of it because of the problem that we have to rely on what people tell us about their 

87 

But that interpretation may not be a translation has been recognised, David Maclagan (1989), op.cit.; 

H. Wadeson (1975) Is interpretation of sexual symbolism necessary? Arts in Psychotherapy, 

V.2(3-4):233- 

9. 

88 Franklin and Plitsky (1992) Problems of interpretation, op.cit. 

89 K. Jaspers (1963) 

General Psychopathology (Manchester U.P., 7th ed. Eng. Trans.). 

41

own paintings, or on interpretations from others, or even on speculative models. These 

alternatives are certainly subjective, probably incomplete and/or distorted, but they are 

virtually all we have to work with. Science has nothing to offer when it comes to 

symbols or unravelling of metaphor. There are no generally accepted methods for 

translation nor is there any sign of such a thing in the near future. Any picture can be 

interpreted in quite different ways by any two 'experts' each following their own theories 

and I know of no empirical evidence which supports one approach at the expense of 

another. There is evidence that there are loose associations between psychiatric 

disturbance and psychiatric indicators in pictures, but we cannot assume there will be a 

simple point for point mapping between verbally explained and non-verbal 

symptomatology, or even a direct relationship. 

How will research benefit from a psychopathology of art? 

As a general topic, there are a surprisingly high number of unknowns about art activity. 

We know very little about visuospatial cognitions except that understanding is not coded 

verbally. Advances in behaviourial science, the clearer definition of diagnostic 

classifications for mental illness and the greater accuracy of statistical procedures give 

hope for advancement in fields which have been traditionally problematical because of the 

interaction of confounding variables. 

Specifically, for art therapy to be seen to be effective: that is, to change the 

condition of the patient, psychotherapy needs to be closely related to topics in which the 

symptomatology is present. This has not yet been demonstrated in the effects of art 

42

therapy. It would markedly improve the psychiatric impression of art therapy to 

identify the conditions where art therapy is most relevant and also to identify the 

direction in which it would be most effective to go 90 . 

More speculatively, a technique which sets us on the road to map visuospatial 

functions may allow a clearer neurobiological understanding of disorder. The ability to 

describe symptomatology relating to widely differing cerebral locations would be of help 

to neurobiological research. There may be groups of disturbed patients whose condition 

may only be described effectively with visuospatial psychopathology and these may 

currently be misdiagnosed and treated. 

The need for another art assessment 

Research based on reported interpretive techniques and clinical observation of patient's 

paintings has proved difficult, partly because of ambiguities in the description. 

Confusion has also arisen in the description of diagnosis, outcome of treatments and 

research methodology. It is unlikely that single case studies will provide more 

information and there are no systematic assessment measures which explore the 

visual/verbal split. 

There seems no reason why there cannot be formal characteristics which 

correspond with particular diagnoses or symptomatology. Projective testing has not seen 

the formal elements of the artwork as the focus of systematic study, and evidence 

90 

Some of this is covered by Joan Woddis (1986) Judging by Appearances, Arts in Psychotherapy , 

V.13(2): 147-9; also Maralynn Hagood (1990) Art Therapy Research in England: Impressions of an 

American art therapist, Arts in Psychotherapy , V.17(1): 75-9. 

43

pointing to integrative or global judgments rather than specific indicators seems to 

indicate diagnosis of holistic disturbance. No evidence, however, supports the benefits 

of such separate diagnosis for psychotherapeutic treatment. Most studies of art have 

chosen not to study the artwork itself, but the message conveyed. This approach neglects 

possible non-verbal elements and also unconscious disclosures. 

The way forward 

If diagnosis matters, psychopathology matters. There are strong hints of systematic 

differences between two dimensional artwork from different groups of patients. We 

cannot understand completely how we use communication by studying only the meaning 

of what is communicated. In order to study meaningful pathology of visuospatial 

relations, it is necessary, not only to investigate what is communicated, but also how it 

is communicated. We must look at communication from the point of communication - the 

object of study. 

The first stage in establishing a measure must be to show the association of 

variables with already existing classifications of symptomatology. Previous literature has 

failed to do this. 

First Steps: Review of the literature 

So where do we go from here? How can past experience inform and develop a 

new approach unless the literature can be compared and classified? Recent suggestions 

include comparison of case study approaches to produce an overall view of qualitative 

44

work 91 . This suggestion has merit and this thesis uses impressionistic reports and case 

studies to generate comparative information as a complement to that of statistical studies, 

in order to provide a balanced view of the overall approach to the investigation of the art 

product in mental illness. 

Chapter 2 details the last 20 years of published research studies into two 

dimensional art by psychiatric patients. There are four reasons why this 20 year period 

is considered: 

1. Reviews and tables of pathological characteristics in the art of mental disorder from 

the more recent literature are neither systematic nor complete. 

2. The literature on diagnosis in art contains similar clinical observations about diagnostic 

groups. These generalisations are not supported by statistical or scientific research. The 

relatively recent refinement of more reliable diagnostic categories, clinical terminology and 

standards of reporting now permits a re-examination of some basic questions about 

psychiatric symptoms in art. 

3. Earlier research was based on clinical observation from many disciplines, later research 

aimed to develop theory and used a variety of illustrative background. 

4. The earlier literature has been adequately summarised before. 

91 A. Gilroy (1992) Research in Art Therapy, op.cit. p.238, "The experimentally based case study ... leads 

to data which is easily comparable with other case-studies and types of therapeutic intervention". 

45

Chapter Two: Review of the recent literature over 20 years. 

1. Is there a way through the jungle? relevant literature to this study 

Anyone who tries to review the literature on art and mental health encounters a huge 

body of literature, most of which is of poor quality. It is difficult to ascertain what is 

known about how the characteristics of mental disorder may manifest pathologically in 

the artwork of those affected since a published comprehensive and systematic review of 

the more recent literature over the last 20 years is not available. Chapter Two aims to 

collect all the available interpretable evidence of pathological characteristics in the artwork 

of psychiatric patients from published papers over the last 20 years. It was more 

appropriate to categorise the literature under methodology rather than concepts as the 

literature is constrained by the methodological difficulties which encumber it. 

The literature search method 

Studies met the following inclusion criteria: 

(a) Subjects for case and controlled studies were adults or adolescent: the evidence 

suggests that children's drawings show considerably more inter-individual 

variation than those of adults 92 , and there are also developmental complications, 

so it seemed sensible to narrow the subject categories in the comparable studies, 

to those whose motivations, psychopathology and clinical picture there is access. 

The impressionistic papers showed more range of illustration for general 

92 

Maureen Cox (1992), Children's Drawings , Harmondsworth: Penguin. 

46

principles, so some were included where their comments/experiences were 

relevant to the range; 

(b) Studies involved psychiatric patients 93 ; 

(c) Studies examined patients' drawings or paintings 94 . 

(d) Reports and papers in English. 

Articles for review were selected from a computerised search of 3 databases and from a 

manual search. The Psychlit, Medline and BIDS databases were searched using the 

following search criteria: 

(i) ART or DRAWING or PAINTING or PICTURE and THERAPY or 

PSYCHOPATHOLOGY or PSYCHIAT* or SCHIZOPHRENI* or 

PATIENT. 

(ii) Not STATE-OF-THE; not SYMPTOM-PICTURE; not CLINICAL-PICTURE; 

not CHILD* in DE; or PRESCHOOL in DE; or SCHOOL-AGE in DE; not 

PICTURE-SORT*. 

This strategy of searching anywhere in the abstract for significant words was not efficient 

as much had to be eliminated by eye due to the context, but assigned descriptors often 

did not mention artwork and studies of interest were classified under disparate categories. 

There were considerable overlaps from the BIDS database and Medline with studies 

93 There were many studies which used undiagnosed groups (including artists), sometimes described as 

'screened' for psychiatric disturbance - the procedure remained ambiguous as did the disturbance. The 

authors typically extrapolated their conclusions to psychiatric patients but as research this is meaningless, 

and such studies were excluded. 

94 But not drawing tests as part of a battery for a purpose which did not depend on the art score, for 

example IQ, ability. Pain drawings and maps and some drawings, e.g. cubes, were excluded as the task 

47

etrieved from the Psychlit, which produced many more hits. The first two sources were 

clearly inferior for this type of material which was well within the Psychlit domain and 

not a borderline subject. 

Because research in the field of art is not fully represented on databases, 

additional unsystematic searches of art therapy journals, books, citations contributed to 

it over the six year progress of this research. Through personal correspondence over four 

years of the writing, I undertook to discover any major omissions and a small amount of 

unpublished work was added. This review concentrates on published studies, but they 

have the advantage of accessibility and of peer review as that of uncatalogued journals and 

unpublished work is of uneven quality. Although, no doubt, not every paper is 

represented here, especially unpublished work, there is sufficient coverage of the area to 

make informed judgements and there is no reason to believe that overlooked papers would 

provide different information 95 . 

All art therapy journals referenced here were international, mostly American, 

There is only one British journal dedicated to art therapy, Inscape 96 , which is neither 

catalogued nor indexed. An unsystematic search of an incomplete collection at the local 

nursing library found articles which were mostly of speculative clinical interest and 

did not call for expression or personal input. 

95 

Studies in other languages, especially eastern Europe seem to have a greater emphasis on interdisciplinary 

therapy (impressions from abstracts). 

96 Produced by the British Association of Art Therapists. 

48

current professional and administrative issues. Articles generally lacked sufficient detail 

to contribute to this review 97 . 

Search Results 

This search resulted in 751 studies of which 428 met the inclusion criteria from the 

databases 98 and 24 were added from other sources 99 . To limit the data to that of direct 

relevance to research, these were classified into: 

impressionistic papers 253 

case studies 148 

controlled studies 51 

Complete references for all papers appear as tables of Authorities in Appendix 3. 

The literature was organised broadly and qualitatively as follows: 

1. Individualistic theories or philosophy of art and healing presented as impressions, 

which were examined for their perspective on the purpose of art in therapy (the 

impressionistic studies introduced a number of popular views about the nature 

of art and healing. It would be unwise, in an exploratory study, to exclude such 

97 A search by Bloch (1988) of 20 years of Inscape articles found only 13 research-based papers (reported 

by Gilroy 1992, Research in Art Therapy op.cit.) reflecting the prelevant view that "research has little 

impact on psychotherapy practise". 

98 Database abstracts were first screened for inclusion criteria for foreign papers difficult to obtain. Suitable 

papers were obtained from British Library resources. Only a few papers were of very limited circulation 

and were omitted but generally papers from the large databases were accessible. 

99 Only one was a controlled study. 

49

a major proportion of the study material without at least investigating what it had 

to say) 100 ; 

2. Studies of artists were separated from the case studies because, although many 

the same assumptions and speculative impressions appeared, they were reported 

differently than those of other patients; 

3. Case studies (including series studies) were examined for their common underlying 

concepts and for generalisable information on imagery or interpretation; 

4. Controlled studies were examined for the common underlying concepts and for 

the generalisability of their findings. 

What we need to know from the literature: 

Two kinds of information were required from this review of the literature: 

1. What kind of techniques, orientation and concepts are involved in art therapy so 

that we may allow for it. 

2. What kind of characteristic is attributed to which set of painted marks. 

Problems of extracting this information 

The traditional anti-scientific bias of art literature, results in a heavy emphasis on the case 

study and otherwise poor methodology. The problem of how to classify the techniques 

and concepts sympathetically is complicated because there is confusion in reports of 

100 The type of classification was broadly qualitative and thematic: originally impressionistic studies and 

opinions were separate from speculation and theories including psychoanalytic theory, but they were 

ultimately combined because distinctions were blurred and their communications indistinguishable. 

50

therapy between what is generally accepted as established theory and the opinions and 

beliefs of the author. Moreover, access to the data is impeded because it is difficult to 

separate what actually happens from how it is interpreted. This is important because it 

affects the types of questions investigated. For example, the question 'where on the 

surface of the paper does the patient express?' is not generally addressed. The main 

assumption, that it is not on the surface of the paper, but from the interaction of the 

client's associations with the work, shapes the presentation of the report and the main 

direction of research towards content analysis. Of course, therapy encourages projection 

of emotions onto transitional objects 101 , and this may include imagery in artwork, but as 

research it is often difficult to form any conclusions about what is reported. Reports 

often neglect much practical detail on what actually happened on the paper to generate 

the interpretation because they are not concerned with point 2 of 'what we need to know' 

- above, but represent the main concerns of the literature with point 1, so this section 

concentrates on the first part of what we need to know, the concepts and orientation. 

Why consider impressionistic reports? 

If the search were limited to properly controlled scientific criteria, very few studies 

would qualify. The subsequent picture would therefore be unrepresentative of the bulk 

of literature. To neglect these voices is to neglect some serious, if not structured or 

proven conclusions from this collected experience about the way art is thought to reflect 

101 

from psychoanalytic theory: an object or person viewed as a psychological bridge, allowing a person 

to make a transition from primary narcissism to a mature emotional attachment to others (adapted from 

A.S. Reber (1985), A Dictionary of Psychology , Harmondsorth: Penguin). 

51

psychopathology, something which is not at all clear from the controlled studies. The 

hypotheses and direction of the controlled studies are often takedn from this collected 

experience and there are many assumptions derived from clinical experience which are not 

at all obvious, especially in the interpretation of results. 

Impressionistic and theoretical studies 

Description of the range of studies included in this breakdown 

There were 253 general impressionistic papers or papers which reported theories or 

personal experiences to show the therapeutic effects or benefits of art. These papers 

differed from research studies in that they focused on the explanatory, speculative and 

theoretical not the particular. They discussed typical work of patients and tried to 

explain their conclusions or argued different theoretical standpoints. The purpose of this 

breakdown and analysis was twofold: primarily, to identify the way therapists 

considered that art produced by a patient contributed to beneficial change in the patient; 

secondarily, to identify the theoretical basis of explanations so that the underlying 

concepts may be explored and to test the relationship of explanation or theory to 

particular benefits gained. 

Characteristics of each paper were summarised. There were 5 categories of 

information common to most papers 102 and the discussions centre around the explanation 

of the value of art to therapy (complete descriptions of categories appendix 1): 

102 A complete description of categories appears in appendix 1. 

52

Descriptive information about the study, whether it gave examples of 

patient's work, techniques, advice or discussed experiences or theories; 

Diagnoses of the patient group; 

Theory of the study: psychotherapeutic, psychoanalytic, diagnostic or 

assessment, environmental, social or psychosomatic; 

Author's personal explanation of how art promotes therapeutic 

change: as an illustration or signpost for the therapist, as innately 

curative, as a vehicle for insight for the patient, as a vehicle for transfer of 

learning, as an environment, or for communication. 

Benefit to the patients: expression of feelings, communication, symptom 

relief or healing, developmental or social, body awareness, through 

relationship. 

The purpose of this analysis was to explore how the collected observations of these 

authors' experiences of the effect of art in therapy varied with the conditions of therapy 

and the diagnosis; that is, how consistent the effect was. 

Analysis of 253 impressionistic and theoretical papers according to their theories of the 

value of art in therapy. Table 1 

D 103 

I 

A 

G 

all 

studies 

freq % 

sign 

posts 

freq % 

self 

healing 

freq % 

group 

interact'n 

freq % 

53 

insight 

freq % 

transfer 

of skill 

freq % 

communi 

cation 

freq % 

1 15 6 6 6.5 1 3 1 5 2 14 1 5.6 3 21 1 2 

2 24 9.5 14 15 1 3 1 5 0 0 3 17 1 7 4 7 

no 

explanation 

freq % 

103 Diagnostic group: 

1 Schizophrenic; 2 Traumatic stress/sex abuse; 3 Substance abuse; 4 Psychotic; 5 

Alzheimer's/Dementia/Brain Damage; 6 Emotional disorder; 7 Depression; 8 Conduct Disorder; 9 Normal; 

10 Retarded; 11 Undifferentiated psychiatric patients; 12 Sex Abnormalities/Abusers.

3 13 5 5 5 1 3 2 10 0 0 2 11 0 0 3 5 

4 12 5 4 4 4 11 1 5 1 7 0 0 1 7 1 2 

5 9 4 0 0 0 0 0 0 0 0 2 11 1 7 6 10 

6 13 5 2 2 4 11 2 10 1 7 0 0 2 14 2 3 

7 12 5 5 5 1 3 0 0 1 7 1 5.6 0 0 4 7 

8 4 1.6 1 1 1 3 0 0 0 0 1 5.6 0 0 1 2 

9 3 1 3 3 0 0 0 0 0 0 0 0 0 0 0 0 

10 15 6 2 2 2 6 1 5 2 14 3 17 0 0 5 8.5 

11 126 50 48 52 20 55.5 11 55 7 50 5 28 6 43 29 49 

12 7 3 2 2 1 3 1 5 0 0 0 0 0 0 3 5 

100% 253 92 36 20 14 18 14 59 

Did the effect vary with diagnostic group? 

Table 1 shows that there were far more papers related to undifferentiated psychiatric 

patients (diagnostic group 11) than to any specific diagnosis. The most common 

explanation of the function of art in psychotherapy for undifferentiated patients and for 

most other diagnoses was that the patient's work was thought to show 'signs' which 

illustrated and provided access to the trauma site for the therapist. No explanation was 

specific to a particular diagnostic group but there were indications that: signpost 

explanations were more common for patients with traumatic stress, schizophrenia, 

depression and non psychiatric patients; healing explanations were more common in 

emotional disorders; and few papers offered explanations of effect for brain disease, brain 

damage or for retardation. 

So, we can conclude, according to the collected experience of these authors, the 

function of art in therapy was not determined by diagnosis. 

54

Did the effect vary with conditions of the study? 

Origin: The papers were divided between whose which offered arguments or presented 

an opinion and those offering an experience or reporting a programme. Similar 

percentages offered no explanation and insight explanations. More opinion studies 

offered signpost and healing explanations and many more communication explanations, 

but experience studies offered more group interaction and transfer of skill explanations. 

Description of study: Only 14% of papers used case material, the majority presented 

either illustrative examples or gave no coherent explanation. Nearly half the papers which 

described techniques gave a signpost explanation consistent with their advice to generate 

them. Advice was more evenly distributed, but just over half gave signpost or healing 

explanations. More than half the general recommendation for art papers offered either 

signpost or healing explanations, but most of the rest offered no explanation at all. 

Table 2a: Environmental description for 253 impressionistic and theoretical papers 

according to the explanation of therapeutic art value. 

Origin of study 

material 

opinion 

discussion 

experience 

programme 

description of study 

case material 

technique 

advice 

general recommend'n 

theoretical base 

psychotherapeutic 

psychoanalysis 

environmental 

all 

studies 

n=253 

freq % 

94 37 

44 17 

90 36 

25 10 

35 14 

96 38 

95 37 

27 11 

77 30 

39 15 

53 21 

sign 

posts 

freq % 

40 43 

14 15 

36 39 

2 2 

11 12 

42 46 

30 33 

9 10 

35 38 

18 20 

10 11 

self 

healing 

freq % 

15 42 

7 19 

14 39 

0 0 

4 11 

6 17 

20 56 

6 17 

10 28 

3 8 

11 31 

55 

group 

interaction 

freq % 

4 20 

4 20 

9 45 

3 15 

4 20 

9 45 

6 30 

1 5 

6 30 

2 10 

4 20 

Insight 

Freq % 

5 36 

3 21 

4 29 

2 14 

2 14 

8 57 

4 29 

0 0 

6 43 

5 36 

1 7 

transfer 


freq % 

6 33 

1 6 

7 39 

4 22 

2 11 

9 50 

6 33 

1 6 

6 33 

1 6 

6 33 

communi 

cation 

freq % 

8 57 

3 21 

3 21 

0 0 

1 7 

2 14 

11 79 

0 0 

4 29 

5 36 

1 7 

no 

explanation 

freq % 

16 27 

12 20 

17 29 

14 24 

11 19 

20 34 

18 30 

10 17 

10 17 

5 8 

20 34

social/developmental 

energy theories 

assessment 

19 7 

31 12 

34 13 

4 4 

9 10 

16 17 

2 6 

8 22 

2 6 

explanation - how it 

works 

no's in each group 92 36 36 14 20 8 14 5 18 7 14 5 59 23 

56 

2 10 

4 20 

2 10 

0 0 

0 0 

2 14 

1 6 

2 11 

2 11 

1 7 

2 14 

1 7 

Complete descriptions of value to therapy categories appear in Appendix 1. 

Theoretical base: The most popular theoretical base was psychotherapeutic. Half the 

environmental and the developmental studies offered no explanation and most of the rest 

used signpost or healing explanations. Despite the theoretical orientation of the 

discussion or therapy, the signpost explanation was more prevalent than any other. The 

assessment methods predictably concentrated on signposts, but a considerable percentage 

of psychotherapeutically orientated papers explained the function of art as an energy or 

power derived through the therapist or through the patient or through communication 

with the unconscious. However, where the discussion centred on the mystical conduction 

of healing power through the therapist to the patient or where the art environment and 

the practice of art itself was thought to be therapeutic in some way, there was still an 

equal focus on the signpost explanation. 

Table 2b: Commonly claimed benefits for 253 impressionistic and theortetical papers 

according to explanation of the therapeutic value of art 

Benefits to patient 104 

express feelings 

develop skill 

communicate 

self awareness 

symptom relief 

relationship 

all 

studies 

freq % 

156 22 

107 15 

159 22 

125 18 

140 20 

22 3 

sign 

posts 

freq % 

72 26 

30 11 

64 23 

43 16 

53 19 

10 4 

self 

healing 

freq % 

19 19 

12 12 

21 21 

20 20 

24 24 

2 2 

group 

interaction 

freq % 

12 20 

12 20 

13 21 

11 18 

11 18 

2 3 

Insight 

Freq % 

7 17 

7 17 

8 19 

8 19 

10 24 

1 2 

transfer 


freq % 

8 15 

8 15 

10 19 

15 29 

9 17 

2 4 

communi 

cation 

freq % 

9 21 

4 9 

14 33 

8 19 

6 14 

1 2 

9 15 

6 10 

9 15 

no 

explanation 

freq % 

29 20 

34 24 

29 20 

20 14 

27 19 

4 3 

104 There were four measures of benefits to patients allowing 4 answers in any order. Frequency and 

percentage here represent totalised positive answers to reduce non-answering bias: only 5% (13) of studies 

did not describe one benefit for the patient, but many studies gave two or more benefits.

Benefits: The most common benefits of art were given as expression of feelings, 

communication and symptom relief, with little emphasis on the relationship as a benefit 

in itself. The majority of studies, no matter which benefits were listed, including 

relationships, offered a signpost explanation; the next most common explanation was of 

healing. 

Summary 

The main purpose of this analysis was to clarify the function of art in therapy and also 

to find out if explanations changed with different diagnostic group, whether explanations 

derived primarily from the opinion of the therapist or through experience changed with 

the theoretical base of the therapy, and whether different benefits were apparent in each 

explanation. 

No explanation stood out within particular diagnoses. The explanations were 

independent of the theoretical base of the therapy/discussion and did not vary with 

different benefits claimed for the patients. Where the paper dealt with a general 

recommendation for art or gave advice, there were more healing explanations, but on the 

whole, signpost explanations were more common. Papers which relied on the opinion of 

the therapist, rather than those which related specific experience or described a 

programme, advanced many more communication explanations and slightly more signpost 

and healing explanations, focusing on content in the picture. Signpost explanations were 

57

advanced from all types of papers but mostly from those with a psychotherapeutically 

based theory and least from those with social or developmental base. 

The self healing explanation, which is obfuscated by the terminology in which it 

is swaddled, seems to derive from Jungian theory of contacting the unconscious, but sees 

the therapist as a conductor for a force or power of healing. This is not an explanation 

but a speculative model. Authors who offered these explanations generally gave advice, 

came from a psychotherapeutic or an environmental base and claimed all benefits equally. 

Explanations other than signpost or healing were marginal and equally thinly 

distributed. All explanations were independent of any variable examined here. The 

papers which described an experience or a programme dealt mainly with group interaction 

and transfer of skill, looking at formal measures. 

Conclusion 

This analysis has clarified the terms and general area of interest, but has not provided an 

explanation of the function of art in psychotherapy, nor any clearer idea of the area of 

operation expected for different theories. The primary benefits to patients were 

expression of feelings, communication and symptom relief. It is assumed that therapists 

have access to a means of decoding personal associative material, but consistent 

explanations were not provided on how this would be accomplished and practically based 

reports dealt with the communication value of art. This is not unexpected in such general 

material, but is irrelevant to the main issue here of exactly what is decoded by the 

58

therapist to aid the therapy or assessment. This issue is further explored in the next 

section which deals with case and controlled studies. 

We can say then that the direction of these papers indicates there is change in the 

patient, which parallels a change in the artwork, and that generally the explanations do 

not relate the change to the methods to direct the change. The therapist reports that 

artwork produced by the patient is translated but the method of translation and how it 

produces change in the patient is not discussed. 

Artists: are they special cases? 

Aesthetic interpretation of psychiatric art by art historians 

There have been what looks like points of convergence between aesthetics and 

psychology, but which are, in reality, similarities in superficial language. Some historians 

have adopted psychoanalytical and psychological jargon, but most of this is 

uninterpretable in a psychoanalytic sense. Various psychoanalytical perspectives on art 

have been given, generally by medical people. Few historians have tackled this area, 

probably with good reason, as the assumption that there must be an essentially normal 

way of painting 105 , and that divergence would have pathological roots, seems 

questionable. Griselda Pollock and others 106 have tried to answer these kinds of 

questions but most work is concentrated on trained artists. 

105 Exemplified by a painting everyone understands - such as Constable's 'The Haywain'. 

106 

Some examples of recent readable texts which seriously attempt to unravel or question unconscious 

symbolic material (but all use artistic illustrations): Griselda Pollock (1988) Ch.6, Women and sign: 

psychoanalytic readings in Pollock, Vision and Difference , London: Routledge pp.120-154; G. Pollock 

and J.M. Ross, (eds.), (1988) The Oedipus Papers , Conn: Madison; Jim Hopkins (1992), Psychoanalysis, 

interpretation and science in J. Hopkins and Anthony Saville, (eds.), Psychoanalysis Mind and Art: 

59

Art therapists begin their career from art training and this influences the ways in 

which they try to make sense of a picture 107 : the search for iconography, the borrowed 

language of art criticism in content appraisal 108 . 

Very little art historical analysis looks at the broad discrete forms of the actual 

work; the language is only relevant and meaningful in relation to other objects. Critical 

descriptive language is used to describe a continuum of iconographical, contextual, social 

and aesthetic perspectives. 

The romanticism generally put forward about artists adds to false assumptions 

and myths that grow up around them. For example, popular opinion sees Van Gogh as 

a typical example of a mad artist, but none of his famous pictures were painted at the 

height of his madness. It is highly unlikely that the crow picture by Van Gogh, 

constantly pictured in movies as his last work before he shot himself, actually was his 

last. Louis Wain's pictures of cats are often quoted as showing the process of degeneracy 

- as the form dissolves, the madness progresses. But who is to say that he was not trying 

to portray or simplify his ideas? In the case of Richard Dadd, there was no visual 

perspectives on Richard Wollheim , Oxford: Blackwell; Peter Fuller (1980) Art and Psychoanalysis , 

London: Writers Readers; Donald Kusbit, Signs of Psyche in Modern and Postmodern Art , Cambridge: 

Cam.U.P. 

Also perspectives on how we understand art: John M. Thorburn (1925) Is art symbolic? (pp.73-79) and 

Art as the relation of outer and inner (pp.151-6) in Thorburn, Art and the Unconscious: a psychoanalytical 

application to a problem of philosophy , London: Kegan Paul; Michael J. Parsons (1989) How we 

understand art: a cognitive developmental area of aesthetic experien ce , Cambridge U.P. (2nd ed. original 

1987) describes 5 stages of perception: favoritism, beauty, expression, style, form. 

107 C.F. Nodine, P.J. Locher and E.A. Krupinski (1993) The role of formal art training on perception and 

aesthetic judgement of art comparisons, Leonardo V.26:219-227 proved differences in perceptions/eye 

movements of people with art training, and without. Main finding was concentration on thematic patterns 

from art trained, and focus on representational issues/accuracy, without. 

108 The requirement of an art degree as a primary qualification for would-be art therapists has provoked 

concerns that too much emphasis is placed on the aesthetic and the mistaken but pervasive concept of the 

creation of art was itself therapeutic, J. Birchtnell (1981), Is Art Therapeutic? Inscape I: 10-13. 

60

counterpart of the thought disorder apparent in his written notebooks 109 . The well 

known collections of psychiatric art work which were used to illustrate psychopathology 

were by selected exceptionally talented painters studied for research. The knowledge 

cannot be separated from the intention. Work by naive artists is personal, rarely involves 

an audience and does not operate in a deliberate way to research and develop the work. 

It does not contribute to art because it does not intentionally refer to it and thus it cannot 

be placed on the continuum. Therefore, for work by non-talented patients, art critical 

interpretations, which vary with the theoretical stance of the interpreter, are not 

appropriate. 

The assumption that a picture is a sort of print-out of how the world is seen and 

that some unconscious force paints through the artist must be wrong. The best 'outsider' 

artists, even though they might lack training and technical skill, show a search for 

organisation, considerable awareness of balance and awareness of the world and that 

knowledge is communicated through their pictures. Studies of art and perception show 

that in order to construct an image of power and balance a great deal of awareness is 

needed 110 . Making a picture is a constructive process and a complicated one, with 

metaphors such as paint standing for light and 3d objects. 

Studies of psychiatrically disturbed artists tended to focus on the discussion of 

whether there was something about mental illness itself which contributed to artistic 

109 

from J.M. MacGregor (1989), The Discovery of the art of the insane , N.J.:Princetown U.P. 

110 

Ernst Gombrich (1977) Art and Illusion: a study in the psychology of pictorial representation , Princeton 

NJ: Phaidon (5th ed. original 1960); J.J. Gibson (1980) foreward in M.A. Hagen, (ed.), The Perception 

of Pictures V.1, New York: Ac. Press, and for an explanation that cognition must be involved in moving 

between images to interpret spatial relations: Shona Rogers and Alan Costall (1983), Pictorial perception 

and Gibson's concept of information, Leonardo , V.16(3):180-2. 

61

talent and therefore do not fit in with other reports. The purpose of this analysis was 

to examine the commonalities between 29 studies of artists and investigate possible 

generalisation. The impressionistic interpretations of pictures or studies about artists 

were summarised (case summaries table 3, appendix 2); 18 were case studies and 11 

discussions. There were 2 types of discussion: 

(1) Whether or how work was creative or aesthetic, and 

(2) that it illustrated mental illness: 

The main focus was on illustration of psychosis or depression (15 studies) and 

of how psychosis affected or enhanced creativity of the mentally ill. 20 studies reported 

that mental illness had a positive effect on the creativity or art of the subject and all 

implied that the practice of art had a 'healing effect', by which they meant that the 

practise of art was seen to relieve the artist of a mental burden. Descriptions were poor 

but generally some expression of emotion and some form of catharsis was reported. 6 

studies reported no effect and only one reported a negative effect. They differ from the 

usual case study in that: 

no other type of medical writing used so little information; and 

what was used was selected, or adopted a subjective view of the product of 

mental illness as a separate issue. 

These works were assumed to deviate from a standard of normal, but, at the same time, 

perfectly normal modern art was also shown to possess the same attributes that were 

described as indications of psychopathology. All studies here concentrated on illustrated 

diagnostic indications of dissolution, fragmentation or disorder of thought and 

62

communication, but ignored the fact that these paintings apparently represented highly 

successful communications of content. The act of illustrating coherently and effectively 

in a familiar medium was not usually impaired. 

Conclusion 

Artists are hard to work with and the meagre evidence suggests art therapists do not feel 

comfortable with their technical skill. It is difficult to assess how many actually 

succeeded in using art for therapy (despite the reporting) as the analytic process rests on 

an unconscious use of compositional relationships, where an artist is all too aware. The 

evidence suggests artists too are uncomfortable with this use of their work 111 

(professionally, their own explanations are rarely accepted as the best interpretations). 

The style and aim of these studies relates to speculations on a possible positive 

aesthetic effect on creative output, thus is contradictory to that of studies of untrained 

psychiatric patients which tries to identify visual elements of individual 

psychopathology from the work. That art has therapeutic qualities is mentioned, but 

although the benefits of expression as a way of externalising conflict and communicating 

with the unconscious are described in both cases, there seems no supporting evidence 

relating concrete visual elements to remission of symptoms or better communication in 

other forms for the artist. 

111 

Leslie Gertler (1985) Therapy with an aging artist, Am. J. Art Therapy , V.23(3):93-9 (study 28), 

recommends methods of removing the concerns of content, as does D.C. Muenchow, J. Aresenian (1974) 

An artist in turmoil during art therapy, Am. J. Art Therapy , V.14(1):18-23 (study 29); The author of study 

9, too, advises readers that the work often goes beyond the interpretation of the artist. 

63

2. Research studies 

There were two kinds of studies which offered evidence to support their authors' 

conclusions: 

1. 119 case or series studies presented examples of work and interpretations or 

extrapolations of this evidence. This kind of study was oriented towards 

exploring and developing the concepts, techniques and orientation of art therapy. 

2. 51 studies of groups systematically compared artwork with that of another group. 

This kind of study attempted to define characteristics common to specific 

groups of patients. 

Section 1. Comparison method for case studies 

Much of the information presented in these studies could not be classified because of the 

personal way it was presented: studies presented a section of a personal history, 

individual to the client; the information given was necessarily selected by the author to 

contribute to their interpretation and thus was not complete. Data was referred to that 

was not presented (other pictures or feelings or comments) and the extent of material not 

presented could not be estimated; thus the interpretation by the author was personal, 

subjective and not generalisable. Statistical analysis of such description would be artifice. 

Organisation of this section 

64

The purpose of this analysis is to explain how art concepts and techniques benefitted the 

individual and whether studies identified diagnostic characteristics from psychiatric 

paintings. There were 4 purposes of making art defended in this literature: 

1. 67 studies presented illustrations of the image drawn by the client and concluded 

that the primary benefit in artmaking was the expression of feelings. 

2. 31 studies presented illustrations of themes or signs in the artwork of the client 

and identified typical diagnostic characteristics. 

3. 17 studies presented illustrations of the image drawn by the client and concluded 

that the primary benefit in art therapy was the therapeutic relationship, within 

which 8 concluded that the primary benefit in artmaking was to occupy the 

patient in engaging activity within a supportive environment. 

4. 4 studies identified a change in the client's behaviour whilst undertaking art 

therapy. 

Descriptive information is presented and discussed through 5 categories of information 

common to all studies 112 . The discussions centre around the primary purposes of art- 

making: the therapy value to the patient, and which variables are independent: 

Descriptive information about the subjects: age (adolescent, adult, old), 

sex, diagnosis (1-15 see table 1, note 2, for details); 

Orientation or intentions of the researcher: not known, cognitive, 

projective, occupational, analytical; 

112 A complete description of all information categories appears in Appendix 1 of this thesis. 

65

Method of study or description of technique: projective, psychoanalytic, 

expressive, occupational, or comparative; 

Form of study - what is described or interpreted: content, formal or 

stylistic elements, mix of content/form, behaviour or verbal; 

Benefit to the patients: cathartic/reflective, communication, 

healing/symptom relief, developmental or social, relationship. 

Accordingly information is presented by levels of benefit identified, which can be 

considered as results for the purposes of this analysis. 

Form and content 

This division is made to differentiate analysis of form, used here to distinguish 

descriptions of the local qualities of elements and regional qualities of complexes within 

a visual design from descriptions of internal relations among the elements and among the 

complexes within the object; i.e. what the painting represents to the individual, how that 

representation is associated with other phenomena in the mind of the patient; in other 

words, the meaning, here described as content analysis. This discrimination has not been 

successfully made in the literature but it is crucial to determining the subjectivity of the 

analysis. 

Expression of feelings. Description of the range of explanations within this term. 

67 studies concluded that the primary benefits of artmaking for the patient was in "the 

expression of feelings". The term was ambiguous: it was used by the majority of papers 

66

and indeed throughout the literature without further explanation to identify a goal for 

therapy and also as a benefit in itself. Few papers questioned whether feelings were 

expressed or what expression was or how they identified that it had occurred; the 

identification was always global and subjective. Thus these studies were separate from 

those which offered specific interpretations for expressive content, which appear later 

in this thesis. The interpretation of expression of feeling was often not particularly 

related to the drawing medium, but rather to the personal experience of the 

therapist/researcher. These studies argued the importance of psychotherapeutic method; 

they illustrated their papers with drawings by the patient, but were vague as to specific 

exemplars; they confirmed personal theories with reference to the illustrations and 

emphasis on the relationship with the therapist. They especially referred to the 

idiosyncrasies of the individual unconscious mind of the patient. The purpose of this 

analysis was to identify how patients are said to express feelings through art and in what 

way their art output contributes to the benefits which are said to derive from that 

expression. 

Who benefits? 

Demographics: The total number of subjects over the 67 studies was 180: 28 studies 

dealt with males, 26 with females and 13 with mixed groups. One study used 42 

subjects, but 67% of studies (n=45) were single cases, the other 21 had up to 10 subjects. 

Age ranged from 8 to 90 years, but only 37% (n=21) studies dealt with under 16 year 

67

olds and only 2 with over 60s. The typical subject was therefore a case study of an adult 

with affective disorder. 

Table 1 showing diagnostic groups for case studies by levels of benefits where the 

primary purpose of artmaking was the expression of feelings 

D 113 

I 

A 

G 

1 

2 

3 

4 

5 

6 

7 

10 

All studies 

n=67 

freq % 

9 13.4 

13 19.4 

4 6 

9 13.4 

5 7.5 

13 19.4 

11 16.4 

3 4.5 

no benefit 

n=8 

freq % 

2 25 

0 0 

0 0 

2 25 

2 25 

1 12.5 

1 12.5 

0 0 

catharsis 

n=16 

freq % 

2 12.5 

5 31.3 

2 12.5 

1 6.3 

1 6.3 

2 12.5 

2 12.5 

1 6.3 

68 

communi 

-cation 

n=20 

freq % 

1 5 

5 25 

0 0 

3 15 

1 5 

6 30 

3 15 

1 5 

healing 

n=10 

freq % 

1 10 

1 10 

1 10 

2 20 

0 0 

2 20 

3 30 

0 0 

social/ 

developm't 

n=8 

freq % 

1 12.5 

2 25 

0 0 

0 0 

1 12.5 

1 12.5 

2 25 

1 12.5 

relation 

ship 

n=5 

freq % 

1 20 

0 0 

0 0 

1 20 

0 0 

1 20 

0 0 

0 0 

There was a broad range of disorders treated with no particular bias to any diagnostic 

group. Cathartic benefits were particularly apparent in people with emotional trauma 

and depression, who also showed higher communicative benefits but the other 

beneficiaries showed more range of distribution. 

Results: From Table 2, overleaf, the majority of the studies (54%, n=36) recorded the 

primary benefits as communicative and cathartic-reflective. These were achieved by 

researchers who were oriented towards projective techniques, who used these techniques 

to facilitate the expression of emotion (for communication there was an equal use of 

educational methods) and analysed the content of the finished work. Secondly came 

113 

1 Schizophrenia 

2 Emotional trauma 

3 Drug/Alcohol addiction 

4 Psychotics or phobias 

5 Brain disease/damage 

6 Adjustment disorder/emotional reaction 

7 Affective disorder/depression 

10 Retarded

healing or symptom relief which was achieved through the same combination although 

there was more emphasis on expression in behaviour in the analysis, but not as an 

intended method. Thirdly, developmental-social benefits were also claimed for 

educational methods and the therapeutic relationship for projective methodology, but 

descriptions of expressive form were inconsistent with this aim, they were almost 

exclusively behavioral for relationship and mostly for social. 

Descriptive statistics for whole study, interactive variables. Table 2, showing 

consistency of the research by levels of benefit from expression of feelings 

LEVELS OF 

BENEFIT -> 

Study variables 

Sex 

male 

female 

mixed 

Orientation 

not known 

cognitive 

projective 

social/occupational 

analytical 

Method of study 

illustrative 

proj./expressive 

behaviour 

psychoanalytic 

educational/exp.ce 

Form of study 

formal/style 

content analysis 

mix content/style 

behaviour 

verbal analysis 

other 

All 

Studies 

n=67 

freq % 

28 41.8 

26 38.8 

13 19.4 

3 4.5 

6 9 

38 56.7 

9 13.4 

11 16.4 

4 6.0 

39 58.2 

4 6.0 

7 10.4 

13 19.4 

1 1.5 

33 49.3 

5 7.5 

17 25.4 

9 13.4 

2 3.0 

No 

benefit 

n=8 

freq % 

2 25 

4 50 

2 25 

1 12.5 

0 0 

2 25 

2 25 

3 37.5 

1 12.5 

5 62.5 

1 12.5 

1 12.5 

0 0 

0 0 

1 12.5 

0 0 

4 50 

0 0 

0 0 

Cathartic 

benefit 

n=16 

freq % 

10 62.5 

4 25 

2 12.5 

1 6.3 

2 12.5 

12 75 

0 0 

1 6.3 

1 6.3 

9 56.3 

3 18.8 

2 12.5 

1 6.3 

0 0 

9 56.3 

1 6.3 

4 25 

2 12.5 

0 0 

69 

comm'n 

benefit 

n=20 

freq % 

9 45 

8 40 

3 15 

1 5 

3 15 

12 60 

1 5 

3 15 

2 10 

11 55 

0 0 

1 5 

6 30 

1 5 

8 40 

3 15 

4 20 

3 15 

1 5 

healin 

g 

n=10 

freq % 

3 30 

5 50 

2 20 

0 0 

0 0 

6 60 

3 30 

1 10 

0 0 

7 70 

0 0 

2 20 

1 10 

0 0 

4 40 

1 10 

3 30 

2 20 

0 0 

develo 

pment/ 

social 

n=8 

freq % 

0 0 

5 62.5 

3 37.5 

0 0 

1 12.5 

3 37.5 

3 37.5 

1 12.5 

0 0 

3 37.5 

0 0 

1 12.5 

4 50 

0 0 

2 25 

0 0 

3 37.5 

2 25 

1 12.5 

relation 

ship 

n=5 

freq % 

3 60 

1 20 

1 20 

0 0 

3 60 

0 0 

0 0 

2 40 

0 0 

4 80 

0 0 

1 20 

0 0 

0 0 

1 20 

0 0 

4 80 

0 0 

0 0 

Primary benefit 8 12 16 24 20 30 10 15 8 12 5 7.5 

The main purpose of this analysis was (a) to determine the concepts and techniques of 

studies which claim to produce expression of feelings, and (b) to describe the pictorial

form of this expression and how it was therapeutic. The form of expression was 

predominantly through content of the picture and the primary benefits were cathartic 

release of emotion and communication. The overriding orientation of the research was 

towards content analysis through projective methodology. However, there were 

indications that other methods seemed to produce similar benefits. 

The table does not indicate whether the orientation of the research was consistent 

in method and results. Accordingly contingency tables were produced 114 , from which 

Chi-square results (summarised below in table 3) showed no correlations between the 

description, the method of study used, the form of expression or the benefits claimed. 

Table 3: Chi square results for association between method of study, form of expression 

and benefits for 67 studies which claimed 'expression of feelings' as the main benefit for 

the use of Art with psychiatric patients. 

Orientation of researchers _ 2 = 26.29640 

df = 20: p

stringent cutoff point of p

Content: 16 studies reported changes or signs in the themes, the subject matter or what 

was represented. 43 patients (22 males and 21 females) were described 115 . 11 were 

single case studies and the diagnostic groups were fairly evenly distributed. The studies 

interpreted common themes in drawings by the same patient. They focus on two types 

of information: 

(1) the therapeutic effect of the treatment, and 

(2) description of the characteristics of the subject's pictures and associations with the 

diagnosis. 

Table 4 (Appendix 2) summarises demographic, diagnostic, pictorial and interpreted 

information. 

How Art Promotes Therapy: The art therapist decodes and sometimes co-author a 

private language, the complexity of which may provide a way of avoiding direct 

confrontation with an emotive issue or at least distance. The interpretation thus also 

becomes a product of both the therapist and the patient. The art begins as a device for 

indirect communication until therapy ceases to be a non-verbal event. The therapeutic 

value may be similar to desensitisation therapy in that it becomes easier to face the 

underlying issue which is producing the psychological damage by repeated exposure to 

analogues of it. 

Are there consistently meaningful systematic signs in content of the art work? 

115 2 studies (15 and 16) described paintings over many years in a variety of settings. 

72

There were no specific visual constructs to which a particular meaning could be 

assigned and in fact observable representations were not generally discussed. These 

studies mostly described common patterns 'read' by the therapist 116 : a struggle 

progressing through the guidance of the therapist which generally related to inner 

resolution of the immediate situation of the patient, especially to body image. Symbols 

were interpreted in 11 out of 16 studies: for example, the metaphor of broken land was 

said to correspond to body image from a male with brain injury 117 ; the mouth as a symbol 

for transition through childhood from an autistic adolescent 118 ; and in psychotics, a 

struggle for separation 119 and egocentrism 120 ; ambivalence by a foster child as a reaction 

to his life changes 121 ; metaphors of loss from an alzheimer's patient who died of 

cancer 122 ; symbols of realistic hopes in depression 123 and less recognisable imagery from 

aphasics 124 . 

116 

Shown graphically by B.M. Cohen and Carol, T. Cox (1989) (Breaking the code: Identification of 

multiplicity through art productions, Dis. Progress in the Dissociative Disorders , V.2(3):132-7), (Table 

4, study 16) who identify 10 categories described as thematic, structural and process (but all fit the 

content/thematic category in this review) which relate directly to the language and techniques of 

psychotherapy. 

117 Table 4, study 8. 








73

Pictures by bipolar depressives show gloomy colours and themes (minus 

phenomena) in the depressive phase and (plus properties) bright colours in the manic 

phase 125 , which tends to support the illustration-of-the-illness hypothesis assumed by 

many of the authors, but it will be seen in the report from observable characteristics 

(next) that pictures by unipolar depressives and schizophrenics often show these same 

qualities 126 or, equally, bright colours and happy themes 127 . 

Where studies described the outcome of therapy, they tried to show that changes 

in the theme of the artwork parallelled improvement in the patient 128 . Additionally, the 

element of hostility, discussed in 8 studies (indicated on table 4 by *), probably 

represents denial, the initial opposition to the therapeutic alliance, which provides a 

supportive structure for confrontation. These conclusions suggests that thematic 

interpretation of pictures relate to therapy rather than the illness. 

Conclusion for content studies 

There is no agreement as to how the meaning of what is represented is extracted, or 

consistency of application to further examples, although Cohen and Cox (1989) have 

made a promising start. Categorisation of signs can only be attempted when terms and 

methods are systematic or consistent, but terminology, methods and theoretical base vary 

in all studies considered here. Much background knowledge is also assumed on the part 

125 Table 4, studies 6 and 12. 

126 Table 4, study 5; Table 6 studies 20, 23, 24. 


128 Table 4, studies 3, 5, 8, 9. 

74

of the reader. The opinion of the interpreter is inextricably linked with what was actually 

observed and what is known about the patient 129 . Largely, the therapist commented upon 

the meaning of the picture and its internal relations based on what the patient said, 

knowledge of the patient and observations on significant relationships between figures, 

feelings, colours and details. Thus content is not divisible from style. The difficulty of 

interpretation is illustrated by the description of pictures produced by a Native American 

psychiatric patient, whose compositions were thought of as impoverished and 

incongruent with instructions until her background was considered 130 . A few studies 

mentioned but did not analyse equally diverse specific identifiable formal signs or changes 

in the paintings attributed to therapy, which are included in the following discussion of 

form where appropriate. 

The most common uses or benefits suggested for art therapy were as a monitor 

of progress and as a therapeutic communication. These suggestions are only specifically 

valid for art if there is some meaningful way to access the images. The interpretation 

varied with the relationship between therapist and patient, orientation of the therapist, 

and the emotional involvement of both, which is not to say that it is not meaningful; 

certainly it has meaning and effects as related to the verbal interaction with the patient, 

just that no evidence justifies its relation to the art. 

Observable characteristics in the artwork of patients (form) 

129 Problems for the therapist in personal involvement are discussed later under relationships. 


75

This section does not deal strictly with form as there were overlaps between what was 

observed and what was recognised in depicted material, that were impossible to separate. 

This group of studies, however, was qualitatively distinct from those categorised as 

content analysis because the findings were primarily to do with observable changes in the 

artwork of the patient. Art therapy reports commonly focused upon the content of the 

artwork to describe individual variation in the artwork of the patients rather than 

collective. Their style of reporting often neglected the objective findings to concentrate 

on the analysis of meaning. The categorisation here thus may actually contradict the 

theoretical orientation expressed by the authors of some of these papers. 3 papers using 

mixed groups of 'psychiatric patients' accounted for 65% of the total cases and their 

general findings are described first. 

General signs of psychiatric disturbance 

General signs were summarised seperately (Table 5, appendix 2). There were three 

general indications of psychiatric status: 

(1) distortion of figures; 

(2) odd placing of drawing elements; 

(3) circling behaviour. 

Specific diagnostic signs 

Table 6 (appendix 2) summarised studies which reported specific diagnostic signs in the 

analysis of formal artwork. 

76

Analysis 

There were many overlaps and contradictions among studies that reported a majority of 

formal signs in descriptions of patient art. Actual events were often obscured by the 

reporting style of emotive description, techniques and the general imprecision of clinical 

observation; only suggestions for further investigation can be made. As previously noted 

in the content section, the characteristics of depression are particularly unclear 131 ; the 

most confusing reports are of parallel illustrative affect (e.g. random uncontrolled lines 

and colours, lack of structure or organisation and focus, expressive of disorientation, 

turbulence and lack of connectedness 132 ) also noted in the depressive phase of bipolar 

disorder 133 , characterised by disturbed content and missing detail as mutilated figures, 

more primitive drawings, while two studies report monochromatic rigid well defined still 

life 134 , sombre dull colours which parallel the depressive state 135 , also noted in bipolar 

disorder 136 , changing to bright colours on recovery. However, 2 studies reported bright 

colours and happy themes characterising art therapy in depression as a state of hope 137 . 

This conflict of opinion perhaps explains the non-significant findings reported from a 






136 Table 4, study 12, together with less creative activity, less or missing detail, less action. 

137 Table 4, studies 7 and 15 mainly content scale. 

77

correlation of art elements with depression or anxiety tests on 100 patients with 

alexithymia who were asked to draw their illness 138 . 

Organic disorders were characterised by distortion of form 139 (which was also a 

general sign), perseveration, simplification & proportion errors, disconnections, limited 

colour & difficulty comprehending directions 140 . All of these were also apparent in 

borderline personality disorder, depression, brain injury, aphasia, manic depression and 

dementia 141 . 

Degeneration of the image appeared as a product of declining intellectual 

function 142 , but regression to childlike forms was present in dementia, manic depression, 

schizophrenia and personality disorder 143 . Fragmentation in personality disorder 144 may 

easily be mistaken for the description of uncontrolled lines and lack of connectedness in 

depression, aphasia or disconnections in organic disorders and schizophrenia 145 . Lack of 

structure appears in reports of depression, schizophrenia, aphasia 146 and is difficult to 

differentiate from disorganisation, which was identified as a general sign (Table 5, 


139 Table 5, general signs, studies 30 and 31. 


141 Table 6: Borderline personality disorder, study 19; depression, study 20 and 23; brain injury, study 17; 

dementia, study 18; Table 4: aphasia, study 14; manic depression, study 6. 

142 Table 6, studies 17, 18 and 8. 

143 

Table 6, childlike forms, in: dementia, study 18; schizophrenia, study 26 personality disorder, study 

19; Table 4: manic depression, study 6. 

144 Table 6, study 19 

145 Table 6, lack of connectedness in: depression, studies 20 and 23; organic disorder, study 27; 

schizophrenia, study 26; Table 4: aphasia, study 14. 

146 Table 6, lack of structure in: depression, studies 20 and 23; schizophrenia, studies 26 and 27; Table 4: 

78

appendix 2), present in the above groups, in personality disorder and organic disorders 147 . 

Rigidity was described as characteristic of both schizophrenia and depression 148 . 

There is a suggestion that visual learning may occur unconsciously 149 and that 

anorexics may communicate more effectively nonverbally as they produce more and 

better quality visual work 150 . Indeed, this result relates to that of 500 alcoholics, who 

also produced more drawings of a person of better quality, that is, finer and improved 

detail, under treatment but with the qualification that previous measures may have been 

taken under the effects of drugs or starvation 151 . It is commonly thought such signs may 

be affected by drugs 152 , or concealed and distorted when the patient is under 

chemotherapy 153 . 

Summary of form 

It is clear that the methods used to analyse style or form of pictures between individuals 

or diagnostic groups were dependent on the subjective associations of the therapist or 

were inconsistent by type. For example, although manic depressives were judged 

depressed from the content of their paintings, they were judged manic on characteristics 

aphasia, study 14. 


148 Table 6, rigidity as a characteristic of: schizophrenia, study 26; depression, study 20. 




152 

H. Wadeson (1980), Art Psychotherapy , New York: Wiley. 

153 

Manny Sternlicht, Pincus Rosenfeld, Louis Siegel (1973), Retesting with graphic production: resolution 

of a diagnostic dilemma, Art Psychotherapy , V.1(3-4):299-300. 

79

of form 154 . The formal elements were inseparable from the content issues where they 

were described emotively; for example, sombre colour, and by negative characteristics, 

which tended to favour content issues and overlap between groups. It could be argued 

that in many cases the intentions of the formal analysis were not so rigid, but if evidence 

which is said to be objective is presented to support the subjective conclusions of the 

therapist or researcher, then it is necessary that it be differentiated from those opinions. 

The formal analysis reflects the confusion of the content analysis, in that each study is 

individualistic, presenting different information for each subject and there are few 

associations within types of patient and little systematic description of the output of the 

patient. 

Conclusion for formal and content analysis 

Three points arise from this discussion of case and series studies: 

(1) Increased output may be associated with withdrawal of drugs and different mood 

states as much as with therapy; and 

(2) If the immediate situation of the patient is, as suggested by the content analysis, the 

overriding element in the pictures, and these associations are too subjective and individual 

to be consistent within patients, then holding the content constant should emphasise the 

characteristics of artistic style. This would help to test whether the apparent diversity 

of pictorial characterises in depression was due to environmental circumstances or some 

other factor; 


80

(3) Formal characteristics may be easier to standardise, systemise and rate than content 

because they do not depend on subjective opinion. 

I suggest that formal characteristics are rated on positive scales, without reference to 

content and with firm discriminations between terms so that they do not overlap with 

other terms. 

The Therapeutic relationship 

Table 7 (appendix 2) summarises papers which concluded that the therapeutic or 

supportive relationship was the most important feature of art therapy. There were three 

types of relationship presented by 18 studies: 

1. Nurturing relationships; 

2. Communicative relationship; 

3. Relationships which were environmentally supportive. 

Nurturing relationships 

7 studies (4 males and 3 females with largely different diagnoses and aged 15-30) dealt 

with personal and individual guidance of subjects towards a resolution of their situation. 

The therapists claimed to recognise structural or developmental psychopathology in the 

artwork of the patient and that psychodynamic exploration of these images gave them 

access or understanding of their patients' world. They claimed to undertake role play 

which allowed the client to transfer their undesirable emotions onto them and thus 

through guidance resolve it, or by directed drawing or mirroring to help the client 

81

ecognise and work through the situation visually. The nurturing relationships showed 

two different therapy styles: 

(1) Drawing or 'painting together' was used for three cases by four therapists who saw 

themselves as operating from within the patient, they saw aspects of the patient resisting 

or using defenses and who must be made receptive. They did this through a special kind 

of bond with the patient described as a symbiotic relatedness, merging with another 

person, uniting, and giving empathetic response. The therapist acted as a kind of 

'psychic plumber', tracing blockages in the system and replaced the damaged part with 

a new corrective experience, or provided... (what was) denied, reorganised and 

restructured leaving room for further growth. The 'inside' therapists used the art as a 

holding environment for the patients and saw their products as records of progress, and 

as maps of the system of the patient. 

(2) the other three therapists saw themselves operating outside the patient, their job was 

to encourage, to focus, to help nourish the inner self and emotional needs , to help 

develop insight in the patient and promote growth, they described their relationship as 

an alliance, as having good relations, serving as self-objects. This relationship allied the 

therapist with the patient in a common goal to communicate and saw patient's products 

as communications whose meanings were obscured. 

Communicative relationships 

Three communication relationships were all developed with young male non-verbal 

schizophrenics by female art therapists who claimed to use art as an outlet for the 

82

expression of unsocial feelings of the patient. The interaction itself seemed to be the main 

benefit to the patient and the art was most useful as an environment for it. 

Supportive relationships 

From 14 patients (2 young females and 12 young adult males) 11 were retarded. Various 

techniques were used with the aim of increasing self esteem through acquiring control over 

the materials and skill which, it was claimed, would then generalise an understanding of 

internal control in other areas of the patient's life and increase self awareness. It was 

emphasised that art was most useful as an environment, especially with retarded people, 

because it provided an atmosphere of equality and respect with natural interaction 

Summary for case studies primarily benefitting from the therapeutic relationship 

Mostly, drawings were said to illustrate the present situation of the patient and thus 

change it in an analogy to psychotherapy. In the nurturing relationships, the therapist 

implemented change through other procedures than art, but used art as a containment area 

(or holding environment). Communicative relationships also used the art environment as 

a base for interactive therapy, although the therapists pointed out elements which were 

said to refer to feelings, it was from a personal knowledge of the patient rather than from 

any characteristics inherent in the art. The naturally nonthreatening environment was 

again the main benefit of art in supportive relationships, although some of what was 

reported was not therapy orientated but occupational, in that there was no change in the 

patient expected. 

83

Conclusion 

The use of art was not inherently related to the therapy for the patient but was felt by 

the therapist to provide a special sort of receptive atmosphere. Artwork was an activity 

in which patients felt able and liked to participate. When used therapeutically, it offers 

a non direct form of confrontation with underlying issues of conflict and the obscurity 

of the communication encourages verbal interactions and allows mutual involvement 

towards the goal of interpretation of the meaning through this medium. Therefore the 

stated purpose of the use of art in therapy relationships was communicative, but the 

underlying purpose of the art component was distraction and distancing for the patient. 

4. Change in behaviour 

Table 8 (appendix 2), summarised information from 4 studies which used an art 

environment but measured changes in behaviour. Their results reflect the conclusions of 

the supportive relationships; the environment offers a non-threatening situation which 

is enjoyed by the subjects. The skills learned increase self esteem, especially if 

recognised by others and increased involvement in the work. The other studies reported 

verbal/nonverbal comparisons of disturbance of thought in schizophrenia (1) that lower 

levels of disorder occurred whilst engaging in artwork; and (2) Speech and language were 

both affected, but planning and carrying out a plan were the most affected. These results 

do not cover the area, but one suggests that nonverbal pathways may not be as affected 

by thought disorder as verbal pathways. Speculatively, it is possible that the reason art 

84

is less affected is that drawing is not rigidly sequential and that relationships and time are 

expressed in different dimensions than the construct of language. 

Summary of Case Studies 

There were two elements recorded in art therapy research using case studies: (a) the effect 

of the art process upon the patient of which reports the studies mostly consisted, and 

(b) the process of decoding the picture, which was reported obscurely, individualistically 

and inconsistently. 

(a) Therapy: The use of art with patients seems to be therapeutic since observational 

evidence of lower symptom levels and educational or social benefits such as skills learnt 

by the patient are presented and there is a suggestion that art may provide an alternative 

route to communication for the thought disordered patient. Art therapy is generally 

useful for retarded people as an activity where people feel able, although there is no 

agreement on what kind of techniques to apply. The relationship between the therapist 

and the patient was very important in the view of the therapist and was said to provide 

therapeutic benefits in itself, but the nature of the involvement by the therapist tended 

to obscure the reporting. Thus the therapist was not the ideal researcher. 

(b) Decoding: The largest section examined here was that categorised as general 

expression of feelings, where projective methods and content interpretation were thought 

to induce cathartic release and facilitate communication between the therapist and patient. 

However, these benefits seemed to be independent of method or orientation of the study 

and seem to indicate that the art provides a third interactive function for the patient. 

85

Thematic interpretation varied with the patient and was dependent on the relationship 

with the therapist. No common correspondence could be discerned when comparing 

studies in this review. The interpretation of content was a shared communicative device, 

depictions often bore emotional loads, were idiosyncratic and did not translate to 

universal characteristics. 

Observable characteristics in artwork do indicate psychiatric status, whatever the 

orientation of the therapist or the psychiatric status of the patient, but there is no 

agreement on differentiation, definition of terms or typical diagnostic characteristics. 

Systematic research which differentiates between content and form would further this 

investigation and test premises which are expressed as knowledge in the literature; no 

study used formal characteristics alone in this review. 

Case studies are the traditional and best known method of reporting therapy and 

Chapter One describes how this type of research is still recommended by prominent 

writers and the weaknesses of this approach. The authors are unable to even describe the 

paintings, as the problem of standardising terminology, identifying and describing changes 

in observable form or in content has not been successfully addressed. The usual method 

has been to print sample paintings from which it is intuited which elements represent the 

improvement of the patient. The lack of established psychopathological links means that 

the case study method does not fulfil the crucial point discussed, how psychopathology 

is expressed in artwork. This is a very poor method of assessment. 

86

Controlled Studies. Comparison and Analysis 

Problems in categorising the data for analysis 

Several factors limit the conclusions which can be drawn from this review of controlled 

investigations into patient art. The tendency of the research was towards clinical tools, 

and there was little replication or validation of the plethora of instruments proposed. 

Speculative studies and unpublished, unvalidated measures were often cited by other 

studies as though they were proven instruments; some studies did not even specify 

which scale they were using and others did not explain or validate measures developed 

for the study. 

Inappropriate statistics were frequent, and test design and results often bore little 

relation to the intentions, conclusions and interpretations of the author. This meant the 

orientation of the researcher and the relation of the description or purpose of the 

instrument to what was recorded had to be considered. In many studies the focus on the 

interpretation of the work dominated the description of the objective phenomena, and the 

opinions and involvement of the therapist were also treated as objective phenomena. The 

use of subjective or interpretive criteria was often erroneously described as formal, or 

objective. Behavioural and other changes occurring in the patient, were attributed to the 

art therapy even though it may have been geared towards a totally different goal, and 

other therapeutic influences were ignored. 

There were two stages to this analysis: 

(1) to find out what kind of techniques, orientation and concepts produce results or no 

results of whatever kind in art therapy; and 

87

(2) to find out how the art relates to the kind of characteristics attributed to it. 

The problems were: in (1), that the study definitions of approaches were sometimes 

inconsistent with their practice; and in (2), the information reported was often 

incomplete. The solution I adopted was to descriptively examine as much of the 

literature as possible for the first question and to narrow the focus gradually for the 

second question, dropping out studies which could not supply the information. 

The DAPA 1996 study 

One of the studies picked up by the literature search was the DAPA pilot study 

(1996) 155 , it has not been included because as part of the present thesis, this research was 

itself developed from an informal version of the process of examination of the literature. 

Hypotheses and development of the measure has occurred over a period of 6 years. 

Inclusion of the DAPA test would hardly affect the qualitative analysis, because it carries 

few content fields, but would probably bias the meta-analysis which tries to show the 

direction and efficacy of the main body of literature. 

Organisation of this section 

The literature is discussed in 3 parts 156 : 

155 

Hacking, S., Foreman, D., Belcher, J. (1996) The DAPA: a new way of quantifying psychiatric 

paintings, J. Nervous Mental Dis . 184 p.425-9. 

156 There are three analyses which contain different variations from the same pool of 79 studies. For clarity, 

studies retained the same identification number in all analyses. Numbers 1-79 alphabetically are used 

throughout. A full list of studies appears in Appendix 3 (Table of Authorities). 

88

1. All studies reported enough information about tests between patients and 

controls, or patient groups to be evaluated methodologically for orientation, 

concepts and results. 

2. A small number of studies which investigated the correspondence of art tests 

against criterion measures and were not included in group 1 were added for the 

discussion of validity. 

3. A small group of studies which investigated inter-rater reliability were added to 

those studies from group 1 which used more than one rater for: 

(a) an evaluation of psychopathological signs in patient artwork; 

(b) a meta analysis to determine the effect size for art measures (Chapter 3). 

Amongst the 51 controlled studies were 4 comparisons between therapy groups. They 

measured behavioural details using non-art measures and one rater, although two used 

another criterion measure. They are included in the analysis where appropriate, but their 

aims, directions and information presented were different and they were omitted from 

some of the tables for clarity. Group sizes therefore do not always add up to 51. 

Methodology for analysis of controlled studies 

Characteristics of each paper were tabulated according to the variables described below. 

Descriptive statistics were used for a preliminary comparison of data from all 51 studies 

to find out what results were claimed for art therapy. There were 3 categories of 

information common to most papers: information about the test subjects, the study 

purpose and procedure, the results and conclusions from the test. 

89

There were 7 demographic variables: 

sex of subject; 

ages, whether adolescent (13-18), adult (18-60), older adult (60+); 

diagnosis of condition 1, 2, 3 and 4 (condition 1 was the main experimental 

group and condition 2 the main comparison group, which were normal controls 

if included); 

number of subjects in condition 1; 

total no. of subjects in study; 

whether subjects were matched on age and sex; 

no. of judges. 

There were 5 study factors: 

orientation, type of therapy offered; 

measurement method, what the instrument was intended to measure; 

design of the test - pre and post intervention, post intervention only, 

comparison of test pictures or retrospective; 

no. of measures used; 

derivation of the main study measure, whether own test, adapted or established. 

Sensitivity of the test and results. 

measurement form, what type of elements in the picture the instrument was 

actually sensitive to; 

the results of the study: differences between patients and normal or patient 

controls; or no difference. 

90

One alternative was marked for each category 157 . For ease of readability, integer 

percentages are used here. Interactive effects were investigated and the results for the 

ordinal variables are presented in tables 8a and 8b. 

Demographic variables: descriptive statistics for demographic variables are shown in 

Table 1 and Table 2. 

Table 1. Descriptive Statistics: controlled studies n=51 

Variable Mean Std. Dev. Min. Max. 

Numbers of subjects 

in experimental 

groups 

No. subjects each 

paper covered 

39 40 5 239 

115 190 11 1373 

No. of judges 2 8 1 60 

No. of measures 2 2 1 15 

Table 2. Frequency and percentage of demographic variables for 51 controlled studies by 

levels of result. 

Variables 

Sex male 

female 

mixed 

Age 13-18 

18-60 

60+ 

Controls 

Matched 

Unmatched 

Frequency 

& Percent 

all studies 

n=51 

freq % 

5 10 

4 8 

42 82 

6 8 

41 80 

4 8 

20 39 

31 61 

Result 1 

Difference in 

patients/nonpatients 

n=21 

freq % 

0 0 

2 14 

18 86 

0 0 

17 81 

4 19 

10 48 

11 52 

157 A full list of alternatives is presented in Appendix 1. 

91 

Result 2 

Difference 

patient 

subtypes 

n=12 

freq % 

3 25 

0 0 

9 75 

2 17 

10 83 

0 0 

5 42 

7 58 

Result 3 

No Difference 

or 

Inconsistency 

n=14 

freq % 

2 14 

1 7 

11 79 

2 14 

12 86 

0 0 

3 21 

11 79

No. 1 

judges 2 

3 

4 

60 

No. 2 

Study 3 

groups 4 

35 69 

9 18 

4 8 

2 4 

1 2 

32 63 

15 29 

4 8 

13 62 

3 14 

3 14 

1 5 

1 5 

13 62 

6 29 

2 10 

92 

8 67 

2 17 

1 8 

1 8 

0 0 

6 50 

5 42 

1 8 

10 71 

4 29 

0 0 

0 0 

0 0 

10 71 

3 21 

1 7 

Age and sex: Few studies gave much demographic information. Many studies simply 

described the group as 'adult', but the majority described only the group ranges or the 

mean age even when they were considerably wide. The sex distribution was often only 

described as 'mixed' so could have been considerably uneven and sometimes group 

numbers were missing, especially of diagnostic categories. 

Controls: 72% of studies used non-psychiatric controls, and gave little information on 

age, sex, origin, screening procedure and numbers. Where descriptions of controls were 

given, they were always hospital staff. Mostly, there was no indication that control 

pictures were done under the same conditions, or even the same number of pictures! 

(One study used an average of up to 99 pictures from therapy sessions for patients, 

against one picture painted in a non psychiatric outside art group 158 ). 

Matching: Chapter one makes the point that IQ is difficult to match for psychiatric 

patients, since tests may not be sympathetic to psychiatric disturbance, but the majority 

of studies failed to match for age, sex and mostly even group numbers. 

158 

C. Bergman and M. Gonzalez (1993), Art and Madness: can the interface be quantified? Am. J. Art 

Therapy , V.31:81-90 on development of the SPAR scale.

Table 3a. Diagnostic groups 1-4. Frequency and percentage for 51 controlled studies. 

Diagnosis, 

schizophrenia 

emotional trauma 

drug/alcohol 

psychotic phobia 

neurological damage 

depression 

conduct disorder 

retarded 

gender disorder 

personality disorder 

mixed patients 

normal 

All studies, 

diagnosis 1 

n=51 

freq % 

15 29 

4 8 

1 2 

3 6 

6 12 

6 12 

1 2 

1 2 

1 2 

1 2 

12 23.5 

0 0 

All studies, 

diagnosis 2 

n=51 

freq % 

5 10 

1 2 

0 0 

2 4 

2 4 

1 0 

1 2 

0 2 

0 0 

0 0 

3 6 

36 71 

93 

All studies, 

diagnosis 3 

n=19 

freq % 

2 4 

0 0 

0 0 

1 2 

5 10 

1 2 

2 4 

0 0 

0 0 

0 0 

6 12 

2 4 

All studies, 

diagnosis 4 

n=4 

freq % 

0 0 

0 0 

0 0 

0 0 

1 2 

1 2 

0 0 

0 0 

0 0 

0 0 

0 0 

2 4 

Diagnoses: 1. Main experimental group; 2. Control group; 3. Experimental group 2; 4. Experimental 

group 3. 

Table 3b. Diagnostic group 1. Frequency and percentage by levels of result. 

Diagnosis, 

1 

schizophrenia 


drug/alcohol 



depression 


retarded 




1. Difference 

patients/nonpatients 

n=21 

freq % 

7 33 

2 9.5 

0 0 

0 0 

3 14 

4 19 

0 0 

1 5 

0 0 

1 5 

3 14 

2. Difference 

patient 

subtypes 

n=12 

freq % 

4 33 

1 8 

1 8 

2 17 

2 17 

0 0 

0 0 

0 0 

0 0 

0 0 

2 17 

3. No 

Difference or 

inconsistency 

n=14 

freq % 

4 29 

1 7 

0 0 

1 7 

1 7 

1 7 

0 0 

0 0 

1 7 

0 0 

5 36 

Diagnoses: Frequency tables for diagnoses are shown in Table 3a, and in 3b by 

experimental group results. The main comparison group were classified under condition 

2, and the experimental under condition 1. Those normal controls appearing in groups 

3 and 4 were less important to the study than the main comparison group. The most 

frequent diagnosis was Schizophrenia, mostly undifferentiated and which probably 

included diagnoses which were differentiated by other studies. Schizophrenia is not a

satisfactory classification as it is not an exact diagnosis and there are forms that have 

quite different phenomenology. Some studies simply tested ward groups (which can be 

very variable) and in many cases there was no operational criteria typical of a common 

symptom picture. 

Other study effects: It was impossible to control for experience of art, as the vast 

majority of studies did not describe the psychiatric history of their patients. Although 

one or two tried to control for art experience, their reliance on formal or school education 

tended to favour the controls and did not account for therapy sessions, which could be 

part of a patient's life for many years. 

Time: the studies were spread fairly evenly over the 22 year period; 50% of the studies 

either side of 1986. 

Table 4. T-tests were performed to compare the means of ordinal demographic variables 

by Year of Study. 

GROUP 1 = YEARS 1973-1977 (12 CASES); GROUP 2 = YEARS 1992-1996 (18 CASES) 

df=28 for all variables 

Variable 

Group-- 

No. Subjects 1 

(Condition 1) 2 

Age 1 

3=13-18; 2 

5=18-60; 6=60+ 

Sex 1 

1=male; 2 

2=female; 3=mixed 

Matched 1 

Controls(age/sex) 2 

match 1=yes; 2=no 

No. Judges 1 

2 

No. Measures 1 

2 

mean Standard 

Deviation 

33.50 

39.22 

4.83 

4.83 

2.83 

2.61 

1.58 

1.61 

0.67 

0.78 

1.42 

2.44 

26.62 

38.56 

0.58 

0.92 

0.58 

0.70 

0.51 

0.50 

0.99 

1.35 

0.79 

3.31 

Standard 

Error 

7.68 

9.09 

0.17 

0.22 

0.17 

0.16 

0.14 

0.12 

0.28 

0.32 

0.23 

0.78 

94 

T 

Value 

-0.45 0.66 NS 

0.00 1.00 NS 

0.91 0.37 NS 

-0.15 0.88 NS 

-0.24 0.81 NS 

-1.05 0.30 NS 

Pooled Variance 

2-tailed probability

Table 5: Non-parametric tests were performed to compare the ranks of categorical study 

variables by Year of Study. 

GROUP 1 = YEARS 1973-1977 (12 CASES); GROUP 2 = YEARS 1992-1996 (18 CASES) 

df=28 for all variables 

Variable 

Group - 

Diagnosis 

Orientation 

Measurement method 

Measurement form 

design 

test derivation 

results 

mean 

rank 1 

15.67 

11.00 

11.92 

12.08 

14.92 

11.58 

16.08 

mean 

rank 2 

15.39 

15.17 

17.89 

17.78 

15.89 

18.11 

15.11 

95 

z score pooled variance 

2 tailed prob. 

-0.0857 

-0.3644 

-1.9695 

-1.8276 

-0.3664 

-2.2196 

-0.3122 

0.9317 

0.7156 

0.0489 

0.0676 

0 7141 

0.0264 

0.7549 

Elements of change over 22 years: t-tests were performed to compare ordinal 

demographic variables over the period of the study (22 years) (Table 4), in order to 

assess change in research techniques and orientation. The categorical variables were 

compared by rank, using the Man-Whitney non-parametric t-equivalent (Table 3b). No 

differences were found in demographic variables, in orientation of therapy, measurement 

form, the design of the test or the results, but there were differences in the measurement 

method (the described purpose of the test). Derivation of the test and measurement form 

just missed significance but is considered a strong trend here (see Table 6). Both the early 

tests and the later described their methods as formal comparisons or mixed content and 

form comparisons, but the earlier studies used more direct formal comparisons and the 

later more mixed and more non-art tests. The earlier emphasis on form probably reflects 

the exploratory nature of the studies and their developmental basis. Their tests are 

almost exclusively self-developed and more sensitive to style and formal elements; the 

later studies were more split between self-developed and existing tests. They compared 

and described more interpretatively and used behavioural terms, their tests were less 

sensitive to form than content comparisons in the same test. They also used behavioural

or non-art tests which were not seen at all previously. The actual tests do not 

significantly differ in their orientation, but the differences in the other variables tend to 

support the trend. 

Table 6: Significant variables identified from the Mann-Whitney non-parametric 

association test. Frequency and percentage for Group 1, early studies 1973-1977; Group 

2, late studies 1992-1996. Changes in methods and measurements. 

Variables with scales Early studies 

freq % 


Formal 

Meaning content 

Mixed form and content 

Behaviour- non-art 


Formal comparison 

Meaning interpretive 

Mixed form and content 

Non-art or behaviour 

Verbal 

Derivation of test 

This study self-developed 

Adapted existing 

Existing 

Observational/clinical 

7 58 

1 8 

4 33 

7 58 

3 25 

2 17 

10 83 

1 8 

1 8 

Late studies 

freq % 

5 28 

1 6 

9 50 

3 17 

6 33 

4 22 

2 11 

4 22 

2 11 

7 39 

3 17 

7 39 

1 6 

The z values for all variables in Table 5 are negative which indicates linear relations. Over 

22 years, similar elements are measured in art tests although there were differences in 

orientation towards content and more interpretation of content from the later studies. 

Most earlier tests were developed for the research and the later studies used a mix of self 

developed and existing tests, but with no greater controls. Controlled comparisons exhibit 

the same type of mixed sex and ill-differentiated groups. There is no better match of 

controls to condition 1 subjects and results are still ambiguous and inconsistent. Thus, 

research into art psychopathology has remained static. 

96

Table 7: Frequency and percentage of test variables for whole sample by Results 159 . 

Variables n=51 

freq % 

Test design 

pre & post int'n 

post intervention 

comparison only 

retrospective 

No. measures 

1 

2 

3 

4 

15 

Derivation of test 

developed this study 

adapted 

observation/clinical 

established 

Orientation 

comparison only 

expressive 

therapy - self esteem 


formal comparison art 

meaning/content 

mixed comparison 

nonart/behaviour 


objective detail 

content subject/theme 

mix objective/content 

other behaviour 

verbal 

All studies Result 1 

Difference 

patients/ 

nonpatients 

6 12 

3 6 

36 71 

6 12 

31 61 

9 18 

8 16 

2 4 

1 2 

23 45 

8 16 

4 8 

16 31 

43 84 

3 6 

5 10 

19 37 

4 8 

21 41 

7 13 

18 35 

11 22 

13 26 

7 14 

2 2 

n=21 

freq % 

2 10 

1 5 

16 76 

2 10 

14 67 

3 14 

3 14 

0 0 

1 5 

8 38 

5 24 

1 5 

7 33 

21 100 

0 0 

0 0 

8 38 

2 10 

11 52 

0 0 

9 43 

4 20 

7 33 

1 5 

0 0 

97 

Result 2 

Difference 

patient 

subtypes 

n=12 

freq % 

1 8 

0 0 

9 75 

2 17 

8 67 

3 25 

0 0 

1 8 

0 0 

5 42 

1 8 

3 25 

3 25 

10 83 

1 8 

1 8 

5 42 

0 0 

6 50 

1 8 

4 33 

2 17 

4 33 

2 17 

0 0 

Result 3 

No Difference or 

inconsistency 

n=14 

freq % 

1 7 

0 0 

11 79 

2 14 

7 50 

2 14 

4 29 

1 7 

0 0 

9 64 

2 14 

0 0 

3 21 

12 86 

1 7 

1 7 

6 43 

2 14 

4 29 

2 14 

5 36 

5 36 

2 14 

0 0 

2 14 

Design: The majority of the studies (71%, n=36) compared a picture specially produced 

for the test rather than pictures produced during therapy. Pre and post measures were 

159 Results - all cases frequencies percentage 

1. Difference patient/non patient 21 41.2 

2. Difference subtypes of patient 12 23.5 

3. No differences / inconsistencies 14 27.4 

4. Difference for therapy groups 4 7.8 

TOTAL 51

favoured (12% n=6) over post measures (6% n=3) for therapy state of patients. 12% 

compared spontaneous pictures retrospectively. 

No. of measures: 61% (n=31) of studies used only the test described and the diagnosis; 

18% (n=9) used one other measure and 22% (n=11) used 3 or more. 

Derivation of measure: 69% (n=35) of tests were either; designed for the study (23), 

were adaptions of an existing test (8), or were observed or clinical ratings (4), and only 

31% of studies used an established test. 

The orientation variable shows 84% (n=43) of studies measured drawings produced for 

the study and not as part of a therapy programme. 

Measurement method: Scales have not been contrasted on this review as many studies 

failed to provide coherent definitions of what they did measure, relying on common art 

terms. Most studies included present or countable items, but this form of measurement 

is not always objective as it often requires interpretation, if only in the sense that marks 

must be recognised and judged against an internal model by the rater. For example, to 

note that a head is or is not unusually large, a head must be reconstructed from the marks 

on the paper and compared with what the rater thinks is normal. 

This category brings together what is generally accepted as observable criteria: i.e. 

those generally recorded in draw-a-person tests that there is little disagreement in 

recognising. In applying the main test measure to the drawings, 41% (n=21) of tests 

used a comparison requiring both subjective and objective judgments; 37% (n=19) used 

a direct comparison of observable detail (e.g. draw a person tests); 12% used non art tests 

(e.g. IQ, achievement, behavioural tests etc.). 

98

Measurement form: The most frequent forms measured from the patient were observed 

details (35%), the next was a mix of details and content (25%) closely followed by 

content measures of subject/theme (22%) and behaviour (12%). 

Results: (see notes, Table 7). According to this analysis of 51 studies, 72.5% (n=37) of 

studies report differences between the experimental group and controls, either between 

patient/non patient (41%, n=21), subgroups (23% n=12) or therapy groups (7.8%, n=4) 

(these claims will be further investigated in Chapter Three, within the tightly controlled 

comparison criteria of meta analysis). 

Summary: The typical test compared a drawing done in standardised conditions by 

about 30 adult schizophrenics of both sexes, and an unmatched control group of people 

without psychiatric history. The test would be designed for the study, be rated by the 

author, and would not be compared with any other measure except the diagnosis. 

Patients' pictures would be expected to differ from non-patients by both content, 

typically subject or theme decisions; and objective detail, such as particular colours and 

positioning of figures. 

Interactive effects for study variables by level of Result (shown in Tables 2 and 7). 

Demographics: Most studies employed mixed sex experimental groups, adult subjects 

and 2 conditions (normal controls). Sex and age were often only reported as a range or 

categorically, i.e. adult. Differences between patients and controls were found in all of 

the older groups (Table 2), but this may reflect differences in expectations, measurement 

99

procedures, or publishing bias, since there were very few studies using old people. 

Control groups for studies that found differences either in patient/control or between 

subtypes, were equally balanced in matched controls and non-matched, and more often 

schizophrenic, than a range of other psychiatric diagnoses. Where no differences were 

found, control groups were not usually matched (Table 2), but there was a clear 

predominance of either undifferentiated patients or schizophrenics. Unsurprisingly, 

studies finding subtype differences used more experimental groups; 4 included normal 

controls. 

Design and sensitivity of test: The tests finding differences were most frequently 

designed to measure a mix of observable qualities and interpretative elements and their 

instruments were generally congruent with his aim, although 20% measured content 

exclusively. Studies finding no difference emphasised the measurement of formal 

elements in the design rather than content, but a third of their instruments were 

exclusively sensitive to content. Tests which found patient/nonpatient differences used 

a mix of self-developed, adapted and established tests; tests finding differences between 

subtypes used a mix of self developed, observational and established tests; but tests 

which found no differences used many more tests developed for the study (Table 7). 

Reliability and Validity: The majority of studies which found no differences used 

slightly more 1-rater tests (Table 2) but more criterion measures than studies finding 

differences (Table 4), all results levels had few measures and raters. 

100

Summary: Studies finding no differences were fewer and less controlled than those 

which found differences; they used more unmatched controls, more undifferentiated 

patients, and more tests developed for the study, coupled with less judges. Their 

instruments were less suited to their stated purpose than tests that found differences. 

Table 8a: Analysis of variance compared 5 demographic variables by 7 study factors. 

162 

Study Factors Diagnoses Design Valid Test 

Test variables 

No. of subjects 

condition 1 

age of subjects 

3=13-18; 5=18-60; 

6=60+ 

sex of subjects 

1-male; 2-female; 

3-mixed 

controls matched 

1-yes; 2-no 

df=12 sig 

F of F 

df=3 sig 


101 

df=3 sig 


0.51 0.89 0.62 0.61 0.28 0.84 

1.68 0.12 0.67 0.58 1.79 0.16 

2.41 0.02 160 

0.28 0.84 0.38 0.77 

1.78 0.09 2.10 0.11 4.40 0.01 161 

no. of judges 0.19 1.00 0.11 0.95 0.57 0.64 

160 Too few cells are filled for meaningful analysis. 2 of the 12 diagnostic groups cover 53% of studies. 

161 Studies using adapted tests were less likely to match for age and sex in controls. 

Summaries of age and sex match in control by levels of validated test 

VALIDTEST LEVELS Mean Std Dev Cases 

For Entire Population 1.61 .49 51 

1 test developed for study 1.83 .39 23 

2 test adapted 1.25 .46 8 

3 established test 1.44 .51 16 

4 observation/clinical 1.75 .50 4 

162 Nonart behaviourial measures tended to be used with younger subjects. 

Summaries of age group for condition 1 by levels of measurement method 

LEVELS OF METHOD Mean Std Dev Cases 


1 direct comparison 4.89 .57 19 

2 meaning 4.75 .50 4 

3 some interpretation 4.95 .74 21 

4 nonart - behaviourial 4.33 1.03 6

Table 8b. Analysis of variance performed to compare the means of 5 ordinal 

demographic variables by 7 study factors. 

Study Factors Orientation 

(df=5) 

F p 

No. of subjects 

condition 1 

subjects age 

3=13-18; 5=18-60; 6=60+ 

sex of subjects 

1-m; 2-f; 3-mixed 

controls matched 

1-yes; 2-no 

Measurement 

method (df=5) 

F p 

102 

Measurement 

Form (df=5) 

F p 

Results 

(df=4) 

F p 

1.03 0.36 0.72 0.58 2.05 0.10 0.81 0.53 

1.92 0.16 2.63 0.05 7 

5.29 0.00 163 

0.35 0.71 0.44 0.78 2.88 0.03 165 

2.47 0.06 164 

0.92 0.46 

0.49 0.62 1.58 0.20 1.39 0.25 0.92 0.45 

no. of judges 0.16 0.85 0.34 0.85 0.39 0.82 0.41 0.80 

6 personality 3.00 .00 1 

163 Studies which used measures of behaviour or content used younger subjects. 

Summaries of age group for condition 1 by levels of measurement form 

MEASUREMENT FORM Mean Std Dev Cases 


1 objective detail 5.17 .38 18 

2 content - theme 4.36 .92 11 

3 mixed 1 and 2 5.00 .41 13 

4 behaviour 4.00 1.10 6 

5 verbal 5.00 .00 2 

6 expressive other 5.00 .00 1 

164 Therapy groups were younger; groups in studies using criterion measures tended to be older; and studies 

finding a patient/nonpatient difference used no adolescents and contained all the older groups. 

Summaries of age group condition 1 by levels of result 

LEVELS OF RESULT Mean Std Dev Cases 


1 difference in experim'l group1 5.10 .54 21 

2 diffs. in subgroups 4.67 .78 12 

3 no difference 4.80 .63 10 

4 therapy group 4.00 1.15 4 

5 noncorrelation/inconsistent 4.50 1.00 4 

165 Mixed objective/subjective elements were measured exclusively in mixed groups. 

Summaries of sex by levels of measurement form 

MEASUREMENT FORM Mean Std Dev Cases 


1 objective detail 2.72 .67 18 

2 content - theme 2.64 .68 11 

3 mixed 1 and 2 3.00 .00 13 

4 behaviour 2.67 .82 6 

5 verbal 1.50 .71 2 

6 expressive other 3.00 .00 1

Demographic interactive effects: The means of ordinal demographic variables were 

compared between test factors and results are shown in Tables 8a and 8b. The study 

population was mostly adult and mixed sex. Analysis of variance showed most 

differences related to age of the study population: that studies using adapted tests were 

least likely to match for age and sex in controls; nonart behaviourial or content measures 

were used with younger subjects as were therapy groups, possibly reflecting recognised 

difficulties in the interpretation of children's art 166 as the lesser success rate for 

patient/nonpatient differences indicates; groups in studies using more criterion measures 

tended to be older probably reflecting the greater level of disability measures given as 

standard in this population, medical opinion on these groups and also the longer term of 

their confinement. 

Table 9: Frequency and percentage for Measurement Form by No. of criterion measures 

Diagnosis + 

Test = 1 

Measures n=31 

Freq % 


objective comparison 

meaning/content 

mixed formal/content 

nonart/behaviour 

verbal 

9 29.0 

7 22.6 

10 32.3 

3 9.7 

2 6.5 

Diagnosis, test + 

1 other = 2 

n=9 

Freq % 

2 22.2 

1 11.1 

3 33.3 

2 22.2 

1 11.1 

103 

Diagnosis + 3 or 

more others = 3+ 

n=11 

Freq % 

7 63.6 

3 27.3 

0 0.0 

1 9.1 

0 0.0 

Design of test levels by criterion: 31 studies used no other criterion measure than 

diagnosis and the study test (Table 9) and these were mostly studies which found 

differences (Table 2). The comparison of artwork for 1 criterion measure was broadly 

166 

Glynn V. Thomas and Angele, M. J. Silk (1990) An Introduction to the psychology of children's 

drawings , Herts: Harvester Wheatsheaf.

spread between subjective and objective scales but with the addition of 1 other criterion 

measure, the number of content measures dropped and behaviour measures increased. 

For 3 or more measures (n=11) (which were equally split - difference/no differences), 

tests favoured objective comparison of countable items (n=7), although there were some 

content measures, there were no mixed comparisons. So, the observable and countable 

measures tended to use more criterion measures, the mixed formal and content measures 

used less criterion measures. 

Table 10: Frequency and percentage for test derivation and results by No. of judges. 

Judges 1 Judge 

n=35 

Freq % 

Test Derivation 

developed this study 

adapted 

observation/clinical 

established 

Results 

diff. pat/nonpat 

diff. patient groups 

no difference 

therapy groups 

12 34 

6 17 

4 11 

13 37 

13 37 

8 23 

10 29 

4 11 

2 Judges 

n=9 

Freq % 

7 78 

0 0 

0 0 

2 22 

3 33 

2 22 

4 44 

0 0 

104 

2+ Judges 

n=7 

Freq % 

4 57 

2 29 

0 0 

1 14 

5 71 

2 29 

0 0 

0 0 

Test derivation and result levels by judges: The vast majority of studies (35) used 

only one rater and 13 used established tests (Table 10), most of which found differences. 

Thus, reliability was not established for 22 tests, of which most found no differences. 

There were fewer tests using more raters, but the majority of 2-rater tests (n=7; 78%) 

were developed for the research; half reported differences. All 7 tests with more raters

eported differences between patients/controls or between subgroups. So, generally, 

findings of difference increased with the number of judges 167 . 

Summary: Whether or not studies found differences, they were poorly controlled, but 

control was even poorer in studies finding no difference. Generally, all studies used test 

items which measured more content than they intended to, but the studies finding 

differences used mostly formal or mixed test measures which were consistent with the 

aims of the study. The majority of 1 rater tests found differences, but of studies which 

found differences, more multi-rater tests and more established tests were used, although 

they used less criterion measures, more mixed measures than those finding no difference. 

The studies finding no difference predominantly used instruments which measured 

content qualities only, but were usually described as formal or mixed. They used less 

raters, but slightly more criterion measures, more content tests, more behaviour tests and 

many more self-developed tests (although all result levels had high percentages of self- 

developed tests). A validity note is that as more criterion measures were added, the use 

of form-only measures increased and mixed comparisons and content measures decreased. 

This probably reflects the rigour of the studies. 

Validity analysis of the literature 

Tests designed for study: Very little evidence has yet been produced that characteristic 

symptoms, which, when associated, lead to diagnostic categorisation of psychiatric status 

167 If we assume that established tests have already been reliability tested. 

105

are linked to those artistic characteristics which are interpreted by art therapists. Many 

of the studies reviewed here developed their own tests for the study using artistic 

characteristics which were said to be equivalent to the behaviourial symptomatic 

characteristics used for diagnosis. The only criterion used in many cases was how the 

experimenters thought the visual sequelae of thought disorder should look, supported by 

previous examples of the same process. This is not enough. It is unsound to conclude 

that paintings are or are not diagnostically valid if there is no evidence that the test items 

are a) reliable themselves or b) measure any symptomatic behaviour and c) relate to visual 

output. The DDS team 168 have argued that they cannot produce a validity index since 

there is yet no comparable instrument with the DDS, but there are many other 

established tests measuring diagnostic and other qualities which could provide non-visual 

indices for DDS correlations, and which so far have not been used. Indeed, the DDS itself 

has not even produced good correlations with its only criterion, diagnosis itself 169 , 

although it has produced a reliable format. Adapted tests too, must provide a criterion 

measure, so that it is certain that aspects which have been deleted are not integral to the 

validity of the test. The first validity question therefore must be: are these assessment 

measures really measuring what they are designed to measure? 

Even where obvious and relatively consistent phenomena are reported, what is 

measured may be a confounding variable, something which accompanies the symptom, 

168 Mills et. al. (1993) Reliability and validity tests of the Diagnostic Drawing Series, 

Psychotherapy , V.20:83-88. 

106 

Arts in 

169 

See my critique later in Chapter 2, reliability analysis. DDS produced by B. Cohen, J. Hammer and 

S. Singer (1988) The Diagnostic Drawing Series: a systematic approach to art therapy evaluation and 

research, Arts in Ps ychotherapy , V.15(1): 11-21. Although to be fair, the DDS is head and shoulders 

above the competition, and further research on the statistics would produce a more suitable analysis.

ather than the symptom itself, thus unreliable, since it may appear in other 

circumstances 170 . The validity of a test is proved when it correlates highly with another 

proven method which measures similar elements. 

Validity Analysis of Controlled Studies 

70 studies were included in the analysis: all the controlled studies were included (51), 12 

studies were added from the literature which dealt specifically with criterion validity and 

7 studies from the literature on reliability 171 . 33 (47%) studies used an art test simply 

against the diagnosis and 37 (53%) used the diagnosis and another criterion. The criterion 

which was primary in the discussion was used for this review: 6 studies used a self 

report; 1 study used a test with both content and formal evaluations; 27 (39%) used a 

nonprojective measure of ability or IQ; and 3 used a verbal evaluation. The tables describe 

5 validity characteristics from each of 70 studies 172 . 

170 

For example, R. Langevin, and L.M. Hutchins (1973) found that judgement of patient status correlated 

higher with quality of the artwork than diagnosis, even when judges were prewarned what to expect (An 

experimental investigation of judges ratings of schizophrenic and non-schizophrenic paintings, J. 

Personality Assessment , V.37(6):537-543). 

171 All studies are detailed in the Table of Authorities (Appendix 3). Study numbers for those which 

appeared in the controlled analysis remain the same. 

172 A full list of alternatives appears in Appendix 1. 

107

3 Demographic variables were used from the controlled analysis: 

sex of subject; 

age, whether child/adolescent (under 18), adult (18-60), older adult (60+); 

diagnosis of the main experimental group; 

There were 3 study factors: 

arttest form, what form of information did the art test collect; 

criterion form, what form of information did the criterion collect; 

no. of criterion measures used; 

Sensitivity of the test and results. 

comparison, what type of qualities were the instruments being compared on; 

the results of the study: did the art test results correlate or significantly agree 

with the other criterion test. 

One alternative was marked for each category. Tables 1 and 2 show frequency and 

percentages of study factors for all studies, and are divided between studies showing 

association or none between the main art test and the criterion. The mean ranks for 

study factors between the two result levels were subjected to a non-parametric test of 

association, and the results are presented in Table 3. 

108

Table 1. Frequency and percentage of criterion variables for 70 studies by result 

Variables 

No. criterion 

measures 

0 

1 

2 

3 

4 

15 

Comparison 

cognitive 

emotion 

development 

diagnosis 

Criterion form 

diagnosis 

self report/picture 

mix of content/form 

behaviourial/IQ 

verbal 

Art-test form 

KFD 

DAP 

Formal other 

copy 

other theme 

free 

all cases Result 1: 

associatio 

n 

n=70 

freq % 

33 47.1 

13 18.6 

12 17.1 

9 12.9 

2 2.9 

1 1.4 

11 15.7 

12 17.1 

9 12.9 

37 52.9 

33 47.1 

6 8.6 

1 1.4 

27 38.6 

3 4.3 

6 8.6 

24 34.3 

3 4.3 

5 7.1 

16 22.9 

16 22.9 

n=42 

freq % 

26 61.9 

6 14.3 

4 9.5 

3 7.1 

2 4.8 

1 2.4 

5 11.9 

8 19.1 

2 4.8 

27 64.3 

26 61.9 

2 4.8 

1 2.4 

12 28.6 

1 2.4 

3 7.1 

11 26.2 

1 2.4 

4 9.5 

12 28.6 

11 26.2 

109 

Result 2:no 

association 

n=28 

freq % 

Result 1: significant association of measure with criterion test. 

Result 2: no association of measure with criterion test 

7 25 

7 25 

8 28.6 

6 21.4 

0 

0 

6 21.4 

5 17.9 

4 25 

5 35.7 

7 25 

4 14.3 

0 

15 53.6 

2 7.1 

3 10.7 

13 46.4 

2 7.1 

1 3.6 

4 14.3 

5 17.9 

Most of the criterion tests used measured diagnosis or IQ. Diagnostic criteria were 

compared with a mix of art tests (DAP 24%, free 30%, other theme 36%); thematic were 

more popular and they were always compared on diagnosis. Achievement tests were 

popularly compared with the Draw-a-person protocol (44%) but were compared equally 

on cognition (30%) and development (30%), and a smaller percentage but equal 

distribution of emotional (18.5%) and diagnostic functions (18.5%).

Table 2. Diagnostic groups for 70 studies with criterion measures. Frequency and 

percentage by levels of result. 

Result 1: sig. 

association 

Diagnosis, condition 1 n=42 

freq % 

schizophrenia 


drug/alcohol 



depression 


retarded 




11 26.2 

5 11.9 

1 2.4 

2 4.8 

5 11.9 

4 9.5 

1 2.4 

3 7.1 

0 0.0 

1 2.4 

8 19.0 

Result 2: no 

association 

n=28 

freq % 

7 25.0 

2 7.1 

0 0.0 

1 3.6 

2 7.1 

2 7.1 

1 3.6 

2 7.1 

1 3.6 

0 0.0 

10 35.7 

Result 1: significant association of measure with criterion test. 

Result 2: no association of measure with criterion test 

Table 3. Non-Parametric test to show differences between study factors for findings of 

association and non-association of art-test with criterion measure. Mann-Whitney U - 

Wilcoxian Rank Sum Test. 

Study variables Mean Rank for 

association of 

test- criterion 

n=42 

Age group 

Diagnosis 

Criterion form 

No. of criterion 

measures 

Art-test form 

Comparison 

36.58 

33.13 

30.29 

30.67 

39.32 

39.33 

Mean rank for no 

association of 

test - criterion 

n=28 

33.88 

39.05 

43.32 

42.75 

29.77 

29.75 

110 

Z scores Significance 

level. 

2-tailed p 

value. 

-0.6545 

-1.2151 

-2.8692 

-2.5916 

-1.9900 

-2.1027 

0.5128 

0.2243 

0.0041 

0.0096 

0.0466 

0.0355 

There were no biases in demographic variables of age and diagnosis for studies which 

showed association or not. The majority of studies which showed associations between 

the art test and the criterion measure did not employ other criteria than the clinical 

diagnosis and used a mixture of test methods, whereas the tests which found no 

associations used predominantly cognitive criteria (IQ or achievement tests), were equally 

divided between 0-3 other measures than diagnosis and used primarily formal test

measurements, favouring the Draw-a-person protocol. The comparison was 

predominantly developmental, which category was absent from the tests which showed 

associations; cognitive measures were also popular and least popular was emotion, which 

was most popular in the test which showed associations. 

Summary: There were many more tests which showed associations with the criterion 

measure, but almost half the tests employed no other criteria than clinical diagnosis. 

However, the relationship of the diagnostic criterion to the art test was consistent with 

the comparison made by the study (on diagnosis), whereas the majority of the measures 

which employed another measure were achievement tests and their comparison was often 

not consistent with the orientation of the art test (37% compared achievement tests on 

diagnostic or emotional criteria). If the tests using only the diagnostic criteria were set 

aside, there are 2 points to note: 

(1) Tests which compared developmental qualities in drawings showed no association 

with criterion measures; and 

(2) Tests which compared emotional qualities tended to show association with 

criterion measures. 

There were equal numbers of studies on both sides for tests which compare cognitive 

aspects. These results confirm the recognised doubts about the validity of painting or 

drawing tests as developmental measures for psychiatric populations discussed in 

Chapter 1, and so their predictions of cognitive function and use in place of IQ tests. 

111

However, there were few tests which actually provided a suitable criterion for emotional 

qualities. 

Conclusion: For the controlled studies, the derivation of the measure had an influence 

on the control of the study as did poor control on the result levels of no difference. Type 

of treatment (orientation) and number of criterion measures varied with the age of 

subjects. The interaction of demographic variables with levels of result together with the 

failure to match or describe experimental samples in many studies and the confusion of 

comparisons with criterion measures show the substantial quandary of treating this 

literature as a whole. The advantage of examining a number of studies is that the general 

direction of the majority overrides the diversity of confounding variables, but 

developmental or cognitive criterion measures are inappropriate. This preliminary 

overview has accomplished its purpose in that it has shown, generally, differences 

predominate over no difference findings, and that diagnostic and emotional dimensions 

rather than developmental and cognitive dimensions are valid directions for further 

investigation. Further investigation, especially for characteristics which relate the art to 

symptomatology must use studies which conform to common research criteria and which 

minimise confounding variables. Comparable studies are those which use matched control 

groups, at least on age and sex, a reliability index (if using a test which is not established, 

if the rater is untrained or if there are mainly content variables). 

112

Reliability Analysis 

Judgement of characteristics differentiating patient groups 

All rating scales have limitations, especially those involving human subjects. Given 

enough different people performing a measurement, individual differences will contribute 

to error, but a single rater may be inconsistent, or may be scoring on other criteria than 

the published instrument. If a measure is unreliable, there is no possible way that any 

sort of statistically significant relationship or difference with that measure can be 

documented. It makes little sense therefore to list the characteristics for every study in 

the controlled and case analyses unless they have established inter-rater reliability so that 

it is certain their scoring is consistent and their definitions of terms unambiguous. 

Terms used in this analysis of studies 

Most studies have some counted or presence/absence scales, but there is a wide range of 

opinion on what is described as objective or formal qualities. Here, formal qualities are 

broadly differentiated from objective qualities as relating to the structure of the picture; 

how it is made, rather than why it is made or what it represents 173 . Objective decisions 

can be made about elements of form and content; although a characteristic can be both 

formal and objective, it cannot be formal and subjective. For this review, objective 

categories may be considered as observable dimensions; for example: the presence or 

absence of some element, countable items, differentiation of structural aspects or 

elements of the picture, such as lines, shapes and colours. Objective dimensions also 

173 This form description is broader than the formal description for the DAPA, which appears in Chapter 

3. It is clearly not reasonable to apply criteria to studies which are not aimed at that point. 

113

include recognisable or identifiable objects/persons (but do not attribute meaning to the 

image or compare it with an internal model). These objective categories can be 

differentiated from subjective categories in that they do not require interpretation of the 

image (fitting a meaning to the marks or images), do not require judgements of relations 

between images or opinions on such personal judgements as aesthetic quality or 

emotional associations. E.g. to note the presence of decoration, a subject must be 

reconstructed from the marks on the paper and compared with what the rater thinks is 

essential to structure: this is an opinion. On the other hand, phrasing can be misleading: 

rating criteria demanding presence or absence of a symbol does not require an objective 

but a subjective decision, because it requires the opinion of the rater on the intentions of 

the artist. Many of the tests here had global elements for which operational definitions 

cannot be considered reliable for a single rater. 

Selection: To minimise confounding variables, the studies which were to be included in 

the reliability assessment were those: 

1. Which actually measured art variables from the pictures (4 studies of the benefits 

of art therapy were excluded because the tests did not measure attributes of the 

picture; they used self reports or behaviourial assessment. 3 other non-art 

studies were excluded: Study 71, which used the TAT Make a Picture Story Test 

protocol but assessed the verbal explanations of the patients; Study 62 and 15, 

which used rigid copy accuracy measures. 

2. Which used more than one rater if the rater was not trained for an established test 

or if the test used mainly content variables. 

114

3. Which assessed agreement between the raters: 2 studies were excluded, because 

although they used multiple raters, they did not assess their agreement but 

compared the judgements with diagnosis directly (including the most famous and 

often quoted series of studies of judgements by Levy and Ulman 174 , who used 

intra-rater measures, every judge being their own control), . 

18 studies survived these strictures, 13 of which had 2 or more raters from the controlled 

analysis, the majority using a test developed for the study. 5 studies used one rater and 

claimed to use a previously established test; they will be discussed first. 

Established tests with 1 rater - further exclusions 

These studies claimed to use recognised tests, but examination reveals they used art 

directives, adding their own scoring and therefore consistency was needed. Study 77 

found differences using the protocol for a projective tree drawing test with elderly 

schizophrenics, demented and control subjects on the basis of proven reliability, but did 

not reference this statement and used their own interpretive system, which was not 

subjected to reliability analysis. Study 29 found no significant differences in the size of 

figures drawn by depressed patients and controls using a Draw-a-Person protocol, but 

this is only one element in the DAP scale and the method should be tested independently 

for reliability. 

Two studies used tests of emotional indicators: Study 70 used the DAPQ (Karp 

1990, unpublished) to find more incest markers in the drawings of abused than control 

women and different treatment of sexes. Study 55 found no differences in development 

174 

B.I. Levy and E. Ulman (1974) The effect of training on judgement of psychopathology from paintings, 

Am. J. Art Therapy , V.14:24-5 (study 43). 

115

and emotional indicators in drawings from schizophrenic mothers than from control 

mothers using a Draw-a-Man test (unspecified) but 5 significant differences between the 

children. 

The study of emotional indicators as symptoms of pathology have mostly been 

done on drawings of children. Their clinical utility is low as indicators are rare but their 

use as danger markers is recognised 175 . There is no evidence to show these studies may 

generalise to adults. 

Study 34 used the DDS 176 to compare 81 eating disordered patients with an 

undescribed control sample, collected and rated by Cohen 6 years earlier. It is most 

undesirable for the two ratings being compared to be carried out by different observers 177 . 

Any systematic variation between observers would have been inseparable from any 

difference between groups. The original 1988 study is also not included since the DDS 

team have not been able to supply basic information such as numbers of controls and of 

patient groups used in the study 178 . 

The reliability of the measures in these five studies is clearly more questionable 

than in studies which used their own tests and two or more raters. Therefore, from the 

175 

Maralyn M. Trowbridge (1995) Graphic indicators of sexual abuse in children's drawings: a review of 

the literature, Arts in Psychotherapy , V.22(5):405-93. 

176 Cohen et al (1988) op.cit. 

177 

It is included in the analysis of controlled studies, but not here as it did not include a separate reliability 

test. 

178 Despite repeated personal communications over 4 years: 1994, 1996 and 1998. The original paper states 

that further information is available, but from private letters and other communication the team cannot 

comment on the statistical basis of the paper. Their reliability study, however, reported fully in 1993 was 

included. 

116

main analysis of 51 controlled studies, only those 13 studies whose characteristics were 

rated by more than one rater were included in the reliability analysis. 

The exclusion of the DDS 

The Diagnostic Drawing Series, published and peer reviewed in the art-therapy press 179 

is currently the most well known contemporary art therapy assessment instrument in 

America. It has repeatedly claimed to be the only art assessment method which has been 

reliably tested, validated and has demonstrated reliable differences between diagnostic 

groups. It uses 23 categories, most of which would be considered here as a more 

objective form of content analysis but half of which are claimed by the authors to be 

formal measures. The DDS is a useful therapeutic tool in that it offers a standardised and 

structured format for assessment which is acceptable to a therapeutic milieu. Three 

pictures are required, a person, a tree and a free picture. The reliability of the categories 

has been demonstrated as good between 2 or 3 raters, although their methods of 

calculating reliability are not clear and one study found that only 6 out of 23 categories 

showed good reliability as calculated by the Kappa statistic between 2 raters, which gives 

room for questions 180 . To ignore this major study could be seen as serious neglect, so I 

will give my reasons for leaving out this study at length. 

Are the claims for the DDS valid? 

179 

Cohen, Hammer and Singer (1988) op.cit.; also Art Therapy No. 15 1996, passim. The DDS appears 

all through this issue as the premier assessment method for art therapy and research. It is repeatedly 

claimed to have demonstrated clinically reliable differences between patient groups. 

117

The DDS (1988) study was an exploratory study which described an evaluation 

procedure applied to the pictures of 3 diagnostic groups of patients: Dysthymia, 

Depression, Schizophrenia, and one non-patient group within a population size of 239. 

In order to evaluate it properly, it would be necessary to know the sizes of the sample 

groups, since the detection of 100% accuracy in one sample may refer to a different 

number than another group. There were indications within the text that the control group 

was in some way abnormal or small. 

The instrument itself rated up to 23 categories for each of three pictures by each 

patient. Some categories were reduced to 2 binary variables, and some with 3 or more 

choices were reduced in some other way that was not explained. The text indicated that 

there were then 36 variables in the end for each picture giving a patient profile of up to 

108 variables between 3 pictures, treating the repeated measures as independent. This 

procedure was not well explained and their illustration form did not employ either 23 

categories or 36 variables. Furthermore, if the extra variables were included as was 

indicated on the results tables, there would have been more than 108 variables. Despite 

repeated enquiries, none of these concerns have been addressed by the authors. 

4 multiple-regression analyses were calculated, one for each group against the 

total population. That for an analysis to have 108 variables was unsatisfactory because 

of the sample size required was recognised by Cohen in the paper. The variables were 

rotated by some unspecified procedure but it is a mystery why they used the variables 

that appear in the resultant tables, which were supposed to compare between diagnostic 

180 

E.L. Neale (1994) The Children's DDS, Art Therapy , V.11(2):119-126. 

118

groups, rather than any other. Each table used a different set of variables so they were 

difficult to compare. In addition, the variables were treated as though they were 

completely unrelated, but there must have been a high degree of multicollinearity (most 

of the variables must be related, especially those which are derived from the same 

category and those which measure different pictures using the same variable) and most 

would not contribute anything extra to that of the main differentiator, which means the 

co-efficient presented cannot really be interpreted as an effect. 

Cohen quotes the F-test as a measure that the combination of predictors does 

better than chance, meaning that some element in the equation differentiates the 

dependent variable (patient or control). However, this does not mean that it is effective. 

All the ANOVA tells us is that at least one characteristic is good. There is evidence from 

some of the t-tests that the co-efficient of the variable is not 0, but even ignoring the 

method, looking at the coefficients as effect sizes 181 , the Dysthymia group shows an 

almost negligible effect (-0.08 to 0.13); the Depressive results and Controls are similar 

(depressed 0.13-0.17; controls 0.13-0.28), the strongest are water scenes for both 

(depressed 0.37 and control 0.36 182 ), which is not mentioned in the discussion of the 

results; only Schizophrenia shows a high effect on one variable, minimal trunk (0.63, but 

otherwise 0.16-0.29). 

I therefore disagree with most of the statements in the discussion of significant 

characteristics which are supposed to identify diagnostic groups, which include some 

181 

The coefficients could be interpreted as effect sizes if the variables were independent in the same way 

as the t-statistics. 

182 But the t-statistic has a significance of p=0.07 which does not indicate exclusivity. 

119

which were not significant - and I would totally disagree with the assumption that 

negative coefficients implied another characteristic was a strong indicator of 

predictability, especially when the variable itself was tested, but not included: eg. "a 

striking feature of dysthymia was light pressure" (indicated by a negative coefficient on 

medium and heavy pressure). The t-values for heavy pressure were greater than one in 

both picture A and B, which merited some discussion, but surely this indicated heavy 

pressure was not applied, not that light pressure was applied! One of the study variables 

was light pressure - why was it not included in the results? Similarly monochrome as a 

significant characteristic is inferred from the negative correlations on multicoloured 

pictures from schizophrenic patients. Monochrome was one of the study variables, why 

was it not included in the schizophrenia results if it was a significant characteristic? 183 

It is obvious the technique of multiple regression is not appropriate for this 

analysis, as reflected in the low levels of the multiple r-squared statistic 184 and does not 

do justice to the clinical merit of the DDS. 

When the DAPA was being developed, the DDS was already rather famous. 

Over 10 years, it has developed a 4 page resources list 185 . I contacted the DDS team and 

183 The DDS team have declined to answer any of these serious criticisms. They have also ignored my 

requests for clarification of their methods, since they are no longer in contact with their statistician. But 

the DDS team are still encouraging art therapists to use this measure and bring in new work (DDS 

Newsletter Dec. 1998). 

184 Multiple r 2 measures the fit of the model to the information provided - the closer to 1 the better. A 

good fit would typically be 0.7-0.99. The DDS results were: Dysthymia 0.15; Depression 0.10: 

Schizophrenia 0.22; Control 0.44. The control shows the best fit and the t-statistics are significant on 

more variables, but very weak. However, if the numbers in the group are very different - as is hinted in 

the paper, this might have a confounding effect. 

185 

DDS Resource List (1988) unpublished. 64 items mostly unpublished in cassette form. All published 

material is discussed in this thesis. 

120

invited them to provide substantiation for their claims since their original 1988 published 

study was uninterpretable for this review. Despite this study being ten years old none 

of these criticisms had been put to the DDS before 186 , which shows the statistical naivety 

of their readership. Their whole output of papers and other resources are based on the 

1988 study. The DDS team could not provide me with a better estimate of the 

effectiveness of the DDS. 

Tabulation of studies for reliability and discriminant characteristics 

Firstly, each study had different combinations of reliable variables and different systems 

of combining these variables for analysis. 28 studies were included in the analysis. 18 

studies (which included 13 from the controlled analysis) were taken from the validity 

analysis of 70 criterion measures, 3 were series uncontrolled studies (examined in the 

analysis of 163 case studies, Chapter 2). The remaining 7 studies were not discussed 

elsewhere: 3 were studies which examined judges predictions of patient status from their 

own criteria, 2 were related studies which examined judge reliability on interpreting self- 

images from paintings and 2 were specific reliability studies for the same test (the DDS). 

There were three more controlled replications of studies by the same authors, all of 

whose results cast doubt on their initial acceptable reliability. Study 9 was succeeded by 

study 10; study 37 was succeeded by study 38; and study 58 was succeeded by study 

59. Only the later studies are considered in the breakdown of elements. Those studies 

which are not marked unreliable and do not show discriminant characteristics are either 

186 Private communication, Anne Mills and S. Hacking 1998. 

121

eliability studies or studies which use comparisons of total scores rather than isolated 

elements. The total score comparisons are entered separately into the table as composite 

variables. 

In order to compare studies it was necessary to identify commonalities in 

variables between studies and classify them into categories. These categories were 

tabulated into 14 different areas of drawing analysis. The tables show the original terms 

as far as possible. Terms are usually defined by the studies, and some produce booklets 

of rating criteria, but they do not exactly compare with each other. These definitions are 

not reproduced as each is individual; a list would be lengthy, require specific vocabulary 

in some cases and serve little purpose. Different studies recorded similar elements, 

globally and through combinations of details; I have tried to reflect this in the text. There 

is little information on unreliable categories, as they tend to be barely mentioned and do 

not appear on the variable lists, but those mentioned are presented in the tables, although 

these are much fewer than in reality. Reliability is presented according to the author's 

own evaluations, since this is a clinical decision, unless otherwise specified, as most 

present only their final statistic. Some reliabilities are quoted by their authors only as 

'better than chance' or 'acceptable', without figures. These were included here, but not in 

the meta-analysis. Reliability tests are given by type, a key to which appears under 

every table. A discussion of the limitations of the reliability statistics appears separately 

at the end of the section. Discrimination analyses were simpler and test details are not 

presented. Studies here present a more objective approach than is usual in this literature. 

122

Studies which included reliability tests from controlled and uncontrolled analyses 

of literature on art tests 1974-1996 

Studies showing reliability only do not test discriminant properties. 

Divisions are for subcategories of like variables by heading or by 1st variable in 

bold; (o) objective (s) subjective (c) content (f) form. No.s are study No.s from 

Table of Authorities (Appendix 3), No.s below headings denote same term 

different study. 

Variables tested individually for reliability scores in bold, others are reliabilities 

for whole test. 

123

Thematic variables 

Table 1: reliability statistics and discriminating variables for category of theme. 

Thematic variables (Study No.) 

(o) objective (s) subjective (c) content (f) 

form 

presence of main image (48) (c) (o) 

(49) 

absence of focal configuration (56) 

unintelligible essential (36) 

omission of essential (36) 

presence of named elements (c) (o) 

house (56) 

1 dwelling or building, 2, 2+, estate (46) 

people present (48) 

(46) 

(21) 

(49) 

(3) 

animals present (48) 

(46) 

(49) 

tree present (48) 

(49) 

water landscape (48) 

(49) 

inanimate object (48) (s) 

(49) 

(33) 

% other 

ag't test 

(1-6) rel'y 1 

99 

77 

4 high 

90 5 .915 

90 5 .915 

4 high 

96 

100 

96 

3 .90 

77 

3 .96 

99 

96 

77 

96 

77 

93 

77 

124 

discriminates patient 

/nonpatient control 

(nf=no figures) 

NS 

(nf) Alzheimer's 

nf 

NS 

Organic** 

discriminates subgroups of 

patients 

NS 

NS 

NS 

NS 

Depression/ Organic** 

depressed p.d. ** 

97 

77 

94 4 .96 severe mental retd'n **; 

acute/chronic psychosis* 

1 - reliability tests: 1 = % agreement; 2 = product moment correlation; 3 = correlation coefficient; 4 = association test Chi 

sq. or T; 5 = Kappa; 6 = Anova. 

** p

Discrimination: From 26 reliable variables, 8 were tested for discrimination properties 

by 5 studies; there were 4 differences. There were no significant differences between 

schizophrenics and controls on absence of focal configuration (56). A similar variable, 

omission of essentials, was identified as a strongly significant and frequent predictor of 

Alzheimer's disease against normal controls (36) and was distinct from unintelligibility, 

in which there was no difference in the same patient group. Between presence of named 

elements, people present were drawn more frequently by normal controls than patients 

with both depression and organic brain damage (21; this study probably lacks power as 

the numbers are very small) and this result is partly supported by similar findings from 

a study of depressed patients with a main diagnosis of personality disorder (3, but no 

subgroup numbers were given). The findings of study 46, that schizophrenics and other 

patients scored equally on countable named elements in pictures also support this 

differential score for depression. There were differences between different partitions of 

schizophrenic patient groups from study 33, which distinguished duration of psychosis 

as long or short and severe from other grades of mental retardation (33), in the use of 

inanimate objects, but neither compensation, nor power calculations were made for the 

process of multiple testing and unequal numbers. 

Summary: Objective thematic evaluation of content is reliable. Normal controls may 

draw more people than patients and Alzheimer's patients may omit more essential 

elements than both controls and patients. Use of inanimate objects may distinguish 

125

etween grades of the same diagnosis, particularly in retardation, but the evidence is very 

weak for all suggestions. 

Content 

Table 2: reliability statistics and discriminating variables for category of content. 

content variables (study No.) 

(o) objective (s) subjective (c) content 

(f) form 

paucity content (36) (s) 

general poor content (36, composite v) 

bizarre content (38) (s) 

(36) 

(33) 

incongruity (36) 

fused/hybrid image (36) 

morbid content (36) (s) 

hopelessness (75) 

suspicion (36) 

masklike drawing (33) 

personal content (s) 

expressive (44) 

(36) 

symbols (38) 

original (38) 

problem solving (21) 

identification of themes (50) (s) 

continuity of themes (50) 

several ideas (38) 

related ideas (38) 

interest self (75) (s) 

interest family (75) 

% other 

ag't test 1 

(1-6) rel'y 

126 

discriminates patient/ 

nonpatient control 

(nf = no figures) 

90 5 .915 Alzheimer's freq. 

(nf) 

Alzh'rs ** 

2 NS 90 

5 .915 

70 4 .566 

90 5 .915 

90 5 .915 

90 5 .915 

2 .94 

90 5 .915 

NS 4 NS 

3 .63 

90 5 .915 

2 NS 

2 > .60 

3 .92 

own criteria NS 

own criteria 

NS 2 

NS 2 

>.60 

2 .94 

2 .94 

Alzheimer's freq 

(nf) 

nf 

nf 

nf 

depressed ** 

nf 

nf 

NS 

patients ** 

NS 

depressed ** 

depressed ** 

discriminates subgroups of patients 

paranoid from non-p schizophrenia*; 

mild from other retarded 

schizophrenics**; retarded from nonr 

schizophrenics* 

schiz. coping techniques* 

depressed ** 



** p

implied contradictions between studies measuring similar variables. The studies using 

overall scores showed high agreement (mostly over 90%), although they were results of 

5 different types of measurement and so, difficult to compare. Reliable subcategories 

were: paucity of content (36) and interest in self and family (75). Personal content and 

morbid content were similar variable types which seemed reliable if rated globally 

(subjective decisions such as masklike drawing [33] or symbols [38] were unreliable), but 

there may have been large variations in terms. Bizarre content was rated by 3 studies, 2 

indicating high agreement between 3 raters (36, 33), but study 38 found the same term 

unreliable between 2 raters. Since study 33 used a similar patient group, the most likely 

difference would be in definition. There was poor agreement for the theme subcategory, 

in identification and continuity and in 2 variables from study 38, where related ideas were 

reliable, which is of questionable value if it is difficult to determine if there is more than 

one idea (several ideas, 38 unreliable). It is more likely that this variable measures some 

other quality of the picture such as internal relations between elements but it was not 

clear and therefore was rejected as ambiguous. 5 subcategories were therefore reliable. 

Discrimination: From 10 reliable variables tested for discrimination properties, 8 

showed results. Schizophrenia groups were distinguished in paranoia and retardation 

from non paranoic and non retarded, and particularly, mild retardation from other grades 

in the presence of bizarre content in their paintings (33). This point was supported by 

qualitative reports from study 46, of more bizarre work by schizophrenics than other 

patients, and better results from paranoid than other schizophrenics. Within 

schizophrenic groups, the coping strategy of 'sealing over' promoted the use of more 

127

personally expressive images than 'integration' (44). Poor content, a totalised score of 11 

separate variables, was a significant predictor of Alzheimer's disease against normal 

controls (36), within which, paucity of content was one of two variables which always 

occurred and bizarre content was identified as a frequent and significant indicator (36). 

The suggestion from study 46, which noted qualitatively that schizophrenics used more 

personal and self-centred content than other patients, was not picked up generally in this 

table although study 38 also noted, but did not pick up more originality from 

schizophrenics than normal controls. There are indications that depressed patients use 

less problem solving strategies (21) than other patients. Some support is given from the 

finding that depressed patients, produced more hopelessness (75), and also differed from 

normal controls in their disinterest in self and family (75). 

Summary: Subjective judgement of global content is reliable, but not when referenced 

to the image. This indicates that what is interpreted has little relation to the picture, 

except in the differentiation of Alzheimer's disease, where pictures were poorer in content 

and more bizarre than normal controls. This could, however, reflect the physiological 

signs, such as control of the media, rather than intentional imagery, as indicated by the 

lack of specificity in 'bizarreness', such as confusion or hybrid imagery. There are 

indications of differences within patient groups for personal content, but the evidence is 

weak because of small numbers and in the vague definition of 'expression' (44). Large 

differences were reported between depressed patients, normal and patient controls by 3 

studies on what seems reflective of situational despair or disinterest. 

128

Body Detail 

Table 3: reliability statistics and discriminating variables for category of body detail in 

picture. 

Body detail variables (study No.) 


(f) form 

emotional indicators (c) (o) 

incest markers (9) 

incest markers (10 187 ) 

sex difference (75) 

incest markers (57) 

trees (c) (o) 

knotholes (52) 

broken limbs or damaged trunk (52) 

leafless (52) 

size of figure (c) (o) 

self (75) 

family (75) 

figure relationships (s) 

self-other distance (75) 

self isolation (75) 

family isolation (75) 

identify self image (58) (s) 

(59) 189 

% other 

ag't test 1 

(1-6) rel'y 

96 

96 

96 

2 Mod 

2 NS 

2 .94 

5 .71 

2 .94 

2 .94 

2 .94 

2 .94 

2 .94 

129 



(nf= no figures) 

stat. not clinical 

depressed ** 

NS 

NS 

dissociative 

disorders 30% 

freq. 188 (nf) 

depressed ** 

depressed ** 

depressed ** 

depressed ** 

depressed ** 


94.3 

61.9 unreliable 54% (5 soc.wkers); 78% 

(5 health prof) 93.4% (2 Art ther) 

1- reliability tests: 1 = % agreement; 2 = product moment correlation; 3 = correlation coefficient; 4 = association test Chi 


** p

to trees (52); size of figure (75); figure relationships (75) which all scored over 90% 

percentage agreement or correlation between 2 or 3 raters. The fact that neither of these 

measures gives an adequate assessment of true agreement is illustrated in the remaining 

subcategories, by two pairs of studies using the same tests with better controls and more 

raters. Studies 58 and 59, which identified self images, initially obtained high agreement 

between 2 art therapist raters, but, subsequently, using different raters, obtained 54-78%. 

The author's claim of acceptable reliability nonetheless for identification without 

reference to the patient, is clearly questionable, since a likely explanation of these figures 

is that subjective identification of the meaning of images probably depend on the rater's 

acquaintance with the patient's personal imagery. Studies 9 and 10 reported but did not 

quote 'moderate correlations' between 2 raters for their first study, whereas their second 

study using 4 raters achieved such poor reliability that the authors admitted serious 

doubts about their previous results. Study 57, which used the same patient groups, in 

similar numbers achieved good reliability as measured by the Kappa statistic; it seems 

likely that definition problems in study 10 were avoided in study 57 which focused 

purely graphic features. Study 75 achieved a very high correlation with another specific 

variable, sex differences. The emotional indicators subcategory was therefore judged 

reliable for specific graphic elements. 

Discrimination: From 11 variables between 3 studies tested for discrimination 

properties, 8 results showed significant differences. Differences between controls and 

depressed patients were shown in size of drawing, relationships between and sex 

differences in figures (75), but not among 74 graphic features measured from figure 

130

drawings by sex abused adolescents (57). Although no test was applied, trauma 

indicators from drawings of trees with damages found that psychotics drew more broken 

limbs or damaged trunks than normal controls (52). 

Summary: emotional indicators became reliable when judged objectively on specific 

graphic features. Certain features may discriminate drawings of depressed or psychotic 

patients from normal controls, but they were not apparent in victims of sexual abuse, the 

expected client group which is most frequently exposed to this kind of measure. Studies 

9 and 10 reported most of their variables were 'statistically but not clinically significant' 

for drawings from victims of sexual abuse, i.e. they were rare in that group. This finding 

is consistent with the recent literature 190 ; most studies failed to establish sex markers and 

presence of genitalia were rare. 

Quality 

Reliability: 6 experimental studies and 1 study of validity between tests generated 15 

variables, which were grouped among 2 subjective subcategories of content appraisal and 

1 formal subcategory. All the tests for agreement were the same, so studies compared 

well. Reliable subcategories were: presence of specific elements of drawing sophistication 

(38, 35, 61, 31), and proportion of the image, in parts (38) and overall (35, 38, 36, 20). 

190 

Comprehensively summarised by M.M. Trowbridge (1995) Graphic indicators of sexual abuse in 

children's drawings: a review of the literature, Arts in Psychotherapy , V.22(5):485-93. 

131

Table 4: reliability statistics and discriminating variables for category of Quality. 

Quality variables (Study No.) 


(f) form 

aesthetic quality (38) (s) 

pleasing/good (14) 

poor (61) 

care (38) 

craftsmanship (38) 

drawing sophistication (c) (o) 

painterly/graphic (38) 

dry brush (38) 

brush strokes (38) 

redrawn line (35) 

corrections (61) 

drawing sophistication, form (31) 

drawing sophistication, space (31) 

proportion (s) 

object (38) 

parts (38) 

overall impairment (35) 

poor graphic quality (36, composite) 

quality copy (20) 

% other 

ag't test 1 

(1-6) rel'y 

2 NS 

own 

2 .97 191 

2 NS 

2 NS 

2 >.60 

2 >.60 

2 >.60 

2 .84 

2 .97 

2 .77 

2 .77 

2 >.60 

2 >.60 

2 .84 

2 .78-.92 

132 




common prefs 192 NS. 

NS 

NS 

NS 

NS NS 

NS 

NS 

brain damage** 

Alzheimer's** 


patients 

NS 

Alzheimer's 193 



** p

interpretation. Equally, the variation in scores for craftsmanship or care probably reflect 

individual differences, which would vary with raters' experience, so this subcategory was 

unreliable. 

Discrimination: From 9 reliable variables tested for discrimination properties, there 

were 4 significant results. There were no differences between pictures by controls and 

brain damage (35) or schizophrenics (38) on elements of drawing sophistication, although 

coverage of this area was very poor, nor in proportion of objects or parts of the pictures 

(38) for schizophrenia. Overall, quality of the drawing from a 9 variable composite, most 

discriminated Alzheimer's disease (36) and brain damage (35) from controls and among 

grades in the corresponding deterioration of the image or copy with departure from 

normality (longer illness and loss of brain weight in Alzheimer's (20); damage to the left 

brain (which is more noticeable in normal operations) against that of the right and controls 

[35]). 

Summary: Subjective personal judgements of quality were unreliable. Reliability can 

be achieved when the criteria are defined as elements of the drawing. Although non- 

significant, study 38 noted trends towards more graphic work by schizophrenics and less 

proportion between objects and parts. Global quality was a good discriminator variable 

for brain disease or damage, but there were indications that the coverage of this area was 

patchy. 

133

Line 

Table 5: reliability statistics and discriminating variables for category of line quality. 

Line quality variables (Study No.) 

(o) objective (s) subjective (c) content (f) 

form 

counted elements of line (f) 

number of lines (38) 

number of angles (35) 

angle production (35) 

% rightangles (35) 

% acute angles (35) 

obtuse angle (35) 

length (48) 

(49) 

long stroke (38) 

short stroke (38) 

degree short strokes (38) 

predominance long short (38) 

varied length (38) 

line quality (48) (f) 

(49) 

(21) 

heavy/light brush (38) 

predominance thick/thin (38) 

description of lines (f) 

reinforced (36) 

1 stroke (38) 

joined (35) 

crossed (35) 

jagged (38) 

broken (38) 

splintered (38) 

quavery (38) 

shaky (36) 

tremor (35) 

sketchy (33) 

curve (38) 

straight (38) 

straight/curved predominance (38) 

straight/curved variation (38) 

purpose of line (c) (s) 

aimless (36) 

enclosure (48) 

(49) 

(38) 

(46, composite) 

degree outline (38) 

for texture (38) 

for fill in (38) 

for shade (33) 

other marks (c) (o) 

blotches for line (38) 

blotches/form, mass, decor'n, texture (38) 

smears (38) 

dabs (38) 

degree dabs (38) 

dabs for form, mass, decor'n, texture (38) 

% other 

ag't test 1 

(1-6) rel'y 

99 

77 

97 

77 

2 >.60 

2 .84 

2 .84 

2 .84 

2 .84 

2 .84 

2 >.60 

2 >.60 

2 >.60 

2 NS 

2 >.60 

3 .32 NS 

2 >.60 

2 >.60 

90 5 .915 

2 NS 

2 .84 

2 .84 

2 NS 

2 >.60 

2 >.60 

2 >.60 

90 5 .915 

2 .84 

82 4 .63 

2 NS 

2 >.60 

2 NS 

2 >.60 

90 5 .915 

98 

77 

2 >.60 

2 >.60 

2 >.60 

2 NS 

85 2 .68 

2 NS 

2 >.60 

2 NS 

2 >.60 

2 NS 

2 NS 

134 

discriminates pat. 

/nonpat. control 


NS 

brain damage ** 

left b. damage** 

right b.damage* 

left b.damage* 

NS 

NS 

NS 

NS 

NS 

NS 

NS 

nf 

NS 

NS 

NS 

NS 

NS 

nf 

brain damage ** 

NS 

NS 

nf 

NS 

NS 

NS 

NS 

NS 


patients 

NS 

left b.d. from r.+ control** 

right b.d. from left+control* 

left b.d. from right+control* 

NS 

NS 

NS 

R. from L. brain damage ** 

Grades retarded schiz 2 ** 

Retarded schiz from non R.* 

NS 

Schizophreniform/nuclear s.* 

1 - reliability tests: 1 = % agree; 2 = product moment corr.; 3 = correlation coefficient; 4 = association test Chi sq./t; 5 = Kappa; 6 = Anova. 

2 - mild to moderate mental retardation in schizophrenia, distinguishes amongst grades. 

** p

Reliability: 5 experimental studies and 2 reliability studies generated 54 variables, which 

were grouped between 3 formal, 1 subjective and 1 objective content subcategory. 

Although only 5 variables between 3 studies actually gave individual figures for the 

reliable items (the others gave the averaged test agreement statistic), the variables and 

statistics within subcategories were congruous for the majority of studies. 13 of 14 

unreliable variables came from one exploratory study (38), which used large numbers of 

variables, sometimes promoting confusion amongst similar terms. It must be remembered 

that few studies report their measurements of unreliable variables, so these measures 

must take on more weight in discussion than the minority of studies they seem to 

represent. The most reliable subcategories were: counted elements of lines (48, 35, 49, 

38), except for predominance of short or long lines (38), which is confusing, considering 

that long and short lines were identifiable. This same problem occurs in the subcategory 

of description of line. Presence of straight or curved line and variation of straight or 

curved line was reliable, but predominance was not. It is likely to be due to difficulties 

in relative judgement, which puts the objectivity of some of the other categories in doubt: 

reinforced lines were reliable (36), but not lines made with one stroke (38). Taken 

together it seems that polarisation in quality of line may be discerned, by relation to the 

whole and considering only the extremes. However, this technique would tend to allow 

the judgement to vary according to variation in individual style and range of marks. This 

subcategory was considered reliable for broad distinctions of presence. Joined or crossed 

(35), broken or splintered lines (38) were scored reliably present as were shaky or sketchy 

lines (38, 36, 33, 35), but not jagged (38) (which probably blurred with splintered). 

135

Purpose or use of line contained one unreliable variable among 8, fill-in (38), which was 

probably confused with the texture variable of the same study. Shade (33), a similar 

variable, achieved acceptable reliability. Study 21 achieved a correlation coefficient of 

only 0.32 on quality of line between 3 raters, whereas three other studies achieved 

acceptable correlations and high agreements between 2 raters. The author of study 21 

admits unresolved problems in definition and reports previous results of (0.73-0.95), so 

the quality subcategory was considered reliable. The other marks subcategory (13 

variables, all from study 38) was generally unreliable where decisions of degree were 

made between similar variables; blotches, but not dabs (although they could be marked 

present) or smears, could be reliably differentiated as used for form, mass, decoration 

and texture (but not as used for line) so reliability was achieved only for presence of 

blotches within the image. 

Discrimination: From 27 reliable variables tested for discrimination properties, there 

were only 5 differences reported among 3 reliable subcategories. There were differences 

within patient groups of left or right brain damage and between patients with left brain 

damage and controls in difficulty of producing angles and in number of acute angles, 

within patient groups and between left brain damage and controls in right angles, but no 

difference in obtuse angle production (35). There were no differences among these 

groups or among schizophrenics and controls in number (35, 38) of lines, or among 

schizophrenics and controls in length or quality of lines or presence of substitute marks 

(38). Within groups, nuclear schizophrenics were reported to use more shading than 

those with schizophreniform illnesses (33), but there were no differences in purpose of 

136

lines between controls and Alzheimer's patients (36), schizophrenics and other patients 

(46) or schizophrenics and controls (38). Differences among diagnostic groups were 

shown in, shaky lines or tremor, probably betraying physiological damage, discriminating 

brain damage from normal controls (35). Sketchy line discriminated mild from other grades 

of schizophrenic retardates and schizophrenic retardates from normal schizophrenics 

(33). 

Summary: The reliability may vary with the range of line expressed and its relative 

extremes. Overall, line does not seem to be a discriminable dimension against normal 

controls for schizophrenia or Alzheimer's disease. Line does show up logical difficulties 

in control, particularly in the drawing of angles by patients with brain damage. This 

probably reflects loss of fine motor control rather than a distortion in concept of the 

image. The deterioration of controlled line the further towards retardation in 

schizophrenia may point towards a theory of regression for that group. 

Shape Table 6: reliability statistics and discriminating variables 

Shape variables (study no.) 


(f) form 

% other 

ag't test 1 (1- 

6) rel'y 

paucity shape/form (36) (f) 90 2 .915 nf 

differentiation of line/shape (48) (f) 

(49) 

variation in form (38) 

variation in mass (38) 

shape dimensions (f) 

dominant shape (69) 

size of shapes (69) 

regularity of shape (69) 

similarity of shapes (69) 

flat shape (36) 

repeated forms (38) (f) 

3+ abstract forms mannerism (56) 

3+ same shape (69) 

4 shape/detail stereotype (56) 

98 

77 

2 >.60 

2 >.60 

137 


nonpatient control (nf= 

no figures) 

NS 

NS 

4 Acc. 

4 Acc. 

4 NS 

4 Acc. 

90 5 .915 nf 

2 >.60 

6 Acc. 

4 Acc. 

6 Acc. 

NS 

patients/schizophrenic* 

NS 


NS 

NS 

NS 

Schizophrenic/patients* 

NS 

NS

Shape variables (study no.) 


(f) form 

delineated form by mass, contour (f) 

(38) 

delineated form by line (38) 

% other 

ag't test 1 (1- 

6) rel'y 

2 >.60 

2 NS 

138 


nonpatient control (nf= 

no figures) 

NS 




** p

Summary: Shape does not appear to distinguish any group of patients reliably. There 

are ambiguities in terms from the literature which are not shown in the reliability tests, 

possibly reflecting individualistic research which shows itself in lack of congruency in 

type of variables between studies. 

139

Colour 

Table 7: reliability statistics and discriminating variables for category of colour. 

Colour variables (study no.) 


(f) form 

number of colours (38) (f) 

(14) 

(75) 

(44) 

(36) 

colours used (14) (f) 

actual colour (38) 

colourtype (48) 

(49) 

mixed colour (f) 

blend (48) 

blend (49) 

muddy (38) 

mixed on surface (38) 

mixed colour (38) 

pure colour(38) 

thick (38) 

watery (38) 

dominant hue (69) (f) 

prominence (21) 

light/dark tone (69) 

brighter tone (69) 

brightness (69) 

brightness (38) 

dominant tone (69) 

consistency of colour (38) (f) 

(69) 

1/6+ 1 colour (56) 

masses 1 colour (38) 

decoration or outline in colour (38) 

colour fit (21) (c) (s) 

idiosyncratic colour (48) 

(49) 

colour harmony (69) 

colour relations (3) 

% other 

ag't test 1 

(1-6) rel'y 

2 NS 

own criteria nf 

2 .94 

3 .63 

90 5 .915 

own criteria nf 

2 NS 

98 

77 

92 

77 

97 

77 

2 >.60 

2 >.60 

2 >.60 

2 NS 

2 NS 

2 >.60 

4 Acc. 

3 .90 

4 Acc. 

4 Acc. 

4 Acc. 

2 >.60 

4 Acc. 

2 NS 

4 NS 

4 Acc. 

2 >.60 

2 >.60 

3 .86 

4 Acc. 

3 .83 

140 


nonpatient control (nf= no 

figures) 

patients less (nf) 

depressed ** 

Alzheimer's less (nf) 

patient pref.Red/Black(nf) 

NS 

NS 

NS 

NS 

NS 

NS 

NS 

NS 


schiz. coping strats 194 * 

psychotic depressives 195 ** 

patient groups * 196 

neurotics * 

NS 

NS 

neurotics * 

NS 

NS NS 

NS 

pers. disorder; dep. less (nf) 



** p

applied between studies but there was high congruency of variables within subcategories. 

10 variables between 2 studies gave an item reliability score and there were 6 unreliable 

variables although these were spread over 4 subcategories. Reliable subcategories were: 

brightness of hue and tone (69, 21, 38) which were undifferentiable in most studies so 

are grouped together here. (study 69 did differentiate them and found evaluations of 

these elements highly correlated); coloured detail (38), and colour fit (21, 48, 49, 3, 69). 

4 studies with the same term definition (75, 14, 36, 44) achieved high reliability on 

number of colours, but correlations between raters were very low in study 38. This 

study also found low correlations for colours used, found reliable by 3 other studies (14, 

48, 49, although two of these used no figures). The raters for study 38 were art trained 

and it is likely that there were too many delineations of colour in this study. Therefore 

these subcategories are considered reliable when not too complicated. Colour mix was 

reliable on premixed colour (38, 48, 49), on surface mixing (38), muddy or watery colour 

(but not thick or pure, which probably denotes difficulty in decisions on relative 

consistency)(38). Consistency of (i.e. the most prevalent) colour was found unreliable 

by 2 studies (38, 69) and the reliability for amount of single colour was only 'acceptable' 

in study 56. This was probably due to global assessment of the whole picture, whereas 

specifics, such as detail in decoration or outline or masses were reliable. This category 

is therefore considered reliable for specific details. 

Discrimination: From 21 reliable variables tested for discriminant properties, there were 

8 significant results among 3 subcategories. General psychiatric patients, Alzheimer's 

patients and depressed patients (14, 36, 75) all scored less than normal controls on 

141

number of colours. Furthermore within coping strategies of schizophrenic groups, 

'integrators' scored more than 'sealers-over'(44). There were no tests on colours used, but 

patients were reported to use more red and black (14) than normal controls. Neurotics 

were differentiated from other patients on 2 highly correlated variables; tone and hue (69). 

Study 38 found no differences between schizophrenics and normal controls among 4 

mixed colour variables and 2 details in colour variables. 2 studies found no differences 

for colour fit (69, 21) but a tendency to less appropriate colour by depressed patients 

with personality disorders was reported (3) although there were no test results. 

Psychotic depressives were differentiated from 5 patient groups on dominant hue (69), 

which concurred with initial findings of significant difference between 4 patient groups 

and controls using the same test statistic (21). The author of Study 21 reports no 

significance for this result because the Sheffé test did not isolate a single group, but I have 

disregarded this post-hoc analysis: the test procedure increases the power of the results, 

but the small numbers and overlap between groups in each of these two studies (21 

N=25; 69 N=33), make complex statistical procedures inappropriate and limit the 

comparability of the results, so results from study 69 and initial findings from study 21 

are here considered equivalent and valid. 

Summary: Normal controls generally use more and brighter colours than all patient 

groups although there could be more subtle inter-group differences amongst 

schizophrenics. Prominent or dominant colours or tones may offer discrimination 

between patient subgroups but clear distinctions between groups have not yet been made. 

142

Reality 

Table 8: reliability statistics and discriminating variables for category of reality. 

reality variables (study no.) 

(o) objective (s) subjective (c) 

content (f) form 

overall reality (c) (o) 

reality (21) 

degree verisimilitude (38) 

representative (48) 

(49) 

abstract (48) 

(49) 

abstract symbol (48) 

(49) 

verisimilitude masses & forms (38) 

verisimilitude objects (38) 

ambiguous shapes (36) 

reality in content elements (c) (s) 

omissions (38) 

additions (38) 

distortion (38) 

faulty recall (36) 

displacement (35) 

place error (33) 

unusual place (48) 

(49) 

logic (21) (c) (o) 

light source (38) 

connections:path, door; correctly 

placed path, door, window (46) 198 

horizon/ground line (c) (o) 

ground line (48) 

(49) 

base line (46) 

horizon (56) 

(46) 

% other 

ag't test 1 

(1-6) rel'y 

77 

77 

88 

77 

93 

77 

3 .88 

2 >.60 

2 >.60 

2 >.60 

90 5 .915 

2 >.60 

2 >.60 

2 >.60 

90 5 .915 

2 .84 

56 4 .56 

99 

77 

96 

3 .92 

2 >.60 

100 

77 

96 

4 good 

96 



figures) 

organic dis.** 

NS 

NS 

NS 

nf 

143 


NS 

NS 

NS 

Alzheimer's (more) nf. 

R/L brain damage** R.brain-d from L.brain-d 197 

Acute/Chronic schizophrenia*; 

grades in mental-ret'd. schiz.**; 

non-ret'd/retarded in schiz's.** 

organics ** 

NS 

NS 

depressed from mania+organic** 



** p

subcategories were congruous and all overall percentages showed good-very high 

agreements with no unreliable variables. Reliable subcategories were: recognisable content 

(48, 21, 49, 38, 36), horizon or base line (56, 46, 48, 49) and logical connections between 

named elements (46, 21). Although measures of placement showed good agreement 

generally in addition, absence, or distortion (38), placing errors (33), a term applied to 

placement of the central figure in the middle of the picture, showed much lower 

percentage agreement than the other studies (0.56). However, acceptable significance 

levels (p

omissions, distortions or additions of elements (38), although the same type of departure 

from reality (evidence of faulty recall) was more marked in Alzheimer's disease than in 

controls (36 or 35). The displacement variable showed significant differences between 

left brain damaged patients and normal controls or right brain damaged patients (35), also 

between a patient group partitioned 3 ways (33): (a) non retarded schizophrenic from 

retarded schizophrenics; (b) profound from other grades of mental retardation; and 

between acute and chronic schizophrenia. 

Summary: The polarisation of representation of reality and logic between controls and 

organic brain damage seems to be supported by findings of no differences between 

schizophrenics, other patients and controls on corresponding indices. It is thus 

reasonable to suppose that the results for Alzheimer's disease, as it affects the brain, may 

share some of the qualities of organic brain damage. Displacement of main images seems 

to strongly indicate general abnormality. 

Space 

Reliability: 11 experimental studies, 2 reliability studies and 1 validity study generated 

36 variables which were grouped between two subjective, one objective content 

subcategory, and one formal subcategory. There were 6 variables between 6 studies 

which gave item reliabilities and only one unreliable variable in the table. Reliable 

subcategories were: coverage of the paper (49, 44, 48, 21, 75, 35, 38, 36); relations 

between the main elements (3, 35, 61); presence or absence of perspective or indicators 

145

(35, 46, 36, 38, 33); and indicators of dimensionality (56, 61, 36, 46, 38). The exclusion 

of rotation (21) did not affect the other subcategory variables. 

Table 9: reliability statistics and discriminating variables for category of space. 

Spacial variables (study no.) 


(f) form 

picture space used (f) 

(48) 

(49) 

(44) 

(21) 

(38) 

empty space (75) 

neglect (35) 

impoverishment (46, composite) 

neglect (36) 

spacial relations (35) (s) 

(3) 

expansive/constrictive (61) 

presence of perspective (35) (c) (o) 

(46) 

depth (38) 

proportion (36) 

distorted perspective (36) 

perspective elements 

building top page (46) 

size errors (33) 

distance small (46) 

distance systematic (46) 

foreshortening: all elements, in roads, 

progressively in roads, systematically 

in roads (46) 

overlap (35) 

(46) 

+1 overlap (46) 

lines overlapping (36) 

organisation of space (46, composite) 

dimensions (s) 

2 dimensional (primitive) (56) 

3 dimensional (61) 

2 sides building (46) 

2 different angles of building (46) 

transparencies (38) 

rotation (21) 

birds eye view (36) 

worms eye view (36) 

% other 

ag't test* 

(1-6) rel'y 

92 

77 

3 .63 

3 .92 

2 >.60 

2 .94 

2 .84 

96 

90 5 .915 

2 .84 

3 .89 

2 .97 

2 .84 

96 

2 >.60 

90 5 .915 

90 5 .915 

96 

70 4 .62 

96 

96 

96 

2 .84 

96 

96 

90 5 .915 

96 

96 

4 Acc. 

2 .97 

2 >.60 

3 NS 

90 5 .915 

90 5 .915 

146 




NS 

NS 

depressed ** 


Alzheimer's (more) nf 




NS 

nf 

nf 

NS 

NS 

nf 

patients * 


NS 

NS 

right from left b.damage** 

Schiz. from patients** 

NS 

depressed pers.dis (nf) 

NS 

NS 

NS 

grades ret'n in schizophrenia* 

NS 

NS 

* - reliability tests: 1 = % agreement; 2 = product moment correlation; 3 = correlation coefficient; 4 = association test Chi sq. or 

T; 5 = Kappa; 6 = Anova. 

** p

of elements, differentiated controls from mixed patients (56) but not within 

schizophrenics/mixed patients (46, 56). The perspective subcategory did not differentiate 

between schizophrenics and other patients either (46) or between left/right brain damage 

(35) or between schizophrenics with and without mental retardation (33). There were 

no differences either, between controls and schizophrenics on depth perspective (38) or 

size errors (33) which did distinguish severe mental retardation in schizophrenia from 

other grades (33). Brain damaged patients generally (left or right) were distinguishable 

from controls by overall perspective but not by strategy (overlap). Patients with brain 

damage (35) or personality disorder (3) used less spacial relations than controls. Empty 

space, apparently, distinguished depressed patients (75), Alzheimer's patients (36) and 

brain damage (35) from controls. Furthermore, study 46 reports, impoverishment in 

pictures by schizophrenics compared to other patients though both patient groups were 

equally poor against normal children. These results, however, were not picked up by 2 

studies which reported that picture space used neither distinguishes between patient 

groups of: mania, depressed, organics, schizophrenia and controls (21), schizophrenics 

and controls (38). 

There seem two obvious sources of confusion: Most significant findings were 

from measures of neglect or emptiness (which could be taken to mean incompleteness). 

Measures which gave non-significant results as proportions of media coverage were 

typical of highly controlled studies, but which used very small group sizes (each group 

(21, N=25; 38, N=33) so probably suffer lack of power. 

147

Summary: There are unresolved definition ambiguities of the qualities measured. 

Neglect measures appear to distinguish patients against controls and schizophrenia from 

patients although coverage of paper does not. Mixed patients use more 2 dimensional 

space than controls although there are no specific differences in schizophrenia. Patients 

with brain damage use less spatial relations than controls and share some perspective 

abnormalities of mental retardation, but the qualification mentioned previously in reality 

above (study 33), may apply to both mental retardation and brain damage; limitations on 

measurements of drawing qualities show that severe retardates make less errors because 

there is observably less on the paper, so the utility of this form of measurement may be 

compromised. 

Energy Table 10: reliability statistics and discriminating variables for Energy. 

energy variables (study No.) 


(f) form 

energy (21) (c) (s) 

(3) 

tension (38) 

balance of motion (69) 

motion (44) 

(48) 

(49) 

motion shown thru line (38) (c) (s) 

motion in objects (38) 

motion shown through colour (38) 

main subject of picture (c) (o) 

energy in self (75) 

energy in family (75) 

human action (46) 

graphic human action (46) 

1, 2, 3 buildings, function visible (46) 

community building (46) 

good representation bldg function (46) 

% other 

ag't test 1 

(1-6) rel'y 

97 

77 

96 

96 

96 

96 

96 

3 .60 

3 .89 

2 >.60 

4 Acc. 

3 .63 

2 >.60 

2 >.60 

2 NS 

2 .94 

2 .94 

148 




organic ** 


NS 

NS 

NS 

depressed ** 

depressed ** 


depressed from organic** 199 

depressed pers. dis. (less) nf 

paranoid from non (schiz) * 

coping strategies schiz. 200 (p

Reliability: 7 experimental and 2 reliability studies generated 19 variables which were 

grouped between 2 subcategories of subjective and 1 objective subcategory of content 

evaluation. There were 3 significant variables independently tested for item reliability 

between 3 studies, and only one unreliable variable appeared in the table. Reliable 

subcategories were: overall energy (21, 3; 48, 44 in movement, 38 in tension and 69 in 

balance of motion); specific energy in the main subjects of the picture (75 in family or self, 

46 in action or function); and motion conveyed by form (line and objects), but not by 

colour (38). 

Discrimination: From 15 variables tested for discrimination properties, there were 6 

significant results between 2 subcategories. There was no great concordance of items 

within subcategories. Neither specific function of the main picture elements nor human 

energy distinguished schizophrenics from other patient groups (46) but human energy 

(self or family) did discriminate depressed patients from controls (75), giving support to 

the findings of discrimination in global energy ratings between depressed patients, 

controls and patients with organic mental disorder (21). There were also indications that 

a secondary diagnosis of depression may be discriminable (3). There were no significant 

differences in global tension or balance of motion between schizophrenics and controls 

(38, 69), but within patient groups, paranoid schizophrenics were distinguished from 

other patient groups (69) and schizophrenics who integrated experiences were 

distinguished from those who sealed over (44). 

149

Summary: The effect which distinguished depressed patients from controls and organics 

on global energy is supported by the discrimination of depressed patients from controls 

on specific human energy. Although there is probably another energy factor which does 

not occur under the main elements of the picture which discriminated between patient 

groups. 

Detail 

Table 11: reliability statistics and discriminating variables for category of pictorial detail. 

Pictorial detail variables (study No.(s) 


(f) form 

omission of detail (33) (c) (o) 

missing detail (56) 

presence of detail (75) 

(35) 

(44) 

(21) 

presence of 14 details: civilised 

objects, 2 civ objects, roads, 2 roads, 

path, sidewalk, window, windows, 

door, garden, nature, relief, vegetation, 

shadows (46) 

amount of detail (38) 

superfluous detail (c) (o) 

(56) 

(35) 

(36) 

(61) 

decoration (38) 

external detail (35) 

words (48) 

word script (56) 

words on building (46) 

words (49) 

extra letters (36) 

% other 

ag't test 1 

(1-6) rel'y 

63 4 .59 

96 

4 Acc. 

2 .94 

2 .84 

3 .63 

3 .80 

2 >.60 

4 Acc. 

2 .84 

90 5 .915 

2 .97 

2 NS 

2 .84 

100 

4 v.good 

96 

77 

90 5 .915 

150 




patients ** 

depressed ** 

left brain damage** 

organics ** 

NS 


mild from other grades schiz'c 

retardation**; schizophreniform from 

nuclear schiz*; retardation from nonret. 

schiz'cs. ** 

NS 

Left brain d. from R. ** 

schiz. coping groups ** 

organics and mania 



** p

one unreliable variable, decoration (38), which may have been confused with other similar 

elements. The other items were congruent within their subcategories and gave high overall 

reliabilities. Reliable subcategories were: the presence or absence of detail (56, 46, 61, 75, 

35, 36, 44, 21, 33) and superfluous detail (48 56 35 46 49 36 61). 

Discrimination: From 28 variables tested for discrimination properties, there were 6 

significant results which occurred only in the objective presence or absence of details 

subcategory. Superfluous detail, which included words was rated universally non 

significant by 5 studies and in support, study 46 included in its qualitative report, the 

comment that words and microscopia are equally common in children, schizophrenics 

and patient controls. All studies measuring global elements found differences. 2 studies 

reported within patient group results: between the 'integration' and 'sealing over' coping 

strategies of schizophrenia (44), and within 3 partitions of schizophrenic and retarded 

subjects (study 33). 4 studies reported results against normal controls: Depression was 

discriminated from controls (75) and left brain damage from controls (35). However, 

while study 21, supported the brain damage/control difference, their control scores 

overlapped those of mania, and did not discriminate depression or schizophrenia on this 

index. The solution probably lies in the results of the fourth study which supports most 

results, that mixed psychiatric patients were discriminable from normal controls (56), but 

not schizophrenia, so, the findings of no differences in 75 counted detail elements 

between schizophrenics and other patients (46) are also supported. 

151

Summary: Striking variation in global subjective evaluation of detail indicates that what 

is measured is not detail, but some element of completeness. The variety of patient 

groups distinguished, including the patient/non-patient distinction, indicate that missing 

detail is a good predictor of patient status, although brain damage patients were right/left 

differentiable, but right scores overlapped those of controls. 

Complexity 

Table 12: reliability statistics and discriminating variables for category of complexity. 

complexity/differentiation variables 

(study no.) (o) objective (s) subjective 

(c) content (f) form 

regression/complexity (c) (s) 

simplification (35) 

childlike (56) 

developmental (21) 

simple/complex (38) 

differentiation (46, composite) 

differentiation (c) (o) 

variation in building detail (46) 

complexity in dwelling (46) 

difference in: structure of building - 2, 

or 3 types; dwellings, 2 different or 

personalised; heights, widths, doors, 

number or kind of windows (46) 

% other 

ag't test 1 

(1-6) rel'y 

96 

96 

96 

2 .84 

4 poor 

3 .88 

2 >.60 

152 



figures) 


organic or mania** 

NS 


left from r. brain damage** 

depressed from organic ** 

schiz's from patients ** 



** p

Discrimination: From 16 variables tested for discrimination properties there were 2 

significant results which both fell into the global regression/complexity subcategory. 

Controls were differentiated from brain damage (35), which result was also supported by 

study 21, differentiating brain damage from 4 patient and a control group but which found 

mania scores overlapped the brain damage (21). Depression was also differentiated from 

brain damage in the same study but not schizophrenia. There were no differences 

between schizophrenics and controls (38) in another study and no differences in any of 

the elemental scores for differentiation between schizophrenia and other patients (46). 

Summary: There were global but not elemental significant differences in elements for 

schizophrenia and other patients. This indicates an additive effect which should be 

differentiable by logistic regression. Other global elements differentiated brain damage 

from controls. 

Control 

Table 13: reliability statistics and discriminating variables for category of control. 

somatic signs (study no.) 


(f) form 

perseveration (35) (c) (s) 

(21) 

(33) 

pers. in line/form (36) 

pers. in theme (36) 

% other 

ag't test 1 

(1-6) rel'y 

2 .84 

3 .54 NS 

NS 4 NS 

90 5 .915 

90 5 .915 

153 





NS 

Alzheimer's (more) nf. 

discriminates subgroups 

of patients 



** p

Reliability: Perseveration is a non-art term from diagnostic criteria. It was rated by 4 

studies; the two with good reliability gave composite test scores (35), by structure and 

theme (36). Another 2 studies used individual item ratings which were unreliable. 

Perseveration is not an objective definition because a subjective decision of intent is 

required to rate it. This category was considered unreliable for the remaining variables. 

Summary: There are indications of effect for studies with consistent definitions of 

terms, in brain damage and controls in 2 studies but there are questions of content validity 

which have not yet been addressed. 

Composition 

Table 14: reliability statistics and discriminating variables for category of composition. 

composition variables (study No.) 


(f) form 

orientation of picture (35) (f) 

tilt (48) 

(49) 

centre of focus (69) (f) 

dominance of image (38) 

top/bottom (69) 

left/right (69) 

right/left/top/bottom (36) 

structural relations (c) (s) 

rhythm (38) 

serial elements used structurally (69) 

relation of pic to frame (38) 

integration (21) (c) (s) 

(48) 

(49) 

compositional integration (3) 

general integration (3) 

unity (38) 

organisation (75) 

disorganisation (33) 

incoherence (56) 

fragmented gestalt (36) 

disorganisation (36, composite) 

balance (38) (c) (o) 

symmetrical balance (38) 

equilibrium (69) 

imbalance (56) 

% other 

ag't test 1 

(1-6) rel'y 

99 

77 

2 .94 

4 Acc. 

2 >.60 

4 Acc. 

4 Acc. 

90 5 .915 

2 >.60 

4 NS 

2 NS 

3 .94 

94 

77 

3 .80 

3 .91 

2 NS 

2 .94 

4 NS 

4 Acc. 

90 5 .915 

2 >.60 

2 >.60 

4 Acc. 

4 v.good 

154 



figures) 

NS NS 

NS 

Alzheimer's (more)nf 

NS 

organic/manic ** 

patients (less) nf. 

patients (less) nf. 

depressed ** 

NS 

nf 

Alzheimer's ** 

NS 

NS 

patients more ** 


patients 

NS 

NS 

NS 

organic from manic ** 

depressed/non-d pers.dis(nf) 

depressed/non-d pers.dis(nf) 



NS 

NS 

NS

** p

(including schizophrenics) against controls (56). Both studies are equally well controlled, 

but study 38 used very small numbers and is therefore open to type 2 error, the authors 

qualitatively note that schizophrenics' pictures frequently show less balance and 

symmetry, although this did not show statistically. This review therefore accepts the 

results from study 56. Depression was distinguished from controls on organisation (75), 

but not by study 21, which distinguished controls, organics and mania amongst 2 other 

patient groups (depression and schizophrenia) (21). The findings of no significance 

between schizophrenia and other patients, and mixed patients against controls tends to 

support both results (21, 75) by suggesting overlaps between certain groups (especially 

depression, schizophrenia and controls) and reduces the chance of the confusion between 

a diagnostic and a patient effect. Study 3 noted but did not test less compositional and 

general integration in pictures by patients with personality disorder than controls, and 

study 36 used a composite variable organisation, encompassing its derivatives listed in 

this table, which distinguished patients with Alzheimer's disease from controls. 

Summary: The composition category is generally non discriminatory for schizophrenia 

although there are indications of lack of balanced work. The most discriminable diagnosis 

was Alzheimer's or brain damage on central variables and organisational, particularly 

integration for brain damage. Depression also distinguished integration, but there were 

indications depressed scores might overlap with schizophrenia. 

Summary of reliability study 

156

There were more reliable elements than unreliable, but the studies examined here do not 

represent the major part of the literature in their clear, and mostly objective, definitions 

of search criteria. Only 27% of the controlled test situations are represented here and 

1.8% from the case studies. There were 15 formal and 37 content categories, split 

between 21 subjective and 16 objective decisions. 5 subcategories were found to be 

unreliable, all of them subjective. 

Unreliable elements of pictures seemed to predominate in interpretation, fine 

distinctions between two similar elements and global judgements. Raters could not 

identify symbols, themes or the continuity of themes between pictures, whether several 

ideas were expressed, differentiate ordinary from bizarre content, identify childlike 

elements, incest markers or self images or use their own criteria for patient versus non 

patient status judgements. They could not describe a painting, whether it was unified, 

organised or coherent, nor decide whether elements were used structurally, agree on care 

or craftsmanship (although they recognised quality). Detail decisions were inconsistent: 

although raters could identify length of lines they could not tell if particular types 

predominated, whether lines were jagged or used for fill in, whether shapes were more 

regular than other shapes, amount of single colours, whether colours were thick or pure 

(although they could differentiate watery or mixed colour) and the consistency or 

intensity of colour. They did not agree on errors of size and placing, on omission, lack 

of detail or decoration, perseveration, whether motion was conveyed by colour, line by 

blotches or whether dabs were used for form, mass, texture or decoration (although they 

could for blotches). 

157

The studies are difficult to sum up collectively in any meaningful way as each 

study examines a different selection of qualities, which makes them difficult to compare 

or replicate and the final interpretation comes as a synthesis of the study. Some of the 

definitions seem unclear, especially those which deal with global categories and some 

studies dealing with objective qualities provide a huge unwieldy instrument where 

alternative terms are difficult to differentiate 201 . Most conspicuously, there are 

considerable problems as to the authors' use of statistics (which will be discussed next). 

Mostly, the statistical bases on which the reliability is calculated contain serious 

methodological flaws. 

Measures of agreement 

Agreement between categorical assessments compares the ability of different raters to 

classify subjects into one of several groups. The reason studies use 2 or more raters is 

usually to see if the raters agree well enough for one to replace another or for raters to be 

used interchangeably. One consideration which would improve the quality of some of the 

studies reported here would be the definition of what is meant by agreement, also the 

degree of agreement. 

Most reported measures of reliability gave an 'overall agreement' statistic, which 

took the mean of the summed agreement percentages for each element. It is not possible, 

of course, in many cases, to measure these quantities directly and the decision on what 

constitutes good enough agreement must lie with the clinical conditions. However, 6 

201 

W.L. Wadlington and H.J. McWhinnie (1973) The development of a rating scale for the study of formal 

aesthetic qualities in the paintings of mental patients, Arts in Psychotherapy , V.1(3-4):210-20. 

158

studies did not even quote figures, 4 because they were too poor (50, 12, 10, 14). The 

other 3 reported categories of 'very good' to 'acceptable' agreement (9, 11, 39; study 39 

reported that 3 raters own criteria judgements of patient status, from 200 paintings was 

10% better than chance but gives no other figures, although we know (study 14) that own 

criteria judgements are based on widely differing individual values. Significant agreement 

is reported, but with no indication of how this was arrived at). No study justified their 

cut off points for 'good agreement' and these varied considerably from study to study. 

Worse, perhaps than no figures, a good percentage of these reliability studies are 

mis-analysed 202 . In particular, the correlation between the values reported by individual 

raters or groups of raters is calculated in 9 studies (75, 35, 37, 38, 31, 10, 44, 21, 3), with 

a high value of r interpreted as an indication of good agreement. Correlation is an 

inappropriate analysis, firstly because the correlation coefficient is a measure of the 

strength of linear association between two variables, not agreement. Agreement is 

assessed directly. Secondly, there may be a high degree of correlation when the agreement 

is clinically poor, as recognised by the actions of the authors of study 37, who used 7 

terms with correlations below 0.31 because agreement was clinically high (but didn't drop 

any clinically low ones). A high value of r can be obtained because, as for studies 3, 37, 

38 and 31, there is large variation between subjects. The authors of study 37/38 

recognised large differences between subjects in 37. They used a much more rigidly 

defined group of subjects for study 38 and a higher cut off point for the correlation, to 

202 

Much of the information here is quoted from D.G. Altman (1994) Practical Statistics for Medical 

Research , (4th reprint, original 1991), London: Chapman Hall. 

159

indicate greater agreement (even though their earlier study had recognised the correlation 

was not a good indicator of good agreement). It is clearly not reasonable to assess 

agreement by a statistical method that is highly sensitive to the choice of the sample of 

subjects. Similarly a famous and well quoted study 203 (33) incorrectly judged agreement 

by a _ 2 test which is also a test of association. 

Another incorrect analysis appears in a well quoted study using the comparison 

of means by a paired t-test, which is a hypothesis test (69). Similarly Study 56 204 used 

60 judges in groups of 10, to rate 5 pictures and compared the variation between scores 

of 0-10 agreements between groups, using Friedman's Anova, which although it is a 

category ranking test, is yet another test of association. They found few significant 

differences and drew up a table of poor to good agreement categories. 

Methods cannot be deduced to agree well because they are not significantly 

different. A high scatter of differences may well lead to a crucial difference in means 

(bias) being non significant. Using this approach, worse agreement decreases the chance 

of finding a significant difference and so increases the chance that the methods will appear 

to agree. Despite the authors' claims of good statistical agreement in study 69, most of 

the discussion reported their difficulties with the measure seriously affected their study 

results and recommended a shorter form for better reliability. 

The simplest approach is to see how many exact agreements exist. 7 studies 

reported percentage agreement by tables of elements or overall agreement. The 

203 S.R. Kay (1978) Qualitative differention in human figure drawings according to schizophrenic subtype, 

Perceptual Motor Skills , V.47:923-32. 

204 S. Russell Lacy et al. (1979) An experimental study of pictures produced by acute schizophrenics 

160

percentage agreement figures look reasonably high but can be unreliable when more raters 

are added (see for example, study 48 and 49: 95.7% agreement for 2 raters decreased to 

77% for 29; studies 58 and 59: 94.3% agreement for 2 raters decreased to 61% for 10; 

studies 9 and 10: 'good' agreement for 2 raters decreased to 'poor' agreement for 4). Study 

46 and study 61 report figures of '0.96' and '0.97' respectively, which, it is assumed, 

represents percentage agreement as there is no other information. 

The DDS 205 merits some consideration, under this heading, as one of few tests 

which attempt to validate, reliably rate their instrument and encourage replications. 

Described as a "standardised evaluation supported by extensive research" 206 , only 3 

interrater studies have been included in this analysis: study 48 207 reports agreement 

scores from 77-100% over 23 categories, giving 95.7% overall after "2 months training" 

of the 2 main authors rating 30 sets of drawings by undescribed subjects. Study 49 

reports only 77% agreement between 29 naive raters performing the same measurements. 

Study 52 reports 96% agreement between raters of 4 details in tree drawings, by 30 

patients with post traumatic dissociative disorder and 30 controls, taken from the DDS 

rating guide and protocol. Other studies used peculiar methods and were not included in 

this analysis. 

subjects British J. Psychiatry , V.134:195-200. 

205 Diagnostic Drawing Series, Cohen et al (1988) op.cit. 

206 

B.M. Cohen, A. Mills, A.K. Kijak (1994) An Introduction to the DDS: a standardized tool for 

diagnostic and clinical use, Art Therapy , V.11(2):105-10. 

207 Mills et al (1993) Reliability and Validity studies, op.cit. 

161

Two weaknesses lie in the simple calculation of agreement; there is no account of 

where in the table the agreement was and secondly we would expect some agreement 

between raters by chance. A more reasonable answer is obtained by considering 

agreement in excess of the amount by chance, which is only attempted by one study (39), 

and lacks other figures. The best approach to this type of problem is that adopted by 

studies 44 and 36, the kappa statistic, which may be interpreted as the chance corrected 

proportional agreement, but it is important to show the raw data (which they don't). In 

support of this statement, Neale's application of the DDS to children 208 , found a much 

lower level of reliability than that reported by Mills 209 : only 12 variables reached 

significance using the Kappa measure of agreement between 2 raters. 

Conclusion 

Generally, specific decisions are more reliable than global. 

Content decisions were most reliable where objective, because they were more specific 

and probably easier to define and rate. Most categories contained subjective decisions 

and largely where these were global they were unreliable. This is particularly exemplified 

in the category of Quality, where personal judgement was not reliable because experience 

of art was clearly an influence on aesthetic appeal. Global subjective decisions became 

more reliable when not referenced to the image, but suspicions must arise that the rating 

208 

E.L. Neale (1994) The Children's DDS, Art Therapy , V.11(2):119-26, but not included in this review 

because the subjects were children. 

209 Mills et al. (1993) op.cit. 

162

has then little to do with the artwork itself. The tables show discriminatory properties 

for drawing areas. 

Alzheimer's disease and brain damage tended to be discriminable on similar indices in 

7/13 categories: omitting more essentials, poor quality, bizarre content, poor reality and 

logic and poor integration, although brain damage was particularly distinguishable in 

drawing angles, so it is reasonable to suppose they share similar qualities which are 

particularly apparent in their artwork. 

Normal controls were also discriminable in 8/10 categories, generally supplying more 

complete paintings without morbid content. 

Schizophrenics or psychotics paintings were discriminable from controls through empty 

space in the picture, on their inclusion of emotional indicators (which two characteristics 

also distinguished within types), and in global measurement of regression. 

It is also worth noting that against all commonly believed theory, emotional indicators 

drawn as body details did not distinguish sex abuse, but thought disorder. 

This organisation of the literature has helped to distinguish reliable categories of 

art variables from non-reliable by contrasting similar variables measured by different 

studies. However, the observed validity of the drawing procedure is delimited by the 

clinical relevance and reliability of the selected drawing features. There are limitations to 

those studies; they use small numbers, their interpretation of the figures is questionable, 

by and large they are unreplicated, and those few which are replicated seem to produce 

inconsistent results. This is consistent with the overall findings reported at the beginning 

of this chapter. It is now necessary to further investigate the utility of the classifications 

163

of drawing areas and to quantify whether reported discriminations of patients are 

clinically meaningful and experimentally sound. 

164

Chapter 3: Positive Thinking: what are the common 

psychiatric characteristics of paintings? 

Chapter 3 summarises the review to identify the central importance of developing 

systematic, content-free assessments of psychiatric patients' paintings. 

Firstly the findings from the literature review showed the kinds of measurement 

which had been employed and had the best repeatability for a suitable test. These 

selected papers will now be subjected to a further analysis designed to make some sense 

of their contradictions and put them on an equal footing, so as to find out what kind of 

effects to expect. Then, the development of a novel instrument (the DAPA) for such 

assessments is presented. 

Meta Analysis of reliable studies identified by the literature review 

Analysis of tabulated categories and variables from the empirical literature was performed 

in 2 ways: 

1. The reliability and the validity of this classification system was qualitatively 

assessed in Chapter 2, by discussion and comparison between all studies on 

similar variables. This process of simplifying and displaying common themes 

was exploratory. 

2. A meta analysis was performed on studies that conformed to the minimum 

scientific criteria for quantitative work to complement the discursive assessment. 

165

Is Meta Analysis appropriate for this literature 

The discursive summary was not as informative as it might have been either with respect 

to summarised significance levels or with respect to summarised category tables, because 

it reflected the conclusions of the studies, which tend to provide equivocal answers to 

imprecise questions. Research environments are difficult to control, common definitions 

are not always available nor accepted, and methods, techniques and sampling 

characteristics vary from study to study. This situation is made more difficult by the 

proliferation of studies that address common research questions (e.g. is there a difference 

between pictures by abnormal groups and pictures by normal controls), but do not report 

essentials such as definitions or reliability of variables, sample sizes, statistical methods 

(many report 'significant' results, but not the number of tests, which variables were tested 

and how many dropped), or even fully report the characteristics of their experimental 

group. Furthermore their literature reviews are notorious for depending on the subjective 

judgments, preferences and biases of the reviewers. Conflicting interpretation of the 

evidence is common and consistent 210 . 

There is no lack of literature but the study area shows what Rosenthal 211 calls 

poor cumulation, lack of orderly development building directly on the older work. Each 

study seems to replicate the same process to produce conflicting results which can lead 

210 

See for instance: E. Ulman and B.I. Levy (1974) An Experimental Approach to the Judgement of 

Psychopathology from Paintings, Am. J. Art Therapy , V.8:3-12 (reprinted 1975, 1984 and 1992) although 

their results showed that health workers scored no differently and some people with no experience of 

psychiatric paintings were more accurate, they concluded that diagnostic classification of pictures was a 

skill which could be taught and this opinion has been related through the later literature as a proven fact. 

211 

Robert Rosenthal (1984), Meta Analytic Procedures for Social Research , Beverley Hills, CA: Sage, p.9- 

10. 

166

to no acceptable answers but conclude with calls for further research. This literature, 

despite its heavy emphasis on qualitative reports, is an appropriate candidate for meta- 

analysis. 

Meta analysis is the application of statistical procedures to collections of 

empirical findings from individual studies for the purpose of integrating, synthesizing and 

making sense of them. A common metric aggregates diverse statistics across studies, and 

standardised methods help to produce an unbiased assessment of the reliability of a 

variable measured across studies. It addresses five methodological difficulties which have 

been identified with traditional literature reviews 212 

(1) selective inclusion of studies often based on the reviewer's impressionistic view of the 

quality of the study; 

(2) differential subjective weighting of studies in the interpretation of a set of findings; 

(3) misleading interpretations of study findings; 

(4) failure to examine characteristics of the studies as potential explanations for disparate 

or consistent results across studies; 

(5) failure to examine moderating variables in the relationship. 

Selection of studies for Meta-analysis 

The first criterion for analysis of absolute differences between groups was that terms 

should be reliable. From the pool of 51 controlled studies, 35 employed no assessment 

or indication of reliability, therefore any bias would be overwhelming. Because weighting 

212 

Summarised by Frederic M. Wolf (1986), Meta Analysis: quantitative methods for research synthesis , 

Beverley Hills, CA: Sage, p.10. 

167

techniques which compensate for unreliability of variables 213 require information which 

is often unavailable from these studies, and because there was considerable variability in 

definition of terms, I have decided that this technique would require too many estimations 

of quantities which are not predictable in this range of studies and therefore be unreliable 

and inappropriate 214 . 

Method of selection of studies 

31 studies from the pool of controlled studies, series uncontrolled studies, validity and 

reliability studies employed more than one rater. The numbers assigned to them in 

Chapter 2 215 were retained through the further elimination procedures and eventual 

analysis. 6 studies (11, 12, 39, 43, 65, 66) were eliminated because they reported 'hit 

rates' rather than reliability between raters: that is, they compared the rating with the 

actual diagnostic group, but not between raters. 25 studies were retained for further 

analysis. 

Replication studies which tested the reliability of former studies and proved 

them unreliable (9, 14, 50, 10, 37) were eliminated and those which did not compare 

groups on diagnosis (58, 59, 48, 49, 31, 20, 61), together with 2 studies which included 

no figures for analysis (3, 52; study 3 did provide some figures for suicide groups of 

patients with personality disorder against non-suicides, but gave no indication of the 

213 

J.E. Hunter, F.L. Schmidt and G.B. Jackson (1982), Meta Analysis: cumulating research findings 

across studies , Beverley Hills, CA: Sage. 

214 Rosenthal (1984) also considers this procedure too burdensome. 

215 see Table of Authorities for numbers assigned to all control, validity and reliability studies, Appendix 

3. Studies selected for meta analysis are marked (M). 

168

ange of tests administered. They also presented figures for patients cross classified by 

diagnosis, but they gave no group numbers or indication of the range of tests performed). 

This left a total of 11 studies (69, 56, 75, 35, 46, 44, 21, 57, 38, 36, 33) for meta analysis 

of variables between group categories of measurable drawing elements. 

There were 5 further departures from the tabulated discursive elements between 

these 11 studies: 

1. Unreliable variables were removed from the analysis. 

2. Non significant results were included in the analysis. The procedure for 

studies which did not quote figures for non-significant variables (studies 

38, 69, 56 216 , 35, and 44) was to assume a significance value of 1.000 217 

(Study 38 did note frequent signs and these are marked and noted in the 

table). 

3. Study 44 reported p levels only for their positive results, and these were 

converted to Z scores and then into effect sizes, along with results from 

tests other than Chi-square or t-tests, which were converted directly to 

effect sizes 218 . 

4. Study 36 and 46 listed but did not test individual variables (they were 

grouped and discussed with the other tests under the tabulated areas of 

216 Study 56 also reported significant results from other tests on covered space, yellow, blending and 

variety of colour, but gave no reliability figures or indication of the range of tests which proved 

nonsignificant, so these results were not included. 

217 Recommended by Rosenthal (1984) op.cit. p.33. 

218 Rosenthal (1984) op.cit. Recommended procedure to convert t or _ 2 to effect size - using broad theory: 

Test of = Size of x Size of p.20-21 gives examples of relationships and equations. 

significance Effect Study 

169

drawing evaluation with comments from the studies where frequent and 

significant predictors were indicated). Tests performed are included here 

under category headings as a total or category score. Study 57 provided 

only a total score which was included as a single variable in the analysis. 

5. Each study tested differences between patients and normal controls or 

between a defined group of patients and another group of patient 

controls, although there were some which tested both. In order to assess 

differences between the effect size of patient/nonpatient and 

patient/patient, each result was calculated separately (since there were 

two tests done). 

This analysis was not intended as a confirmatory statement, but as a synthesis and an 

integration of the tabulated information which tried to assess the reliability of research 

findings across several studies. It takes into account 4 criticisms of meta analyses 

identified by Glass 219 : 

1. No logical comparison can be made between dissimilar techniques 

of measurement and operational definitions. 

Tabulation of the information from several studies into similar areas goes some way 

towards analogising definitions of variables and subjects from studies which used 

different measuring techniques, that were previously too dissimilar in scope to compare 

equally. 

219 

Gene V. Glass, Barry McGraw, Mary L. Smith (1981) Meta Analysis in Social Rese arch , Beverley 

Hills, CA: Sage. 

170

2. Results are uninterpretable between studies using poor designs and 

those with good. 

Rather than making statistical compensation for poor studies, only studies which used 

reliability measures for their terms were used. Design otherwise was equally poor. 

3. Published research is biased in favour of significant findings 

because nonsignificant findings are rarely published: the 'File 

Drawer Problem'. 220 

Checks were made on unpublished controlled studies through private correspondence; 

there is every reason to believe that unknown unpublished studies of other types than 

the two which are used in this review would show similar conflicting viewpoints, poor 

design and statistical rigour as those published which are subject to peer review. There 

does not seem to be a lack of published nonsignificant findings, so there may be little bias 

in this field. A test was applied following procedures from Wolf (1986) 221 which 

estimated how many additional studies with nonsignificant results would be necessary 

to reverse the conclusion drawn, providing some estimate of the robustness and validity 

of the findings. 

4. Multiple results used from the same study bias or invalidate the 

meta analysis and make the results appear more reliable than they 

really are because they are not independent. 

220 

Not everyone is agreed on whether this point exists: a recent discussion of the various issues as to how 

to estimate the proportion of conflicting evidence, in M.T. Bradley, R.D. Gupta (1997), Estimating the 

Effect of the File Drawer Problem in Meta Analysis, Perceptual and Motor Skills , V.65(2_:719-22. I 

followed Rosenthal's recommended checks (1984) op.cit. p.107-110. 

221 

Wolf (1986) Meta Analysis, op.cit. The 'fail-safe N' p.37-39, which was simpler than the calculation 

from Rosenthal. 

171

There are few answers to this criticism which do not lead to possible inferential errors, 

and it is a question of judgement in using a procedure which is appropriate for the sample 

and reflects the classification and variety of variables encompassed. 

Wolf 222 describes a method using only the most significant results from each 

study, but this technique lends itself to type I error. Rosenthal's 223 adaption of the 

Stouffer method, i.e. averaging between significance levels transformed to z-scores to 

produce one variable per study, are clearly not appropriate here because the standard 

deviations and direction of significance of studies must be similar, and the variables non- 

correlated, so that they can be weighted equally 224 . Furthermore, although 4 from 11 

studies show a very high effect size aggregated in this way and 3 more show a small to 

medium effect, 3 studies did not actually report the large numbers of non-significant 

statistics, of which their study mostly consisted, and therefore estimates of p=1 would 

probably contribute to artificially low averages resulting in a much too conservative 

estimate. 

Kulik, Rosenthal and others recommend using separate analyses for each variable, 

when each study uses several of the same type of variables. There were two main 

problems which made this type of analysis difficult in this study: (1) There were tests 

between patients and normal controls and between patients and patient controls; and (2) 

there was no way of knowing how similar variables with similar terms, which were 

tabulated together, actually were. Few studies contributed variables to most of the 

222 Wolf (1986) op.cit. p.46. 

223 Rosenthal (1984) op.cit. p.72. 

172

tabulated drawing areas, so some studies measured areas completely neglected by others 

and there were no tables to which all studies contributed. The partition into tabulated 

areas was useful for the qualitative part of the analysis, but more than one variable from 

most studies described aspects within the same area, and there were no grounds to 

assume these variables were correlated. 

Glass et al. 225 used multiple tests from the same studies in a single analysis, but 

this technique is not popular 226 , since multiple results are said to inflate the sample size 

and effects beyond the number of individual studies 227 and increase the power of the 

meta-analysis. The studies analysed here though were unrepresentative of the majority 

of studies in this field, but their variables are typical of the kind of constructs usually 

employed. 

The practical answer, to eliminate the variables that did not fit clearly affects the 

type of study included and the results; if the results within a study are averaged, it 

precludes analytical examination of differences and similarities for different categories of 

outcome and tends to increase the chance of type I error 228 . Furthermore, meta analytic 

methods have recently been criticised on this basis, that treatment trials pay less 

224 Rosenthal (1984) op.cit. p.33; Wolf (1986) op.cit. p.36-37. 

225 

M. Smith & G. Glass, (1980) Meta Analysis of research on class size and its relationship to attitudes 

and instruction, Am. Educational Research J. , V.17:419-33; Glass et al., (1981) op.cit. 

226 for example: Rosenthal, (1984) op.cit.; Wolf (1986) op.cit. 

227 

J. Kulik (1983), Review of G.V. Glass et al. (1981) op.cit. Evaluation News , V.4:101-5, but the studies 

represented here comprise only a tiny proportion of the field. 

228 M. Strube (1985) Combining and comparing significance levels from non-independent hypothesis tests, 

Psychological Bulletin V.97:334-341. 

173

attention to overall effect sizes than the difference between individual studies 229 . The 

complex issue of which set of statistics to use is largely a matter of judging the structure 

of the data and applying as fair a method as possible 230 . This problem was dealt with 

empirically by coding the characteristics for each study and comparing the different 

partitions of the variables 231 as tabulated in the qualitative analysis. 

Tables were prepared using 2 techniques: 

(1) all variables were included to produce a single aggregated case for each 

experimental group in the analysis; 

(2) the identified tabulated areas were compared on effect size and subsets of the 

most significant tables, which retained all studies in the analysis were aggregated 

for each type of control group; 

Other criticisms focus on interaction effects, of which 2 are taken into account in this 

analysis; small sample sizes and weighting for size of study 232 . 

There were 4 questions to be answered: 

Is the art-test a discriminable dimension for psychiatric diagnosis for (1) patients 

from non-patients; and (2) within patient groups. 

229 

David Healy (1998), Commentary: meta analysis of trails comparing anti-depressants with active 

placebos, British J. Psychiatry , V.17:232-4; David Sohn (1997), Questions for meta analysis, 

Psychological Reports , V.81(1):3-15. 

230 

R. Rosenthal (1998) Meta analysis: concepts, corollaries and controversies, in J.G. Adair and D. 

Bellanger (eds.) Advances in Psychological Science , V.1:371-384. 

231 

Rosenthal (1984) op.cit; Wolf (1986) op.cit. and using procedures for calculation from Carol Taylor 

Fitzgibbon and Lynn Lyons Morris (1987), How to Analyse Data , Beverley Hills, CA: Sage, Chapter 7. 

Meta Analysis pp.132-145. 

232 The major criticism of bias in meta analyses of treatment methods, Wolf (1986) op.cit. 

174

Do different variables show agreement in effect sizes? and if not: (3) which 

drawing area showed greater effect; and (4) was there a greater effect for form or 

content, objective or subjective variables? 

Statistical Procedure 

Mathematical procedures were facilitated by the use of SPSS, version 4 for DOS. 

Treatment of the data 

Effect sizes (_) were calculated for each variable from z scores, Chi-square or t- 

tests as described, between patient/normal controls and between patient/patient 

controls from the results given in the papers. Cohen's d, 233 the usual statistic was 

adopted throughout, with a confidence interval of 95% to indicate a significant 

relationship, if zero was not encompassed, at the 0.05 level. 

All reliable variables were included to produce a single aggregated case for each 

drawing area according to control group (1) patient/nonpatient and (2) 

patient/patient; 

Effect sizes of the identified tablulated drawing areas were aggregated and 

compared between patient/nonpatient and patient/patient controls and subsets 

of the most significant tables, which retained all studies in the analysis were also 

compared; 

Form and content areas were compared on aggregation of effect size as were 

subjective and objective areas. 

233 

J. Cohen (1977) Statistical Power Analyses for the Behavioral Sciences , New York: Ac.Press, p.20, 

methods described in Wolf (1986) op.cit. 

175

The 'File Drawer Problem' (refer back to [3] criticisms of meta-analysis), was dealt with 

in the manner recommended by Wolf (1986) using Orwin's (1983) fail-safe N 234 , selecting 

d=0.2 (small effect) as the criterion value. This provided an estimate of the number of 

variables necessary to reverse the conclusion of a significant relationship and thus of the 

robustness of the validity of the findings. 

There were 2 compensations made: 

(1) The Hedges and Olkin 235 adjustment for small sample sizes, which is appropriate 

since some groups were under 10 members; 

(2) the weighted _ (wd) technique 236 which produces an unbiased estimate of effect size 

for the corrected group sizes. 

Validity of drawing area Classification 

The usual procedure to test the validity of my assignment of variables to the 

drawing area categories would be a test of equivalence of proportion to indicate the 

homogeneity of effect size for each variable and their relation 237 . However, this was 

inappropriate here because the vast majority of the non-significant results were not 

available, so the assumption of p=1 creates a false disparity between the significant and 

non-significant findings, imposing hetereogeneity. 

234 using Wolf's (1986) op.cit. p.39, suggestion from Orwin (1983) fail-safe N for the average effect size 

that can be obtained, selecting d=0.2 (small effect) as the criterion value: 

Nfs. = No. of variables with an effect size

Results 

Row 1 of Table 1 presents the results of an aggregated analysis of the total number of 

variables included in the analysis which related to performance by patients against normal 

controls and row 2 against patient controls. It can be seen that the confidence levels do 

not encompass zero, so we can assume a significance level beyond chance expectation 

(p

Table 2. All variables for 11 studies from the tabulated 15 different areas of drawing 

measurement. 

Drawing 

Area 239 

1 

2* 

3 

4 

5 

6 

7 

8 

9* 

10* 

11* 

12 

13 

14 

15 

ES1: Effect size for 

patient/normal controls 

(confidence intervals) 

and p values. 

0.0000 (-.2922; 0.2922) NS 

0.8795 (0.6362; 1.1228) p

(2) For variables discriminating between patient groups but not between patients and 

controls, diagnosed groups of psychiatric patients differed in: thematic content or subject 

of the picture; used less or different qualities of line, less or different colour groups, their 

pictures depicted reality or abstraction and were more or less complex. 

Table 3 shows the aggregation of all the variables over 14 drawing areas 

partitioned at whether they were categorised as content, subjective or objective, or 

form 241 . Subjective variables seemed to produce the largest effect, but there were 

demonstrable if small effects for the other two types of variable. 

Table 3. Aggregated results for patients/all controls by form or content variables 

Variable type Effect Size (_) 

Subjective content 1 

Objective content 2 

Form variables 3 

Confidence limits 

for _ (all significances 

p

Less than a third of the drawing areas both discriminated patients from controls 

and within diagnostic group. Five drawing areas, which measured subjective content 

information, were sensitive to general differentiation of patients and normal controls, but 

were insensitive to diagnostic differentiation. Five drawing areas which measured 

objective information were sensitive to specific diagnostic differentiation, but were 

insensitive to general discriminations between patients and normal controls. This 

suggests a major conceptual flaw in constructs common across the field of investigation 

explaining the schematics and cognitive constructs of artwork, such as in the description 

of the work of art therapy and in psychological drawing tests relating to artistic 

psychopathology. 

Furthermore the failure to include non-significant findings in the results and 

conclusions of much of the literature suggests that current applications of research 

findings to the assessment of psychiatric artwork lack construct validity and predictive 

validity. 

Form and Content variables 

There was a demonstrable form effect and it was significant, but low. Against all 

predictions from art theory, observational case and series studies and narrative personal 

experiences by therapists, particularly of schizophrenics, there was a failure to show 

specific effect of form superior to content. However, there were twice as many content 

variables; formal variables were often inappropriate for the eventual type of analysis, 

were discordant and patchy. 

180

Conclusion 

The type of analysis used was the most appropriate for the data; all indications 

were that other methods would have introduced more methodological discrepancies. 

Despite everything, there are strong indications of an effect which differentiates 

not only patients from controls (which could be predicted from environment), but also, 

different diagnostic classes of patients. The large observational literature and reports 

from art therapists predict much larger effects, suggesting very serious measurement 

problems. 

Summary of the findings of the literature review 

Generally, it seems that constructs common across the field of investigation into the 

schematics and cognitive constructs of artwork, such as in the description of the work of 

art therapy and in psychological drawing tests are only slightly related to artistic 

psychopathology. Failure to demonstrate previous published systematic studies 

suggests that current applications of the assessment of psychiatric artwork therefore lack 

construct validity and predictive validity. Thus we cannot talk about psychopathic art 

or of defined marker areas. 

These findings support the introductory statement that we know nothing about 

the phenomenology of art from psychiatric patients, and it is shown all through the 

review that, contrary to popular opinion, there has been a complete failure to understand 

the system. It is clear that there is an urgent need for immediate work on the design of 

more suitable, sensitive and psychodynamic evaluation measures for psychiatric artwork. 

181

Case study and controlled research has largely ignored cautions and tried to 

codify symbols or signs, relationships between, and distortion of, images by relating 

explanations to a theory of the unconscious in an apparent attempt to produce an 

analogical translation that was largely unsuccessful. 

Case studies of artists were more concerned with the debate as to intentionality 

and generalisability of illustrations of what has been seen as psychopathology to other 

psychiatric populations. This has also been largely unsuccessful. 

The general direction of the impressionistic or discursive literature indicates that 

only the patient has access to signs. The job of the therapist is to gain access to that 

very personal language and delicately manipulate it. But unless the language is universal, 

or at least common to a particular group, which most research insists that it isn't, it is 

futile to try and chart it except retrospectively to extract general principles for the 

charting of another individual course. This has now become the general direction of case 

study research. 

Research based on the idea that art is healing in itself, because it produces a 

remote tangible communication outside the patient but from the patient to himself, rather 

than from the therapist, tended toward the 'nurturing' case study. The emphasis on the 

therapeutic relationship relies on the assumption of communication through the artwork 

as the main outcome for the integrity of the therapy as art-related. The use of art was not 

found to be inherently related to the therapy but provided a receptive atmosphere, which 

could presumably be achieved in other ways. 

182

The common focus has been in the interpretation of the meaning of a message but 

there are no agreements as to what form the message takes. Problems occur when the 

associations of the rater or therapist are not clearly distinguished from those of the 

patient, which likely alternative explanation is largely ignored by the literature. It is 

dangerous to make assumptions about content, especially when dealing with psychosis. 

The nature of the illness affects the verbal expulsions of psychotic people and therefore 

ratings based on what they say may be inconsistent and fallacious. The distinction 

between response and record is important because it is a primary assumption that what 

is measured comes from the patient, otherwise discriminatory properties could be due to 

other related issues than to what is described, thus producing erratic results. 

The majority of the literature is of poor quality especially the reliability and 

consistency of terminology in previous studies because though what is measured across 

studies is described similarly, for example: line quality, heaviness of line, articulation, 

what is understood by the term digresses from study to study. If we cannot assume 

studies measure the same aspects because they use the same terms, studies, or variables 

within studies, are not comparable. 

There was a demonstrable and significant form effect, although it was low. 

Content measures, such as bizarre imagery, disconnections, inappropriate or disordered 

colour, perseveration, inessential detail and subject matter require judgments of intention 

or meaning, are difficult to validate, difficult to define, unreliable and not specific to 

psychiatric populations. Formal characteristics may be seem to have differentiating 

183

potential for psychiatric populations, and have the advantage of being easier to define and 

rate 242 . 

The next stage, the development of a test takes on the problems of reliability, 

content validity and ambiguity of definition of the objective phenomena for the purpose 

of testing these findings. It dismissed, as far as possible, interpretation by the rater of 

the intention of the artist, used simple terms relative to the work which were widely 

distinct from each other and the minimum number of categories to describe the work. The 

Descriptive Assessment for Psychiatric Art (DAPA), uses a method which fragments the 

art object into a collection of mostly formal variables. This research tries to answer one 

important question which unfolded, but has not been fully answered from the review; is 

psychopathological evidence from artwork sensitive? 

242 For example, Wadlington and McWhinnie (1973) revised their unreliable 18 variable scale which relied 

on aesthetic (and therefore content based) terms, to 4 formal dimensions which indicated reliable and 

distinguishable categories. 

184

Chapter Four: The Descriptive Assessment for Psychiatric Art (DAPA) 

The ideal Characteristics for a new test: development of the DAPA 

Differentiation of Form and Content 

Studies of psychopathology have stressed the importance of distinguishing between form 

and content 243 . Jaspers 244 explains: 

In all psychic experience there is a subject and an object. This objective element 

conceived in its widest sense we call psychic content and the mode in which the 

subject is presented with the object (be it as a perception, a mental image or 

thought) we call the form. 

Thus in describing how a subject is presented with the object (the content), we are 

concerned with the description of the form, or mode of presentation of the content; i.e. 

how the picture is made. Rating of content occurs when raters judge what is represented 

(e.g. 'unnatural' colour, abstraction, groundlines, movement, integration). 

Theory and justification for each DAPA Scale 

The purpose of this section is to present a table of mostly formal characteristics, likely 

to be reliable and valid, based on the literature analysis, which are said to exist in the 

artwork of psychiatric patients in order to define the parameters of a test which premises 

are understood universally and can be compared quantitatively. Positive characteristics 

243 

Karl Jaspers (1963) General Psychopathology , 7th Edition: translated, Manchester University Press; 

Andrew Sims (1988) Symptoms In The Mind: an introduction to descriptive psychopathology , London: 

Tindall. 

244 Jaspers (1963) op.cit., p.59. 

185

only are discussed (indicators which have been noted, rather than contradictory tests 

which have reached no significance) with no weight given to one characteristic above 

another. 

Content: themes, quality of picture and specific details 

Table 1 simplifies under three headings the positive findings and notations of all case and 

controlled studies considered in this review relating to the content of the picture. Most 

of these qualities could not be related to specific diagnoses and therefore could only be 

used in a limited way to differentiate patients from controls 245 . They have a common 

negativity, except for a few manic patients (but these were small numbers n=5) and an 

odd finding for depressive pictures, of happy and complete work (but this may be related 

to treatment stage). 

Content characteristics were simplified to positive or negative content. The aim 

of the test, to eliminate interpretation of intentions, meant totally excluding content 

which would be a major omission and probably rather pig-headed. The reliability of an 

acknowledged ownership of an impression by the judge was probably better than a guess 

as to what the patient intended. 

245 as did study 31 on distorted figures and 56 on lack of detail (except schizophrenics). 

186

Table 1: to show the simplified positive findings from case and control studies reviewed 

relating to content of picture. 

Type Theme or subject matter Quality of picture Detail 

Psychosis/ Schizophrenia 

Brain Damage 

Mania 

Depression 

Anxiety 

Personality 

Disorder 

1. case studies 

2. controlled studies 

3. artists studies 

threatening; religious or conflict 1 

illustrating symptoms 13 

problem solving 3 , 

separation, individuation 1 

repeated numbers 1 

disturbed images 1 

symbols 1 

mild/bizarre content 21 

energy/ global tension 2 

personal 2 /(expressive 

3 1 

originality 2 

use of inanimate objects 2 . 

subject broken, disruption 1 

Archetypal images 1 

less reality/logic 2 

no people 2 

(Alzheimers + cancer metaphors of loss 1 ) 

(Alzheimer's: poor/lack of content ( 2 ) 

bizarre content 2 ) 

(autism mouth 1 ) 

'plus phenomena' 1 

rapid expansive euphoric 1 

'minus phenomena' 1 

self disclosure personal information 1 

expressive 3 

sombre gloomy themes 12 

disinterest /less human energy self or family 2 

mutilated, twisted, distorted, or aggressive figures 13 

complete happy scenes with symbols, yellow sun, flowers 1 

(improvement: impressionistic, realistic with fantasy images 1 ) 

less problem solving 2 less global energy 2 

twisted or distorted aggressive figures 3 

(anorexia good quality subject matter 1 ) 

more people 1 

187 

fragmented 13 , 

nonintegrated 3 ; ossified, 

static 1 

balance of pic 12 

displacement 2 

simplification 

/regression 2 , 

simplistic imagery 2 

(aphasic 1 ; dementia 1 ) 

poor quality 2 

(Alzheimer's 2 ; also poor 

organisation) 

fragmented 3 , 

nonintegrated 3 low 

quality of execution 1 

disorganised 2 

wild random uncontrolled 

incoherent drawings, 

unconnected 1 

more logic than other 

patients 2 

less compositional 2 and 

general integration 

developmental 

indicators 1 

damage to trees, 

broken limbs 1 

lack of detail 1 

simple shapes/ 

omissions 1 

proportion errors, 

disconnections 1 

lack of detail (left 

brain damage 2 ) 

(Alzheimers: faulty 

recall 2 ; 

essentials omitted 2 ) 

1, 2 

less detail 

smaller drawing, odd 

relationships between 

sexes, few sex diffs in 

figures 2 ; 

depression as 

secondary diagnosis is 

discriminable 1 

The DAPA Category of Emotional tone: The emotional tone of the section of picture 

under examination, as it is perceived by the rater, is recorded as positive, neutral or 

negative. Positivity is not a popular scale of content measurement and certainly does not 

cover the content spectrum mentioned above, This method has the advantage that

specific areas of positivity could be compared and that these impressions are distinct 

from the other variables. 

Measurements of Colour from the literature analysis 

The evidence suggests that normal controls generally used more colours than all patient 

groups. However, few studies examined the colours used, but employed some grouping 

system in the rating: darks and lights, warm and cool, tonal variations and monochromatic 

variations. These divisions are all relative to the picture itself, since red and green can be 

seen as 'dark' together, whereas with other colours, such as brown or black, they can seem 

'lighter'. Dark can also be relative to the intensity of use and therefore these terms are 

ambiguous, may require special knowledge of the behaviour of tones, and contain layers 

of judgement decisions. The terms 'gloomy' and 'sombre' colours were often used as an 

indication of depression, but no evidence supports such associations. Previous research 

has recommended formal factors 246 , hue, value, chroma and tonality as likely to contain 

differentiating information. Whereas the basic hue of a colour is discernable, the other 

three qualities require a trained eye and may be too sensitive for an initial study. Most 

of what they convey can be summed up in the quality of intensity. Particular associations 

between intensity and hue may be better dealt with in the analysis, as decisions such as 

dominant or prominent colour lend themselves to misinterpretations and to the subjective 

associations of judges. 

246 

W.L. Wadlington and H.J. McWhinnie (1973), The development of a rating scale for the study of 

formal aesthetic qualities in the paintings of mental patients, Arts in Psychotherapy , V.1(3-4):201-20. 

188

The DAPA category of colour: The DAPA describes colour in the presence or absence 

of 9 basic hues within each section examined: Red, Yellow, Orange, Green, Blue, Brown, 

Purple, White and Black. Only the media is scored, not the paper. 

Intensity is coded seperately as high, neutral or low. 

Measurements of Line from the literature analysis 

There were more different categories of line than any other, some were mixed up with 

shape, the definition of which was ambiguous. No differences were shown between 

normal controls and schizophrenia or Alzheimer's disease, but there were suggestions that 

physiognomic difficulties in control would probably affect results although some 

definitions were understood emotionally rather than visually and some were visual 

transformations of expected symptomatology. The studies which attempted to interpret 

the patients intentions through assessing the purpose of the line showed the most 

variable reliability and results. The definition of line quality, which typically rated 

internal relations within pictures; i.e. lines were rated relative to other lines within the 

picture, was probably easiest to compare objectively because people tend to judge the 

relative extremes. It seems reasonable to suppose that a simple note of internal variability 

of line of the picture would be comparable with that of another picture and would be 

difficult to invest with meaning. 

The DAPA Category of Line: The DAPA describes 'Line' using 3 levels of quality: 

Heavy, varied and thin. Development of the measure modified the coding method slightly 

from the first study and line is now coded separately as drawn or painted. The DAPA 

189

Rating Guide (Hacking & Foreman 1994) describes the division into painted line and 

drawn line when estimating variability of thickness. In the first study, line was a 

summary of painted and drawn lines. 

Measurement of Space in the literature 

There were two elements to space; coverage of the paper with the media and pictorial 

space (the picture plane). Content based judgements seem to be sensitive to skill in that 

patients were distinguishable from controls on their lesser use of virtual picture planes 

(perspective) and it is hard to imagine how the associations and culture of the rater do 

not contribute to the judgement of spacial relations between drawn objects. Formal 

assessments of the amount of paper covered were affected by variability of definition of 

cover of the paper (where the space was considered part of the composition in one case 

and not in another, according to the rater's assessment of the intention) which found no 

differences in patients and controls. Neglect measures did distinguish patients from 

controls and schizophrenia from mixed patients. Therefore a measure which objectively 

defined media cover of the paper without reference to the image would break new ground. 

The DAPA category of Space: The DAPA area category records how much paper 

within each section examined remains uncovered by media by quarters: up to 10%; 10- 

25%; 25-55%; 55-80% and 80-100%. 

190

Measurements relating to Form from the literature 

This element covers a composite of variables which indicate mass, shape and focus. 

Many disorders indicate that fragmentation, disorganisation or degeneration of the image 

takes place in psychiatric illness. Lack of or dissolution of form indicating disassociation 

has been graphically portrayed by artists as symptomatic of depression and other 

psychiatric illness, but not of stress disorder such as anorexia. Interpretation of 

regression from childlike forms has been inconclusive. Repetition of forms is said to 

differentiate schizophrenia from other patients and normal controls, but repetitions are 

hard to identify without aesthetic training and probably vary considerably. The simple 

consideration of presence of form should differentiate at least patients from controls, 

with a possibility of exclusion of stress disorder. The other characteristics require 

judgements about skill or intention. 

The DAPA Category of Dominant Form: Global judgements commonly try to make 

an aesthetic assessment of the composition. Evidence also suggested that displacement 

of main images strongly indicated general abnormality. Wadlington and McWhinnie's 247 

concept of significant form seemed to encompass the main elements of this commonality. 

Their attempt to define it was incoherent, partly because it depended on artistic 

terminology. It is adapted here, perhaps simplistically, as dominant form; the dominant 

shape and the simple assessment as to where it lies. Dominant form was a later addition 

to the measure and was used for the main study but was absent in the first study. 

247 Wadlington & McWhinnie (1973) op.cit. 

191

Table 2: Summary table of expected characteristics from the literature. 

Positivity of 

Emotional 

Tone 

Colours by 

hue 

Intensity 

by strength 

high-low 

Drawn line by 

thickness 

PREDICTIONS 

1. All patients v Controls 

2. Difference to other patients 

3. Prediction of order 

1. More negative 

2. Schizophrenics and depressives negative> all 

patients 

3. Negativity: Schizophrenics>brain 

damage/disorder>other disorders> 

personality disorder>control. 

Depressives mixed (most -ve) (some +ve) 

1. Less and darker colours; more red and black 

particularly, possibly brown, green, blue. 

2. Schizophrenics and depressives: red, black> 

other patients; Schizophrenics and 

depressives 1 : No. colours< other patients. 

3. Black/brown: Depression>schizophrenia> 

other groups> stress disorder>control; 

Yellow control>patients 

1 Depressives may be variable 

1. Darker colours, lower intensity 

2. Schizophrenics and depressives brain 

injury 

Empty Space 1. More 

2. Brain damage/disorder > schizophrenics 

3. Brain damage/disorder> depressed/ 

schizophrenia >other patients> controls 

Largest most 

dominant 

Form 

1. Less form in total 

2. Depression

Objectives of the test 

The main objective of the Descriptive Assessment for Psychiatric Artwork 

(DAPA) was to describe an object produced directly by the patient (the painting) 

so that relations with another such product, by a different patient were 

comparable along the same indices. 

Subsidiary objectives were: 

to find suitable dimensions of a picture so as to include as much information as 

possible without making the scale unwieldy. 

that the scales should be valid; they would measure the attributes for which they 

were designed. 

that the scales be reliable; several raters would not disagree significantly on 

scoring. 

Hypothesis 

that the test would be useful, understandable and applicable outside the art 

therapy profession. 

1 Formal variables will distinguish paintings by different diagnostic groups of 

psychiatric patients. 

2 If people with similar diagnoses use a similar characteristic style in their paintings, 

then the majority of people in a given group should make pictures which are more 

similar to those who suffer the same diagnostic psychiatric disorder. 

193

Previous methods of assessing atomistic elements of pictures have mostly dealt with the 

whole picture at once which can be complex because quite often not all of the picture is 

the same and therefore focus is directed to part of the picture. The grid overlay helps to 

deal with the totality of the picture elements whilst avoiding the domination of the 

assessment by the content. 

The DAPA Rating Guide (figure 3), gives a detailed explanation of the procedure 

and method for rating (helpsheets and rating sheet with a copy of the DAPA guide can 

be found in Appendix 4). The illustration below gives an example of the use of the grid 

system. An element of the picture, on the left hand side, is difficult to interpret in the 

conventional sense, but no aspect of the DAPA procedure requires us to either translate 

it or ignore it. Red scores for each square are given below. 

Red Scores from top left, reading across to bottom right. Row 1: 0, 0, 1, 1, 1. Row 2: 

1, 1, 1, 1, 1. Row 3: 1, 1, 0, 0, 0. Row 4: 0, 0, 0, 0, 0. 

194

Dapa Rating Guide, Version 3. Method for rating according to the Descriptive 

Assessment for psychiatric artwork. 

Methods Section 

Organisation of methods section: There are 3 different research tests to be covered: 

1. Main Study, which describes a study of spontaneous paintings with no 

prescribed subject in non-test conditions by 109 subjects, 83 of whom were 

psychiatric patients; instruments and procedures are described in detail. 

2. Interrater study (experimenter and 6 additional raters). 

3. First Study, which describes a study of self-portraits in standardised conditions 

by 50 subjects, 39 of whom were psychiatric patients. 

This chapter is organised into 3 sections. The Main study is presented first because 

extended explanations are more appropriately discussed within the greater rigour of the 

main study rather than in the initial more experimental study. The complete interrater 

and initial studies are presented next, thus references and comparisons are more 

comprehensible. 

Section 1. Main Study 

Permission and ethics: This project was submitted and passed by the North 

Staffordshire Medical Ethics Committee 1995. Permission to access patients notes and 

to use paintings for research was sought from consultant psychiatrists in charge of the 

cases because most patients were not volunteers and there were ethical issues in some 

195

cases as to whether informed consent was appropriate. There was no involvement by 

S.H. with the patient, for the purposes of this research retrospective paintings were 

viewed as information kept as notes on the patient, therefore they were owned by the 

hospital and formed part of the records. Consent forms were used for access to casenotes 

where patients were already in a painting group and staff agreed to save their paintings 

for the project. These were accompanied by written explanations of the project for staff 

and patients, and instructions on how to treat the paintings after collection, but there 

were no refusals in these groups (samples of consent form with explanatory sheets are 

attached, Appendix 5). There were no changes to the usual ward routine for the patient. 

Demographic information 

Patient Selection: Participants were drawn from mixed sex wards of psychiatric 

hospitals serving an industrial community in North Staffordshire, England. The hospitals 

accept the full range of adult psychiatric disorder requiring admission. 130 subjects for 

the study came from nine wards treating in-patient substance abusers, psychotic 

disorders, depressive disorders and personality disorders. Seven wards were sited in a 

large country mental hospital, which included a rehabilitation unit housed separately 

within the grounds of the main hospital building. The study encompassed the whole 

population of the hospital's recreational art programme. The substance abuse unit was 

sited in the City General hospital and the other ward was a community based mental 

health centre, which dealt with adjustment, anxiety and affective disorders. 

196

Controls: Staff members and nursing students from all participating wards agreed to act 

as controls and completed their paintings together with the patient groups, so that control 

conditions were identical to those of the patients. 

Table 1: Demographics for subjects from all experimental groups 

TOTAL Sex M Sex F Age Mean Age S.D. 

Entire Population 109 49 60 46.17 16.50 

Affective Disorder 18 3 15 58.33 13.02 

Schizophrenia 35 22 13 57.8 13.69 

Personality 

Disorder 

9 3 6 32.78 7.51 

Drug Abuse 24 15 9 35.96 11.62 

Controls (staff) 23 6 17 34.83 9.81 

Sample: Table 1 shows demographic statistics: 86 psychiatric patients (43 males, 43 

females) formed the patient group. 23 staff members (6 males, 17 females) formed the 

control group and painted alongside the patients (49 males, 60 females). The mean age 

of the controls compared well with the other groups although there were more females. 

Choice of patients 

It was not possible, due to the numbers of patients available, to randomise groups and 

all suitable available patients 248 within the main county hospital at the time were involved 

in the study, most patients were in chronic stages of illness. The patient group available 

was quite large and permitted the comparison of general effects against specific effects. 

248 Those who were able and willing to paint, for whom there were facilities, and were not on a locked ward 

(for security reasons). Paintings were done on the ward and in the occupational therapy dept. 10 wards 

from the main hospital and 2 from the city general hospital were involved in the study. 

197

It was decided to use a large mixed group of general psychiatric patients who were split 

into several diagnostic groups rather than one smaller group of schizophrenics as previous 

research has done. 

Exclusions: Two wards which were asked to produce pictures for the study did not: 

only 4 patients from the traumatic brain injury unit produced the required number of 

paintings as art groups were irregular with frequent changes of staff and patients, so they 

were excluded on numbers. Wardstaff withdrew a chronic schizophrenia group from the 

study due to misgivings about confidentiality because their artgroups were dynamically 

rather than recreationally based. There were 2 patients on whom information was not 

available (short stay patients, untraceable); and one patient who withdrew from the 

study. The other exclusions were on diagnostic criteria which are shown in Table 5 under 

procedures below. 

Unequal group sizes 

Patients: because diagnosis was only taken after the artwork had been collected, 

numbers fluctuated and there were also overlaps between wards, especially with 

schizophrenics. 

Non-patients: All the non-patients were staff members or student nurses who worked 

with the group in the same conditions and whose paintings had been saved along with the 

patients. All staff members involved agreed to contribute their paintings. Most of the 

control paintings came from the groups which agreed to save their paintings weekly 

because many staff paintings, especially those of transient student nurses, were excluded 

198

ecause they were difficult to identify and single, and even those of regular staff had not 

been saved for long. 

Measures 

Age and sex were recorded and their means are shown in Table 1. 

Four additional demographic variables were taken from the files 249 , but on examination, 

discarded: 

1. Marital status had changed often for some patients and there were signs to 

suggest that files were often inaccurate and insensitive to patient's outside 

relations, especially when the patient had been hospitalised for a long time. This 

variable was discarded. 

2. IQ was not recorded because it was not routinely tested, the researcher was not 

clinically involved with patients and had no training for such measurement. IQ 

measures are known to be unreliable with psychiatric populations, because the 

illness itself interferes with the verbal component. Some studies use 

developmental indicators from the pictures themselves, but there is strong 

evidence to suggest that the scoring procedure is inconsistent in psychiatric 

illness 250 . 

3. Drugs was discarded: Only a handful of patients were not taking serious 

medication and some patients' medication fluctuated often and the date of 

249 

Forms were developed so that information taken would be standardised and comparable. A sample form 

is included in Appendix 5. 

250 see introduction: projective tests. 

199

paintings was not reliable enough to relate to it; all were inpatients, but some 

were in hospital for one or two days only and there may have been other 

influences, especially in the substance abuse group. 

4. Chronicity of patients: There were three variables to determine chronicity: new 

admission, previous admissions, and whether the patient had ever been sectioned. 

It was initially decided to examine and compare work in both acute and chronic 

stages of illness. The advantage of examining work by patients in acute stages 

of illness, as well as the traditional chronic groups, is the comparison of indicators 

which have been identified as distinguishing psychiatric illness that may be due 

to the institutional environment. However, patients were difficult to classify, 

even as inpatients, as their status fluctuated. Most of the wards which 

participated actually contained patients with chronic illnesses, especially 

schizophrenia. However, in three out of four wards which were identified 

initially as dealing with acute illnesses (drug unit, rehabilitation unit, and 

community mental health unit) casenotes revealed that the majority of frequent 

attenders (3 paintings or more) had previous admissions and few were new to the 

hospital. Another acute unit, for traumatic brain injury was excluded. This 

variable was discarded. 

200

Instruments 

Diagnostic Tests: What is the ICD10(DCR) 

The International criteria for Diagnoses developed by the World Health Organisation 

(WHO) is the most widely used classification system in the world. Its development is 

detailed elsewhere 251 . It is recognised as a standardised, easy to apply system with 

excellent reliability between raters. The DSM 252 system, which is more popular in art- 

therapy literature represents North American modifications of the ICD sections; DSMs 

must be compatible with ICD. The main differences are in the higher rate of multiple 

coding of selected disorders encouraged by the use of DSM-III. Collaborative 

development of ICD-10 with DSMIV has now aligned these even more closely 253 . 

Because of the diagnostic procedure, and the experience of the clinician, for this research, 

the ICD-10 classifications provided the simplest and most reliable procedures. 

Reliability: All ICD-10 clinical diagnoses are organised into 10 two-character groups 

(e.g. F2 for all Schizophrenic disorders). These two-character groups are subdivided into 

3 character groups (e.g. F20 for schizophrenia), which in turn are subdivided into 4 

character codes (e.g. F20.0 for paranoid schizophrenia). Interrater agreement can be 

251 

J.E. Cooper (1988), The structure and presentation of contemporary psychiatric classifications with 

special reference to ICD9 and 10. British Journal Psychiatry , V.152 (suppl.1):21-28. N. Sartorius (1991), 

The classification of mental disorders in the Tenth Revision of the International Classification of Diseases. 

European Psychiatry , V.6:315-322. Details of planning, organisation and conduct of international field 

trials are also provided elsewhere, WHO DMH Mental behavioral and developmental disorder ("clinical 

descriptions and diagnostic guidelines"), in International Classification of Diseases , Tenth Revision (June 

1987 Draft for Field Trials). Geneva, WHO, 1987. J. Burke (1988), Field trials of the 1987 draft of 

chapter V (F) of ICD-10. British J. Psychiatry , V.152 (suppl.1):33-57. 

252 

American Psychiatric Association (1987), Diagnostic and statistical manual of mental disorders (3rd ed. 

rev.), Washington D.C.:Author. 

253 

D.A. Regier, C.T. Kaelber, M.T. Roper, D.S. Rae, N. Sartorius (1994), The ICD-10 Clinical Field 

Trial for Mental and Behavioral Disorders: Results in Canada and the United States, Am. J. Psychiatry , 

V.151(9):1340-1350. 

201

computed on any of these levels. Groups of 2 character and 3 character codes combine 

related categories, and kappa coefficients at these levels tend to be higher than for more 

specific 4 character categories, since they ignore some differences in diagnostic 

disagreement 254 . For the purpose of this research, subjects were classified by 3 character 

groups although diagnoses were actually made at the 4 character level, which is usual for 

clinicians, as shown in table 10. 

The ICD-10 DCR (Diagnostic Criteria for Research, 1993) version was used for this 

research 255 , which is consistent and compatible with the Clinical Descriptive version and 

other national classification systems (e.g. DSM-IV) 256 . The criteria are explicit, easy to 

apply and are specified in more detail than in the more narrative equivalent statements 

in the clinical descriptions and diagnostic guidelines from which they were derived. Very 

high interrater agreements have been reported 257 , which was important for this research 

as reliability of diagnoses was not statistically investigated. The criteria contain 

descriptions of symptoms and other attributes of the patients, together with statements 

about the frequency, relative importance and duration of symptoms. Exclusion and 

inclusion statements are also provided. 

254 Ibid. 

255 

Division of Mental Health of the World Health Organization (1993), International Criteria for Diagnoses 

in the Mental and Behavioral Disorders: Diagnostic Criteria for Research (ICD-10 DCR), Geneva: Author. 

256 

N. Sartorius, T. Bedirhan Ustun, A. Korten, J.E. Cooper, J. van Drimmelen (1995), Progress toward 

achieving a common language in psychiatry, II: results from the international field trials of the ICD10 

diagnostic criteria for research for mental and behavioral disorders, Am. J. Psychiatry , V.152(10):1427- 

1437. 

257 Although in trials, numbers were low for some diagnostic groups. The population was not randomly 

selected and the range of possible diagnoses were more limited than the field trials for the ICD-10 clinical 

202

Accommodation of this project to identified weaknesses of the ICD-10 DCR in 

interrater agreement. 

For some categories, such as those dealing with certain polymorphic psychotic disorders 

or milder forms of affective disorders, the criteria have been rated difficult and reliability 

was low 258 . Difficulties usually came from the fact that two conditions were coded in 

combination, a situation which was avoided in this research, since subjects with 

secondary diagnoses were excluded. Difficulties in distinction between related states or 

in fine differentiation of levels were addressed by limiting the classification to 3 characters 

which allowed combination of related categories. Most subjects were in chronic state and 

hospitalised, so the somewhat low agreements on polymorphic syndromes (eg acute 

psychotic disorders) or milder categories, where distinction between normal and case was 

vague, were avoided. Categories showing lowest kappa values tended to present the 

greatest difficulty. There were obvious weaknesses in diagnosing psychiatric illness 

from casenotes. The notes did not usually contain a formal ICD-10 designation for the 

patient, but they did usually present a detailed description of symptoms and 

observations on the patient by an experienced psychiatrist and other staff. Patients who 

participated in this research had major psychiatric dysfunction, and patients with 

secondary diagnoses were dropped. For this research, where there were difficulties, 

ambiguities or different conclusions from that recorded in the notes, DF consulted with 

the psychiatrist in charge of the case. These cases were rare. 

descriptions. 

258 Sartorius et al (1995), common language in psychiatry, op.cit. Although these tests were between 

countries worldwide and low reliability mostly reflected North American familiarity with the DSM-111. 

203

The DAPA (Descriptive Assessment for Psychiatric Artwork) 

The DAPA was piloted at Post Graduate School of Medicine, Dept. of Psychiatry, Keele 

University. Details of the instrument and the initial study were published in 1996 259 and 

the first study is described in section 3 of this chapter; Section 2 details the interrater 

reliability of the instrument. 

The DAPA test procedure uses a rating sheet for standardisation 260 , and the rating guide 

describes categories as objectively as possible in observable and simple terms with 

examples for comparison to minimise imposed interpretation by the rater. A full list of 

operational definitions appears in the DAPA Rating Guide (Hacking and Foreman 1994: 

which appears at the beginning of Chapter 4, also appendix 4) 

Application - Scoring procedure 

The six categories are measured by a grid drawn on a transparent overlay, of 20 squares, 

consisting of 5 columns and 4 rows. The grid fits over the whole painting, corner to 

corner. Its absolute size is therefore defined by the size of painting. For each square 

respectively, 9 colours are recorded as present/absent (1,0); brightness or density (colour 

intensity) of the media is recorded as high, medium, low (3,2,1); line is recorded as thick, 

varied, or thin (3,2,1); the percentage space covered by the media is scored in quarters: 

10, 25, 55, 100%; subjective emotional tone is scored as it appears to the rater as 

259 

S. Hacking, D. Foreman, J. Belcher (1996), The Descriptive Assessment for Psychiatric Artwork 

(DAPA): a new way of quantifying paintings by psychiatric patients, J. of Nervous and Mental Disease , 

V.184(7):425-430. 

204

positive, neutral or negative for each square (3,2,1); and Dominant form is recorded for 

each square as present or absent. This produces 20 scores for each of 15 variables. 

These twenty scores are averaged for each variable over one painting. To eliminate any 

further effect of content, all the paintings by one individual were again averaged providing 

a subject profile of 15 scores. 

Development: Appendix 4 shows early versions, labelled 1 and 2, and the developed 

version of the DAPA (version 3) used in the main study and the reliability study. The 

initial study used version 2. 

Subordinate Analyses 

Treatment of the Data: Procedures to approximate a normal distribution were taken on 

the raw data and to counteract any confounding variables. 

Not all the subjects completed all the paintings. The non-parametric equivalent 

of ANOVA, the Kruskal Wallis test was performed on the categorical variables of 

diagnostic group by number of paintings to determine bias, as content in the early 

paintings would therefore be emphasised. Additionally correlations were calculated 

between all variables to show association with number of paintings done. 

There were more females in the control group, so the ANOVA procedure was 

used to determine interactions of sex with significant variables. 

260 Sample in Appendix 4, version 3 of DAPA. 

205

The extremes of the distribution for each variable were examined for consistent 

outliers which could be eliminated, to compact the data and decrease noise; tables can be 

found in appendix 2; from Chapter 5 (figs 3a-f and tables/figs 1a-l). 

Analysis of the paintings: Most of the raw data was rank-ordered or classificatory, but 

the final score for each subject was a ratio of the distribution of each variable over their 

output of paintings, fulfilling the conditions for parametric analysis. All calculations 

were done using the computerised Statistical Package for Social Sciences, version 4 for 

DOS. 

Analysis to differentiate groups and the importance of population distribution 

The Analysis of variance test procedure was the main differentiating analysis in this 

study. It allows cases to fall into different groups based on their values for one variable. 

The one-way Analysis of Variance has the advantage that it is a single analysis which 

compares all the data at once, rather than employing t-tests between different groups, 

which is problematic when there are a number of tests. But ANOVA gives a clumsy 

answer because it employs an omnibus approach which compares equality of population 

means for each test variable; it assumes to 'null hypothesis', that there is no difference 

between the 5 different diagnostic groups. 

The test compares the variation between the means of the groups with that 

expected from the variability between individuals in the groups. The comparison takes 

the general form of an F test (variance ratio test); if two normally distributed populations 

206

have equal variances, the ratio of the two sample variances has a sampling distribution 

called the 'F' distribution, that is, the ratio of sample variances or square of ratio of the 

sample standard deviations. There are two values for degrees of freedom - for each 

variance, the first relates to the numerator and the second to the denominator. If the two 

standard deviations are markedly different, it is unlikely that the two samples come from 

populations with the same variance. ANOVA assumes two conditions and tests are 

discussed below: 

1. Each of the groups must be a sample from a normal population. 

2. The variances within groups must be equal. 

In practice the analysis of variance gives good results even if the normality assumption 

doesn't quite hold but because of the imbalance in the number of observations in each of 

the groups, the equal variance assumption was important. Distributions of values for 

each variable were computed using the SPSS EXAMINE procedure. 

The analysis of variance test does not isolate particular differing groups: it can 

only tell us whether there is a difference and not where the difference lies. For this a 

multiple comparison test is used. Because there were no grounds for prior hypothesis, 

a planned comparison would be inappropriate with an omnibus test such as Anova. 

Having observed a statistically significant effect using the oneway procedure, the 

RANGE subcommand (Duncan procedure) was used to compare each group with every 

other group; significance levels are attached to those groups showing most difference. 

The comparisons use t-tests applied between independent samples for each variable, 

comparing each pair of means in turn. 

207

The difficulty with using t-tests is that multiple significance testing gives a high 

probability of a type 1 error (a false positive result) because the probability becomes 

much more than 5%. Duncan's multiple range test controls the overall type 1 error rate 

at no more than 5% using the Bonferroni correction for multiple comparisons. The 

procedure is suitable for groups with uncorrected variances and can also be adjusted for 

unbalanced design 261 . The disadvantage of this and similar methods available on SPSS is 

that they are 'conservative' so that errors are on the side of safety (non-significance). 

Therefore small numbers of group comparisons (up to 5) are recommended, with 

specified research objectives 262 . In addition, since it is likely that some of the measures 

for ANOVA are correlated: in real life we can assume some correlation between multiple 

tests, it is more likely that the Bonferroni estimate would be conservative, placing any 

suspicion on non-significant data. 

Discriminatory power between controls and patients 

This final analysis aims to give distinct answers to 2 direct questions; 

(i) Is the DAPA as effective as other art assessments; and 

(ii) can the DAPA practically discriminate between patients and controls. 

These two questions need to be attacked differently because they are respectively 

conjectural and pragmatic; (i) is answered through the illustration of effect sizes from t- 

test results, using the methodology explained in Chapter 2, which derived effect sizes for 

261 

It is a popular misconception that groups must be orthogonal for comparison tests, R. West (1991), 

Computing for Psychol ogists (London: Harwood). 

262 D.G. Altman (1994), 

Practical Statistics for Medical Research , London, 3rd. reprint, original 1991: 

208

the most interpretable studies from 20 years review of the literature; and (ii) is answered 

through the interpretation of the discriminant analysis performed on the collected data 

from patients and controls. 

(i) Is the DAPA a better assessment than the other tests reviewed in Chapter 2? 

In order to contrast the effect from the DAPA with that of the general tenor of the 

literature, the basic differences in effect size between controls and patients on each 

variable from the DAPA were determined by another t-test. Each variable was treated 

as though it was independent, purely for the theoretical comparison. These tests cannot 

be regarded in practice as independent, as there were obvious correlations in the data and 

so there was likely to be confounding errors, due to multicollinearity -one variable may 

be the main predictor, subsuming those correlated with it to insignificant contributions, 

thus true results for the DAPA should take account of direct relations between variables. 

(ii) Can the DAPA practically discriminate between patients and controls. 

Regression analysis was not applicable to this study because from the discussion of 

results it was obvious that there could be interactions and correlations between one or 

more of the predictor variables. The more complicated regression techniques require more 

cases. The discriminant analysis is an older technique, but for 2 groups gives a similar 

result. Discriminant analysis avoids the problem of multicollinearity by setting a 

tolerance level which excludes variables that are highly correlated with each other. In 

Chapman and Hall, p.211. 

209

addition it leaves out other variables which are not necessarily non-discriminatory 

independently, but their ability to add to the discrimination having taken account of the 

other variables already used is judged low. It reduces the test to a subset of useful 

variables from a larger set of candidates and indicates to what extent a combination of 

independent variables will allow discrimination between controls and patients. 

Discriminant analysis was used to find a combination of variables that 

classified a large proportion of subjects into the correct group as an instrument of 

allocation or diagnosis for new subjects. The analysis used the same subject group 

detailed in table 1 (109 subjects: 23 controls and 86 patients). The method is robust and 

makes few assumptions, but two recommendations are suggested for the sake of 

interpretation 263 : 

1. that most variables have a normal distribution with the same s.d. within each group 

(although some authorities have argued that discriminant analysis is robust for binary 

distributions); and 

2. five times as many subjects are recommended per group as variables. 

It was appropriate to consider this method, then, for 2 groups: patients and controls; 

subgroup analysis would require more cases. The Mahalanobis method, which is a 

variation on the stepwise method, was selected. Using SPSS, the steps of the calculation 

are clearly shown. The analysis works by finding a combination of variables that 

maximises the distance (D 2 ) between the groups. It may, perhaps, do slightly less well 

263 Altman (1994), op.cit. recommends that in order to correctly interpret the associated significance that 

variables should have a normal distribution, but generally authorities are mixed on whether this issue is 

critical. 

210

than the stepwise option at correctly classifying the subjects but there is a clearer 

indication of the extent to which particular variables contribute to the discrimination 

process. 

It was necessary to control for uneven numbers between groups as the patient 

group was nearly four times the size of the control group, otherwise there wouldn't be 

an even chance of allocation to either group. The PRIORS subcommand within the SPSS 

program adjusts the calculation for the sizes of the groups according to the prior 

probability of chance allocation to one group or another. Prior probability was thus set 

to 75/25%. 

Subordinate analyses 

Correlations between DAPA variables 

For exploratory analysis, the Pearson Product Moment Correlation (Pearson's r) is the 

most commonly used measure of linear association between continuous variables. Bi- 

variate scatter plots for the significant variables were generated to check the distribution 

of the data because there are restrictions on the validity of the associated hypotheses 

tests. The significance of the correlation coefficient is valid for random samples with at 

least one normally distributed variable. 2 tailed tests were used because, although 

hypotheses were made, there was little scientific reason to expect that correlations would 

be in any particular direction. 

Correlation is often used as exploratory analysis, but even with only a dozen 

variables here, 66 r values are produced. 5 populations are tested, thus 1 value in 20 will 

be significant at the 5% level purely by chance! This level of analysis was rather too 

211

nebulous for reasonable conclusions and two tailed tests of significance tightened up the 

data and allowed for type 1 errors. Much depends on the sample size, but significant 

values of r below .6 would not contribute much to a speculative general discussion 264 . 

Because there is little background knowledge, it would be imprudent to infer 

relationships from analysis of correlations alone. It was clear from previous studies 265 

that some exploratory analysis was necessary, as interrelationships between the variables 

could contribute to the explanation of difference in the results of this analysis from 

previous work or accepted knowledge. The secondary purpose, in further development 

of the test, was to identify any possible reduction of the scales to increase efficiency if 

some of the scales measured the same quantities. 

An analysis for the whole population as if they were the same diagnostic group 

may mislead because other differences in samples, or indeed a third unknown variable 

might influence ratings, bunching particular groups and inflating the correlation. In 

addition in large populations, very small correlations become significant. Correlations 

were calculated between reliable variables within each diagnostic group. 

Procedures 

264 Altman's (1994) op.cit. recommended method to modify over-enthusiasm may be adopted here; the 

calculation of 100r 2 on 0.7 gives 49%, the percentage of the variability of the data that is explained by the 

association of the two variables. 

265 For instance: the DDS (Cohen et al. 1988, op.cit) see my criticism of their results, Chapter 2; 

Wadlington and McWhinnie (1973), op.cit. found significant associations between scales similar to those 

used in the DAPA test. 

212

Procedure for diagnoses: ICD-10 diagnoses were made from case records by Dr. D. 

Foreman 266 , who is a Consultant psychiatrist with training in both general and child 

psychiatry. D.F. was blind to the originating ward and paintings while making the 

diagnoses. Disagreements were discussed with the consultant in charge of the case. 

Table 2 shows category definition of case assignment to 4 types; Affective Disorder 

(n=18); Schizophrenia (n=35); Personality Disorder (n=9); Drug Abuse (n=24). 

ICD-10 Diagnostic categories for research (1993) N ASSIGNED 

TO TYPE 

Moderate Depressive Episodes (Affective Disorder) (4 x F25.2; 3 x F25.1; 2 x 

F25.0, F33.3; 1 x F33.1, F32.8, F32.3, F32.1, F31.7, F31.6, F31.0). 18 3 

Schizophrenia (24 x F20.3; 4 x F20.0; 4 x F20.9; 2 x F20.5; 1 x F20.2). 35 1 

Personality Disorder: (3 x F60.3; 1 x F60.3 + F68.1; 3 x F10.2 + F60.3; 1 x 

F10.2 + F60.9; 1 x F45.0 + F61.1). 9 5 

Substance Abuse: (14 x F10.2; 3 x F19.2; 2 x F11.2, F18.2; 1 x F11.1, F13.2, 

F15.2) 24 2 

Table 3: 21 Patients who were excluded from the study 

Diagnostic type with ICD-10 category N 

Diagnosis of Affective Disorder with secondary diagnosis 

(1 x F33.4 + F00.1; 1 x F33.4 + F02.3; 1 x F31.3 + F70.1; 1 x F33.2 + F22.0) 

Diagnosis of Schizophrenia with secondary diagnosis: (1 x F20.0 + G20.0; 1 x F20.3 + 

F70.1; 1 x F20.3 + F07.8; 1 x F20.9 + F70.1) 4 

Diagnosis of Organic Mental Disorder: (1 x F00.1 + F31.7; 1 x 0.1 +F25.1; 1 x F01.2; 1 

x F07.0) 4 

Diagnosis of Anxiety Disorder, Eating Disorder: (1 x F41.2 + F10.2; 1 x F10.2 + F50.3; 

2 x F50) 4 

Diagnosis of Mental Retardation: (2 x F71.1) 2 

Procedure for Painting Generation: All patients and staff who had attended art 

groups run by nurses, as part of the recreational program of the hospital in the wards 

266 Dr. D.M. Foreman, M.Sc., MRC Psych., Clinician and Senior Lecturer, Psychiatry Dept., Post 

Graduate School of Medicine, Keele University. Dr. Foreman supervised this Ph.D. research. 

213 

4

identified were included in the study. The art groups took place at the same place and 

time each week in daylight hours for one hour a week. They contained up to 8 

participants who were either patients or staff from the ward. In each case the most recent 

10 paintings produced by the subject were used for the study, these varied in date 

because although the study was initially retrospective, paintings by patients were not 

kept by all wards 267 . Where it was a practise to dispose of the work, art groups agreed 

to keep and label the work for a specified period. Paintings were identified with a number 

by the nurses at the time and a separate sheet was provided a key to names and staff 

identification, which was kept separately until after the scoring period. S.H. collected all 

the paintings from the nurses weekly, but was unaware of diagnosis, which paintings 

were by staff members and unacquainted with the group. No themes or subjects were 

set 268 and the group leaders followed their own agendas or used free painting. Art 

materials were those available to the group leaders, pencil and paint, but were not 

standardised, although labelling instructions did indicate that all the basic colours should 

be available to the patients if possible. Most of the paper provided was white 17" x 12", 

but some used white 8" x 12". 

267 This is surprising if art work is considered as information relating to the patient, but actually few 

patients are given true art therapy due to the shortage of therapists. Most 'art therapy' is given by nurses 

who have taken short courses. Paintings were discarded because they contribute to fire hazard and also 

fat-file disease: the patient's file gets thicker the longer the hospital stay. 

268 But where suggestions were asked for, S.H. made the recommendation of a self portrait. 

214

Summary 

After the pictures were drawn/painted and collected and measured according to the 

DAPA specifications above, there were 6 stages to the analysis of the study data, their 

applications are divided between results and discussion. 

RESULTS: 

• The data was transformed, so that the distribution of the majority of variables 

approximated normal. Variables with low frequencies were excluded from the 

analysis. 

• A variance analysis was applied to 13 scores representing 6 measured dimensions of 

paintings obtained from the DAPA procedure to determine whether the instrument 

differentiated between controls and 4 patient groups of different diagnostic types. 

• The Duncan procedure identified where differences lay. 

• The discriminant analysis determined the predictive value of differences between 

patients and controls. 

• Subordinate correlational analysis was used to determine the within cells correlations 

for the 13 variables from the DAPA procedure, to assess the validity of the 

categories. 

• T-tests for each variable were calculated using the same procedure to determine effect 

sizes for comparison with the best studies from the literature. 

215

DISCUSSION 

• The validity of the DAPA categories was examined, strengths and limitations of the 

procedure. 

• The results were explained and compared and contrasted with those detailed in the 

literature review and the results of the pilot study, in which the content was 

controlled. 

• The interactions and correlations of the 13 variables from the DAPA procedure were 

discussed and compared with impressions from the literature taking account of the 

limitations of the procedure for the effect sizes produced by the t-test. 

• The discriminant procedure was discussed and compare the final outcome with 

previous investigations and predictions. 

Section 2: Reliability Study 

An abbreviated version of this study, together with the first study (section 3) appeared 

in an article by S. Hacking, D. Foreman and J. Belcher (1996) 269 . 

Purpose of the Study 

The amount of rating in this set of studies was considerable. A little over 1000 paintings 

were rated for the main study and the first study by the author for this research. It was 

necessary to find out if the rater's judgement of pictures was a contributing factor to 

significant differences in discriminating variables. There are various ways of conducting 

inter-rater reliability tests on human subjective judgements. There is nothing unscientific 

269 S. Hacking, D. Foreman and J. Belcher (1996), The Descriptive Assessment for Psychiatric Art: a new 

216

about subjective judgments but care is needed in making them credible. It is essential to 

be able to demonstrate that at least two people can independently come to fairly similar 

judgments. Multiple rating of the whole test would be time consuming, costly and 

impractical since it is better to employ more than two people; two people closely 

involved can reach an understanding which is not apparent in the written material and 

over hundreds of ratings, the significance of small deviations decreases. The more people 

employed, the greater the risk of individual variation on rating areas which are not clearly 

defined. 

Inter-rater reliability statistics judge the extent to which agreement is reached, 

usually by reporting the correlation between raters, together with a summary of the 

agreements and disagreements on level of rating. This study took a small sample of 

pictures (1%) from the total amount of pictures previously rated by the author, and used 

a relatively large number of judges. The object was to find out if several people 

independently could give the same or similar scorings using the DAPA scale to the 

scoring given by the author; if so, it can be reasonably deduced that the author's rating 

was consistent within the test categories. 

Choice of Subjects 

Raters: 7 first year art students (6 females 1 male 19-24 yrs.) from a local University 

were recruited as raters. They had no previous knowledge of the DAPA or of other art 

tests. Art students were chosen because the training would take some time, concentration 

way of quantifying paintings by psychiatric patients, J. Nervous and Mental Disease , V.184(7):425-9. 

217

and the test used terminology which would be familiar to them. 1 rater was dropped 

during training because his responses were inappropriate to the task. Raters received 2 

hours training with the rating guide used in the main study (Version 3, shown in Chapter 

3). This was in the form of a workshop, which took them through the guide, included 

explanations, examples of terms and the rating of one training painting before using the 

scale. 

Picture Selection: 25 paintings were selected by the author from paintings rated some 

months previously as part of a study with large numbers of other such work. The 

paintings showed a range of different subjects and treatment of media. They were each 

by different long term psychiatric inpatients from a local mental hospital, or by staff 

from the same facility. Each rater on arrival selected one painting from the study pool 

and these paintings were used for the study (ratings made by the author for the selected 

paintings were retrieved at the analysis stage for the comparison and were not available 

at the time). 

Method 

Raters were given the opportunity to discuss the categories with the author in training 

as indicated. They all rated the same training picture at the end of the training session to 

iron out any inconsistencies and misunderstandings, and then individually rated seven 

pictures, in series, in different orders, referring to the rating guide and helpsheet provided 

by the author. They worked by themselves at separate desks so that they could not 

discuss their ratings, they changed over pictures with the next person until they had 

218

finished the set. They were asked for their comments and suggestions. Most 

participants took about 10 minutes for the whole process as described in the DAPA 

rating guide (Chapter 3) per painting by the end. 

Analysis: treatment of the data 

A point by point comparison of every category per gridsquare would have been 

ridiculously long and complicated. The propriety of different methods of agreement are 

discussed at the end of Chapter 2 (reliability). Altman 270 recommends Kappa for 

categorical variables, and warns against the misapplication of the correlation coefficient 

to measure agreement for categorical scales. However, a disadvantage of kappa is that it 

takes no account of disagreements and is not useful for numbers of raters, numbers of 

categories, non-ordinal scales and large tables, often requiring considerable collapsing of 

the data and thus not for this study. A categorical comparison was therefore both 

unwieldy and unnecessary, since it is the final mean score, used as continuous data, 

which is the hub of the DAPA process. The questionable propriety of the correlation co- 

efficient for analysis of agreement, as expounded by Altman, is that although it indicates 

linear association, how nearly the scores are ordered in the same way, it does not indicate 

whether the level of the scores have changed. This is important because ordinal 

positioning is not relational and therefore particularly makes nonsense of categorical 

correlations. 

270 

D.G. Altman (1994), Practical Statistics for Medical Research , London, 7th ed. originally 1991: 

Chapman Hall, p.284, and 409. 

219

How the data were structured 

Although ordinal scales are often treated as though they were interval scales, only very 

limited mathematical and statistical operations make sense using ordinal data. However, 

a common quasi-legitimate procedure 271 was applied to scores from the DAPA, both for 

the main tests and for the reliability test. Normality was assumed in the underlying 

distribution and the interval units of the scale were adjusted to match the average 

observation for the whole picture (over 20 squares), which makes sense, because there 

is a maximum limit for each variable over the painting (e.g. Range of Red = 0 - 1). Even 

though, pragmatically, the limitations of the measurement method must be taken into 

consideration in the final analysis, statistical advantages of parametric analysis allow 

more powerful techniques of comparison. 

The raw scores for colour and form for each picture (count of up to 20 

gridsquares) were scaled 0-20 and had two possible scores for each square, but the scores 

for Intensity, Painted Line, Drawn Line, and Emotional Tone were scaled 0-60 with 4 

choices and those for Space, 1-100 with 5 choices 272 . It was therefore necessary to align 

the scores on the same scaling points for comparability of repeated measurement. The 

usual testing procedure reduces the scores to an average gridsquare rating over the whole 

set of paintings, but this was inappropriate to test the scoring procedure 273 . To keep the 

data as simple as possible, a count per picture for colours was used; scores from the 0-60 

scales, were divided by a factor of 3, and the 1-100, by a factor of 5. 

271 The same as that done with IQ data in order to convert it to an interval scale. 

272 There weren't any zero scores (no marks at all). 

220

Measuring accuracy 

Altman's recommendation to plot the differences against the average score, for continuous 

measures, seemed clear and appropriate. Tables 1-15a (appendix 2) show rater's scores, 

discrepancy levels, the mean score for each subject and differences to that of the author. 

Plots of the distribution of the raters' scores (Figs 1-15 appendix 2) show concordance 

with the mean rating; for clarity the same minimum and maximum limits are used 

throughout. It must be remembered that the principal rating (R7 by the author) is not the 

true value, which is unknown, and for this purpose, the average of the mean trainee rating 

and that of the author 274 , acts as the best estimate for the unknown true value. A 

summary of these scores, the standard differences are tabulated below (table 16). 

Table 16: Standard deviation of the differences between the mean of the 6 trainee raters 

and the author ratings over 7 paintings 

S.Diff 

Variable Mean Std Dev Min Max 

RED -.02 1.35 -1.50 2.67 

YELLOW 1.12 1.21 .00 3.00 

ORANGE -.24 .42 -1.00 .00 

PURPLE -1.26 2.09 -5.33 1.00 

GREEN -.86 1.20 -3.00 .17 

BLUE -1.36 1.23 -3.00 .00 

BROWN -1.07 2.51 -5.83 2.17 

WHITE -.24 .63 -1.67 .00 

BLACK -.07 .69 -1.17 1.00 

INTENSITY 1.02 1.54 -.89 3.83 

PAINT LINE 1.21 1.26 -.33 2.72 

DRAW LINE -.06 .11 -.28 .00 

SPACE -.65 .68 -1.77 .00 

EM-TONE .17 2.01 -2.17 3.11 

FORM -.31 .68 -1.33 .67 

221 

95% limit of agreement; 

(expected differences by scale points); 

and likely direction of discrepancy 

-2.68 to 2.70 (

How well does the method agree? 

Table 16 shows a summary of the standard differences (S.diff) between the 6 trainee 

raters and the author's score (column 1), plotted in Figs 1-15 275 (Appendix 2). The 

scatter of differences remains constant and does not increase with the mean, so the 

differences can be further investigated in the raw state 276 . A test of association would 

be inappropriate at this stage as we cannot deduce that methods agree well if they are not 

statistically different. There were large variations in the sample which may have 

regressed the mean and may well lead to important differences seeming non-significant 

(see tables 1-15 accompanying figs. 1-15, appendix 2). 

The S.diff. can be used as a measure of agreement by itself, but it is more useful 

to construct a range of values from it, which covers the agreement between the raters for 

most cases. 

For reasonably symmetric distributions we can expect the range mean +-2 S.D. 

to include 95% of the observations. We can therefore take mean +-2S.Diff. as a 95% 

range of agreement for individual paintings. This range defines the 95% limits of 

agreement (shown in Table 16, column 2). For the present data, from the 95% ranges, 

the author is expected to score within 1 point of scores from independent raters on drawn 

line, orange and white; within 2 on yellow, black, space, and form, with a slight bias 

towards higher scores; and within 3 points on a further 5 variables: red, green, blue, 

intensity, and painted line, with discrepancies likely in either direction. 3 variables have 

275 against Author+RATS/2. 

276 Rather than translation to logarithmic scores. 

222

wider ranges: purple and brown, which had 4 or 5 point limits, are mixed colours which 

are harder to define and therefore more variable to rate; raters tended to score lower. And 

emotional tone, which had 4 points limit, depended on the associations of the rater 

(discrepancies equal). 

So, how can we define good agreement? 

For this research, the standard deviation of the differences as a measure of agreement is 

appropriate because the subjects themselves define their own limitations. However, this 

does not facilitate comparison of the measure. Interpretation of agreement depends upon 

the circumstances, it is not possible to use statistics to define acceptable agreement; it 

is more important to quantify the variability of the individual data points. But it is still 

necessary to define some answer to the question: how well do the raters agree? within 

the larger context which gives it meaning of, how do we compare this agreement with 

other measures? It is a complicated question, and there are two components to the 

answer. 

(1) The mean difference is an estimate of the average bias of the raters relative to the 

principal rater. Here the means are mostly negligible and we can say that agreement is 

excellent on average. 

(2) It is essential to consider the agreement for an individual painting for which purpose 

the standard deviation of the differences (S.diff; Table 16) can be used. 

A rough comprehensive overall statistic can be deduced from examination of the 

raw data (middle columns of tables 1-15, appendix 2). A total 480 out of 630 decisions 

223

- 76% - of the scales were rated within one scale point of the author's score; the number 

of exact agreements was 58% (365); and a further 10% within 2. These figures are well 

within the expected limits of agreement shown in Table 16 (column 5) for 86% of the 

data. Ordering of the most reliable to least reliable DAPA categories (table 18 below) was 

based on the above considerations. 

Table 18. Ordering of DAPA variables for Reliability 

Most reliable categories 

Variable / agreement within 1 

point of R7score 

Best Agreements limits 

Draw-Line 88% .2 

Form 91% 1.5 

White 95% 1 

Orange 88% 1 

Black 86% 1.5 

Green 86% 2.5 

Moderate Agreement 

Purple* 81% 4 

Yellow 79% 2 

Red 78% 3 

Space 73% 1.5 

Lower Agreement 

Brown* 67% 5 

Blue 60% 2.5 

Paint-Line 55% 2.5 

Intensity 50% 3 

Em-Tone+ 40% 4 

over 2 

points 

diff's. 

2% 

2% 

5% 

12% 

4% 

7% 

14% 

14% 

17% 

8% 

21% 

23% 

26% 

31% 

39% 

*the actual figures within 1 point for brown and purple are acceptable because there were some wide fluctuations 

in the estimate which brings the mean figure up. 

+Emtone was a more subjective variable, but 61% of the data is consistent within 2 points. 

But there still remains the question of comparability with other measures. There is error 

in every measurement. The amount of error in a measure is indicated by various 

estimates of the reliability of the measure. A test with a low reliability of, for example, 

60, has more error than a test with a high reliability of, say, .80. 

224

Variable 

name 

Red 

Yellow 

Orange 

Purple 

Green 

Blue 

Brown 

White 

Black 

Intensity 

Paint-Line 

Draw-Line 

Space 

Em-Tone 

Form 

Authorities differ on recommended methods of inter-rater reliability statistics, 

and there are few previous good examples in this field 277 . A supporting equivalence test, 

such as Cronbach's alpha, used to demonstrate internal consistency between items 

measuring the same attribute is recommended 278 . 

Table 17. to show means and standard deviations* of rater scores for each variable over 

the sample of 7 pictures. There is a maximum of 20 point scores for each variable. 

Simple counts are used. 

Rater 1 

5.29(4.31) 

7.43(5.47) 

3.57(7.16) 

5.29(7.57) 

6.86(4.88) 

9.29(6.63) 

5.28(5.50) 

0.86(2.27) 

12.14(6.31 

) 

15.38(4.46 

) 

5.62(4.41) 

0.81(1.86) 

8.46(5.36) 

13.05(4.01 

) 

5.57(5.56) 

*S.D. in parenthesis 

Rater 2 

6.86(5.52) 

7.57(5.00) 

3.57(6.88) 

4.86(5.90) 

6.86(4.95) 

9.71(6.50) 

3.43(4.58) 

1.00(2.65) 

11.86(6.31 

) 

14.48(2.57 

) 

7.19(4.64) 

0.62(1.50) 

8.11(4.79) 

13.86(2.62 

) 

4.86(5.96) 

Rater 3 

6.14(4.88) 

7.14(4.49) 

3.71(6.97) 

4.00(5.45) 

6.29(4.96) 

8.86(6.23) 

3.00(5.20) 

1.00(2.65) 

11.43(6.21 

) 

16.19(4.03 

) 

6.19(3.80) 

0.62(1.64) 

8.49(4.97) 

15.62(3.75 

) 

4.57(5.88) 

Rater 4 

6.86(4.26) 

7.86(5.61) 

2.71(7.18) 

4.71(6.78) 

5.57(4.04) 

8.71(5.94) 

4.86(5.43) 

1.00(2.65) 

12.14(6.54 

) 

16.33(3.41 

) 

7.19(4.84) 

1.38(3.65) 

7.00(3.96) 

13.52(3.90 

) 

4.71(5.88) 

225 

Rater 5 

5.00(4.00) 

7.57(5.38) 

3.14(7.08) 

5.00(6.88) 

6.29(4.54) 

10.43(6.35 

) 

3.29(4.72) 

0.57(1.51) 

11.29(6.52 

) 

16.86(3.57 

) 

6.81(4.98) 

0.81(2.14) 

7.97(4.61) 

12.52(4.94 

) 

4.71(5.88) 

Rater 6 

5.57(4.20) 

7.57(5.88) 

2.57(6.80) 

3.57(4.79) 

6.43(4.47) 

10.00(6.35 

) 

5.43(6.40) 

1.00(2.65) 

11.71(6.45 

) 

14.67(4.23 

) 

6.29(3.82) 

0.71(1.89) 

7.94(4.66) 

13.00(3.21 

) 

4.86(5.52) 

Rater 7 

6.43(5.16) 

8.14(5.64) 

3.14(7.08) 

4.14(5.70) 

5.86(4.45) 

8.14(5.34) 

3.14(5.40) 

0.00(0.00) 

11.86(6.59) 

16.67(3.35) 

7.76(4.74) 

0.76(2.02) 

7.34(4.11) 

13.76(4.95) 

4.57(5.88) 

Table 19. Inter-rater reliability showing Cronbach alpha score for internal consistency 

of scores between raters; and correlation coefficient for linear association between scores 

of raters. 

Variables Cronbach 

Alpha 

Red 

Yellow 

Orange 

Purple 

.987 

.994 

.995 

.993 

Intra-Class 

.975 

.988 

.991 

.986 

277 

Graham Dunn (1989), Design and Analysis of Reliability Studies: the statistical evaluation of 

measurement errors , London: Arnold, recommends the correlation coefficient; Carol Taylor-Fitzgibbon & 

Lynn Lyons-Morris (1987), How to analyse Data , Beverley Hills, CA: SAge, echo the concerns of Altman 

that linear association does not imply agreement and suggest additional notes of discrepancies and 

difference statistics. 

278 Fitzgibbon & Morris (1987) op.cit.

Green 

Blue 

Brown 

White 

Black 

Intensity 

Painted line 

Drawn line 

Space 

Em Tone 

Form 

.994 

.993 

.966 

.994 

.998 

.962 

.950 

.983 

.993 

.961 

.992 

.988 

.984 

.934 

.988 

.995 

.926 

.905 

.966 

.987 

.925 

.984 

Table 19 presents the results of the inter-rater correlations analysis. The two 

statistics support each other and give scores for each of the 15 elements of the test and 

are comparable with every other study which has been covered in the literature analysis. 

As the significance of a reliability co-efficient is its absolute size, the closer to 1.00 the 

better, the overall reliability for raters was excellent for each element across the range of 

paintings (alpha >.98): Bausell's recommended reliability floor of .60 is well exceeded 279 . 

However, Altman's point on the inadequacy of the correlation coefficient is well taken, 

since the variation in the subject matter (pictures 1-7) is quite large (see raw data tables 

1-15, which show the data count for each rater for each variable, appendix 2), and this has 

possibly falsely increased the value of r, because of large fluctuations. It is 

inappropriate to use a measure which is sensitive to variation in the subjects and Altman 

extends this criticism to the use of regression analysis for the same purpose. It is 

however wise to use a correlation index, cautiously for support, to check for negative 

correlations; even though the level of scoring may be close, its rhythms may vary. It 

remains to say that the most informative statistics we can get for this study are those 

279 

R. Barker Bausell (1986), A Practical Guide to Conducting Empirical Research , New York: Harper 

Row, p.204-6. 

226

shown in table 16, the mean difference and limits of agreement, which provide a good 

summary of the data. 

Conclusion 

It may seem that I have gone into too many tests in this section, but the importance of 

method comparison is paramount here for the individual subject and it is important to 

show why this method rather than another is used; there is little point in taking 

measurements between groups if the measurement method has poor repeatability, or if 

judgements may be made at different levels since systematic variation will occur. 

The limitations of this type of test and the resources available must be 

remembered here. For unreplicated studies it is difficult to compare the repeatability of 

the measurement and thus also the resulting statistics because there are no other studies 

with a similar systematic approach which publish enough information to allow it. In 

some ways the test defines itself: if 6 raters are used, they have either learnt the method 

or not, and the variation in their scores will indicate the limits of agreement. The general 

trend of the measure indicates that the method is repeatable, but the raters are 

inexperienced, they were less motivated than I should have liked and the sample size was 

smaller. Good agreement can only be reached when all raters are accurate. The 

correlations were high and the level of agreement only varied within 1 points for 76% of 

the scale, and within 2 points for 86%. I therefore claim good reliability was achieved. 

Weaknesses of the instrument and problems with rating 

227

All of the scales were understood by the raters at the time except for FORM, where the 

basic rating criteria were not followed, rendering analysis irrelevant, so it was not 

reported at that time, pending further research. Further research amongst professional 

artists found that the terminology referred to an artistic application which visual 

description or definition varied considerably even according to their own criteria 280 . 

There was theoretical agreement that significant or dominant form referred to dominating 

structural regular shapes. Wadlington and McWhinnie 281 also found that the term 

Dominant Form caused much confusion amongst raters, their advice was to discard the 

term 'dominant', but this merely fogs the form definition and removes the essential 

element, in my opinion. A further test, done with 7 similar University students (2 male, 

5 female age 19-24), without an art background and with a more detailed explanatory 

sheet 282 , produced a reliability score of 0.99. The students needed to look at the picture 

as a whole first, and the position of the term dominant form at the end of the rating sheet, 

and the previous sectioning into grids may have influenced the previous raters' 

understanding of the process, so repositioning of the form element was indicated. 

280 see appendix 5: Artist's form questionnaires, sample copy. I used these among 15 trained and training 

artists to determine how the parameters of my definition should change. 

281 Wadlington and McWhinnie (1973) op.cit. 

282 see Appendix 5 again, more detailed explanation, category slightly changed. 

228

3. Study 1 

Permission and ethics: This project was submitted and passed by the North 

Staffordshire Medical Ethics Committee 1994. Permission to access patients notes and 

to use the paintings for research was sought primarily directly from patients themselves 

through written or oral consent and also from the consultant psychiatrists in charge of 

their case. Consent forms explained the project in simple terms, that patients would not 

be identified and that the project had no connection with the treatment of patients. 

Sample consent forms and explanatory notes for patients can be found in Appendix 5. 

Oral consent was taken by hospital staff from the ward with whom the patient was 

already acquainted. One patient withdrew her pictures from the study pool although she 

attended the groups and made pictures with the rest until the end. 

Patient Selection: 39 participants were drawn from mixed sex wards of a psychiatric 

hospital serving an industrial community in North Staffordshire, England. The hospital 

accepts the full range of adult psychiatric disorder requiring admission. Four self- 

contained specialised wards were selected to provide subjects for the study. These wards 

treated substance abusers, the psychiatric consequences of brain injury, and psychotic 

disorders. The substance abusers were out-patients who attended a general hospital ward 

weekly; the other three wards were in-patient acute admission. The brain injury and one 

rehabilitation ward were sited in a large country mental hospital, the other psychotic 

ward in a community based mental health centre. 

229

Table 1: Demographics for experimental groups. Study 1 

Total Sex M Sex F Age 

Mean 

230 

Age S.D. 

Entire Population 50 33 17 34.8 11.0 

Affective Disorder 9 6 3 38.0 11.0 

Non-Affective Psychosis 10 7 3 36.8 11.4 

Brain Injury 11 10 1 38.4 14.6 

Drug Abuse 9 7 2 32.2 6.4 

Controls (staff) 11 3 8 29.0 8.2 

Table 1 shows demographic statistics: 39 psychiatric patients and 11 controls made 

paintings in the same conditions according to the same set criteria with standardised 

materials. 

Choice of subjects 

Patients: The groups of patients were chosen for availability and ease of access. Only 

patients who were judged able to give their consent and who volunteered participated. 

There were no larger groups of patients with a single diagnosis available, but primarily 

this investigation was to test the sensitivity of the measure - and also to give an idea 

whether general effects (patients against controls) against specific effects shown in the 

literature could be investigated (diagnostic differences). Most of the patients were in 

acute stages of illness. 

Controls: 11 staff members from the Substance Abuse ward and from the Community 

Mental Health Centre, these included student nurses with no experience of therapy 

groups, agreed to act as controls and completed their paintings together with the patient

groups, so that control conditions were identical to those of the patients. The advantage 

of the same conditions and environment outweighed unequal numbers. 

Exclusions: Most patients identified were included in study 1 and there were no 

exclusions for missing data. The study was voluntary and therefore did not encompass 

the whole population of the identified wards. One patient who was found to suffer a 

psychiatric disorder other than those mentioned was dropped from the study. 2 

unidentified pictures which were probably by student nurses were also dropped from the 

study. 

Measures 

Age and sex were recorded and their means are shown in Table 1. 

IQ was not recorded as IQ was not routinely tested and the researcher was not clinically 

involved with patients and had no training for such measurement. In addition, such 

measures are known to be unreliable with psychiatric populations, chronicity and drugs. 

Drugs: patients were mostly under assessment and were on low or no drugs although this 

was not always true, many were suffering from the effects of previous use of unidentified 

substances. 

Chronicity of patients: It was initially decided to examine work by new patients in 

acute stages of illness and wards were selected with this aim to control for traditionally 

identified indicators which have been described previously as common to the institutional 

environment or the long term effects of drugs. However, patients were difficult to 

231

classify, even as in and out patients. The wards selected dealt with acute illnesses, but 

casenotes revealed that although most patients were in acute stages, the majority had 

previous admissions and few were new to hospital admission. 

Diagnosis 

The ICD10 clinical diagnostic classifications were taken from patients hospital records. 

Description of the use of ICD10 for the purposes of this research appears in the 

instruments section of the Main Study. 

Inter - rater reliability - DF. made all the clinical decisions, but decisions which differed 

from what appeared in the patient record were discussed with the psychiatrist in charge 

of the case. 

The DAPA 

The DAPA rating guide version 2 was used which appears in Appendix 4. This was 

essentially similar to that presented with the Main study, however there were 

differences: 

1. One statistic appears for Line as a summary of painted and drawn lines. Although 

drawn line was distinguished from painted line when estimating variability of 

thickness, the two types of line posed relational problems in judgment. They 

were separated in the rating guide when interrater reliability was measured. The 

method of summarising was; squares would be scored as varied if either a drawn 

or painted line was of variable thickness; or there was a thick drawn line together 

232

with a thin painted line; or where a thick painted line appeared together with a 

thin drawn line; 

2. There was no form measurement; and 

3. Space was rated as an estimate of how full the picture was in tenths, whereas 

further development changed to the more successful 'bubble method' presently 

used in Version 3 (main study) and interrater study. Version 2 of the DAPA 

rating guide can be found in Appendix 4. Scoring procedures were the same. 

Treatment of missing data 

Painting Combination: Not all the subjects completed all the paintings. This could 

produce bias, as content in the early paintings is therefore emphasised. A Kruskal-Wallis 

ANOVA performed on the groups and the number of paintings each patient completed 

suggested a trend (_ 2 9.22, df=4, p=0.056). The number of paintings from each patient 

was collapsed into three ordered categories (1; 2, or 3; 4 or 5), and two-way ANOVAs 

(No. of paintings by diagnostic type) were performed on four significant variables. The 

variable scores did not vary with the number of paintings (F=0.02-0.52, df=2, N.S.), and 

there were no significant interaction effects (F=0.43-0.59, df=6, N.S.). 

Outliers: no extreme values were excluded in study 1 as this was an exploratory study 

and numbers were too small to determine whether these were important. 

Distribution of data: There was no need for transformation of data for the initial study 

as the Kolmogorov-Smirnov goodness of fit test revealed a normal distribution over the 

variable spread. Most of the raw data was rank-ordered or classificatory, but the final 

233

score for each subject was a ratio of the distribution of each variable over their output of 

paintings, fulfilling the conditions for parametric analysis. 

Comparison of groups: Statistical procedures are the same as those covered in the main 

study. Analysis of variance tests compared the variances for individuals within and 

between groups and tested the differences between the means of five diagnostic types 

over each of the 13 variables. However, Anova assumes the same variance between all 

groups and there may have been variance differences between groups not apparent 

because of the small samples, which would mask differences. The Multiple Range Test 

(Duncan procedure), which applies t-tests between each independent sample for each 

variable and which used the Bonferroni correction for multiple comparisons, highlighted 

the most different groups as before. This use of the Bonferroni is most suitable for 

groups with uncorrected variances. If differences of variances exist, it is likely that 

variances between groups are different as whole. 

Procedure 

Procedure for diagnoses: ICD-10 diagnoses were made in the same way as the main 

study, from case records by Dr. D. Foreman D.F. was blind to the originating ward and 

paintings while making the diagnoses. 

Table 2: Diagnosis: Assignment to type. 

ICD-10 DIAGNOSTIC CATEGORIES (1993) N Assigned 

to type 

Moderate Depressive Episodes: (1 X F31.6, F32.1, F32.10; 3 X F33.1). 6 1 

234

ICD-10 DIAGNOSTIC CATEGORIES (1993) N Assigned 

to type 

Schizophrenia/Psychosis: (1 X F10.73, F16.7, F19.5, F19.7, F20.0, F20.1, 

F25.0, F25.2; 2 X F20.5). 

10 2 

Organic Brain Injury: (1 X F06.3, F06.8, F10.6; 5 X F07.0). 8 3 

Substance Abuse: (1 X F10.4, F11.2, F12.2, F18.2, F19.3; 4 X F10.2) 9 4 

Moderate Recurrent Depression + Alcohol Dependency: (F33.1 + F10.2). 1 1 

Specific Personality Disorder: (F33.1 + F60.8). 2 1 

Huntingdons + Dementia: (G10 + F02.2). 2 3 

Organic Psycho Syndrome + Epilepsy: (F07.9 + G40). 1 3 

Diagnostic types: (1) Affective Disorder, (2) Non-Affective Psychosis, (3) Brain Injury, (4) Drug Abuse 

Table 2 shows category definition of case assignment to 4 types; Affective 

Disorder (n=9); Non-Affective Psychosis (n=10); Brain Injury (n=11); Drug Abuse 

(n=9). This includes six cases with multiple diagnoses whose assigned categories are also 

shown. Type assignment was made on the basis of the clinically presenting 

psychopathology on admission; e.g. a case presenting drug dependency and psychosis, 

not resulting from immediate drug toxicity was categorised as Non-Affective Psychosis. 

All the patients available for art in the identified wards were used. This meant that some 

patients had secondary diagnoses and may have overlapped groups. 

Painting Generation: The paintings were produced in art familiarisation groups, run 

as part of the recreational program of the hospital. All painting procedures were 

discussed with the region's art therapist to maximise the experiential and reducing 

similarity to psychotherapeutic sessions. 

The art groups took place at the same place and time each week in daylight hours, 

took one hour a week for 5-6 weeks, and contained up to 8 participants who were either 

patients or staff from the ward. I knew the patients from the non-patients but was 

unaware of diagnosis and therapeutically unacquainted with the group. I ensured that 

235

each participant received the same materials and instructions and maintained a neutral 

supportive atmosphere in collaboration with a member of the hospital's therapeutic team 

in each ward. The work was collected and rated by me at the end of the series. 

Participants painted in rooms where there were no pictures visible. They worked in 

groups of two and three, placed so that they could not see each others work without 

effort. Table tops rather than easels were used so that art could take place in the usual 

environment of the ward rather than in a special place which may have proved difficult 

for some participants. Two of the wards had not previously been offered art, but this 

approach limited disruption to ward routine. The other two groups had used this format 

before. 

Themes were set to hold the content constant and provoke personal involvement 

from the patients, because it is recognised that sometimes methods such as free painting 

can be demanding for people with functional impairments and they often produce no 

picture at all 283 . The thematic focus was self portraiture: previous research on draw-a- 

person studies has demonstrated that figure drawing works across a wide variety of 

abilities, and suggests some personal involvement with the work. Staff were instructed 

to be encouraging but not to make comments or suggestions. The same subject matter 

was specified in all groups for 5 sessions based around self portraiture: (1) Draw yourself 

(2) Draw yourself as you would look if you were an animal (3) A picture which shows 

you doing something you enjoy (4) A picture of your life with future and past (5) A 

picture which shows how you are feeling now. One person with cerebral injury used 5 

283 

J.B. Couch (1994), DDS Research with older people diagnosed with organic mental syndrome and 

disorders, Art Therapy , V.11(2):111-115. 

236

sessions for the self portrait because of his extreme slowness in manipulation, producing 

only 2 paintings in all. All the other participants were asked to finish their paintings 

within the hour. Most participants made one painting per session, although one or two 

individuals drew two or more for the first session. All groups had a mixture of art 

materials; wax crayon, tempera paint, pencil and thick and thin brushes so that the range 

of colours and line quality was available. Most of the paper provided was white 17" x 

12", but some 24" x 17" was also available. Materials were set on the table from the 

start. 

237

Results 

Interaction effects: The mean age of the staff was only slightly lower than that of the 

other groups but there was a clear predominance of males in the sample (see table 1). 

Only one variable, Space, was found to be influenced by Sex. Space was initially 

identified as a variable which distinguished between groups, but there was an interaction 

effect with Sex. When co-varied (2-way ANOVA F=0.89, df=4, P=0.47) neither variable 

turned out to be significant by itself. No other variable was influenced by sex. 

Paintings: Table 3 identifies differentiating variables in bold type, using the Duncan 

procedure; significant ANOVA results are indicated. 

Table 3: Multiple ranges: group means significantly different at 0.05% level. Dncan 

Procedure. 

Groups Affective 

Disorder 

n = 9 

Non-Affective 

Psychosis 

n = 10 

238 

Brain Injury 

n = 11 

Drug Abuse 

n = 9 

Controls 

n = 11 

VARIABLE mean SD mean SD mean SD mean SD mean SD 

Red 

Purple 

Green 

Blue 

Brown 

White 

Black 

Space 

Em tone 

Yellow + 

Orange + 

Intensity + 

Line + 

.24 .17 

.08 .11 

.34 .22 

.37 .25 

.20 .19 

.08 .11 

.60 .27 

7.71 1.79 

1.83 .22 

.14 .11 

.13* .14 

1.92 .53 

1.38 .50 

.42 .19 

.05 .11 

.28 .20 

.28 .19 

.16 .14 

.05 .09 

.45 .27 

5.81 2.65 

1.95 .26 

.18 .15 

.04* .07 

1.99 .40 

1.73 .28 

.22 .17 

.13 .23 

.23 .19 

.34 .26 

.13 .23 

.10 .13 

.40 .28 

5.84 2.85 

2.04 .13 

.12* .15 

.04* .06 

1.96 .46 

1.13* .70 

.25 .16 

.14 .18 

.27 .24 

.31 .17 

.33 .18 

.12 .09 

.44 .23 

7.42 1.92 

1.83 .20 

.29 .16 

.37 .13 

2.00 .48 

1.56 .37 

.42 .33 

.05 .11 

.32 .27 

.44 .16 

.14 .17 

.11 .21 

.50 .32 

7.90 1.74 

1.90 .39 

38* .33 

.07* .09 

2.50 .36 

1.99* .72 

df = 4. 

+ Variables identified by ANOVA as Significantly differentiating groups at the 5% level: yellow (p

orange. Brain Injury were the next most distinguishable type, and there was least 

difference between non-affective psychosis and affective disorders. 

Discussion 

Much of the first study was done on an exploratory basis and some procedures could 

have been better controlled. The group containing mostly patients with brain injury and 

also the affective disorder group made a small number of paintings on coloured paper, 

which may have influenced the choice of colours. However, this effect was minimised 

through averaging between paintings for each patient. The paintings were rated from the 

obvious 'right way up' and from the identification procedure which marks the back right 

hand corner of the work, but orientation of the paper to landscape/portrait might have 

had distortion effects on composition, thus influencing the space score, especially with 

the brain injury group. Better control would have been achieved by specifying particular 

orientation of the paper. 

Few dimensions from previous studies actually compared with the variables of 

this study. However, the meta-analysis of the literature, supported by the qualitative 

analysis, showed significant differences in ratings of form variables relating to patient 

status and between patient groups. The results of this study were consistent with these 

findings, although not with the conclusions and 'common knowledge' implied in the 

literature, especially for depressed patients: their use of black was similar to that of other 

patients, but they did use more orange than psychotics, normal controls and brain injured 

patients; their paintings did not seem more negative than those of other patients. There 

239

was no evidence of impoverishment for Depressed or Schizophrenic patients. Unlike 

previous literature 284 , space filled did not discriminate groups. However, the size of 

paper used was not standardised and varied between 17" x 12" and 24" x 17". This had 

the effect that the media became more widely distributed over the picture plane, thus 

variably reducing the score for space. Emotive tone did not produce a discriminable 

dimension, possibly because it was measured as a distribution over the picture plane. 

This would tend to even out positive and negative scores to neutral. 

The diagnoses were consistent with the ICD-10 (1993), but patients with 

multiple diagnoses were included. This may have blurred the distinction between groups 

and so produce conservative errors. Some non-significant results could easily be due to 

lack of power, owing to small group size. However, this does not explain the positive 

results. 

Conclusion and limitations of the study 

This study presented a reliable method of describing paintings for research in an 

appropriate systematic way suitable for analysis. The method is general enough to be 

used by investigators with different theoretical backgrounds and shows promise for 

future development. The sample size of this study was only sufficient to categorise 

differences in patients and controls as the clinically differentiated groups were very small 

and included mixed diagnoses. There were suggestions, however, that this measure may 

284 

A. Kirk & A. Kertesz (1989), Hemispheric contributions to drawing, Neuropsychologia, 

V.27(6):881-6; 

J.H. Wright & M.P. Macintyre (1982), The Family Drawing Depression Scale, J. Clin. Psychol. , 

V.38(4):853-61; M. Milkjkovitch & G.M. Irvine (1982), Comparison of drawing preferences of 

schizophrenics, other psychiatric patients and non-schizophrenic children on a draw-a-village task, Arts in 

Psychotherapy , V.9:203-16; and N.M. Knapp (1994), Research with diagnostic drawings for normal and 

Alzheimer's subjects, Art Therapy , V.11(2):131-8. 

240

detect formal differences in the painting of patients with different psychiatric diagnoses. 

The study also showed selection bias, which, although impossible to quantify, merits 

some consideration due to the nature of volunteer groups. 

241

Chapter 5. Results 

This chapter presents the results of the main analyses for study 2. There are 3 sections: 

1. Treatment of the data, which details the preliminary procedures to prepare the 

raw data for analysis; control of potential confounding variables, and 

transformation to normal distributions where appropriate; 

2. Results of the main analyses. 

3. Results of the subordinate analyses. 

Preparation of the data 

Transformation of the data: Tables and figures 1a-l, 2a-f and 3a-f can be found in 

Appendix 2. This set of statistics presents the raw data before and after transformation. 

Each variable is shown as: (i) Boxplots, for easy comparison between groups; (ii) Tables 

of means, for each group and whole population; (iii) Spreadlevel plot of the logarithmic 

co-ordinates for each group from which the Levene statistics are calculated. Other tables 

which summarise the information are presented in text. 

Variables which did not show a normal distribution 

There was marked heterogeneity of variance within groups for 9 untransformed variables; 

red, yellow, orange, purple, brown, white, painted line, drawn line and form. Tables and 

figures 1a-i (appendix 2) show the raw data for variables which were transformed or 

deleted. Levene test results and projected transformations of the data to achieve normal 

distributions are presented in table 4 below. 

242

Table 4, showing projected transformations for data based on computations designed to 

verify the assumptions of the ANOVA test. 

Tests of homogeneity of variance [df1=4; df2=104] 

Dependent 

variable 

Red 

Yellow 

Orange 

Purple 

Green 

Blue 

Brown 

White 

Black 

Intensity 

Paint-Line 

Drawn-Line 

Space 

Em-Tone 

Form 

Levene Statistic and 

significance level 

3.0023 (p=0.02) 

4.2948 (p=0.00) 

5.4983 (p=0.00) 

* 

1.9975 (p=0.10) 

1.2702 (p=0.29) 

3.1268 (p=0.02) 

* 

2.7400 (p=0.03) 

2.5948 (p=0.04) 

* 

2.9744 (p=0.02) 

1.6085 (p=0.18) 

2.4954 (p=0.05) 

6.0704 (p=0.00) 

Power for 

transformation 

.329 

.709 

.529 

* 

.789 

-.198 

.544 

* 

1.391 

0.502 

* 

1.241 

4.756 

1.622 

0.657 

243 

Action 

SQRT 

SQRT 

SQRT 

* 

LEAVE 

LEAVE 

SQRT 

* 

SQUARE 

SQROOT 

* 

SQUARE 

LEAVE 

SQUARE 

SQROOT 

* Median not positive so LN of Spread vs LN of Level is not plotted. 

Homogeneity of variance not tested. Insufficient unique spread/level pairs to compute the regression slope. 

Table 5, showing transformed data based on computations designed to verify the 

assumptions of the ANOVA test. 

Tests of homogeneity of variance [df1=4; df2=104] 

Dependent 

variable 

Red 

Yellow 

Orange 

Brown 

Black 

Intensity 

Drawn line 

Em tone 

Form 

Levene Statistic and 

significance level 

0.6942 (p=0.5976) 

1.8480 (p=0.1253) 

4.7938 (p=0.0014) 

1.2466 (p=0.2959) 

5.0957 (p=0.0009) 

2.8094 (p=0.0292) 

1.8426 (p=0.1263) 

2.4488 (p=0.0508) 

1.0938 (p=0.3636) 

Action 

RETAIN 

RETAIN 

+ 

RETAIN 

* 

+ 

RETAIN 

+ 

RETAIN 

* Squaring the data did not produce appreciable difference and the removal of outliers did not affect the 

distribution. Therefore no clear appropriate transformation of this figure emerged. 

+ Although there was some improvement on Orange, values remained highly significant so this variable 

was dropped. The other 2 variables, Emotional Tone only gained slightly and was only just significant 

in its original state so was judged better left within tolerance (0.05); Intensity became significant on 

transformation (p=0.04) so it was also left. 

Variables left untransformed 

Transformation achieved no better results for homogeneity in the population than the 

original statistics for 3 variables: black, intensity, emotional tone (tables/figs 2a-f,

appendix 2) and these were left in their original state along with those that showed 

homogeneity in the Levene tests: green, blue, space (table 4 below). 

Transformed variables 

6 variables were successfully transformed: red, yellow, brown, painted 285 and drawn line, 

form, (tables and figures 3a-f, appendix 2). Levene calculations for homogeneity 

appear in table 5 above. 

To summarise, twelve variables which remained in the final analysis, transformed 

or not (tables 2a-f and 3a-f). Two variables, Purple (see table/fig. 1d, appendix 2) and 

White (1h, appendix 2), were dropped at this stage for 2 reasons; (1) their values were 

not plottable because of insufficient use, and (2) homogeneity tests within the analysis 

of variance (Bartletts-Box, detailed later in this chapter, table 8) showed their range was 

unacceptable. Plots of their standardised differences (plots 7b and c,) showed 

concentration of cases below the mean. White was obviously irredeemable; the plot (7a, 

appendix 2) showed concentrations at 0 for all groups. Purple however (7b), looked more 

promising: although there were concentrations below the mean (at very low levels) for 

most groups, group 4 showed a wider scatter of differences. Cutting off all values of 

Purple above 0.28 (9 cases) did not redeem the median from negative but Bartletts-Box 

showed acceptable homogeneity (F = 1.751; p=0.136). However, all previous 

significance disappeared when the ANOVA was calculated (F = 1.81; p=0.132). These 

285 Painted line was retained because, although the square root transformation of Painted Line had a 

negative median, the calculation for the Bartletts Box test (table 8) placed the variance within acceptable 

levels. 

244

findings are unreliable because cases were mostly removed from one group: 6 cases from 

the control group, 2 from group 5 and one from group 3, so purple was dropped. 

There were 2 further variables, Orange and Black ((table/fig 2a and 2b, appendix 

2), which showed significant heterogeneity in the groups. Transformation of the data did 

not produce appreciable difference and the removal of outliers did not affect the 

distribution. Therefore no clear appropriate transformation of these figures emerged. 

The assumption that the groups came from populations with the same variance is 

important: the standard differences from the mean of each variable by group was plotted 

(Plots 6a-m and 7a-c, appendix 2). The plot for Orange (7a) clearly shows that diagnostic 

groups 1 and 4 have a much wider scatter of differences than the others and there are 

cases concentrated below the mean. The plot for Black (6f) shows only one group 

(controls) with wide variance and no concentrations of cases. The results of the 

Bartletts-Box Homogeneity of Variance Test 286 (table 8 below) showed the range was 

unacceptable for Orange and it was dropped from the analysis, but was within tolerance 

for the ANOVA for Black which was retained. 

Normality of the final distribution 

There were 12 remaining variables (tables/figures 2a-f and 3a-f, appendix 2 show mean 

values, standard deviations and standard error of the mean (how much the sample means 

vary in repeated samples from the same population)). Most of the standard errors were 

286 

Bartletts test is an extension of the F test for assessing the null hypothesis that more than two samples 

come from populations with the same variance, recommended with ANOVA: P. Armitage and G. Berry 

(1987), Statistical Methods in Medical Research , Oxford: Blackwell, p.209. 

245

fairly small, less than 0.1, indicating homogeneity within groups. There were no 

consistent outliers which could be easily eliminated and at this early stage it was not clear 

exactly what was important, so it would be unwise to change the data, and possibly the 

assumptions, merely to decrease the noise in the data. 

5 plots of group variances (plots 6a-m shown as the standard differences from 

each group's mean, Appendix 2) showed a wider scatter of differences for diagnostic 

group 4 (controls) generally, and five show a smaller scatter for group 2 (depressed). Six 

plots showed concentrations of group 1 (schizophrenics) cases below the mean, but 

generally the plots show a similar overall distribution for each of the five groups on every 

variable. A certain amount of deviation does not compromise the ANOVA test, even in 

unbalanced designs, providing group sizes result from chance fluctuation as fits the case 

here. 

The Main Analyses: comparison of Groups 

Table 9 identifies 10 variables as significantly different, using the results of an ANOVA 

performed among the 4 patient groups and the control group, pairwise comparisons are 

indicated using the modified LSD procedure, which compensates for multiple tests. F- 

values are shown in table 8. 

246

Table 8: showing results of analysis of variance for the purpose of identifying diagnostic 

grouping variables between 4 groups of psychiatric patients (total n=86) and 1 control 

group (n=23) on 13 formal measures of their paintings. 

DAPA 

Variable 

Blue 

Brown 

Orange 

Red 

Yellow 

Green 

Black 

Intensity 

Paint Line 

Drawn Line 

Space 

Em'Tone 

Form 

mean (S.D.) Confidence 

Interval 

.26 .20 

.30 .24 

.09 .12 

.45 .26 

.38 .25 

.25 .23 

.46 .28 

1.96 .48 

.31 .49 

1.03 1.05 

2.00 .48 

2.14 .36 

.39 .21 

0.22-0.30 

0.26-0.35 

0.07-0.11 

0.40-0.50 

0.34-0.43 

0.20-0.29 

0.41-0.51 

1.87-2.05 

0.42-0.60 

0.83-1.23 

1.91-2.09 

2.07-2.21 

0.35-0.43 

Bartlett-Box 

Homogeneity 

of variance 

(sig. level) 

1.62 (0.17) 

0.75 (0.56) 

6.42 (0.00) 

1.00 (0.41) 

0.95 (0.44) 

1.79 (0.13) 

2.24 (0.06) 

2.45 (0.05) 

2.37 (0.05) 

2.05 (0.09) 

0.96 (0.43) 

2.48 (0.04) 

1.25 (0.29) 

Table 9: Multiple Comparisons: Duncan Procedure 

GROUPS Affective 

Disorder 

n = 18 

Schizophrenia 

n = 35 

247 

Personality 

Disorder 

n = 9 

F. 

Ratio 

1.00 

1.64 

1.63 

4.33 

2.62 

4.25 

8.12 

3.41 

3.21 

3.86 

3.05 

5.34 

6.31 

F. 

Prob. 

.409 

.170 

.172 

.003 

.039 

.003 

.000 

.011 

.015 

.006 

.020 

.001 

.000 

Drug Abuse 

n = 24 

Controls 

n = 23 

VARIABLE mean SD mean SD mean SD mean SD mean SD 

blue 

brown 

Red☺ 

Yellow☺ 

Green☺ 

Black☺ 

Intensity☺ 

Linepaint☺ 

Linedraw☺ 

Space☺ 

Em tone☺ 

Form☺ 

.21 .16 

.29 .24 

.47 .25 

.45 .26 

.26 .25 

.50* .27 

2.04 .51 

.59* .47 

.84* .69 

2.07* .54 

2.14* .20 

.23_ .18 

.25 .18 

.24 .24 

.43 .26 

.30* .24 

.21* .22 

.30_ .21 

1.75_ .52 

.55 .52 

.93 1.16 

2.00 .47 

2.11* .29 

.37* .16 

.26 .15 

.34 .16 

.47 .26 

.40 .20 

.21* .16 

.43 .27 

2.09* .36 

.50 .55 

1.39 1.27 

2.22* .29 

2.16* .38 

.39* .19 

.24 .20 

.30 .21 

.30* .18 

.35 .20 

.16* .16 

.66* .18 

1.96 .29 

.22_ .29 

1.62_ 1.00 

2.13* .47 

1.94* .42 

.41* .19 

Analysis of Variance 

df = 4; ranges 2.81-3.12; harmonic mean cell size = 17.8327 

☺ Variables identified by ANOVA as significantly differentiating groups (p

Red, Green, Black, Drawn Line, Emotional Tone and Form all distinguished 

diagnostic categories at high levels of significance (p

Colour: Red, Yellow and Brown are distinguished by *T* (meaning transformed). The 

normal distribution was achieved by taking the square root transformation; the lower 

values were pushed from zero (no red) towards 1 (colour in every part of the picture). 

The greatest effect was to compress the latter half of the scale (half covered - fully 

covered), so that a score of 0.75 reveals that half the picture has the colour in it. The 

dotted line indicates a half way point on each plot. The plots are divided in two. The 

upper section shows those groups showing significant differences, with the differential 

single group in bold, and the whole group is marked '*'. Where there are two differences, 

there are two bold differentials; group* first, the second group is marked ''. 

10a. Confidence intervals and means by diagnostic type 

for variable RED *T* 

______________________________________ 

_ : _ 

*2_ •_|__• : _2 Substance abuse 

_ : _ 

T *4_ •___|___•: _4 Controls 

Y _ : _ 

P ______________________________________ 

E 1_ •__|__• : _1 Schizophrenia 

_ : _ 

3_ •____|___• : _3 Depression 

_ : _ 

5_ •______|_____• : _5 Personality disorder 

_ : _ 

______________________________________ 

0 .25 .5 .75 1 *(p

1. Neither schizophrenics nor depressives were distinguishable from other patient groups 

or controls. 

2. Substance abusers used hardly any red, were the lowest scoring patient group, and 

scored significantly lower than controls. 

3. Diagnostic differences were not distinguishable between patient groups; personality 

disorder spanned all groups. 

4. As expected, the mean of the controls was higher than all patient groups (although not 

significantly different from any except substance abusers). 

There was no evidence for red as a predictor of schizophrenic or depressive diagnosis. 

10b. Confidence intervals and means by diagnostic type 

for variable YELLOW *T* 

______________________________________ 

_ : _ 

*1_ •__|__• : _1 Schizophrenia 

_ : _ 

T *4_ •___|___• : _4 Controls 

Y ______________________________________ 

P 2_ •__|_• : _2 Substance abuse 

E _ : _ 

3_ •___|___• : _3 Depression 

_ : _ 

5_ •____|____• : _5 Personality disorder 

_ : _ 

______________________________________ 

0 .25 .5 .75 1 *(p

1. Schizophrenics but not depressives used very little yellow and significantly less than 

controls. 

2. Diagnostic differences were not distinguishable between patient groups. 

3. Against expectations, depressives covered the same range as the controls, so therefore 

there was no indication of low quantities of yellow as a predictor of depressive diagnosis. 

10c. Confidence intervals and means by diagnostic type 

for variable GREEN 

______________________________________ 

*4_ •__|___: _4 Controls 

_ : _ 

*1_ •_|__• : _1 Schizophrenia 

T _ : _ 

Y *2_ •_|_• : _2 Substance abuse 

P _ : _ 

E *5_ •___|___• : _5 Personality disorder 

_ : _ 

______________________________________ 

_ : _ 

3_ •___|___• : _3 Depression 

______________________________________ 

0 .25 .5 .75 1 *(p

schizophrenia was indistinguishable from other patient results. The lowest mean was for 

substance abusers. Patient status could be inferred from less green but not depression. 

10d. Confidence intervals and means by diagnostic type 

for variable BLUE 

______________________________________ 

1_ •_|_• : _1 Schizophrenia 

_ : _ 

T 2_ •__|__• : _2 Substance abuse 

Y _ : _ 

P 3_ •_|__• : _3 Depression 

E _ : _ 

4_ •___|___• : _4 Controls 

_ : _ 

5_ •___|___• : _5 Personality disorder 

_ : _ 

______________________________________ 

0 .25 .5 .75 1 *(p

*T* Brown: is a dark, sombre and neutral colour, commonly understood as a dead colour, 

associated with waste and particularly excretion. More use of brown in pictures by 

depressives and schizophrenics than other patient groups could be expected, and more 

from patients than controls. 

1. There were no significant differences within patient groups or between patients and 

controls. 

2. Against expectations, the control group mean was the highest (although not 

significantly higher) than patient groups. There was no evidence to support indications 

of schizophrenia, depression or patient status from use of brown. All groups used 

equally low quantities. 

10f. Confidence intervals and means by diagnostic type 

for variable BLACK 

______________________________________ 

*1_ •_|_• : _1 Schizophrenia 

_ : _ 

*2_ : •__|__• _2 Substance abuse 

T _ : _ 

Y *3_ •____|___• _3 Depression 

P _ : _ 

E *4_ •____|:___• _4 Controls 

_ : _ 

5_ •______|______• _5 Personality disorder 

_ : _ 

______________________________________ 

0 .25 .5 .75 1 *(p

Black: Black is the darkest colour and has a common association with death and 

emptiness. Depressives were expected to use most, schizophrenics next, other patients 

could be expected to use less black and controls least. 

1. Depressives were not differentiated from controls on use of black. 

2. Schizophrenics used least black, significantly less than depressives and controls. 

3. Depressives, schizophrenics and controls used significantly less black than substance 

abusers. These results indicate support indicators of schizophrenia for small quantities 

of black, which is against expectations. The highest score was from substance abusers, 

who spread black consistently throughout more than half of the picture surface and were 

differentiated from all other groups. Controls and depressives were not differentiable 

from non-schizophrenic other patients on high or low use of black. 

254

10g. Confidence intervals and means by diagnostic type 

for variable INTENSITY OF COLOUR 

________________________________________ 

*1_ •__| • _1 Schizophrenia 

_ : _ 

*4_ : •__| • _4 Controls 

_ : _ 

*5_ : •___|__• _5 Personality disorder 

T _ : _ 

Y ________________________________________ 

P 2_ : •|• _2 Substance abuse 

E _ : _ 

3_ : •__|__• _3 Depression 

_ : _ 

________________________________________ 

0 1 2 3 *(p

the other groups since no confidence interval takes in 1(low) or 3(high). 

Structural variables 

Line: was understood as a defining border: outlines, lines used in pattern, dots, writing, 

broken line, straight ruled lines, and not blocks of colour intended for shading or close 

patterned pencil lines for shading which were treated as blocks. It was rated light/thin, 

varied (where thin lines appeared with thick), thick/heavy. 

Line quality was split into painted and drawn lines for ease of rating, since where 

pencil line coincided with painted line, the relative difference in thickness always 

polarised the pencil to thin and the painted to thick, thus creating ambiguities in the 

information. The scoring task asked for relative thickness of the lines within the picture. 

The literature tends towards expectations of thick or heavy lines for patients. 

Controls were expected to have more range, and substance abusers, speculatively, might 

suffer difficulties in control similar to people with brain injury, which are said to produce 

thin or shaky lines. 

10h. Confidence intervals and means by diagnostic type 

for variable PAINTED LINES 

_______________________________________ 

_ : : _ 

*2_ •__|_• :t :v t_2 Substance abuse 

_ :h :a h_ 

T *3_ •____|___• :i :r i_3 Depression 

Y _ :n :i c_ 

P *4_ •____|___• : :e k_4 Control 

E _ : :d _ 

_______________________________________ 

1_ •___|___• : : _1 Schizophrenic 

_ : : _ 

5_ •________|________•: : _5 Personality Disorder 

_______________________________________ 

.25 .75 1.25 1.75 *(p

Painted lines: The normal distribution was achieved by taking the square root 

transformation, the effect of this is to push the lower values, below one, up from zero 

towards 1, and compress 1-3, so the maximum score becomes 1.73 (thick lines covering 

the paper). 

1. No group's paintings were characterised by thick painted lines. 

2. Controls were not separable from other patient groups other than substance abusers. 

3. In line with expectations, substance abusers scored less than all other groups, but 

scores indicate lack of use of line rather than thin lines; they were not separable from 

schizophrenics. There was no evidence to support the diagnosis of depression, 

schizophrenia, patient status or control status from thick or thin painted lines. Scores 

indicate lack of use rather than proliferation of thin lines. 

10i. Confidence intervals and means by diagnostic type 

for variable DRAWN LINES 

_______________________________________ 

_ : : _ 

*2_ •|• : _2 Substance abuse 

_ :t :v t _ 

*4_ •| • :h :a h _4 Control 

T _ :i :r i _ 

Y *3_ •| • :n :i c _3 Depression 

P _ : :e k _ 

E 5_ •___|__• :d _5 Personality Disorder 

_______________________________________ 

1_ • |• : : _1 Schizophrenic 

_ : : _ 

_______________________________________ 

0 2 4 6 8 *(p

Drawn line: The normal distribution was achieved by squaring the results, so as to push 

lower values which bunch just below one (thin lines), down the scale towards 0, and to 

expand the range from varied lines (4) to thick, the maximum score (9: thick lines covering 

the picture). 

1. No group's paintings were characterised by thick drawn lines. 

2. Substance abusers used significantly more lines than controls and depressives. 

3. Controls used less drawn lines than any group. 

4. Schizophrenics were not differentiable from controls, or from substance abusers, they 

either used thin or no lines, but their range, in line with expectations was similar to that 

of depressives. 

There was no evidence to support the diagnosis of depression, schizophrenia or patient 

status from thick drawn lines, which were rarely used even by controls. Patients with 

personality disorder showed the greatest variability in use of drawn line but were still 

predominantly in the thin range, however this result is probably compromised by small 

numbers. The division of drawn/painted line is supported because the groups changed 

relative positions, particularly controls and schizophrenics which reversed their 

orientation. 

10j. Confidence intervals and means by diagnostic type 

for variable SPACE 

______________________________________ 

*4_ •|• _4 Controls 

_ _ 

T *2_ •| • _2 Substance abuse 

Y _ _ 

P *3_ • | • _3 Depression 

E _ _ 

*5_ •|• _5 Personality disorder 

258

______________________________________ 

1_ •|• _1 Schizophrenia 

_ _ 

______________________________________ 

0 1 2 3 4 5 *(p

proportions of empty space in the picture. Patient status may be indicated from 

consistent empty space in the picture, but not depression. 

10k. Confidence intervals and means by diagnostic type 

for variable SUBJECTIVE EMOTIONAL TONE 

_______________________________________ 

*4_ • | • _4 Controls 

_ _ 

*1_ •|• _1 Schizophrenia 

_ _ 

*2_ • | • _2 Substance abuse 

T _ _ 

Y *3_ •|• _3 Depression 

P _ _ 

E *5_ •__|___• _5 Personality disorder 

_ _ 

_______________________________________ 

0 1 2 3 *(p

2. Schizophrenics and depressives were not differentiable from other patients. 

3. The lowest scores by patients (although not significantly lower) were from the 

pictures of substance abusers. 

There was no inclination towards negative for patient status but controls did score 

positively relative to patients. There was no support for the diagnosis of schizophrenia 

or depression from high levels of negative emotional tone. 

10l. Confidence intervals and means by diagnostic type 

for variable DOMINANT FORM 

______________________________________ 

*3_ •__|__• : _3 Depression 

_ : _ 

T *4_ •___|__• : _4 Controls 

Y _ : _ 

P *1_ •| • : _1 Schizophrenia 

E _ : _ 

*2_ •__| • : _2 Substance abuse 

_ : _ 

*5_ •____|____• : _5 Personality disorder 

_ : _ 

______________________________________ 

0 .25 .5 .75 1 *(p

1. Depressives showed significantly less dominant form in their pictures than any other 

group. 

2. As expected, the pictures of controls showed the most dominant form (significantly 

more than depressives, schizophrenics and personality disorder). 

3. Substance abusers' pictures were not significantly lower than controls (but they were 

significantly higher than depressed). 

4. Against expectations, schizophrenics showed significantly more dominant form in 

their pictures than depressives. 

There was no evidence to support the diagnosis of schizophrenia rather than any other 

patient group from lack of form, but depression may be indicated by such. Controls did 

score more than any patient group, but this may not be an indicator of health as such, 

because substance abusers overlap these scores. 

Summary of results by characteristics of typical pictures from all other groups: 

Schizophrenia: pictures showing very little black, of low intensity with some 

dominant form. 

Substance abuse: high levels of black, low green, drawn lines not painted, some 

dominant form. 

Depression: moderate levels of black (less than half the picture, but more than a 

quarter), no dominant form. 

Personality disorder: less than half the picture black, low green, higher intensity, 

some dominant form. 

262

Controls: more positive emotional tone, and half or more of the picture contains 

the dominant form. 

Additional characteristics of controls: more red, yellow and green than other 

paintings, more intense colours, painted rather than drawn line and less empty 

space. 

Predictive value of the DAPA for patient status 

In order to find a combination of variables that classified a large proportion of subjects 

into the correct group so as to have good chance of allocating (diagnosing) new subjects 

correctly, the Discriminant Analysis technique was used to determine predictive value 

of the DAPA. A preliminary attempt between patient groups used the whole sample of 

109 and yielded the percentage of grouped cases correctly classified as 81%. However, 

some caution was warranted in interpreting this figure because the classification functions 

were derived from the group of study; most authorities recommend reserving an 

independent data set on which to assess the fitness of the model 288 . 

A much sounder approach, at this stage was to divide the whole sample into two 

samples patients and non-patients and derive the classification functions using one of the 

samples and then, using these functions, to attempt to classify those subjects in the 

second sample as either controls or patients. Table 11 presents the results of the 

classification for the section which derives the functions and for the reserved section 

(which acts as the independent data set) repeated with five different partitions. The 

288 

D.G. Altman (1994), Practical Statistics for Medical Research , London, 5th Ed. original 1991: 

Chapman Hall, p.359. 

263

function contributed significantly to classifying the cases because the groups differed 

significantly. The Wilks lambda was typically around 0.4 which indicates around 60% 

discriminative power, which is not particularly high, but moderate. The derived Chi 

Square statistics were typically 34, which was highly significant (p=0.000). This model 

therefore had moderate discriminative power. 

No variables were correlated with the discriminant function higher than 0.6 and 

more typically 0.3-0.5, so there is no simple interpretation from one or two influencing 

factors, more a complex interaction of the contribution of different variables. 

The final part of the analysis was the classification of cases according to the 

derived function. SPSS predicts which group a subject belongs to by calculating which 

of the mean values of the discriminant function it is closest to. This classification 

appeared to be highly successful on the data set from which it derived the function, and 

overall was 86-97% correct. Using the derived function on an independent data set (half 

the sample) it proved 75-95% correct classification, which is reasonable considering the 

numbers. 

The next chapter will discuss the implications of these results, their relation to 

what is already known and augment them with exploratory and confirmatory subordinate 

analyses. 

264

TABLE 11: Discriminant analysis to classify controls or patients. Classification 

functions from the first sample are used to classify the second sample. Repeated 5 times 

with different partitions of the data set. 86 PATIENTS 23 CONTROLS. 

Actual 

Group 

ill 

well 

ill 

well 

ill 

well 

ill 

well 

ill 

well 

Cases selected for use in the analysis Cases not selected for use in the analysis 

No. of 

Cases 

42 

10 

40 

18 

44 

13 

38 

9 

42 

10 

Predicted Group Membership 

ill well 

40 2 

95% 5% 

2 8 

20% 80% 

correctly classified: 92% 

48 0 

100% 0% 

7 11 

39% 61% 


43 1 

98% 2% 

5 8 

38% 62% 


38 0 

100.0% 0% 

1 8 

11% 89% 


40 2 

95% 5% 

5 5 

50% 50% 


Comparison of effect with the previous literature 

265 

No. of 

Cases 

44 

13 

38 

5 

42 

10 

48 

14 

44 

13 

Predicted Group Membership 

ill well 

43 1 

98% 2% 

3 10 

23% 77% 


37 1 

97% 3% 

1 4 

20 80% 


39 3 

93% 7% 

5 5 

50% 50% 


39 9 

81% 19% 

6 8 

43% 57% 


41 3 

93% 7% 

5 8 

38% 62% 


The results of the t-test indicate that 6 variables: 4 structural and 2 colour, discriminate 

patients from controls at a highly significant level (p

the discriminant analysis. It will be noted that 2 variables have a negative t-value, which 

indicates the direction of the results (using a 1-tailed test, the differences lie on the other 

tail, therefore the tabled p-value was halved). 

Table 12: t-test results for significant differences between means of variables measured from 

paintings/pictures by patients against those of non patients as though they were independent. 

variable from 

DAPA 

Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Painted line 

Drawn line 

Space 

Em Tone 

Form 

Patients 

n=86 

mean SD 

0.4064 0.243 

0.3567 0.233 

0.2063 0.204 

0.2413 0.178 

0.2761 0.223 

0.4542 0.264 

1.9036 0.462 

0.4618 0.476 

1.1494 1.077 

2.0721 0.466 

2.0735 0.332 

0.3567 0.185 

non-patients 

n=23 

mean SD 

0.5945 0.262 

0.4895 0.286 

0.4018 0.267 

0.3307 0.259 

0.3944 0.270 

0.4767 0.320 

2.1725 0.508 

0.6929 0.528 

0.5667 0.787 

1.7304 0.430 

2.3846 0.363 

0.5332 0.246 

266 

F 2 

Value tail 

df=107 prob 

1.16 0.606 

1.51 0.185 

1.72 0.083 

2.13* 0.015 

1.46 0.219 

1.47 0.217 

1.21 0.526 

1.23 0.496 

1.87 0.096 

1.17 0.695 

1.20 0.543 

1.78 0.065 

Tvalue 

3.25 

2.31 

3.81 

1.56 

2.16 

0.35 

2.42 

2.02 

-2.42 

-3.17 

3.92 

3.77 

Sig.ce 

level 

0.002 

0.023 

0.000 

0.131* 

0.033 

0.729 

0.017 

0.046 

0.008+ 

0.001+ 

0.000 

0.000 

*Significant level of p from F-test, indicating non-homogeneous groups, therefore this variable used the separate variance T-test 

(df=27.8) rather than the pooled variance. 

+direction of sign indicates direction of results so the significance level is 2-tailed. 

Table 13a: the separate effect size for each variable from the DAPA test, based on the calculation of D = 

SQRT * 1/n1 + 1/n2 * t-value (patients/nonpatients). 

Variable D (Effect 

size) 

Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Paint 

Em-tone 

Form 

0.7629 

0.5423 

0.8944 

0.3662 

0.5071 

0.0822 

0.5681 

0.4742 

0.9202 

0.8850 

V Lower/Upper 

confidence limits 

.0578 

.0565 

.0588 

.0557 

.0563 

.0551 

.0566 

.0561 

.0590 

.0587 

0.5226 - 1.0033 

0.3047 - 0.7799 

0.6519 - 1.1368 

0.1302 - 0.6023 

0.2698 - 0.7443 

-0.1527 - 0.3170 

0.3302 - 0.8060 

0.2373 - 0.7111 

0.6773 - 1.1631 

0.6427 - 1.1273 

weight 

W=1/V 

17.3082 

17.7132 

17.0139 

17.9464 

17.7666 

18.1366 

17.6720 

17.8134 

16.9519 

17.0361 

W*ES = WD 

13.2059 

9.6053 

15.2170 

6.5721 

9.0086 

1.4901 

10.0383 

8.4469 

15.5993 

15.0769 

TOTAL 0.595 175.36 104.26 

sigma =0.08 Conf. interval (0.4465 - 0.7426) homogeneity stat 11.4075 (p>0.5 Chi-sq 8.34 df=9) 

Positive T-Values 

best estimation of sum(wd) = 104.26 = 0.595 

effect size sum(w) 175.36

Table 13b: the separate effect size for each variable from the DAPA test, based on the 

calculation of D = SQRT * 1/n1 + 1/n2 * t-value (patients/nonpatients). 

Variable Effect size 

D V 

Draw 

Space 

-0.5681 

-0.7441 

.0566 

.0576 

Lower/Upper 

confidence limits 

-0.8060 - -0.3302 

-0.9842 - -0.5041 

267 

weight 

W=1/V 

17.6720 

17.3472 

W*ES 

= WD 

-10.039 

-12.909 

TOTAL -0.656 35.02 -22.95 

sigma = 0.17; Conf. interval (-0.9865 - -0.3241); Homogeneity stat. 0.2714 (p

Subordinate Analyses 

Interaction effects 

Sex: The demographics showed more females than males, especially in the control group. 

Two variables, Emotional Tone and Yellow were found to be influenced by Sex. When 

co-varied (2 way ANOVA; yellow - F=0.10, df=4, P=0.98; emotional tone - F=1.14, 

df=4, P=0.34), this was found to be a function of the combination of the main elements, 

and neither variable was significant by itself. 

Painting Combination: Not all the subjects completed all the paintings. This could 

produce bias, as content in the early paintings is therefore emphasised. A preliminary 

Kruskal-Wallis ANOVA performed on the groups and the number of paintings each 

patient completed seemed to indicate a covariate influence (_ 2 17.30, df=4, p=0.0017) 

from the raw (i.e. untransformed scores). The number of paintings from each patient was 

collapsed into three ordered categories (1 or 2 paintings; 3-5 paintings or 6+), and two- 

way ANOVAs (No. of paintings by diagnostic type) were performed on the final scores 

for each variable to determine interaction effects for the number of paintings on the score 

for any variable remaining in the analysis. 

Table 14 shows that interaction effects were not significant and variance was 

mostly explained by differences in diagnostic grouping. Additionally, table 15 shows that 

only one variable from 13 was correlated with the number of paintings done (p=0.01, for 

the Substance abuse group). We can safely ignore one significant score from 65 on the 

268

asis that multiple tests produce the odd significant figure. Therefore the number of 

paintings done did not affect the average score. 

Table 14: Results of 2 way ANOVA - diagnostic groups by No. of paintings from each 

patient to show the influence of number of pictures on differences between groups was 

insignificant. 

Variable Source of Variation 

(Diagnostic Type) 

df=4 

F value and sig.(p) 

Red 

Yellow 

Orange 

Green 

Blue 

Brown 

Black 

Intensity 

Line-Draw 

Area 

Em-Tone 

Form 

4.913 (p=.001) 

2.521 (p=.046) 

.986 (p=.419) 

3.897 (p=.005) 

1.897 (p=.469) 

2.604 (p=.040) 

9.469 (p=.000) 

4.765 (p=.001) 

3.757 (p=.007) 

2.731 (p=.033) 

5.052 (p=.001) 

7.128 (p=.000) 

Covariate 

(No. of Pictures) 

df=1 

F value and sig. (p) 

0.131 (p=.718) 

3.473 (p=.493) 

0.369 (p=.545) 

0.272 (p=.262) 

0.404 (p=.527) 

1.547 (p=.216) 

2.507 (p=.116) 

1.364 (p=.246) 

0.291 (p=.591) 

1.275 (p=.262) 

1.339 (p=.250) 

0.352 (p=.554) 

269 

Explained 

df=5 

F. Value and sig.(p) 

0.957 (p=.003) 

2.112 (p=.070) 

0.862 (p=.509) 

3.372 (p=.007) 

0.798 (p=.554) 

2.392 (p=.043) 

8.077 (p=.000) 

4.085 (p=.002) 

3.064 (p=.013) 

2.439 (p=.039) 

4.309 (p=.001) 

5.773 (p=.000)

Table 15: showing correlations between No. of pictures within each group with each 

variable. 

Variables Schizophrenia 

Red 

Yellow 

Orange 

Green 

Blue 

Brown 

Black 

Intensity 

Line-Draw 

Area 

Em-Tone 

Form 

n=35 

.0535 

.1611 

.0789 

.0282 

.1560 

.1376 

.3339 

.3276 

.1493 

.2396 

.1938 

.2216 

Substance 

Abuse 

n=24 

.3558 

-.1658 

.1916 

.1450 

-.1978 

.2329 

.1735 

.0852 

.0451 

-.3166 

-.2097 

.3340 

270 

Affective 

Disorder 

n=18 

.4304 

-.1925 

-.0063 

.1010 

.5046 

.5935* 

-.0318 

.0870 

-.1239 

.0188 

.2522 

.4596 

Descriptive analysis: associations between variables 

Controls 

n=23 

.2143 

.2584 

.3820 

.0561 

-.1138 

.3874 

.3458 

.2964 

.0302 

-.0313 

.1694 

-.1506 

Personality 

Disorder 

n=9 

-.3182 

-.2029 

-.3976 

-.6751 

-.5477 

-.6028 

.3055 

.2777 

-.5823 

.2632 

-.4022 

.1234 

Correlations within groups: Bi-variate scatter plots for the significant variables showed 

a reasonably elliptical pattern indicating a normal distribution of the data so the validity 

of the associated hypotheses tests were not violated. The non-significant scatter plots 

were checked for unusual patterns, which the Pearson's r is likely to underestimate. The 

purpose of this analysis was to describe the association of the variables from the DAPA 

test to provide information for the discussion of differences in the results of the DAPA 

test to those of the literature and general expectations. Correlation tables for each 

diagnostic group 16-20 measuring (a) colour and (b) structure can be found at the end of 

appendix 2. Summary information is presented here. 

There were most associations between variables for schizophrenics' paintings, especially 

for colour: 

1. All colours were correlated with intensity except black and brown. 

2. Green was correlated with all colours except black.

3. Painted line correlated with red and green. 

4. Yellow with brown and blue. 

Intensity showed a relationship to bright colour and green appeared most consistently, 

whereas only black was independent. The structural variables were mostly independent. 

There were least associations between variables for paintings by substance abusers: 

1. Only green and brown were correlated from colours. 

2. Blue showed a strong negative relationship with form. 

3. There were no associations of colour with intensity. 

There were associations between variables for paintings by depressed patients: 

1. Green showed a moderate correlation with black. 

2. Green and yellow were moderately correlated with intensity. 

3. Painted line negatively correlated with drawn line. 

There were associations between variables for the paintings of controls: 

1. Red and yellow were moderately correlated. 

2. Intensity showed a correlation with red. 

There were associations between variables for the paintings by patients with personality 

disorder: 

1. There were no correlations between colours. 

271

2. Intensity showed a correlation only with red. 

3. Drawn line was negatively correlated with painted line. 

272

Chapter 6: Discussion 

The question Is there sensitive psychopathological evidence presented in the artwork of 

mental illness? has been answered. The bare results tell us that pictures by people with 

psychiatric disorder contain some characteristic structural and content differences from 

those of normal controls and furthermore, some of these characteristic differences are 

specific to certain psychiatric disorders. The DAPA test has proved effective in that it 

has been sensitive enough to detect differences relating to diagnostic grouping. But this 

question has been answered before, and also proved positive if weak 291 . 

Generally the DAPA test results agree with the other major contemporary 

studies in the field, which is to say that they agree with the general direction of 

assumptions of the literature. However, a close look at the areas of differentiation, each 

of which are discussed below, gives very different discrimination factors. Therefore 

another question presents itself How closely do the answers from the DAPA test resemble 

what is generally 'known' from the rest of the field and if they do not what reasons have 

we to think that the interpretation of the DAPA test answers are more valid than this 

accumulated experience?. The answer to some of this question must be sought in what 

is reported in Chapter 2. The DAPA uses formal measurements of structure whereas the 

other tests were predominantly biased to content, in line with the clinical use of such 

measures in the assessment of art therapy. The other tests are remarkably variable in the 

291 

See B. Cohen, J.S. Hammer and S. Singer (1988), The Diagnostic Drawing Series: a systematic 

approach to art therapy evaluation and research, Arts in Psychotherapy , V.15(1):11-21, and my discussion 

of their results, Chapter 2. 

273

quality and reliability of their measurement, in the definition of their criteria, and their 

results are often uninterpretable because of flawed methodology. 

The DAPA, however, cannot simply claim a higher status if the test establishes 

only the same general results but leaves questions relating to differences with what is 

generally accepted from the accumulated experience of clinical professionals and other 

major statistical studies open. The answer must be accompanied by the answer to these 

subsidiary questions, one of which must be Why should we use the DAPA rather than 

other tests? 

If the DAPA results show a great divergence from established opinion, that 

difference needs to be explained. The discussion explains the results from the DAPA and 

their relation to the literature in 4 parts: 

1. The discussion of the results tries to relate the findings of group differences 

identified by the ANOVA and the complementary corrected t-tests (Duncan 

procedure) to what are generally accepted as psychiatric characteristics from the 

literature. It explains differences and correspondences with that literature and 

speculates on how these elements are interpreted. Interrelations between the 

DAPA variables, identified by the subordinate analyses from the Results section, 

are discussed to determine associations which might affect the results and 

possibly explain some of the deviations from established knowledge; 

2. The findings of Study 1 (Chapter 4) are related to those of Study 2, exploring and 

explaining the differences to find common correspondences; 

274

3. The comparison of effect sizes with those of the literature review, from the 

Results section, is discussed; and 

4. The predictive value and derivations of the functions from the discriminant 

analysis. 

1. Comparison of the results with the predictions 

Note on comparison with the literature: Generally, the style and format of the 

literature reviewed in Chapter 2 of this thesis used content appraisal with selective 

illustration of typical examples. Few studies measured any formal qualities, and these 

were usually interpreted through a theoretical framework. Embedded in content appraisal 

were assumptions that stylistic or formal features of the paintings of the patients were 

reflective of mental disorder. These associations were not overt, and often described as 

global or 'intuitive' assessment, and combining personal and objective dimensions. Often, 

pictures were reproduced instead of explanations as 'obvious' examples of thought 

disorder, or as illustration of the process of recovery, in which their descriptions were not 

explicit (Where explanations occurred, they depended on the interaction of two or more 

formal elements out of context 292 ). Colour associations were rarely mentioned unless 

important to the general message, were usually supported by the reported comments of 

the patient about the work and differed considerably between studies. Furthermore most 

authors advise that colour associations with content are individual. Therefore comparison 

of the DAPA results with characteristics of underlying assumptions of the field, as well 

292 Such as 'inappropriate colour', i.e. green faces, or structural anomalies, i.e. falling apart trees. 

275

as being unreliable, would be methodologically difficult to justify. References to 

interpretations of elements in single studies as typical examples would take comments 

out of context and intention. Most 'tests' relate to protocols for art therapy practice, for 

which the DAPA is not designed. The DDS approach to assessment cannot be compared 

because they have produced no interpretable results so far, although their protocol is 

widely used for art therapy assessment, the assessment process remains with the 

experience and interpretations of the art therapist, not the 'test'. Therefore I have 

concentrated on the theoretical influences of assumptions and 'intuitions' of all these 

approaches in my comments on comparison of the DAPA scores with the literature or 

to studies which use explicit descriptions or statistical evidence, using two of the most 

influential and well known authors to disseminate research results on distinguishing 

features of art to contemporary general and research literature, Wadeson and Amos 293 . 

Both present easily digestible tabulations of common structural and content 

characterisations and are regularly cited in recent literature. 

Organisation of this discussion 

The purpose of this discussion is to explore and discuss possible explanations for 

differences in the results of the DAPA test to what has previously been found. The 

secondary purpose, in further development of the test, was to determine any reduction 

of the scales to increase efficiency if some of the scales measured the same quantities. 

293 

H. Wadeson (1980) Art Psychotherapy, 

New York: Wiley; (1987), The Dynamics of Art Psychotherapy , 

New York: Wiley; (1992) (ed.) A Guide to Conducting Art Therapy Research , Mundelein, ILL: Am. Art 

Therapy Assn; and Stephen Amos, The Diagnostic, Prognostic, and Therapeutic Implications of 

Schizophrenic Art, Arts in Psychotherapy 1982, V.9:131-43. 

276

The scales are explained in two sections; (a) colour and (b) structure. Section (a) includes 

colour intensity because it adds to the conclusions for colour rather than for structure. 

Summary Table of Results: Table 1 

Red controls> substance abuse 

Yellow controls> schizophrenics 

Green controls> all patients except depressives 

Black substance abusers> depressed/controls /pers'y disorder> schizophrenics 

Intensity controls/ personality disorder> schizophrenics 

Painted Line depressives /control>substance abuse 

Drawn Line substance abusers> control or depressives; personality disorders> control 

Empty Space control schizophrenics /personality disorder> depressed 

Em. Tone control> all patients 

The information generated by the DAPA naturally divides between two obvious 

points: controls used more and brighter colours (except black), more line, form, space, 

were more positive than other groups; and schizophrenics or substance abusers scored 

least. Information from the correlation matrices between each group help to confirm, 

explain or elaborate on earlier points from other data. To limit 'data dredging', the most 

obvious hypotheses tests were the predictions from the discussion of the literature. The 

expected associations were: 

Between bright colours and between dark colours reflecting their use together and 

a negative correlation between bright and dark colours generally reflecting the 

opposing emotional tone of the picture. 

Bright hues would generally correlate with intensity. 

277

There would be a correlation between all or most of: emotional tone, hue, 

intensity and form reflecting increased aesthetic harmony with greater structure 

and positivity of the picture. 

Between blue and brown reflecting their neutral status. 

Painted line would negatively correlate with drawn line because patients used little 

painted and more drawn line. 

Differences between groups - Colour 

The focus is on the most important findings: Black differentiated substance abusers from 

all other groups and schizophrenia from 3 other groups; green differentiated controls from 

3 other diagnostic groups. Additionally, there were differences in colour associations 

between diagnostic groups; Figure 3 summarises these relations. Art therapy research 

has provided support for the assumption of a consistent relationship between colour and 

emotion 294 , so the work of people with psychiatric disorders, which are often 

characterised by mood disorder should differ from normal controls. It has been suggested 

that colour usage is related to the adequacy of individual resources for integrating affective 

experience 295 , a facility rarely developed in schizophrenics, so within group differences 

should be expected. Presented here is a summary (table 2) by Amos, of the work of 

Tarmo Pasto, 1968 296 , empirically developed from experience with the use of art in 

294 

Bernard I. Levy (1984), Research into the psychological meaning of colour, Am. J. Art Therapy , V.23, 

(reprinted from V.19, July 1980, pp.87-91). 

295 

D. Rapaport, M. Gill and R. Schafer (1946), Diagnostic Psychological Testing , Chicago: Year Book 

Publishers. 

296 

Tarmo Pasto (1968), The bio-mythology of colour: a theory, in I. Jakob, ed., Psychiatry and art: Art 

278

diagnosis and therapy with psychiatric groups, which probably represents the common 

knowledge of the field. Amos gives the qualification that hypotheses are of little 

consequence without corroboration from other factors so there is very little emphasis on 

this speculation where differences are not obvious. 

Table 2: Interpretations of the use of colour in artistic productions: from S.P. Amos. 

Colour Interpretation 

Red 

Yellow 

Orange 

Blue 

Green 

Violetred 

Purple 

Black 

White 

Self, ego development, active relation to reality, physicalemotional 

balance. 

Inner emotionalism, frustration, threat to ego, identity with violent 

inner forces. 

Aggressive resistance to dependency. 

Aloofness, lack of emotionality, spirituality, overtly controlled, 

emotional blocking. 

Suffering, resisting emotion, positive, dogmatic, insecure. 

The psycho-sexual self, lack of proper sexual identification, 

troubled by sexual drives, emotionalism tied to sexual 

frustrations. 

Passivity, uninvolved, tendency to depression, may represent 

paranoid tendencies. 

Absence of extrinsic emotion, hostility, bound, denying, 

aggressive, fearful. 

Negation of both physical and emotional being, passivity, 

receptiveness, spiritualness. 

of interpretation and art therapy (Vol.2) New York: Karger, tabulated by in S.P. Amos, (1982) op.cit. 

279

Figures 3. Map of Associations between colour variables measured between diagnostic 

groups from the results of the DAPA test. 

_____________________________________________________________________ 

a. Schizophrenics b. Substance abusers 

c. Depressives d. Personality Disorder 

red 

red 

brown gree black 

yello blue 


yello blue 

e. Controls 

red 


yello blue 

280 

red 

red 


yello blue 


yello blue

Figure 3 shows the results of the DAPA correlations as a map of associations between 

colour variables. It is immediately apparent that each group differs within colour 

associations, which informs the discussion of differences identified by the ANOVA 

procedure. Controls used more of all colours than the patients, except black, in line with 

expectations, they used lots of red and yellow, bright colours together (plot 3e), and 

moderate dark colours, so their pictures probably looked brighter and fuller than the 

patients. Depressives were nearest to controls, but there were associations between 

green and black, dark colours, although these were little used. Personality disorder were 

next; substance abusers and schizophrenics showed least use of colour. This finding 

supports the general consensus which reports 'impoverishment' of work by 

schizophrenics 297 but does not support more frequent reports for work by depressives 298 

or by patients generally 299 . 

297 

Examples of later studies, see M. Miljkovitch, M. Irvine, (1982) Comparisons of drawing performances 

of schizophrenics, other psychiatric patients and normal schoolchildren on a Draw-A -Village task, Arts 

in Psychotherapy , V.9:203-16 differentiated schizophrenics from other patients; M.B. Morris (1995), The 

DDS and the Tree Rating Scale: an isomorphic representation of Multiple Personality Disorder, Manic 

Depressive and Schizophrenic populations, Art Therapy , V.12(2):118-128; Wadeson (1976, cited 1980, 

op.cit.) found both complete and impoverished pictures in schizophrenia and noted impoverishment was 

traditionally associated with psychotic depression, p.193; Amos (1982) op.cit. states that many of the 

properties of Manic Depressives found by H. Wadeson and W.E. Bunney (1970), Manic Depressive Art: 

a systematic study of differences in a 48 hour cyclic patient, J. Nervous and Mental Disease , V.150:215- 

31 are also present in schizophrenia and "reflect dimensions important to diagnosis, prognosis and/or 

treatment", p.141. 

298 

See H. Wadeson (1975), Suicide: expression in images, Am. J. Art Therapy , V.14:75-82; (1980) 

op.cit., characteristics of unipolar depression by Wadeson, also tabulation of traditional literature, p.190 

reprinted from Wadeson and Carpenter (1976), A comparative study of the art experience of schizophrenic, 

unipolar depressive and bipolar non-depressed patients, J. Nervous Mental Disease , V.162(2):334-44; Later 

example: H.Wright and M.P. McIntyre (1982), The Family Drawing Depression Scale, J. Clinical 

Psychology , V.38(4):853-61; and Amos (1982) op.cit., endorsed and reprinted Wadeson & Bunney's 

(1970) Mania/Depression table, low colour, closed forms, hopeless, empty. 

299 

S. Russell-Lacy et al. (1979) An experimental study of pictures produced by schizophrenic subjects, B. 

J. Psychiatry , V.134:195-200 found that schizophrenics and other patients performed equally poorly when 

compared with normals; C. Bergland & R.M. Gonzalez (1993), Art and madness: can the interface be 

quantified, Am. J. Art Therapy , V.31:81-90, compared patients with personality disorder with normals 

although they also found an effect for cross classified depression. 

281

Schizophrenic pictures showed correlations between consistent and associated 

moderate use of red and low yellow, green, blue and brown indicating multiple use of 

colours, but from the results of the ANOVA, we can see that they used little of any 

colour but red, so their pictures probably looked more monochromatic and bare. 

Substance abusers tended to use only small amounts of muddy colours together (green 

and brown), with a little bright colour (red or yellow) and lots of black, so their pictures 

probably seemed dark and dramatic with sharp contrasts. Depressives used a little green 

together with moderate black and bright colours so their pictures probably looked fairly 

balanced. Colours used by patients with personality disorder showed balance in colour 

but no associations; they used bright and dark colours moderately but little green and 

mostly were not differentiable from the other groups. Blue and brown were used in 

equally low quantities by all groups, but proportionally they would tend to add more to 

the darker colours in the paintings of schizophrenics and substance abusers. There were 

three obvious and important obvious discussion points in variations of use of colour 

within groups in this study: (1) the use of green and (2) red in controls and schizophrenia 

and the use of (3) black in all groups, but especially substance abusers and 

schizophrenics. (4) Minor differences are discussed after. 

Use of Green: Green was important in schizophrenic paintings. Green appeared with 

all colours but black, especially yellow and multiple colours 300 . These findings are mildly 

supported by impressionistic reports of a preference for, or inappropriate use of, green 

300 Yellow was highly correlated with green and moderately with blue and brown, but not red. So given 

that green was used most with yellow, and yellow turned up with blue and brown, multiple rather than 

singular use of colours are indicated. 

282

from the literature 301 . However, green was more apparent only relatively in 

schizophrenics' pictures, because only a little more green was used than in other patient 

groups; both schizophrenics and substance abusers used significantly less than controls, 

who used twice as much. Depressives covered a wider range, but still used much less 

green than controls. Judging from the placement of the groups, the interpretation of 

suffering for green seems unlikely. 

The use of red: Previous associations and preferences in patients have been found for 

red and black 302 especially for anger. In this study, controls used much more red than 

patients (although they were differentiated only from drug abusers, who used least). The 

confidence intervals for the use of red by depressives and patients with personality 

disorder were wide (Figure 11a, results) so use was quite varied in these groups although 

mean values show moderate amounts of red as in schizophrenia where the use was more 

consistent. 

The balanced use of bright and dark colours by depressives indicates that 

diagnostic impressions of dark, sombre colours 303 in clinical depression are unjustified. 

301 

Roberta H. Shoemaker (1978), The significance of the first picture in art therapy, Proceedings of the 8th 

Annual Conference of the Am. Art Therapy Ass. , (p.156-62) provides a good example of green used in 

a bizarre way, especially for people. She describes the unnatural colouring of relatives faces in green as 

particularly significant. 

302 

Frances F. Kaplan, Previous reports of preferences for red and black among patient groups (R. Langevin, 

M. Raine, D. Day, K. Waxer (1975), Art, intelligence and formal features in psychotics' paintings, Arts 

in Psychotherapy , V.2(2):149-158) may be explained through recent studies of representations of anger 

(Frances F. Kaplan (1994), The imagery and expression of anger: an initial study, Art Therapy , V.11:139- 

143). Kaplan found 52% of the 'angry' paintings of students presenting this combination and 33% more 

only black or hot colours; Further research in 1996 (Positive images of anger in an anger management 

workshop, Arts in Psychotherapy , V.23(1):69-75) reported that deliberately modifying these images 

showed marked decrease in these colours and increase in blues and greens and 30% eliminated black and 

red. Kaplan's qualification that colours were probably related to current mood state rather than propensity 

for anger may indicate a lack of affect in depressives. 

303 Wadeson (1980), op.cit. p.190 and Amos (1982) op.cit. p.140 summarises the majority of the literature 

on the subject; for examples of these principles see D. Arrington (1991), Thinking systems- seeing 

283

The DAPA results for depression are consistent with some studies showing brighter 

colours used by depressives in treatment 304 . 

Red was used by schizophrenics more than any other colour and thus could have 

been clinically noticeable, supporting preferences for red in this group, but not for black, 

which confidence interval was much shorter than the other groups and lower down the 

scale (Figure 10f, results). 

Use of red and black: Of the other groups, substance abusers alone consistently used 

large amounts of black, but depressives, controls and personality disorder all used 

moderate amounts with a much wider variability. 

Generally then, there was no evidence of general patient preference for red, or 

indeed black (except for substance abuse), but there were within-group differences. This 

finding confirms the value of within-group comparisons, since findings for the whole 

population would combine these quite different characteristics. Additionally, the 

interpretation for red in table 2 is consistent with a more positive control position and 

with the conclusions reached by those studies which found brighter colours in depressive 

presentations. 

systems: an integrative model for systemically oriented art therapy, The Arts in Psychotherapy , V.18:201- 

211; M.D. Cagnoletta (1983), Artwork as a representation of object relation in the practice, Pratt Instit ute 

Creative Arts Review , V.4:46-52; D. Heine and M. Steiner (1986), Standardised paintings as a proposed 

adjunct instrument for monitoring mood states: a preliminary note, Occupational Therapy in Mental 

Health , V.6(3):21-7, using modified Wadeson's table of characteristics. 

304 

Shoemaker (1978) op.cit. describes bright warm colours as the depressive patient touches her emotional 

intensity in the process of treatment; S. Buchalter Katz (1985), Observations concerning the art 

productions of depressed patients in short term psychiatric facilities, Arts in Psychotherapy, 

V.12(1):35-38 

describes bright colours and happy scenes reflecting hope. 

284

Use of Black: All groups except schizophrenics used more black than other colours. 

Amongst the range of colours used by schizophrenics, black was not unusually low; the 

variation is because schizophrenics used low levels of all colours but red. 

Black wasn't correlated with any other dark colour, except in depressives, which 

group showed a significant positive association between green and black. This linear 

relationship occurs in no other group (plot 3c); other results show weak negative 

correlations, which confirm that black was used rather more separately than any other 

colour in other groups. The position of the depressives, as indistinguishable from 

controls and below the much greater use by substance abusers, does not support the 

commonly held belief that large values of black indicate depression 305 , since both 

schizophrenics 306 and depressives should then exhibit more of the characteristic than 

other groups, and controls should exhibit less. 

The DAPA results for black support the empirical conclusions of Kaplan 307 , that 

black denotes strong affect in concurrent expression of anger; together with the 

interpretation, from table 2 above, of aggression, fear or hostility, which includes the 

absence of extrinsic emotion (which subjectively, may well characterise the drug 

305 

There is no doubt that angry, depressed and emotionally traumatised people do use large amounts of 

black paint in their expressive work, a recent description of paintings by Soviet post-earthquake 

traumatised children clearly contrasts their obsessive use of white, red and especially black with their 

previous normal work and their gradual return to full spectrum (V.S. Gregorian, A. Azarian, M.B. 

DeMaria and L.D. McDonald (1996), Colors of disaster: the psychology of the "black sun", Arts in 

Psychotherapy , V.23(1): 1-14). However, Kaplan, and others providing hard data (including the above 

study) used normal subjects. 

306 Wadeson (1980), op.cit. reports her 1976 study of schizophrenics (Wadeson & Carpenter, op.cit.) 52 

out of 56 patients drew designations of depressed feelings, describing typical black self-images. 

307 Kaplan, 1994, 1996 op.cit. characteristics of anger. 

285

abusers 308 , but not the schizophrenics). Thus the DAPA results agree with other 

empirical studies. 

The measurement procedures of the DAPA may have contributed to the 

polarisation of scores between schizophrenia and substance abuse. There could be large 

variations in quantity applied to an area and quality of tone, for example, a range from 

pure black, rated as high intensity, and pencil lines, rated at low intensity. Large amounts 

of pencil line would be rated at a very consistent intensity of black, which would make 

it inconsistent with the fluctuations of the other colours. This explanation does fit with 

the low negative correlations for black throughout. Schizophrenics are said to produce 

fragmented and dissolute compositions 309 , indicating lack of or less certain outlines with 

a corresponding low score and drug abusers could similarly have produced more pencil 

lines. If this was the case then black scores should correlate with form or with drawn line 

for schizophrenics and substance abusers; this hypothesis is examined in the discussion 

of structure. 

Minor differences: 

yellow: All groups used moderate yellow except schizophrenics, but as before, 

schizophrenics used little colour. This finding contradicts previous findings of increased 

yellow in paintings by schizophrenics 310 , but this could easily be explained by 

308 Communicated to the author in discussion with group and hospital staff post experimental period. 

309 

Wadeson (1980), op.cit. table of characteristics of schizophrenia, p.190; Amos (1982), op.cit. provides 

typical examples. 

310 Russell-Lacy et al. (1979) op.cit. found schizophrenics and normal controls used more yellow and 

blending than other patients. Russell-Lacy mentioned that a 'template' was used to determine 

286

differences in measurement systems. The finding that paintings of schizophrenics were 

both low in yellow and black, according to table 2 seems to be contradictory. 

'Neutral' colours: Blue and brown were indistinguishable for all groups and the range of 

scoring was not wide. Blue was used moderately and brown was little used, controls used 

less than any other colour, although they used more than patients (but not significantly 

more). The groups most expected to use brown, seen as a dark dismal colour, were 

schizophrenics and depressives, but they used less than any other colour. There was 

thus no support for the use of blue or brown as an indicator of depression, psychosis or 

patient status. 

Indications for removal of colours/alterations: The removal of green, which was 

associated in three patient groups; and blue and brown, which were non-discriminatory, 

would effectively eliminate related colours in patient groups. Removal of associated 

colours in controls would eliminate discriminatory factors. It would be useful to 

discriminate pencil lines from black to eliminate ambiguity of media. 

Summary for colour 

It was expected that there would be correlations between bright and warm colours: red, 

yellow and green and between any or all of green, blue, brown and black. Patients 

generally, but especially schizophrenics and depressives, were expected to produce less 

on the paper, use less colours, show preference for red and black and controls for 

multiple colours, especially the brighter warmer colours. 

quantification of colour and space, but generally this method and how many colours were measured was 

undescribed. One result out of a possible 10 would not exceed chance expectations. 

287

Control pictures showed the only association between the brighter colours, red 

and yellow, but they were not the only group to use multiple colours: schizophrenics 

showed association between all colours but black. Three of the other four groups showed 

associations with green. There was no polarisation to darker colours/brighter colours for 

any or all of the patient/control groups. The separation between controls and the 

patients on quantity of colour is clear, especially in red and green. No colours, including 

black, isolated depression or personality disorder. There were some positive indicators: 

Large quantities of black indicated substance abuse 

Small quantities of black indicated schizophrenia. 

Large quantities of red and green (and possibly yellow) indicated control. 

Most of the literature seemed to suggest more chromatic variation 311 , but comparison of 

the DAPA procedure with other major studies is difficult since they group colours or use 

a system which includes opinion, such as 'inappropriate colour' 312 . Studies claim to be 

supported by reference to the patient, but the assumption that the patient is an informed 

source must surely be questionable, especially as most of the practical literature insist 

that the art process is an unconscious one, that the associations are made afterwards, and 

cannot be made by the patient alone 313 . This research generally refutes the diagnostic 

311 

W. L. Wadlington and H.J. McWhinnie (1973) The development of a rating scale for the study of 

aesthetic qualities in the paintings of mental patients, Art Psychotherapy, 

V1(3-4):201-20, tested chromatic 

variation between 5 patient groups (in value and tonality) but schizophrenics were separated from paranoid 

schizophrenics. They found most depressives and neurotics scored higher than schizophrenics and patients 

with adjustment reaction. 

312 The DDS, Cohen, Hammer and Singer (1988), op.cit.; Linda Gantt (1990)A validity study of the 

Formal Elements in Art Therapy Scale (FEATS) for diagnostic information in patients' drawings, 

Unpublished Doctoral Dissertation, University Pittsburgh, Pennsylvania - 'colour fit'; The SPAR scale, 

Bergland & Gonzalez (1993), op.cit. - expressive 'developmental' level. 

313 

T. Dalley and C. Case (1992), Handbook of Art Therapy , London: Routledge. This subject is addressed 

288

interpretation of the meaning, quality of colour and emotional associations 314 which have 

appeared in the literature and are summarised in table 2. Taking into account the 

diagnostic expectations, few of the common interpretations of the meaning or associations 

of colours made sense within the placement of diagnostic groups in this study; 

observations and experience reported in the literature probably related the colour more 

to the content and associations from the subject. The explanation that the affect value 

of a colour varies with some other characteristic of the painting 315 would probably 

demand a greater variation in the confidence intervals, so cautions from authors presenting 

these theories which recommend support from other case related aspects, as with the 

interpretations from Tasco are well founded. Generally the controls used more of all 

colours except black. This tends to cast suspicion generally on the table of 

interpretations since normality should not represent an extreme. Where agreement with 

the interpretation was indicated, it was between patient groups but some indications were 

contradictory. The lower extremes were split between substance abuse and 

schizophrenia. 

in the introduction. 

314 

R.R. Crane and B.I. Levy (1962) Color scales in responses to emotionally laden situations, J. 

Consulting Psychology , V.26(6):515-9, different emotional situations lead to different colour scaling; I.G. 

Martin, Universal vs learned emotional responses to colors: afterthoughts to thesis research, Arts in 

Psychotherapy , V.9:245-7 discusses theoretical confusion of the literature on the relationship between color 

and affect, whilst broadly supportive of universal meanings of colour. 

315 Levy (1984/1980), op.cit. reported that colour and emotion were related, advised art therapists to 

consider colour "yet another source of information about our clients, a valuable guide in forming helpful 

reactions based on our clients' art work". 

289

yellow 

Structural variables 

Figures 4a-e. Map of association of structural variables measured between diagnostic 

groups using the DAPA test. denotes negative correlation. 

_____________________________________________________________________ 

yellow 

intensity 

Controls 

Painted 

Line 

Schizophrenia Substance abuse 

red 

blue green 

intensity 

intensity 

red 

green 

Drawn 

Line 

Depression Personality Disorder 

Painted 

Line 

Painted 

Line 

Drawn 

Line 

Drawn 

Line 

290 

blue form 

Painted 

Line 

Drawn 

Line

There were two obvious important associations between structural variables: associations 

between intensity and colour for three groups, together with the association of painted 

line and red/green for schizophrenia; and negative associations between painted and drawn 

line. 

Differences between groups - Intensity 

The order of brightness was much the same as that of amount of colour: controls, 

depressives, personality disorder, substance abusers and schizophrenics. We could 

expect relations between hue and intensity because the first qualities are contained by the 

latter, although not necessarily explicitly, but previous studies have found high 

correlations for intensity with colour 316 . Figures 4a-e show associations in three groups 

between intensity and different colours for each diagnostic group, confirming that 

intensity was actually measuring brightness of colour. So colour analysis alone cannot 

fully answer the question whether patients paint darker, or gloomier, pictures than 

controls 317 . 

Different colours in the paintings of patients and controls did vary systematically 

and supported the combination of measurements of hue and chroma, rather than tone 

316 Wadlington and McWhinnie (1973) op.cit., found correlation in hue and chroma and intensity of colour. 

317 

R. D'Andrade and M. Egan (1974) found that emotional associations with colour existed but were not 

confined to hue but to the degree of saturation and brightness in normal populations, The colours of 

emotion, American Ethnologist , Feb. 1(1):49-63. There are also indications, from preference studies, that 

different psychiatric groups may see different colours as dark, such as depressives but not controls grouped 

blue with dark colours in a study by M.J. Garvey and M. Luxenberg (1987), Comparison of color 

preference in depressives and controls, Psychopathology , V.20:268-271. 

291

directly, to answer this question. In combination with reference to the results for colour, 

it can be deduced that: 

Schizophrenics scored mostly neutral, towards low; 

Substance abusers used extremes of high and low intensity; 

Controls and depressives used more variety in colour and intensity. 

Personality disordered patients used a range of tone, but these scores were not 

interpretable due to small numbers in the group. 

The fact that there were no associations with black and intensity probably 

reflected the use of pencil. More pencil (scored as black) would not score higher in 

intensity, neither would large quantities of pink (scored as mixed red). 

Scores for schizophrenia indicated that most colours used were bright, especially 

green and yellow, since as more colour was used, the score for intensity increased. 

None of the substance abusers' colour scores related to intensity. The confidence 

interval for substance abusers was very short which indicated a high degree of conformity 

in the group. They scored only slightly higher than schizophrenics on intensity (who 

scored the least), therefore colours were mainly used as neutral (mixed). The explanation 

of equal coverage of high (3 saturated) and low intensity colour (1 mixed muddy or 

watery colours) is possible but it is unlikely they would consistently use every colour 

in this way. 

Depressives used bright green and yellow but not red (Figure 4c), indicating some 

bright colours but muted reds and greys, not a prevalence of dark, gloomy, low intensity 

292

colours as predicted, which would show up as a correlation between dark colours and 

intensity. 

Controls used bright red consistently, but not bright yellow or green (the reverse 

of depressives), because intensity was correlated only with red. There is a correlation 

between high red and high yellow (figure 3e; but increases were more variable, 

scatterplots 17: results) which implies they were used together but high scores on 

intensity had more to do with the presence of red. Therefore there was minimal influence 

on judged intensity from yellow as for green, blue, brown and black nor negative 

influence. This indicates more muted colours for controls and not bright colours as 

previously thought (except red), but it is likely that controls used more mixed colours, 

thus creating a more positive 'feeling' of light and harmony, which probably positively 

influenced emotional tone and intensity ratings. 

Evidence supports the suggestion that the domination of the picture by gloomy 

and low intensity colours (not black) indicates disturbance of thought, but not depression 

or substance abuse. Controls did prefer bright colours; they were not, however, 

characterised by lack of use of the 'gloomy' colours and they used a varied range of 

intensity. These results suggest varied hues would be appropriate rating criteria for 

controls. 

There was evidence to support the sectioning of patients into high and low 

intensity by diagnostic type, even though the high category included black, since it 

seemed to isolate certain patient groups, but it would probably increase diagnostic rigour 

to eliminate neutral from the intensity category. Although intensity correlated with red, 

293

yellow and green, its removal would remove a discriminating variable for schizophrenics, 

and in combination, intensity may contribute to the qualitative interpretation of the 

structural variables. It would probably be better to incorporate it into a reduced colour 

list. 

Differences between groups - Line quality 

Older studies mention thick heavy line for patients, especially schizophrenics 318 . In the 

DAPA study, thick line was notably absent: if thick lines were scored, they were 

swamped by the lower scores in the production of averages, which seems likely because 

there were inconsistencies in homogeneity of scores for painted lines within groups 319 . 

Contemporary studies tend to show no differences between diagnostic groups on line 

quality 320 , and the results from the DAPA agree insofar as they show there was a limited 

range of line for all groups for both types of line, but the DAPA did pick up differences 

in this limited range. The distribution statistics suggested little use of painted or drawn 

line but the information is ambiguous because there is little difference between DAPA 

measures of few lines and thin lines. The confidence intervals for all groups in painted 

318 

Amos (1982), op.cit. schizophrenics with prominent paranoid tendencies, produce drawings with heavy 

overall line emphasis, p.135. 

319 The Levene statistic was not computable because painted line was infrequently used in some groups. 

Bartletts box (table 8, results) put scores for painted line just within the range for discrimination 

purposes. 

320 Gantt (1990), op.cit. found no differences in 4 groups of patients and a control group in line quality; 

the DDS, Cohen et al. (1988), op.cit. found no differences in 3 types of patients to controls; Langevin et 

al. (1975) op.cit. found no differences in schizophrenics and normal controls and Miljkovitch et al. (1982), 

op.cit. found no differences in line with schizophrenics and other patients. 

294

lines ranged from 0-thin and a little higher in drawn lines, indicating a greater proportion 

of zero scores (lack of use). 

Painted line: Only schizophrenic pictures showed association of line with colour: either 

painted lines were red and green, or they were inconsistent in colour and bright green or 

red was consistently present for some other reason. This provides an opportunity for 

further investigation for clinical utility. 

There may have been an element of lack of control of paint by patients and 

especially substance abusers, who scored least, which was concealed by the non-use of 

painted line by patients, although controls' use was still low. The order of scores for 

drawn line was the opposite of that for painted and there was a strong negative 

correlation between painted and drawn line in every group except substance abusers (who 

used the least painted lines and the most drawn) thus subjects used either drawn or 

painted line, not both at once. 

Drawn Line: Controls should have been mid-range in drawn line, but instead, scored less 

than other groups. In fact, the confidence interval for controls remained consistent 

through painted or drawn lines, it was the patients' strategies that changed (this further 

supports the division of drawn and painted line for patients). It is possible that thick and 

thin lines were always scored together (varied = 2) so reducing the mean score to neutral, 

but most groups scored in the 0-1 range indicating a greater proportion of 0 scores (no 

line present). Drawn lines were more prevalent in substance abusers and patients with 

personality disorder. 

295

Schizophrenics used little colour except red, they used low intensity colours, and 

little line. This implies some other activity than colour was filling the space (since from 

the results, space was filled). The correlation of drawn line with space may be 

underestimated since the plot showed a non linear relationship, unusual in that there was 

a loose correlation up to about half filled with drawn line, so drawn line was most used 

at that point and then as space increased, drawn line decreased. This pattern is consistent 

with the negative correlation between painted and drawn lines shown by most groups. 

The space was filled with either colour or line (and none consistently as there were no 

correlations with space). Line was likely to be light pencil (possibly writing 321 ), which 

fits with the score for low intensity black and predominantly thin line. 

321 Many studies report 'writing in' as a frequent indicator of schizophrenic drawings, Amos 1982 gives 

examples, op.cit., or patient status, Cohen et al. 1988, op.cit., but others have found no differences 

Russell-Lacy et al. 1979, op.cit., or infrequency Miljkovitch et al., 1982, op.cit. 

296

Differences between groups - Space 

There wasn't as much variation as expected between the controls and the patients and no 

other variable had an effect on space left uncovered in the picture. Small but significant 

differences existed, but all groups' paintings lay within the 25-55% space bandwidth and 

no group consistently left large amounts of empty space. These findings are curious in 

view of the reports from the literature which diverge widely so some explanation is 

needed. 

I have already indicated the variety of definition of space in the literature, the 

most common is perspectival space. Psychiatric patients have been distinguished from 

controls on dimensionality of elements or deformation of perspective 322 , but traditional 

views of disintegration of perspective, especially in schizophrenic art have latterly been 

challenged 323 , although some latter-day studies have also found differences in odd placing 

of elements and objects or figures 'floating in space' 324 . The general understanding of this 

'space' is difficult to define because it assumes that paper left uncovered is orientated 

322 Patient groups are differentiated from controls: for example, the SPAR scale found that patients with 

personality disorder scored lower than normal controls on perspectival space (Bergland and Gonzalez 

(1993, op.cit.); Miljkovitch and Irvine (1982 op.cit.) found no differences between schizophrenics and 

other patients but poor performance generally on space from all patients, and schizophrenics were more 

likely to draw planned views than others. 

323 Amos (1982) op.cit., reviews most of the essential 1960s and 1970s literature which characterise 

schizophrenic disintegration of hierarchical perspective, proportion and logical spatial organisation under 

the subheading of 'composition'; Russell-Lacy et al. (1979 op.cit.) found schizophrenics used more two 

dimensional space than normal controls although they weren't differentiable from patient controls. 

Disagreement in later views: Wadeson's table of characteristics of schizophrenia, depression and mania 

report disorganisation, disturbed spatial organisation, disintegration for schizophrenia agree with Amos, 

but her own experiments (1976) with schizophrenics showed wide variations (cited in Wadeson 1980, 

op.cit. p.190-192); Gantt's experiments with the FEATS study show no differences in use of perspectival 

space between 5 groups including controls (1990 op.cit.). 

324 

Cohen, Hammer and Singer (1988) op.cit.; Bergland and Gonzalez (1993), op.cit.; J.B. Couch (1994), 

The Diagnostic Drawing Series: research with older people diagnosed with organic mental syndromes and 

disorders, Art Therapy , V.20(3):231-241. 

297

directly to the environment; assessment includes the objects within it so that it appears 

widespread, whereas a simple groundline would have 'located' the objects 325 . The DAPA 

uses a definition of covered area of the picture, as a less common but recognised objective 

assessment 326 and does not distinguish between these kinds of visual representation. The 

patient scores indicate they produced less on the paper, but also indicate sketchy work, 

which is often seen as empty because it lacks richness, solidity and detail. A thin yellow 

wash could be described as empty space to someone looking for a depiction of a visual 

plane, and filled, by someone looking for floating objects or a ground, but the DAPA 

would record that 'space' as filled without exception. No group in this study consistently 

produced much uncovered space. Any mark within the field was included and the 'space- 

bubble' was estimated around it 327 - if there were two spaces in the square, only one was 

included. Thus sometimes the picture would look as if it had more space than the score 

for space indicated. 

Alternative explanations offered for results from the discussion of intensity and 

line that the type of measurement may have obscured the results when they were 

extreme, cannot apply here. The weighting of 5, given to empty squares would have 

given a higher average score if applied throughout the picture. Therefore there must have 

been a considerable portion of the population with 55-75% filled space. It could be 

325 See explanations of this definition in Cohen, Hammer and Singer (1988), op.cit.; Gantt (1990), op.cit. 

326 Wright and McIntyre (1982, op.cit.) found significant differences in depressive and normal controls 

using a similar method; Russell-Lacy et al. (1979, op.cit.) used 'a template' (the only description) to 

quantify space and found differences in patients and controls on covered paper; the DDS - Cohen, Hammer 

and Singer (1988, op.cit.) found that patients mainly used '33-99%' of paper, but the actual range covered 

was indeterminable as it allowed an inch around the perimeter of the paper for the extra 1%! 

327 see definition for space DAPA rating guide 1994, methods section. 

298

argued that the procedure of taking the mean of several paintings might have simply 

produced a neutral score from wildly different paintings. Three points refute this: (i) the 

scale point in the middle and with the widest interval was 3(25-55%), whereas scores for 

space centred on 2 (10-25%); (ii) the confidence intervals are very small indicating very 

little variation within groups; and the ANOVA between paintings showed no significant 

differences between paintings (Results section). 

Differences between groups - Emotional Tone 

Comparison with other studies is difficult here because it is assumed that the content is 

decodable and assumptions about the meanings of what is portrayed form the basis of 

most studies. Generally the patient picture is expected to score much lower: to distort 

proportion, perspective and to show more negative content than the control 328 ; there are 

said to be reflections of thought disorder in schizophrenia, hopelessness and despair in 

depression 329 . Although the DAPA results agree with the general tone of the literature, 

that controls score higher than patients, there was a narrower band of variation than this 

literature suggests. All patient scores hovered around neutral and there were no 

correlations with other variables, suggesting that structure and colour had no separable 

328 Distinguishing features of psychotic art reported in the literature, collected by Wadeson (1980), op.cit. 

p.190 although she does not endorse all of these characteristics, especially that disorganised behaviour 

reflects in the drawings. She does note that hopelessness and emptiness, enclosed trapped feelings 

predominate in the themes of depressed patients' paintings; Amos (1982), op.cit., in a synthesis of the 

1960s and 1970s literature suggests content reflects the schizophrenic's world view of unusual or 

maladaptive experiences, impaired reality sense, no baseline reference, disconnected and bizarre images, 

especially human, heavy line emphasis, and words, disintegrated composition without regard for 

perspective, primitive style and inappropriate or uncontrollable use of colour. 

329 Shoemaker (1978 op.cit.) provides a sensitive 'guidelist' of how to examine a painting by a patient for 

visually available dimensions 'within which the specific definitions of psychopathology may fall, as a step 

towards measurement'; she suggests: synthessence, space, substance, time, energy, relativity, reflection 

of perception and expression. 

299

influence on apparent negativity. Where precedents for the DAPA results exist, they 

used systematic methods 330 and it is not certain that previous studies have taken the 

effect of quality judgements into consideration 331 , even though the justification for 

selection of features may be theoretically remote. 

A probable explanation for these findings lies in the test procedure. Other studies 

may have placed increased emphasis on negative indicators thus influencing the view of 

the whole painting as negative, whereas corresponding or small positive parts are ignored. 

The DAPA scores tell us that no group consistently produced negative indicators over 

the whole picture surface. Where negative scores were given, they must have been 

balanced by positive scores, because of the centring on neutral. The confidence intervals 

were very short in the groups most expected to produce negative paintings: schizophrenia 

and depression, indicating little variability within group and we know that the sequence 

of paintings did not show fluctuations from negative to positive 332 . 

330 

Russell-Lacy et al. (1979 op.cit.) found differences isolating schizophrenics from both controls and other 

patients in repetitions of abstract forms (mannerism) only, between patients and controls only in these 

form variables: imbalance, detail, two dimensions and space covered between patients and controls. There 

were no differences in relationship of imagery, focal points, monochromism, perspective, words or 

portrayed houses in the picture; Wadeson (1980, op.cit.) warns that casual observation alone revealed no 

particular patterns of content in diagnostic groups; E.L. Phillips, S.K. Geller and M. Ireland (1983), 

Research on the use of art therapy in a university setting, Am. J. Art Therapy , V.23(1):26-9 were unable 

to assess whether themes in artwork were sequential. 

331 

examples of previous studies finding no relationship in thematic content after quality judgements were 

accounted for have been; R. Langevin and L.M. Hutchins (1973), An experimental investigation of judges' 

ratings of schizophrenics and non-schizophrenics paintings, J. Personality Assessment , V.37(6):537-543, 

results from 13 judges ratings of 200 paintings as schizophrenic/normal were only 10% greater than chance 

using their own criteria which was subsequently found to be art quality; E. Feher, L. Vandicreek, H. 

Taglasi (1983), The problem of art quality in the use of human figure drawings, J. Clinical Psychology , 

V.39(2):268-275, although 8 from 16 judges were warned on quality, all returned a 58% hit rate on 

quality. 

332 Different paintings by individuals were compared by analysis of variance (see results section) in order 

to determine the propriety of taking the mean value for each subject, results were non-significant. 

300

The DAPA considers the area of negative tone within the context of the whole 

painting. This may not be clinically relevant for interpretations, since although a negative 

area may be small, it may dominate and give focus to the painting subjectively. However, 

there seems little indication of clinical depression from a large proportion of negative 

areas as measured by the DAPA, since the groups predicted as most likely to score 

negative: schizophrenics and depressives, who actually occupied the same range according 

to the DAPA, scored less negative than the substance abusers. Recent research on 

emotional associations with image intensity shows some correspondence with these 

results and suggests that pictorial intensity reflects current feelings rather than general 

tendencies 333 . These results support Wadeson's 334 contention that schizophrenics 

present with typical pictorial signs of depression. The implication is then that substance 

abusers might subjectively feel more depressed than all groups. The confidence intervals 

for personality disorder are much wider than the other groups, indicating greater 

variability, and more inclination towards positivity (but this probably reflects 

inadequacy of the smaller sample size). 

Comparison of form 

The lower scores for dominant form in depressives and the higher use in controls 

gives support to the general view of dissolution or lack of form in depressive illness 

333 Kaplan, Imagery and expression of anger (1994 op.cit.), found that black and red associate with feelings 

of anger and image intensity reflects current angry feelings rather than propensity. 

334 Wadeson (1980, op.cit.) p.193, 324. 

301

ather than for schizophrenia 335 . This might have been more obvious in content and 

influenced the judgement of emotional tone, so a negative correlation between emotional 

tone and form might have been a reasonable expectation. There is, however, no such 

evidence; small non-significant positive correlations indicate that the judgement of the 

positivity of the painting was not influenced by form. 

The position of substance abuse, which scored significantly more form than 

depressed, indicates that form should be a true predictor of depression, unlike most of 

the other elements which put substance abuse further down the scale than depression. 

Patient groups exhibited some dominance of form, but their focus covered less of the 

surface than that of controls, who tended to use about half the page; this probably 

accounts for the confusing results when untrained raters are apparently able to distinguish 

patients from controls slightly better than chance using their own criteria, which usually 

turn out to be quality. Higher levels of form, though, are not necessarily an indication of 

health as the pictures of substance abusers were not distinguishable from controls. 

Substance abusers did not use more blue or form than other groups, but there was 

a high negative association between blue and form. The plot for blue and form is unusual 

in that very little blue, when half filled with form decreases to no blue as form increases; 

it is likely that blue was deposed by the form, being a background colour (sky?) rather 

335 Amos (1982, op.cit.) reports Billig's 1969 observations of a schizophrenic recovery "beginning with 

random scribblings" and generally dissolution of form in schizophrenia; Wadeson's (1980, op.cit.) 

categorisation of psychopathology from the literature shows schizophrenics were thought to produce 

disorganised and deteriorated compositions, but she reports experiments from 1976, which disagree. She 

found the majority of schizophrenic pictures full formed and developed, depressive-like qualities such as 

colourless, emptiness, were noted in a few paintings from manic/depressive and schizophrenics also. 

Wadlington and McWhinnie (1973), op.cit. found no differences between patient groups (including 

schizophrenia and depressives) on dominant form and size relations. 

302

than a fill colour, but no colour is particularly associated with form so there was no 

consistent fill or outline colour. 

Conclusion for the discussion of results 

The results from the DAPA scales follow the general direction of the empirical literature 

in that psychiatric pictures were shown to use less colour, were of lower intensity, fewer 

lines were drawn and painted, they left more space, were less positive in content and 

contained less dominant form than pictures by controls. However, the results do not 

agree with most of the diagnostic differentiations between patient groups suggested by 

the early impressionistic literature. DAPA results also disagree in the magnitude of the 

patient/control differences. 

Summary: There are two related likely explanations which have probably polarised the 

patient/control differences and suggested other differences between patients because they 

are antithetical strategies: 

1. Reports from the literature could have emphasised the importance of part of a 

picture because of the overwhelming influence of content on subjective 

judgement; 

2. The way the DAPA scores pictures reduces the importance of part of a picture 

because it measures the distribution of an element over the picture plane, rather 

than concentrating on how a message is conveyed over part of it. If small, the 

focus point of a picture could have quite intense scores but the picture would 

score mainly from the material surrounding it, in the production of averages. 

303

Supporting this point, the focus area is usually encompassed by the dominant 

form, which is considerably smaller for patients than for controls. 

This last is an important point because there is no standard form for the way we 

look at and describe pictures, so it seems quite acceptable for us to attend to details in 

one group and whole paintings in another. Judgement may occur on different indices, 

individually and subjectively according to what the judge finds important, or worth 

considering in that group especially in impressionistic reports 336 . There may indeed be 

differences in the pictures, but if, for example, red is actually distributed equally in both 

groups but being attended differently in the focus group because it denotes unsatisfactory 

or violent content (maybe as blood/danger in patients, but cheerful flowers in control), 

what is being reported as amount of red may actually denote something else. 

Unsatisfactory aspects of the procedure for rating 

There are several unsatisfactory issues in the DAPA procedure. The structuring process 

was not essentially statistical. The statistical process was applied afterwards and is 

constrained by its categorical organisation. This difficulty cannot be resolved from 

outside; more experience with statistics has changed my approach to these processes and 

a similar programme would have the statistical procedures organised integrally from the 

beginning. 

336 

J.K. Dent and H.Y. Kwiatkowska, (1970), Aesthetic preferences of young adults for pictures drawn by 

mental patients and by members of their immediate families, Sciences d'L'art , V.7(1-2):43-54. found that 

20 judges of 1500 paintings by mixed psychiatric patients trying to describe the paintings and indicate 

their preferences showed wide individual differences in what they attended to and very poor criteria and 

judgement, out of 20 common descriptive elements, 10 were related to the personality of the judges. 

304

Effect of the distribution of elements over the picture plane 

It is possible that a lot of empty space could swamp a small amount of information 

generated by the DAPA. Presently it is difficult to distinguish a consistent small amount 

of media from a concentrated area in one part of the picture from individual scales, 

although it can be deduced from a combination of related scales. 

Further development of the DAPA should consider the issue of distribution of 

a small amount of material over the picture. The averaging process between all 20 

sections of the grid works for the colour and form measures of presence/absence, but 

intensity, line, space and emotional tone would have a nil rating for empty space, 

confusing measures of little with none as it has for line. I have tried to avoid this problem 

by scoring empty squares on the emotional tone and intensity scale as neutral, but this 

has probably biased the scoring range towards neutral and may even obscure strong 

contrasts. If the mean of line, emotional tone and intensity were taken between occupied 

squares by treating the empty squares as missing data, it would obscure how much of the 

picture was taken up. A better answer would be to reduce the subvariables (low, neutral, 

high) to 2 values (low and high) effectively eliminating neutral. Later development will 

enable different parts of the picture to be considered separately. A better way would 

probably record missing values and average between as many grid sections filled. It 

would also be useful to correlate records of position of the Dominant Form so that 

persistent compositional devices could be measured as products of Space/Form. 

Rating problems. 

305

Several kinds of difficulties were encountered, especially in the attitude of professionals 

towards a content-free measure of art. The positive points were that the form and length 

of the instrument, although training was required, were satisfactory. Raters' agreement 

was high and they found the instrument understandable and reasonably easy to use in a 

systematic way, although tedious, so there were no obstacles to the judges rating. Close 

adherence to the rating guide improved reliability and in this respect art students may not 

have been the best raters, since they already had their own concepts of the terms used by 

the DAPA, especially for form, and were not well disposed towards quantitative ratings. 

None of the raters could suggest any further formal dimension upon which the picture 

could be rated. 

There were 3 areas of discussion of weaknesses of the procedure. They are 

presented here with development possibilities: 

(i) Colours: The rating instrument probably gives too much emphasis to colour, 

however, there seems no obvious grouping system since the traditional dark/light 

separation was not found to relate well to diagnosis, and is subjective since colours look 

lighter and darker with changes in environment. The alternative is to measure only those 

colours which have high discriminatory properties and which do not strongly correlate 

with other variables, so that results are independent. Orange, purple and white were 

eliminated due to infrequent or inconsistent use; blue and brown were non-discriminatory. 

The elimination of green could further remove associations between colours in 

schizophrenia, but equally it may be that the effect of the combination with the other 

colours may be important in discrimination and other associations would occur. The 

306

pattern of associations itself might be important. Colours measured would otherwise be 

reduced to red, yellow and black, which might be too few. Pencil line might have 

influenced scores for black, so it should be scored differently. 

(ii) The information value of Painted line was conveyed by the strong negative 

relationship to drawn line in the majority of groups. The normality of the distribution 

of painted line was questionable, and elimination would make intensity independent for 

schizophrenia. 

(iii) Form was a particularly difficult area for non-art trained people, and even art 

trained people found it difficult to objectify. The initial explanation of form was 

misunderstood, so further development went on. The rating guide (appendix 4) shows 

the final explanation for form. Speculatively though, a simplified 'most intense focus area' 

explanation might point out the crucial focus of the picture in four adjacent squares which 

form a box shape would probably limit the training and provide a more accessible 

explanation, but this requires further development. 

Relation of the results from Study 2 to Study 1 

Differences between methods 

Study 2 used more clearly differentiated subjects and larger groups so differences should 

be more obvious, some differences are expected because of the overlap between subject 

types in Study 1. Study 2 was retrospective, conditions were not standardised and 

content was free, where study 1 held the content constant to some extent with self- 

307

portraiture, so it is difficult to say which of these elements probably contributes the most 

to differences between diagnostically similar groups on specific variables for study 2. 

Differences in scores from the first study: three variables were transformed, and this 

commentary describes the usage figures (transformed back) so as to make better sense 

between relations to figures from Study 1. Five findings from study 1 were generally 

supported; two of the non-significant findings (blue and brown) and three out of four 

significant variables identified in study one (yellow, intensity and line), which showed 

only slight changes in study 2 (the other significant variable, orange, was too infrequent 

to be used). 

There was no signiicant difference between the findings of Studies 1 and 2 for 

brown or blue. Patients used more brown in study 1, this put them equal with controls 

who used roughly the same amount in study 1 as 2; depressed patients used more blue 

in study 1 and controls less, but these small fluctuations did not affect the outcome of no 

significant difference between groups. 

There was little difference in the findings of studies 1 and 2 for yellow. Both 

depressed patients and schizophrenics scored only slightly higher than brain injury in 

study 1 which group was not included in study 2. Controls used slightly less yellow in 

study 2, but were still differentiated from schizophrenics, the group who used least. 

Generally the scores for intensity hovered around the same point, neutral for both 

studies. Controls scored much higher than the patients in study 1; in study 2 the 

schizophrenic score was lower than the rest and this is probably attributable to better 

308

diagnostic grouping, but the controls' score was also reduced, so these two groups were 

identified as significantly different, by approximately the same proportion in both 

studies. 

Two study variables were subjected to a change of scoring procedure for study 

2, so they cannot be accurately compared, but general findings are similar although 

sharper distinctions are drawn. 

There were significant differences in line in both study 1 and 2 between controls 

and patients. Study 1 records more variation than study 2. This is probably due to the 

combined assessment of painted and drawn line in study 1 which tends to see painted line 

as thick and drawn as thin when adjacent, but then judges on relative thickness when 

separated. The position of controls was reversed when the painted line was separated 

from the drawn line, from most (painted) to least (drawn), which probably explains their 

thick line scores in study 1, when there were no thick line scores in study 2 in either 

painted or drawn line. 

The rating for space was made simpler for study 2, so scores cannot be so 

accurately compared. The scores indicated the same sort of media coverage of the surface 

area (the scores for study 1 represented the average percentage coverage of square, and 

in study 2, the average space per square); no group had predominantly empty pictures. 

So generally scores for study 2 were similar to those for study 1 except that 

schizophrenic pictures seemed to cover more surface area and thus the controls were not 

differentiated. This could be an effect of another group characteristic secondary to 

schizophrenia but it is likely that this was an effect of the scoring procedure for study 

309

1, as generally the scores for schizophrenia were stable in other areas, indicating a similar 

percentage of space used. The groups showed more 'bunched' positioning in study 2 at 

around 25-30% space, this had the effect of isolating the controls at around 10-20% space 

in study 2. 

There were slight differences in four variables which produced distinctions from the 

results of study 2: there were trends but no significant differences for study 1. 

Although controls and depressives used about the same amount of red in both 

studies, substance abusers and particularly schizophrenics used much more red in study 

1. Some schizophrenics and some substance abusers for study 1 also had personality 

disorder, which tends to scatter the results (from study 2). Study 2 isolated the controls 

from substance abusers and put the schizophrenics level with depressed, who had not 

fluctuated and were a more discrete group. 

Apart from substance abusers whose score reduced considerably in study 2, there 

were only minimal differences in green between study 1 and 2, but it was enough to 

isolate the controls, who scored slightly more than most of the patients. 

Substance abusers scored much more black in study 2, which isolated this group 

as significantly higher scoring than all other groups. This could be an effect of better 

grouping. Depressives showed slightly higher scores for black in study 1 but some 

secondary diagnoses were alcohol related; the schizophrenic group in study 1 included 

psychosis due to drug and alcohol use. In study 2, the majority of the substance abuse 

was for alcohol and the schizophrenic group did not include psychosis: if drug use pushes 

up the black score, it would explain both higher scores. The drug abuse group scored 

310

much less in study 1, but the sample were mostly outpatients using varied substances in 

a recovery state, whereas for study 2, they were inpatients, more homogenously alcoholic 

and mostly in an acute state. This different group explanation does cover the 

possibilities, an alternative could have been that content influenced work, but this is 

unlikely because the controls who worked in the same surroundings at the same time 

remained constant. These results support the explanation of differences between groups 

for study 2 (at the beginning of this chapter) suggesting that substance abusers may 

communicate more subjective unhappiness through their work than other groups. 

Emotive tone should certainly be affected by content and differences were 

expected between studies 1 (fixed content) and 2 (free content). All groups were slightly 

negative in study 1, with no significant differences; in study 2, all groups were slightly 

positive except substance abusers, whose pictures contained more large quantities of 

black, but whose rating remained stable but relatively lower than other patients. 

Schizophrenics increased their score only slightly, but the pictures of depressives and 

controls were both more positive. The only thing that changed in free content was that 

controls were differentiated as more positive than all patients. 

Summary: Generally, trends from study 1 were followed in study 2, and mostly, groups 

remained surprisingly constant in their use of colour and structure in their pictures, with 

one or two exceptions from particular groups. However, fluctuations due to changes in 

the painting generation procedure, the sharper definition of the patient groups and greater 

311

numbers resulted in differentiation for study 2, where study 1 showed no differences. 

In study 1: 

Controls showed 8 small fluctuations, 6 were probably attributable to content: 

From 4 colour variables, less red, yellow and brown and more blue, only red made 

a significant difference. Their paintings were viewed as less positive and more 

intense. The other two were attributable to changes in the measure: they left 

more space and they used more or thicker lines. 

Substance abusers used more green, less black and yellow. These were all large 

fluctuations and probably attributable to better grouping in study 2. 

Depressives used more blue and brown, less yellow, more line and their paintings 

seemed more negative. They were small fluctuations probably attributable to 

content and made no significant difference. 

Schizophrenics used more red and black and less yellow; their paintings showed 

more space and were less intense. These fluctuations were probably attributable 

to better grouping in study 2. 

All these fluctuations resulted in 6 changes of significance level for study 2, which mostly 

followed the trends from study 1. Although there were differences in the methodology 

of the study, the way some of the categories were rated, the sampling and the results 

from the items rated the general conclusions remained the same: 

Controls were most different from substance abusers and schizophrenics. 

There was least difference between Schizophrenia and Depression. 

312

Patients were clearly differentiated from non-patients. 

In addition, the differences reported from the findings of the DAPA to what is regarded 

as common knowledge in the literature were maintained: 

There was no greater use of black in depressives compared with other groups. 

Depressive paintings were not more negative than those of other groups. 

There was no consistent impoverishment in the pictures of depressives or 

schizophrenics compared with other groups (although pictures by patients 

generally covered slightly but significantly less picture area than those of controls 

in study 2, and schizophrenics used less colour). 

Generally then, the conclusions of Study 1 are supported by study 2. The effect 

of content seemed to be greater on the controls, which was against expectations, and 

better grouping seemed to affect the scores of substance abusers and schizophrenics 

most. 

This measure has the facility to clearly distinguish psychiatric patients from 

controls and also different diagnostic groups from combinations of variables (see results 

section; identification of groups by characteristic). Patients and controls were clearly 

differentiated by most colour ratings and all structural ratings. The findings from study 

2 are consistent with results from study 1. In addition, preliminary finding from study 

1 of inconsistencies in commonly believed characteristics of pictures by patient groups 

were supported. 

In Study 2, 6 from 12 variables, which appeared frequently enough to measure, 

were identified as discriminating groups at very high levels of significance and 4 variables 

313

at or above the usual level. Personality disorder was particularly hard to differentiate, but 

this may reflect wide symptom variability in diagnosis. In the early stages of 

experimentation, it would be more appropriate to use groups which are more clearly 

differentiable diagnostically. Difference in content did affect formal measures of 

paintings, but not as much as predicted by Amos 337 . There were however, large 

differences for emotional tone, the only content variable. It seems that pictures were 

more discriminable using free subjects than with content held constant, so this study also 

predicts possible discriminable differences in content, the measures for which, as 

presented in the published literature, presently do not compare well with the DAPA in 

reliability and discrimination. This study points towards a common metric which could 

contribute to art assessments and complement the present analytic or dynamic methods. 

Discriminatory power between controls and patients 

This part of the chapter examining the comparison between results of the DAPA and 

what is generally accepted as art characteristics of patients by the psychotherapy 

literature discusses the validity of the discrimination between patients and controls using 

(i) comparison of effect sizes with the literature and (ii) the discriminant analysis. 

(i) Is the DAPA a better assessment than the other tests reviewed in Chapter 2? 

Effect sizes 

337 This study clearly refutes the statement by Amos (1982), op.cit. that "prognostic and therapeutic 

implications for the content of schizophrenic drawings remain largely a matter of interpretation and clinical 

judgment. This will be the case for composition, style and use of colour also". 

314

The magnitude of the relationship (effect size) for characteristics of pictures was 

calculated in Chapter 2 for the 11 studies which gave interpretable results as though they 

were independent. This strategy was perhaps controversial as an assessment of the 

papers judged because of interrelationships between the variables. It was justified 

because it gave an indication of the type of characteristics measured by the vast majority 

of studies which give either insufficient information or whose methodology obviously 

compromised the results. There would be a vast degree of multicollinearity in these 

relations, but it is impossible to sort out because of many reasons, not least these major 

contributions to confusion: 

Most of the categories, which were put together by the author from similar 

indices of different studies, were probably heterogeneous within tables. This 

means that where 'line' was measured in one study, 'line' in another study was not 

the same element; 

All studies used different variables from each other, and different diagnostic 

groups, so it was impossible to compare even pairs of studies. Replications often 

brought up different results. 

Of 14 categories from the literature review (effect sizes calculated in Chapter 2), 

the categories of line, form and colour achieved negligible effect sizes (below _=0.02) 

where the DAPA effect sizes were medium and large for line and form and averaged above 

medium effect for colours, which were measured separately (large effects on red and 

green) and a medium effect for the DAPA category of intensity which was also measured 

separately; the space category from the literature review achieved a small-medium effect 

315

size (_=0.36) which contrasts wildly with the medium-large effect from the DAPA 

(_=0.74); 7 other separate categories were encompassed under the DAPA emotional tone 

category: three categories, those of themes, reality and complexity which seemed very 

close in meaning but were measured separately by most studies, showed negligible effect; 

quality showed a low effect; energy and composition, medium effect. Only content as 

defined by counts of specific psychiatric indicators showed a high effect comparable to 

the general category of emotional tone. The other high effect from the literature review, 

body details was not included in the DAPA, there was a medium-high effect on control 

which was not included in the DAPA test and neither was detail in other areas (which 

achieved a small effect). 

The deletion of negligible effects from the literature review set of categories gave 

a subset of 8 significant areas of measurement of drawing with a medium effect size 

(_=0.57), and is still lower than that of the DAPA, but it only covers two DAPA 

categories and was relatively overloaded on content. The DAPA test therefore seems 

more sensitive to different areas of measurement of a painting and is potentially a more 

effective discrimination tool. However, the t-test does not take account of 

interrelationships between variables, nor the number of tests performed 338 so this 

analysis is limited to a theoretical comparison of independent effect of the variables with 

that produced in Chapter 2 and is not an appropriate measure to predict practical 

discriminations. 

338 We could use the Bonferroni correction here, but it merely confuses the data and the problem of 

correlation of the variables remains and it is better to use the following analysis. 

316

(ii) The Discriminant analysis technique - Which variables discriminate between 

patients and controls? 

There were 6 common variables which turned up 3 or more out of 5 times in the 

derivation of the function from 5 different partitions of the data set: most of which 

variables showed the largest effect sizes identified above. Step 1 used Emotional tone, 

which had the largest effect (_=0.92) or green (_=0.89), which had the highest F to enter. 

The other variables in order of their appearance were: Form (_=0.88), Space (_= -0.74), 

Drawn line (_=-0.56), and Black (n.s.). Painted line, which did not appear, was highly 

negatively correlated with Drawn line and so the effect must have been accounted for 

with the entry of Drawn line as it is unlikely that the F value was not high enough on 

Painted line. It is a mystery to me, given the small effect size, why Black was chosen as 

a discriminating variable, unless it was because it took the large effect of Red because of 

the high negative correlation. The results for the ANOVA show that controls were not 

differentiated on either high or low black from the patients. Red was highly correlated 

with intensity, which also wasn't included. On the two occasions Red did turn up, none 

of the 6 common variables were consistently absent, so it was probably excluded because 

its effect became negligible after accounting for other variables. The middle effects were 

not included; Yellow, Brown, Intensity, Painted line, although Drawn line (_=0.57) was 

included and Blue (_=0.36), so these low effects were probably due to correlation with 

Green, although they all showed F less than 1 when the analysis stopped. The 

discrimination set therefore contained most of the variables with high effect sizes and was 

generally consistent with the independent t-tests for effect size. The best discrimination 

317

sets had all the identified high effect variables involved in the discrimination, and the least 

had only 3. Therefore, the best discrimination probably includes most of the variables, 

which was consistent with their correlation with the discriminating function; so 

interactions were complex and there was no major influence from one or two variables. 

Using the information from the discriminant analysis and the t-tests we can say 

that content is a powerful discriminatory index, it comes first in the discrimination 

analysis and it has the highest effect size in both the DAPA and the reviewed literature 

analysis, but that the caution with which most authors regard molecular analysis is 

justified, because few of the molecular measures of content in the review analysis actually 

discriminated. The highest effect from the review, for counts of psychiatric 

characteristics, was highly subjective and probably difficult to operationalise, whereas 

the DAPA global judgement was equally effective and did not require rigorous 

procedures. Green was highly discriminative, but the tests in the review used a different 

index; i.e. 'quality of colour' tests, in which some subset or other partial preprocessed 

colour judgement was made, often mixed up with subjective content judgements, and this 

may explain the difference in effect for colour. Black was included in dark colours. The 

next most valid discriminator was form, only one study in the review actually used it as 

a compound 339 ; different spectrums of shape and composition from other studies were 

found inconsistent. Space, which was mainly measured by perspective in the review, 

distinguished mental retardation but was not as effective as total cover, and of the rest, 

the difference in effect can be explained in that no other study produced a reliable strategy 

339 But raters found their measure difficult to understand and produced inconsistent responses. 

318

for estimating cover. Line was measured in many ways and inconsistently - many studies 

had to be excluded because of reliability issues and the main point of the line review was 

that line was difficult to measure objectively without relation within the picture. 

Because the other variables from the DAPA test are not included in the 

discriminant analysis does not necessarily render those non-significant, especially for 

inter-patient discrimination. The analysis worked slightly differently each time with each 

partition of the data removing certain variables for others. There were medium effects on 

colours and a different system of combining these might remove confounding correlations 

and it would also be useful to use a bigger sample of controls. These other variables may 

be important but the problems of multicollinearity must be addressed. This is a task for 

more extensive statistics which would not be appropriate on this sample. 

Weaknesses of the study 

The study was not able to control for medication, or IQ/ability; measures were recorded 

but casenotes were too inconsistent, so more independent measures could fine these 

results. The size of the control group was too small for proper comparison with each 

patient group and was not matched for age and sex, but these variables were statistically 

controlled and did not invalidate the main findings. Because the staff could not be 

assumed not to understand the purpose of the study, and as with any other such study, 

could have produced deliberately different paintings than the patients, two control 

measures were taken: most of the study was done on retrospective work - the staff and 

patients had already produced paintings as part of the recreational programme of the 

319

hospital; the mean of up to 10 paintings by each person was taken, and all comparisons 

were between groups, so a considerable number of the control group would have had to 

be deliberately and consistently altering their style to seriously affect the results. 

It must be restated here that diagnoses were necessarily quite distinct because 

ICD-10 classifications were made from casenotes, which included lists of observations 

of the patient by trained psychiatrists but nevertheless, some diagnoses may have been 

made from uncertain criteria. These circumstances were controlled as much as possible; 

difficult to classify cases and dual diagnoses were excluded, the groups were as widely 

distinct as possible and patients were usually in severe states requiring hospitalisation. 

Controls were as far as could be determined, functioning members of the working 

population, so existing mental health problems would have been mild and quite distinct 

from the patients. 

Strengths of the study as a whole 

Through a careful review of the literature, this study showed that traditionally the 

study of art has fallen into the domain of the subjective rather than the objective. 

Attempts to externalise subjective and probably non-verbal responses have usually relied 

on explanations which are longer and more complicated than the picture itself and 

influenced by expectation. The argument has been that significant indices of the quality 

or direction of a painting can be indicated by attending to intuitions and a combination of 

knowledge of style, skill and history of the maker that usually serves an encounter with 

art. In this sense mental projection onto the object is intrinsic to the nature of how the 

320

painting is made and viewed. But it has been shown that subjective impressions are 

rather more questionable when they are taken to be an interpretation of fact. 

The DAPA study took a scientific approach to look at what is produced as artwork, 

objectively and did not take account of mental projections onto the object. It attempted 

to measure on externally observable criteria what was publicly verifiable using quantified 

information, which made it easier to specify which aspect of the observation was being 

attended. 

Unlike other studies the DAPA took account of normal distribution of variables in 

order to adhere to the assumptions of the testing procedure and produce valid 

interpretation of the results. 

This study produced a reliable scale through the elimination of subjective decisions, 

which was consistent and unambiguous, and demonstrated a method of comparing 

agreement that was valid, unambiguous and more appropriate than previous studies. 

A careful and thorough testing procedure compared the essential elements with those of 

the previous literature and found some consistencies and gave coherent explanations for 

the discontinuities. 

Strengths of the DAPA 

It was important to establish whether the removal of content from judgements of 

paintings allowed diagnostic distinctions. The DAPA demonstrated an ability to make 

distinction between paintings from different diagnostic groups. This is consistent with 

previous findings using mixed form/content scales but the use of form increases the 

321

eliability of the test and shows the neglect of the literature in this area since formal 

measurements previously employed have been piecemeal and ineffective. The literature 

review showed that content measures can be reliable where such variables are carefully 

described and operationalised. The effect size for this study far exceeds that of previous 

content only measures and thus justifies further research. 

The DAPA can be used as a complementary assessment which does not interfere 

with normal art therapy programmes. It uses standard scientific terminology and 

produces quantitative continuous scores rather than ordinal or graded sections thus 

allowing more powerful statistical comparisons than previous tests. The DAPA does not 

require specific materials and does not need specialist art-trained staff. It does not 

require information from the patient about the painting, therefore inconsistencies are 

minimalised; the systematic approach eliminates attempts to interpret or judge intention 

and it is independent of the theoretical origins of the investigator. The DAPA is primarily 

a descriptive system which provides a standardised medium for a variety of uses and has 

potential for development. 

Although the assessment is quite difficult and training was required, interrater 

results were well ahead of the field. This study therefore supports the use of systematic 

art measures, especially in circumstances where additional verbal material is not available. 

Effectiveness of The DAPA: Error types, 1 and 2, can be related to mistakes in clinical 

testing; 1. To diagnose someone as psychiatrically unstable who is normal; and 2. to 

322

diagnose someone as normal who is psychiatrically unstable. The DAPA is more likely 

to err on type 1, which is on the side of caution. 

Variation was minimal in patient discrimination and ranged only from 95-100% 

on the selected cases and from 81-98% on the independent data; but the control sample 

ranged from 50-88% for identification on the selected sample and from 50-80% (although 

the average was 65%) on the independent data set using the function derived from the 

selected data. When the control sample size was bigger, i.e. when the function derived 

from the control group of 18 was applied to the independent set of 5, it produced a better 

discrimination. The sample size therefore looks like the most influential variation factor; 

greater numbers should improve discrimination. The correct classifications yield is 

comparable with other systems in use such as the G.H.Q. and the MSE, even though the 

patient sample included some with diagnoses which were widely scattered (personality 

disorder). It can be seen from the breakdown of specific differences earlier in this 

chapter, the widest confidence intervals were for patients with personality disorder, they 

most often spanned other groups and were hardest to identify so it is likely that the 

removal of these patients would increase the effectiveness of the discrimination. 

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Chapter 7. Conclusion 

This thesis represents an attempt to devise an empirical measure for art products that 

was theoretically coherent. 

Literature Review 

Chapter One argued that the approach to psychiatric art has neglected rigorous empirical 

study of psychopathology in favour of phenomenology. 

The literature review reported that impressionistic papers provided some 

theoretical consensus that a change in the patient was reflected in the artwork of the 

patient, but there was little sequential comparison offered or relation to the method to 

direct the change, and no evidence of a coherent system to access the artwork. Claimed 

benefits were independent of assessment of the patient or the work, aims or descriptions 

of the therapy and explanatory theory. 

There were 4 routes of access to the image from Case studies: 

1. Most therapists who claimed the artwork produced expressed feelings did not 

define this term, nor present their rationale for relation of feelings to the image. 

They described their use of paintings to monitor progress and develop 

communication, but there was no common base for interpretation. 

2. Signposts Content characteristics identified were dependent upon the importance 

of associations assigned by the therapist. Formal characteristics were overladen 

with emotional terminology, often negative, and there were conflicting findings 

324

from different studies using slightly different definitions. Both of these categories 

lacked standard objective definitions of visual phenomena. 

3. Studies emphasising the therapeutic relationship were all based on a allegorical 

model of activity which did not relate to the picture at all. 

4. Studies which emphasised behaviour change simply described the environment 

of the art room as a relaxing or useful friendly site for implementation of new 

patterns of behaviour. 

Contrary to the contemporary recommendations towards accumulation of this 

kind of reportage as 'data' to be compiled later 340 , there was little transferable information 

relevant to the investigation of the decoding process; it was reported obscurely, 

subjectively, and inconsistently. Benefits reported were subjectively described by the 

reporter and there was no independent evidence. Benefits were found to be unrelated to 

the methods used and the treatment given often bore little relationship to the assessment. 

There was agreement that aspects of visual art did indicate psychiatric status and that 

therapy based on art was beneficial to the patient, but not on description of 

characteristics of paintings, nor on how art related to the therapy. 

Controlled studies 

When the one rater studies, invalid instruments and unreliable variables had been removed 

for the meta-analysis, content measures showed a higher overall effect than form, 

340 

Among others: A. Gilroy (eds.) (1992), Research in Art Therapy, in D. Waller and A. Gilroy, Art Thera py: A 

Handbook , Buckingham: Open University, p.238 advocates the comparison of amassed case 'evidence', but has not 

attempted such herself. L. Gantt (1986), Systematic investigation of artworks: some research models drawn from 

neighbouring fields, Am. J. Art Therapy ,V.24(4):111-8, recommends case studies as the optimum research mode 

325

probably because the form variables were fewer, widely scattered and defined more 

explicitly. Additionally, it was shown that the structures and conceptual fields in which 

drawings were assessed, which were adopted by most studies, may be irrelevant. Thus 

the conclusions of the case studies were repeated - art is sensitive, but we cannot say to 

what it is sensitive. 

There was a significant effect for most of the elements which were assembled into 

the drawing categories defined by the reliablity tables; they differentiated patients from 

controls and patients from other patients. The instruments reviewed discriminated 

controls better than patients. Empirical studies which found no difference were fewer, 

were less controlled and used less valid instruments, with more content-based scales than 

those which found differences. Subjective categories which required interpretation, fine 

distinctions and global judgments were the most unreliable. There were widespread 

conceptual mistakes in the use of mathematical language, flaws in the testing procedure, 

validation of the measure, the analysis and the interpretation of results. 

The DAPA: Development of a valid instrument 

From the literature analysis, it was reasonable to suppose that if the object presented 

some discriminable quality which was consistently encoded in the structure of the work, 

proper analysis of the object would reveal traces of it. 

Objective formal categories were more reliable and accessible than content 

categories. The DAPA presented a more systematic method than most tests currently 

for therapists, as others, see introduction. 

326

in use because it distributes the elements over the whole painting rather than 

concentrating on a part of the image to be subjectively decoded. This systematic and 

objective system is innovative since previous instruments have always placed the 

emphasis on meaning and therefore concentrated on part of the object. It has been 

recognised, although not very widely, that statistics for drawing tests are often unreliable 

because there is physically less, or less definable image, on the patient side 341 , as well as 

a limiting effect because of inadequate translation of intention. This was not a problem 

for the DAPA because the avoidance of subjective identification of elements of content 

throws the focus on the structure of the work, no translation is required. 

Effectiveness and validity of the DAPA 

The DAPA was developed as a psychiatric assessment to objectively define and describe 

psychopathological criteria of paintings. It comprised 6 rating scales of mostly formal 

elements derived from predicted psychiatric symptoms from clinical observations of 

psychiatric pictures and from the literature: colour, intensity, line, space, emotional tone, 

form. 

In three studies, the DAPA has proved: 

reliable 

flexible enough to be used retrospectively 

discriminatory: between patients and nonpatients and to a lesser extent 

341 

Stanley R. Kay (1978), Qualitative differences in human figure drawings according to schizophrenic subtype, 

Perceptual and Motor S kills , V.47:923-932 - reporting floor/ceiling effects in retarded schizophrenics. This effect 

is often reported as 'statistically but not clinically significant'. 

327

etween different groups of patients. 

The Main Study 

The main study reported a validation experiment with 109 subjects, in which there were 

no specific instructions to patients and where there would be no interference with the 

therapeutic milieu. It was hypothesised there would be significant difference between 

two or more diagnostic categories of patients or controls on each of the 12 remaining 

subscales after 3 infrequent colours were removed: colour (1-6) - red, yellow, green, blue, 

brown, black; intensity (7); line (8-9) - painted and drawn; space (10), emotional tone 

(11) and form (12). 

Paintings were collected from controls and hospitalised adult patients mid- 

treatment. Patients fit the ICD10 categories for: schizophrenia, major depression, 

substance abuse, personality disorder. 

Results: Analysis of variance showed significant difference between two or more groups 

on ten subscales from 12. The Duncan pairwise post-hoc comparison showed differences 

in patient/control pictures and between patient groups. 

Patients were significantly different from controls on: 

Schizophrenics on 6 variables: yellow, green, black, intensity, emotional tone and 

form. 

Depressives on 3 variables: space, emotional tone and form. 

328

Personality disorder on 5 variables: green, drawn line, space, emotional tone and 

form. 

Substance Abusers on 7 variables: red, green, black, painted line, drawn line, 

space, emotional tone. 

Within patient significant differences: 

Schizophrenics from depressives on 2 variables: black and form; from substance 

abuse on black. 

Personality disorder from depressives on form; from schizophrenics on intensity; 

from substance abuse on black. 

Substance abusers from depressives on 4 variables: black, painted line, drawn line, 

form; from schizophrenics and personality disorder on black. 

Only three variables showed differences that isolated diagnoses - black (2 diagnostic 

groups isolated); emotional tone, and dominant form. It seemed likely the other groups 

could be isolated through combinations of variables. The discriminant analysis technique 

was the most appropriate instrument for predictive analysis, but entry for significant 

variables was complicated by association between measures. The functions derived 

varied from 3-6 variables, and suggested that most of the variables contributed to the 

result. The analysis consistently differentiated differences between patient and controls 

80-90% accurately. Unlike the measures from the literature, the DAPA differentiated 

patients better than controls. This was encouraging for further development of the 

measure and suggested that formal analyses of paintings provide a extra dimension, 

329

previously unexplored, which complement traditional content interpretation and may 

contribute considerably to the research knowledge of the field. 

The findings do not support the traditional view of colour interpretation. They 

do support the broader picture of artistic impoverishment in psychiatric populations. 

It was important to establish whether the removal of subjective content from judgements 

of paintings allowed diagnostic distinctions. The DAPA demonstrated an ability to make 

distinction between paintings from different diagnostic groups. This is consistent with 

previous findings using mixed form/content scales but the use of form increased the 

reliability of the effect and showed the neglect of the literature in this area since previous 

attempts at systematic measurements have been piecemeal and ineffective. The effect 

size for this study far exceeds that of content only measures and thus justifies further 

research. Though the DAPA worked well, the view of the majority of the literature, 

of content based scales as more sensitive than formal elements, is nonetheless supported, 

because it was the content features of the DAPA: emotional tone and form which gave 

the best and most accurate discrimination. 

The main findings of this study are augmented by the literature review in that it 

was shown that there was no evidence of privileged knowledge available to art 

therapists 342 . Thus the concept of privileged knowledge was unhelpful to the 

development of appropriate theory for this area of investigation, and therefore small 

samples with long texts on personal interpretation have not been helpful to identifying 

342 This has already been recognised for years in the experimental literature, but is not generally acknowledged. 

Study by B.I. Levy and E. Ulman (1967) Judging psychopathology from paintings, J. Abnormal Psychology, 

V.72(2):182-7. 

330

the features of psychopathology. This finding, and the fact that some traditional 

gradations of drawing features were ineffective as discriminators opens up a whole new 

area of primary exploration in both formal and content evaluation. 

Is the DAPA better than other art assessments? 

The question whether the DAPA is better than other art assessments is meaningless. 

Previous assessment methods have tried to do two jobs: to provide a standardised format 

for art therapy approaches, and also to provide immediate accessible lists of 

characteristics from an individual picture for the art therapist. The DAPA assessment 

requires much processing and is not suitable for these purposes. No immediate 

impression can be gained from its indices. However, no other published art assessment, 

to my knowledge, provides a replicable, reliable and effective discrimination between 

patient groups. Effect size comparison between patients and controls places the DAPA 

far above the rest of the field. The majority of other tests assess content as a whole and 

then relative to parts; the other apparent structural indexes are hardly mentioned, 

although they are commented on qualitatively. The DAPA results show that the raw 

data for a simplified objective measure of content (emotional tone) only just satisfied the 

assumptions for ANOVA and the energy-focus of the picture (form) did not satisfy the 

criteria. Simplified statistics therefore are not appropriate for these measures and as far 

as I know, none have taken account of distribution bias or of correlations between the 

variables. This problem of multicollinearity, in addition to the problem of misused 

331

statistical tests and missing data makes most studies uninterpretable and therefore 

incomparable with this study. 

Where do we go from here? 

Improvements and further development of the instrument: 

Replication studies should take into account the weaknesses already mentioned in the 

rating procedure, and use better criteria for patient diagnoses. It is obvious that content 

measures are inescapable even though their rating is difficult and can be inconsistent. 

Greater complexity in description and fine discriminations simply promote confusion and 

do not add significantly to the discrimination properties of the instrument. Furthermore 

human beings cannot simply attend to form and discard the image. Gibson explains that 

a person can: 

notice only the information for the perception of what is represented or he can pay 

attention to the picture as such, the medium, the technique, the style, the 

composition, the surface, and the way the surface has been treated, what is 'in' the 

picture or to the picture itself .... a person can never fully attain to the 

representational attitude and wholly exclude from attention such features of the 

picture itself as its surface texture or its arrangement of line and colour. 

What is needed for further development is a very simple level of measurement at which 

form and content become one. Form in the DAPA context is not a simple matter of 

configuration. Any picture has properties referring to itself and referring outside it when 

relating to something else. The discardable concepts can be understood as those which 

332

elate the picture to external things. What is needed could be synthesised in a new 

concept of feature, where content is measured through the formal internal properties of 

the picture rather than relating to the external, like the measures of dominant form and 

emotional tone already employed on the DAPA, so that they specifically and 

consistently relate to the observer and not to other associative mental projections. This 

is basically what has been attempted all along by previous empirical studies which have 

developed so-called 'formal' analyses. Many describe the 'measurement of pictures' as 

if it was self evident how and what was being measured, often without going through the 

rigorous process of testing the measure appropriately and use evasive and immaterial 

concepts; this is not the answer. The attempt to evolve a metric of visual form through 

the problem of measuring visual form or pattern is a subject ideally addressed by 

objective or scientific research. It may well be a mistake to suppose that expression 

always lies outside the reducible qualities of measureable dimensions. The incorporation 

of 'feature', using the objective internal relation to the picture, offers a potential bridge 

between form and content and is already regularly and reliably used in projective testing, 

such as the appearance of, for example, figures in a painting, and their relative size, 

without going into the psychodynamic inferences. 

The future for measures of psychopathology 

The validity of the sole use of assessments which rely on an interpretative 

construct by the therapist must be questionable, especially in cases where the patient is 

verbally compromised. If there is no relation or an indirect relation between visual and 

verbal symptomatology in the patient, then we cannot use verbal explanations of visual 

333

psychopathology in clinical diagnosis. There are two main arguments to map its 

characteristics: 

a) All the advances in psychiatry have been based on a careful and complete descriptive 

psychopathology of phenomenology. A phenomenology that does not include 

visuospatial elements cannot be a complete description. 

b) The verbal phenomenology under Mental State Examination is hidden in many 

disturbed patients e.g. drug addicts; conduct or behaviourial disorders in children; 

personality disorders and some emotional disorders. If the verbal differential is lacking, 

then the case is diagnosed solely on the history. The descriptive psychopathology of 

artwork by the patient may show other phenomenology which may be categorisable and 

assist differential diagnosis in difficult situations. 

Thus the future must be towards greater distinction and more precise 

measurements. The obvious development here would be to adapt this system for a 

computer programme, using more section divisions, to take advantage of the greater 

facility of scanning technology and repetitive consistent decisionmaking. 

Further development taking account of the weaknesses of the study, replication 

and refining of the instrument is indicated. 

334

Appendix 1 

List of Variables for Analysis of Commonalities 

1. Impressionistic/Theoretical Studies 

2. Case Studies - therapeutic benefit - expression of feelings 

3. Controlled Studies 

4. Validity Studies 

335

6 scales to categorise commonalities in impressionistic, theoretical or experiential papers 

which report therapeutic effects or benefits of art for psychiatric patients. 

One category for each scale, except benefit, where the most emphatic four benefits were 

selected. 

1. Origin of study material, descriptive Information: 

Opinion - Author's philosophy with no specific support, but might 

reference others. 

Discussion - Argues two or more sides of an issue. 

Experience - Report of a specific personal experience using art in 

therapy with psychiatric patients, sometimes illustrated 

and called a 'case report', but with no patient information. 

Programme - Description or update of an arts therapy hospital 

programme. 

2. Diagnosis: under these groups from information in the paper: 

1 schizophrenia; 2 traumatic stress/sex abuse; 3 substance abuse; 4 psychotic; 5 

Alzheimer's/dementia/brain damage; 6 emotional disorder; 7 depression; 8 conduct 

disorder; 9 normal; 10 retarded; 11 undifferentiated psychiatric patients; 12 sex 

abnormalities/abusers; 13 personality disorder. 

3. Theoretical base: 

Psychotherapeutic - supportive, interpretive, humanistic, therapeutic. 

Psychoanalysis - using psychoanalytic language (may not have been 

traditional or valid). 

Environmental - using the art environment for educational or functional 

support or stimulation. 

Social/ using the social group for interaction, providing an 

developmental accessible activity, using behaviourial treatment in the group 

environment. 

Energy theories - suggestions that the patient can be affected by the power 

of the unconscious mind whilst engaged in art, and that the 

therapist can be a conductor of the power. 

Assessment - diagnostic drawings, using art as an initial interview with 

the patient. 

4. Author's personal explanation of how art promotes therapeutic change 

Signposts Patient illustrates their trauma or illness, objectifying it, 

allowing access for therapist. 

Self healing Art as healing in itself, or the therapist as a conductor for 

power from the unconscious. 

Group interaction - Observing behaviour of the group or of an individual whilst 

patient drawing. 

336

Insight New perception of the patient's problems through 

representation of self. 

Transfer of skill - Transfer of learning from one area to another. Thus patient 

may paint angry feelings and explore visually possibilities 

of containment which may be used practically later. 

Communication By visual presentation things patient finds difficult to say, 

increasing understanding through image. 

No explanation Author assumes agreement or no offer of explanation. 

5. Any four benefits derived from art, for the patient, where the author mentioned 

these kind of words: 

Expression of feelings - cathartic expression of feelings, representation of 

the unconscious, psychic energy, expression of 

trauma, self expression and projection. 

Development of a skill - social benefits, practical confidence through skill, 

problem solving strategies, self mastery, creative 

skill, record of progress (for the therapist). 

Communication Cuts through verbal defences, diagnostic, 

verbal/visual bridge, promotes understanding (of 

the patient) and support. 

Self awareness self documenting, reality testing, promotes insight, 

promotes body awareness, male/female issues, 

cognitive gain. 

Symptom Relief healing, resolution of conflict, reduction in anxiety, 

promotes growth, remission of illness. 

Relationship - counter/transference, nonthreatening, friendly, 

alliance. 

6. Against - Observations of negative effect on the patient or the therapist. 

Resistance by patient, limitations of patient, withdrawal or 

confrontation. 

Therapist limitation - Method too powerful, limitations of the therapist, 

individual theory, projective guesses, respect for 

patient's interpretations. 

Standards Low status of art therapy. 

Patient approach Structure of the session wrong, aggression, frivolity 

and setting wrong. 

5 scales to categorise commonalities in 67 case studies with primary benefit of 

expression of feelings; papers report illustrations of the images drawn by the client 

with some demographic and diagnostic information. 

Descriptive information: Age: adolescent (under 18); adult (18+ below 60);old (over 60) 

Sex: male, female, mixed (group). Diagnosis - as impressionistic studies. 

337

Orientation of the researcher, what were the intentions: 

Not known or stated 

Cognitive - 

Projective - projective methods, designed to elicit information about the 

patient's problems, interpreted pictures as representation of self. 

Occupational art as a stimulating or pleasurable activity for the patient. 

Analytical used psychoanalytic theory and language to interpret patient's 

painting in terms of archetypal imagery, universal symbols etc. 

(may not have been traditional or valid). 

Method of Study, description of the practical techniques of eliciting expressionistic work: 

Projective Used a projective test or protocol with some standard meanings 

for content. 

Psychoanalytic Interpreted using psychoanalytic language and concepts (may 

not 

have been valid or intelligable). 

Expressive Primarily eliciting emotional responses and individual expression. 

Occupational Used art as stimulation activity or educational/social activity. 

Comparitive Compared one painting or set with another on formal, content or 

other grounds directly. 

Form of Study, what type of material did the researcher extract from the study: 

Formal Objective or stylistic elements. 

Content analysis Interpretation of subjects of painting, of relationships 

between elements of painting as representing patient. 

Mix of content and style. 

Behaviour Analysis of how the patient behaved in the session, 

emotional, quiet etc. 

Verbal analysis Psychotherapy with the pictorial element as a backdrop. 

Other 

Benefit to the patient, through expression of feelings from the making of art: 

Cathartic/ Intense emotional sense of 

reflective release with new insight. 

Communication Able to talk about or refer to emotional experience. 

Healing/symptom Patient feels better, disturbing 

relief behaviour declines. 

Developmental/ Patient behaves more emotionally 

social mature, and interacts socially. 

Relationship Patient draws comfort/value from the relationship with the 

therapist. 

13 scales to categorise Controlled Studies. Papers reported an empirical study of a psychiatric group with 

one or more normal or patient control groups. 

338

Demographic 

Sex, Age, Diagnosis all as cases. 

Number of subjects in experimental group 

Total no subjects in study 

No. judges in study: authors, other than authors. 

No. independent measures in this study 

Orientation - What the therapist was trying to achieve/ type of therapy offered by the therapist. 

Comparison test only between groups 

Expressive To elicit expression of feelings through the artwork. 

Therapeutic/ To help the patient solve problems or gain insight through 

self actualising rendition of experience through art. 

Behavioural/ Provide peaceful/friendly environment where patient feels 

non-art comfortable or can be active. 

Measurement method - what the instrument was designed to measure 

Direct Comparison of visual characteristics of the patient/control artwork, e.g. circles 

or shapes or lines or colour. 

Meaning Therapist interprets patient's artwork and compares meaning, e.g. happy or 

lonely. 

Mixed Mixed visual and interpreted characteristics. 

non-art Non-projective, non-art measure of behaviour, e.g. quiet, lively. 

verbal Verbal interactions, where therapist records quantity, or quality of language. 

Design of the study 

Pre and post intervention 

Post intervention only 

Direct comparison of current artwork 

Retrospective comparison of artwork. 

Derivation of the main study measure 

One test used, developed for this study 

One test used, adapted from a previous test 

Established and validated test used 

Measure by observation of patient 

Measurement form, what type of elements of the picture was the measure actually sensitive to. 

Form observable visual detail, including DAP 

Content subjects or themes 

Mix of form and content 

Behaviour of subject 

Verbal elements explained by the subject verbally 

Expressive elements of the pictures which the therapist felt expressed the emotional tenor 

of the patient 

Results 

Difference in experimental group and control 

Difference in subtypes of the same diagnostic group 

No difference 

Therapy groups (effect of therapy recognised) 

No association between score and criterion, inconsistent 

339

Validity Analysis of controlled studies. 70 studies reported criterion validity of art test. 

5 fields were tested. 

Demographic 

Sex, Age and Diagnosis as before. 

No. of criterion measures - Diagnosis and test = 1, any more added on. 

Form of Art Test - Form of information the art test collected. 

KFD Emotional indicators. 

DAP Cognitive/Developmental indicators 

Formal other 

Copy Copy drawing test measuring Control 

Other theme 

Free Spontaneous artwork no theme/instruction 

Form of criterion measure. 

Diagnosis 

Picture or self Objective visual (DAP) or descriptive. 

report 

Content or story Meaning of visual image or narrative. 

Mix content/form 

Non projective Non-art measure; I.Q. etc. 

behavioral; 

Verbal Patient describes experience articulately. 

Comparison: the type of quality the instruments were compared on. 

Cognitive function Ability or intelligence level. 

Emotional function Expressive assessment. 

Development According to set criteria. 

Diagnosis 

Statistics: 

Percentage agreement 

Correlation coefficient 

Mann-Whitney or _ 2 (non parametric association) 

Kappa 

Analysis of variance 

Results: association of the art test with the main criterion measure 

Differentiation among grades 

Differentiation towards objective elements 

Differentiation towards subjective elements 

Significant association no direction 

Test did not match or no significant association. 

340

Standard differences from the mean for DAPA variables from the results section, Chapter 5. 

6a. Standard differences from mean of each diagnostic group 

PLOT OF TRED 

________________________________________ 

_ 1 _ 

_ 1 1 _ 

.4_ 1 _ 

_ 1 1 1 1 _ 

_ 4 1 2 4 1 _ 

_ 3 3 1 5 1 _ 

R _ 7 8 5 4 _ 

E 0___7________3_______1_______2________1__ 

D _ 1 2 2 4 _ 

_ 1 2 1 _ 

_ 3 3 3 _ 

_ 1 4 1 _ 

-.4_ 5 _ 

_ 2 _ 

_ 3 _ 

________________________________________ 

1 2 3 4 5 

Diagnostic group 

6b. Standard differences from mean each diagnostic group 

PLOT OF YELLOW 

________________________________________ 

_ 1 _ 

_ _ 

_ 1 _ 

.35_ 3 1 1 _ 

_ 5 3 2 _ 

_ 4 2 1 3 1 _ 

Y _ 1 3 4 5 2 _ 

E _ 3 5 2 1 2 _ 

L 0___3________2_______2_______1 ________2__ 

L _ 2 2 1 1 _ 

O _ 3 2 2 3 _ 

W _ 1 2 1 1 _ 

_ 10 1 1 _ 

-.35_ 3 _ 

_ 2 1 _ 

_ 4 _ 

________________________________________ 

1 2 3 4 5 


6c. Standard differences from mean of each diagnostic group 

PLOT OF GREEN 

________________________________________ 

.75_ _ 

_ 1 _ 

_ _ 

_ 1 _ 

_ 2 1 _ 

G .375_ 1 1 1 _ 

R _ 1 2 1 1 1 _ 

E _ 2 1 1 2 1 _ 

E _ 4 2 1 3 _ 

N _ 2 2 3 4 _ 

0___2________3_______1_______3________2__ 

_ 4 6 3 1 4 _ 

_ 9 7 1 1 _ 

_ 7 4 1 1 _ 

_ 2 _ 

-.375_ 5 _ 

________________________________________ 

1 2 3 4 5 


6d. Standard differences from mean of each diagnostic group 

PLOT OF BLUE 

________________________________________ 

_ 2 1 _ 

341

_ 2 _ 

_ _ 

_ 2 _ 

.3_ 1 1 _ 

B _ 2 1 2 _ 

L _ 2 1 2 _ 

U _ 3 1 2 1 2 _ 

E _ 3 8 2 4 _ 

0___7________________3_______2________1__ 

_ 4 6 2 3 1 _ 

_ 4 3 2 1 _ 

_ 2 2 1 _ 

_ 7 4 2 2 1 _ 

-.3_ _ 

_ 4 _ 

________________________________________ 

1 2 3 4 5 


6e. Standard differences from mean of each diagnostic group 

PLOT OF BROWN 

________________________________________ 

_ _ 

_ 1 _ 

_ 1 _ 

_ 1 1 2 _ 

.325_ 1 1 3 2 _ 

_ 1 1 1 2 _ 

B _ 4 1 1 1 1 _ 

R _ 4 6 2 2 1 _ 

O _ 5 2 1 2 3 _ 

W 0___1________3_______3_______3________2__ 

N _ 1 2 1 2 _ 

_ 1 1 _ 

_ 1 1 _ 

_ 14 6 1 _ 

-.325_ 6 1 _ 

_ 5 _ 

________________________________________ 

1 2 3 4 5 


6f. Standard differences from mean of each diagnostic group 

PLOT OF BLACK 

________________________________________ 

_ _ 

_ 1 1 _ 

_ 1 2 _ 

.35_ 2 2 2 1 _ 

_ 2 2 1 _ 

B _ 2 3 2 1 1 _ 

L _ 3 6 2 1 1 _ 

A _ 8 5 1 1 1 _ 

C 0___1________1_______1_______4________1__ 

K _ 2 3 3 1 _ 

_ 5 2 1 1 _ 

_ 5 2 1 1 _ 

_ 4 2 1 1 _ 

-.35_ 1 1 1 _ 

_ 1 1 _ 

_ 1 1 4 _ 

________________________________________ 

1 2 3 4 5 


342

g. Standard differences from mean of each diagnostic group 

PLOT OF COLOUR INTENSITY 

________________________________________ 

I _ _ 

N _ 1 _ 

T .8_ 3 1 1 _ 

E _ 3 1 _ 

N _ 3 1 3 5 _ 

S _ 2 2 2 3 _ 

I _ 4 4 3 5 2 _ 

T 0___6________6_______3_______1________2__ 

Y _ 5 6 1 1 _ 

_ 1 3 2 4 _ 

_ 3 1 1 _ 

_ 2 1 1 2 _ 

-.8_ 1 2 1 _ 

_ 1 _ 

_ 2 1 _ 

_ _ 

________________________________________ 

1 2 3 4 5 


6h. Standard differences from mean of each diagnostic group 

PLOT OF PAINTED LINE 

________________________________________ 

_ 1 _ 

_ 1 _ 

_ 1 _ 

_ 3 1 1 _ 

.6_ 3 1 3 _ 

P _ 6 2 1 4 1 _ 

A _ 1 1 1 1 _ 

I _ 3 5 1 _ 

N _ 2 1 2 _ 

T 0___3________1_______3________________2__ 

E _ 2 1 1 1 _ 

D _ 13 2 _ 

_ 4 1 1 _ 

L _ 3 _ 

I -.6_ 12 5 _ 

N _ 7 _ 

E ________________________________________ 

1 2 3 4 5 


6i. Standard differences from mean of each diagnostic group 

PLOT OF DRAWN LINE 

________________________________________ 

_ _ 

4_ 1 _ 

_ _ 

_ _ 

_ 1 _ 

_ 1 _ 

D 2_ 1 3 _ 

R _ 1 1 2 _ 

A _ 2 2 1 _ 

W _ 2 1 3 4 1 _ 

N _ 2 5 1 2 _ 

0___5________3_______4________________1__ 

L _ 6 4 4 15 _ 

I _ 14 6 4 _ 

N _ 2 4 _ 

E _ _ 

________________________________________ 

1 2 3 4 5 


343

6j. Standard differences from mean of each diagnostic group 

PLOT OF SPACE IN PICTURE 

________________________________________ 

S _ _ 

P _ 1 _ 

A 1_ 1 _ 

C _ 2 3 1 _ 

E _ 2 1 2 _ 

_ 3 4 2 3 _ 

_ 6 6 2 5 4 _ 

0__10________3_______1_______2________3__ 

_ 3 3 3 3 1 _ 

_ 6 3 3 5 _ 

_ 1 2 1 _ 

_ 1 2 2 _ 

-1_ 1 1 _ 

_ _ 

_ 1 _ 

_ _ 

________________________________________ 

1 2 3 4 5 


6k. Standard differences from mean of each diagnostic group 

PLOT OF SUBJECTIVE EMOTIONAL TONE 

________________________________________ 

E _ 1 _ 

M _ _ 

O _ 1 _ 

T .6_ 1 2 1 _ 

I _ 1 3 _ 

O _ 3 5 1 1 _ 

N _ 4 2 3 2 2 _ 

A _ 6 2 3 2 1 _ 

L 0___5________1_______3_______5_______1___ 

_ 10 4 6 3 _ 

T _ 1 2 1 1 _ 

O _ 2 1 4 1 _ 

N _ 1 3 1 1 _ 

E -.6_ 1 _ 

_ 2 _ 

_ 1 1 _ 

________________________________________ 

1 2 3 4 5 


6l. Standard differences from mean of each diagnostic group 

PLOT OF DOMINANT FORM 

________________________________________ 

_ 1 _ 

_ _ 

.35_ 1 1 _ 

_ 2 2 1 1 1 _ 

_ 1 1 2 _ 

_ 5 3 2 3 1 _ 

F _ 8 6 3 4 1 _ 

O 0___6________5_______4_______1________3__ 

R _ 7 5 1 3 2 _ 

M _ 1 3 _ 

_ 2 5 2 _ 

_ _ 

-.35_ 3 _ 

_ 3 1 _ 

_ _ 

_ 2 _ 

________________________________________ 

1 2 3 4 5 


344

7a. Standard differences from mean of each diagnostic group 

PLOT OF ORANGE 

________________________________________ 

_ _ 

.4_ 1 _ 

_ 1 _ 

_ 2 _ 

O _ _ 

R _ 2 1 _ 

A .2_ 1 2 _ 

N _ 2 1 3 _ 

G _ 2 1 _ 

E _ 2 3 1 _ 

_ 3 2 1 3 _ 

0___6________8_______3________________2__ 

_ 3 9 1 2 _ 

_ 16 9 1 1 _ 

_ 10 3 _ 

_ 1 _ 

________________________________________ 

1 2 3 4 5 


7b. Standard differences from mean of each diagnostic group 

PLOT OF PURPLE 

________________________________________ 

_ _ 

.45_ 1 _ 

_ _ 

_ _ 

P _ 1 _ 

U _ 1 1 _ 

R .225_ 1 1 _ 

P _ 3 1 1 1 _ 

L _ 2 1 2 _ 

E _ 3 2 2 _ 

_ 4 1 1 1 1 _ 

0___1________7_______2_______2___________ 

_ 10 14 11 2 1 _ 

_ 12 2 3 _ 

_ 1 2 _ 

_ 7 _ 

________________________________________ 

1 2 3 4 5 


7c. Standard differences from mean of each diagnostic group 

PLOT OF WHITE 

________________________________________ 

_ _ 

_ 1 _ 

.35_ _ 

_ _ 

_ _ 

W _ 1 _ 

H _ 1 _ 

I .175_ 1 2 _ 

T _ 1 1 _ 

E _ 4 1 1 _ 

_ 3 1 1 1 _ 

_ 1 2 1 _ 

0___1________1______17________________7 _ 

_ 25 19 1 _ 

_ 14 _ 

_ _ 

________________________________________ 

1 2 3 4 5 


345

Correlation table 16 for DAPA variables measured from the pictures of Schizophrenics: a. colours, and b. structure 

DAPA variables 1. Pearson's Product Moment Correlation Analysis 

N of cases: 35 2-tailed Signif: * .01 # .001 

Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 

Red Yellow Green Blue Brown Black 

1.0000 .3604 .4498* .3409 .2366 -.2392 

.3604 1.0000 .7880# .5083* .5327# .0984 

.4498* .7880# 1.0000 .6074# .6303# -.0796 

.3409 .5083* .6074# 1.0000 .2706 .0213 

.2366 .5327# .6303# .2706 1.0000 -.0111 

-.2392 .0984 -.0796 .0213 -.0111 1.0000 

.5791# .6586# .6732# .5751# .3489 .2365 

.4853* .3902 .4364* .4036 .0879 -.2120 

.1772 .2616 .2699 .2713 .3247 .0383 

.2521 -.0318 .0166 .0264 .1028 .0745 

.0116 .1564 .0404 .1680 -.0354 .0151 

.2649 -.0718 -.1720 .1975 -.2605 .0271 


N of cases 35 2-tailed sig *.01 #.001 

Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 

Intensity Line-pnt Line-draw S pace Em-Tone Form 

.5791# .4853* .1772 .2521 .0116 .2649 

.6586# .3902 .2616 -.0318 .1564 -.0718 

.6732# .4364* .2699 .0166 .0404 -.1720 

.5751# .4036 .2713 .0264 .1680 .1975 

.3489 .0879 .3247 .1028 -.0354 -.2605 

.2365 -.2120 .0383 .0745 .0151 .0271 

1.0000 .3566 .3319 .4098 .3551 .1667 

.3566 1.0000 -.4563* .1008 .1048 .0714 

.3319 -.4563* 1.0000 .1408 .0047 .1381 

.4098 .1008 .1408 1.0000 .4216 .1353 

.3551 .1048 .0047 .4216 1.0000 .2572 

.1667 .0714 .1381 .1353 .2572 1.0000 

Correlation table 17 for DAPA variables measured from the pictures of Substance Abusers: a. colours, and b. structure 



Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 


1.0000 .1202 .1591 .0345 .2509 -.0975 

.1202 1.0000 .2480 -.2749 .3064 .0492 

.1591 .2480 1.0000 .3457 .6377# -.0064 

.0345 -.2749 .3457 1.0000 -.0055 -.5103 

.2509 .3064 .6377# -.0055 1.0000 .1927 

-.0975 .0492 -.0064 -.5103 .1927 1.0000 

.2696 .2968 -.0543 -.3901 .3358 .2510 

.2723 .0004 .3538 .0279 .3176 -.0047 

.0087 -.4361 -.1727 -.3542 .0441 .3803 

-.0542 -.1900 -.5125 -.1555 -.3847 -.0569 

.3369 .3586 .3802 .1277 .3853 -.2912 

-.0218 .1279 -.5107 -.7608# -.1848 .3760 



Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 

Intensity Line-paint Ln-draw Space Em-Tone Form 

.2696 .2723 .0087 -.0542 .3369 -.0218 

.2968 .0004 -.4361 -.1900 .3586 .1279 

-.0543 .3538 -.1727 -.5125 .3802 -.5107 

-.3901 .0279 -.3542 -.1555 .1277 -.7608# 

.3358 .3176 .0441 -.3847 .3853 -.1848 

.2510 -.0047 .3803 -.0569 -.2912 .3760 

1.0000 .2961 .0519 -.2999 -.1355 .3715 

.2961 1.0000 .0461 -.4074 -.0350 .0193 

.0519 .0461 1.0000 .2736 -.0167 .1786 

-.2999 -.4074 .2736 1.0000 .1562 -.0363 

-.1355 -.0350 -.0167 .1562 1.0000 -.4231 

.3715 .0193 .1786 -.0363 -.4231 1.0000 

346

Correlation table 18 for DAPA variables measured from the pictures of Depressives: a. colours, and b. structure 

DAPA variables Pearson's Product Moment Correlation Analysis 


Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 


1.0000 .2190 -.2439 .4108 .3544 -.5008 

.2190 1.0000 .5233 .0933 .0456 .0773 

-.2439 .5233 1.0000 .2061 -.1223 .6256* 

.4108 .0933 .2061 1.0000 .3385 -.0127 

.3544 .0456 -.1223 .3385 1.0000 -.1375 

-.5008 .0773 .6256* -.0127 -.1375 1.0000 

.2665 .5996* .6132* .0600 -.1543 .3504 

.4585 .3449 .1690 .2415 .0960 -.0436 

-.3769 -.0852 .2575 -.2248 -.0563 .5134 

.3684 -.1372 -.4742 -.1645 .1790 -.1690 

-.1489 -.3002 .0787 .0370 .0386 .2029 

.2613 -.2483 -.4253 -.1762 .5708 -.2897 

DAPA variables Pearson's Product Moment Correlation Analysis 

N of cases: 18 2-tailed sig *.01 #.001 

Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 

Intensity Line-pnt Line-draw Space Em-Tone Form 

.2665 .4585 -.3769 .3684 -.1489 .2613 

.5996* .3449 -.0852 -.1372 -.3002 -.2483 

.6132* .1690 .2575 -.4742 .0787 -.4253 

.0600 .2415 -.2248 -.1645 .0370 -.1762 

-.1543 .0960 -.0563 .1790 .0386 .5708 

.3504 -.0436 .5134 -.1690 .2029 -.2897 

1.0000 .5619 .0912 .1631 -.1758 -.1220 

.5619 1.0000 -.6944* .1272 -.0563 .1079 

.0912 -.6944* 1.0000 .1170 -.0541 -.1363 

.1631 .1272 .1170 1.0000 .0990 .4917 

-.1758 -.0563 -.0541 .0990 1.0000 .1832 

-.1220 .1079 -.1363 .4917 .1832 1.0000 

Correlation table 19 for DAPA variables measured from the pictures of Controls: a. colours, and b. structure 



Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 


1.0000 .5257* .3993 .2524 .0536 -.1223 

.5257* 1.0000 .4753 .2503 .0811 -.3953 

.3993 .4753 1.0000 .4316 .3416 -.4588 

.2524 .2503 .4316 1.0000 -.1899 -.3905 

.0536 .0811 .3416 -.1899 1.0000 .0919 

.1223 -.3953 -.4588 -.3905 .0919 1.0000 

.6164* .4570 .3484 .3894 .1098 .1566 

.4431 .0635 .2293 -.1029 .2745 .1564 

-.0201 .0065 -.1370 .1684 -.2170 -.0372 

-.0202 .0456 -.0338 -.2078 .0489 .0488 

.1988 .3496 .0326 -.0338 .0822 -.1170 

.2761 .0479 .0446 .4472 -.0955 .1224 



Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 


.6164* .4431 -.0201 -.0202 .1988 .2761 

.4570 .0635 .0065 .0456 .3496 .0479 

.3484 .2293 -.1370 -.0338 .0326 .0446 

.3894 -.1029 .1684 -.2078 -.0338 .4472 

.1098 .2745 -.2170 .0489 .0822 -.0955 

.1566 .1564 -.0372 .0488 -.1170 .1224 

1.0000 .5254 -.2455 .1009 .3627 .3111 

.5254 1.0000 -.6305* -.0161 .2395 -.0204 

-.2455 -.6305* 1.0000 .2629 -.1978 .1931 

.1009 -.0161 .2629 1.0000 .1603 -.1115 

.3627 .2395 -.1978 .1603 1.0000 .1114 

.3111 -.0204 .1931 -.1115 .1114 1.0000 

347

Correlation table 20 for DAPA variables measured from the pictures of Patients with Personality Disorder: a. colours, and b. 

structure 



Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 


1.0000 .4291 .1037 .2665 .5060 -.7479 

.4291 1.0000 .0803 .6943 .6450 -.3775 

.1037 .0803 1.0000 .5832 .6699 -.1882 

.2665 .6943 .5832 1.0000 .6532 -.4694 

.5060 .6450 .6699 .6532 1.0000 -.5087 

-.7479 -.3775 -.1882 -.4694 -.5087 1.0000 

.0062 .4293 .0112 .5181 .1394 -.4951 

.1697 .2417 -.1492 .2956 .1385 -.5908 

.0238 -.0723 .5020 .0131 .2875 .3169 

-.1395 .0427 -.6277 -.3151 -.2847 .2442 

-.2327 .5180 .3585 .6741 .5307 -.2249 

.1801 -.1023 .2526 -.2675 .1488 .1142 



Red 

Yellow 

Green 

Blue 

Brown 

Black 

Intensity 

Line-paint 

Line-draw 

Space 

Em-Tone 

Form 


.0062 .1697 .0238 -.1395 -.2327 .1801 

.4293 .2417 -.0723 .0427 .5180 -.1023 

.0112 -.1492 .5020 -.6277 .3585 .2526 

.5181 .2956 .0131 -.3151 .6741 -.2675 

.1394 .1385 .2875 -.2847 .5307 .1488 

-.4951 -.5908 .3169 .2442 -.2249 .1142 

1.0000 .6197 -.6751 -.1665 .4921 -.2190 

.6197 1.0000 -.8182* .4452 .3427 -.6997 

-.6751 -.8182* 1.0000 -.4715 -.0352 .5385 

-.1665 .4452 -.4715 1.0000 -.1114 -.6429 

.4921 .3427 -.0352 -.1114 1.0000 -.3661 

-.2190 -.6997 .5385 -.6429 -.3661 1.0000 

348

Appendix 2: Tables summarising raw data from the text of the thesis. 

Chapter 2 

Table 3: Summaries of impressionistic studies of or about artists. 

Table 4: Summaries of papers reporting changes or signs in the theme/content of the 

artwork. 


Table 6: Summaries of papers reporting changes or signs in the form of the artwork. 

Table 7: Summaries of papers reporting the most important feature of art therapy was 

the therapeutic relationship. 


Crosstabulations 1-6: contingency tables for Chi-square calculation to indicate 

associations between method of study, form of expression and benefits for categorised 

commonalities of 67 studies which claimed 'expression of feelings' as main benefit for art 

therapy. 

Reliability Study Chapter 4 - Methods. Tables and Plots 1-15. 

Tables 1-15 by variable showing: column 1, Raw data scores for each variable each rater 

( r1-7) over 7 pictures in sequence. 

Column 2, scoring differences between 6 raters and author on 7 rated pictures. 

Column 3, mean differences for raters 1-6 and standard difference to rater 7 (author). 

Plots 1-15 by variable showing individual rater differences around average rating of 6 

independent raters and author. 

Results from Study 2. 

Tables and Figures 1a-i showing abnormal distribution of DAPA variables which were 

transformed or deleted. 

Tables and Figures 2a-f showing normal or near normal distribution of DAPA variables 

which were left in their original state. 

Tables and Figures 3a-f showing normal distribution of DAPA variables after 

transformation. 

Figures 6a-1 showing standard differences from the mean for each diagnostic group for 

DAPA variables with normal distribution. 

Figures 7a-c showing standard differences from the mean for each diagnostic group for 

DAPA variables which were dropped because of infrequent use. 

Correlation tables 16-20 for each diagnostic group for 12 DAPA variables. 

Correlation table 16 for DAPA variables measured from the pictures of Schizophrenics: 

a. colours, and b. structure 

Correlation table 17 for DAPA variables measured from the pictures of Substance 

Abusers: a. colours, and b. structure 

Correlation table 18 for DAPA variables measured from the pictures of Depressives: a. 

colours, and b. structure 

349

Correlation table 19 for DAPA variables measured from the pictures of Controls: a. 

colours, and b. structure. 

Correlation table 20 for DAPA variables measured from the pictures of Patients with 

Personality Disorder: a. colours, and b. structure 

Chapter 2 

Table 3: Summaries of impressionistic studies of or about artists. 

Table 4: Summaries of papers reporting changes or signs in the theme/content of the 

artwork. 


Table 6: Summaries of papers reporting changes or signs in the form of the artwork. 

Table 7: Summaries of papers reporting the most important feature of art therapy was 

the therapeutic relationship. 


Crosstabulations 1-6: contingency tables for Chi-square calculation to indicate 

associations between method of study, form of expression and benefits for categorised 

commonalities of 67 studies from the literature which claimed 'expression of feelings' as 

main benefit for art therapy. 

350

Impressionistic studies, TABLE 3 : summarising studies of or about artists, common concepts and assumptions 

about their work. 

Artist or subject Interpretation of picture or artwork, signs and relation of work 

to psychiatric symptoms 

1 Similarities between 

schizophrenic art, surrealism 

and tribal art of Australia and 

Africa 

2 Spontaneous art contains 

symbols and messages whose 

meaning may be more relevant 

than artist realises. 

3 Depression and art 

psychohygienic effect of 

exorcising own suicidal 

impulses and thoughts 

4 Aesthetic and psychological 

conflicts in work of prof art 

student 4 yrs. therapy 

5 Similarities and differences in 

the paintings of action painters 

and schizophrenics. The artist 

deliberately attempts to 

relinquish intellectual control in 

order to express inner drives in 

the freest manner possible. 

Many mental patients paintings 

unconsciously expressed in the 

same way. 

6 Outsider art, individuals outside 

fine arts circles and outside 

society. 

7 73 yrs male artist agnosia 

following occipital cerebral 

vascular accident - memory 

disturbance but essentially 

intact linguistic and cognitive 

capacities, effects on artists 

capacity to draw examined 

8 Argued that quality of 

creativity in paintings by 

Munch not compromised by his 

hospitalisation. 

9 Charles Filiger's work 

represents characteristic traits 

of schizophrenic psychosis. 

Exceptional man sparse 

biographical data, total isolation 

from world amid persecution 

delirium ending in suicide. 

10 Describes 12 collections of 

psychiatric art 

11 Rembrandt. Photo electric lux 

measurements from 

reproductions 

12 Joan Miro. Explores the 

relation of Miro's spiritual 

Understood in terms of phytogenetic and ontogenetic 

development of the personality structure 

Stimulates individual expression and interpersonal reaction, 

example van Gogh. 

Reactivates the nondominant hemisphere of the brain, 

particularly in chronic or recurrent depressions also opens up 

new perspectives for the solution of the problems that drive to 

depression, example Goethe 

351 

type of study 

discussion 

theory 

theory 

Identity conflicts. Description. case 

3 assumptions - motivation of patient is compulsive, artist makes 

free choice; patient painting is incoherent and random, artist has 

periods of emotional detachment/ intellectual consideration of 

work; the art final product is an integrated whole, but not 

patient's. 

Because many practitioners emotionally disturbed, some 

generalisation of conclusions to all mental patients 

Despite inability to recognise scene or object subject was able to 

copy the display well. When displays were recognised or if 

given name of object, no effect shown. Postmorbid drawings 

similar to early works, but features such as insufficient 

differentiation of figure from ground, over elaboration of detail 

and areas of neglect revealed effect. 

Middle period of Munch best known previously repressed drive 

derivatives found full expression in his imagery. At the end of 

this period disruptive personal factors contributed to the failure 

of his defensive structures. Psychiatric intervention prevented 

further psychopathology and led to an altered artistic focus. 

A painter's psychosis may stimulate an original creation, valid in 

its own right as a work of art. Effects of disorder not 

necessarily destructive and work may go beyond the personal 

problems of the creator and acquire meaning for spectators. 

Concept of 'psychopathology of expression' represents a 

distortion of truth in whatever the artists inner experiences 

were, their expressive faculty remained intact or grew stronger 

to encompass them 

Differences in light and darkness in Rembrandt's self portraits 

would reflect his mood (particularly depression) in conformity 

with various life events. Results were inconclusive. 

There seems a connection between feelings of despair and 

inner torment and the evolution of his art. Depressed state 

speculation 

discussion 

case 

case 

case 

discussion 

case 

case

eliefs to depression. cannot be matched to specific artworks, yet the author feels it is 

revealed in many paintings. 

13 Picasso and pathology of 

cubism. 

Represents less stylistic or formal revolution than partially 

successful attempt to come to terms with certain conflicts. 

Unwittingly therapeutic, gave him psychological control. 

14 Modigliani's works Illustrates expression of psychodynamic forces, principally 

resistance against emotional closeness and indications of 

superego pathology. Paintings exemplify defense mechanisms 

which dealt with anxiety. 

15 Van Gogh, diagnosed by 

Gachet as melancholic. 

16 Goya - reviews the literature 

on illness and dynamic 

interpretations. 

17 Mondrian. Determines 

connection between the man 

and the art. 

18 Compares schizo-phreniform 

symptoms, aspects of modern 

art and literature, to emphasise 

the defensive /disruptive role of 

forms of self-consciousness 

(pathological reflexivity). 

19 M. Ramirez, little known 

Mexican final 25 years of 

severe psychosis. 

20 Correlation between early life 

of Munch and subsequent 

psychodynamics as revealed in 

his life and art. 

21 Jochen Seidel 

Psychotic episodes 

22 Prevalence of mood an mind 

disorders in 14 modern abstract 

expressionist artists who, using 

psychic automatism to reveal 

unconscious material, created 

psychologically and spiritually 

significant art that addressed 

mythic themes of creation, 

birth, life and death. 

23 Mark Gertler 

Viccitudes of his career, 

depression and suicide with 

reference to primal scene 

trauma. 

24 Meaning of images of doors in 

20th C. paintings of mostly 

completely normal artists. 

Portrait of Cachet is discussed as to how it expresses Gachet's 

own melancholia. 

Detailed knowledge and depictions of mental hospital scenes 

and recent data from Real y General Hospital in Zaragoza 

support affective psychosis indicate mental illness in family. 

Symbolistic and psychiatric perspective. To best appreciate the 

art, his personality should be disregarded. Artists' bio-graphical 

data considered poor indicators of creation. 

Challenges view of disordered thought of schizophrenia as 

manifestation of developmentally primitive modes of 

consciousness. 

Similarities in theme and formal structures of patients to modern 

art and thought are delineated. 

Artwork is more than clinical material, but has expressive 

vitality and coherence from which one can relate its testimony 

to the universal psychological meaning of the struggle to be born 

from the forces of nonbeing and chaos. Expresses the 

archetypal movements within our personal psychology that can 

be construed as sickness, but may be that which ultimately heals 

blindness to the depths of the soul. 

Munch's art reflected his attempts to recreate the image of his 

dead sister. Disappointing relationships with women resulted in 

heavily affect laden paintings. Later work showed women 

more positively and aggression. Munches transitional 

relationship with his paintings helped him deal with his fear of 

ego-fragmentation, serving function of completion and 

autonomy. 

Artist attempted to resolve deep-seated psychological conflicts 

through painting. Material from life illustrates efforts to deal 

with loss, depression, guilt and anxiety through art. Creative 

work is a response to loss and an effort at self-healing. 

Negative relationship between creativity and psychosis assumed 

by psychoanalytic studies is challenged. 

Data collected from published biographies and archival 

material. Over 50% of artists had some psychopathology, 

predominately mood disorders and preoccupation with death, 

often compounded by alcohol abuse. Subjects tended to die 

young from suicide, accidents, other causes. 40% sought 

treatment and 20% were hospitalised for psychiatric problems. 

Results suggest depression inevitably leads to turning inward and 

to painful reexamination of the purpose of living and the 

possibility of dying and may have put these artists in touch with 

the mystery that lies at the heart of the tragic and timeless art 

that the abstract expressionists tried to produce. 

Psychoanalytic interpretation using historical material and work. 

Gertler's art expresses the tensions between stillness and 

motion, inanimate and animate and the one and the many 

represented a struggle with the sequelae of early primal scene 

trauma. 

Human being's relationship to the environment are explored and 

balance, intimacy separation, limits and boundaries are 

considered. Doorways are seen as metaphors for the artists' 

352 

case 

case 

discussion 

description 

discussion 

discussion 

case 

case 

case 

discussion 

case 

discussion

Compared with untrained 

therapy clients. 

internal psychic worlds, dialectical integration of inside and 

outside. Artwork of patients also seen as doorway to inner 

world not accessed by words. 

25 Michelangelo depression. The attempt to destroy the Florentine Pieta and immediate and 

sustained creative effort of his last 10 years to recreate another 

Pieta, whilst cutting it up, represent sublimation of the main 

infantile conflicts of his life: loss of mother in early infancy and 

abandonment by parents. Influence of these conflicts on his 

character and creativity and lifelong depression and confusion 

about the role of parental images and self-image. 

26 Female painter and female 

sculptor case reports to 

illustrate Jungian analytic 

concepts 

Central aim to bring clients to a realisation of their creative 

forces. Inappropriate reasons that many artists use to avoid 

therapy. Jungian psychology considers the relationship between 

the conscious and the unconscious to be creative and analysis 

may help some artists overcome disturbances that hinder them in 

fully realising their creative potential. 

27 Vincent Van Gogh as artist Explores the psychoanalytic sources of the intensely personal 

quality and powerful sense of communion with nature in 

Vincent Van Gogh's art. Life was saga of disappointment, 

disillusionment and failure. Dominated by spectre of stillborn 

brother from early life, fantasy motif in later years. Art 

replaced all other attachments, goals, ambitions or meaningful 

involvements as van Gogh struggled with sense of self. 

Immersion and devotion to nature may be connected to 

dynamics of idealised cosmic image of nature substitutes for 

idealised parent. So, art may serve as form of transitional 

relatedness to the mother of his infant experience. 

28 82yrs male artist stroke, 

aphasic, paralysis 

29 Artist not willing to use his 

work as part of the therapy 

Special measures to free the artist from preconceived notions, 

pressures and expectations. Successful - renewed creative 

energies and desires. 

Illustrates some of the conflicts and complications inherent in art 

therapy for artist. Patient used the therapist as a stimulus to 

creativity, but as an artist he was not willing to use his work as 

part of the therapy. He was unable to separate himself from his 

artistic productions and it continued to be important for him to 

suffer in order to paint and work. 

353 

case 

cases 

case 

case 

case

Table 4: summarising changes or signs predominantly reported in the theme/content of the artwork. 

Study Case description/ diagnosis Summary themes reported in 

artwork 

354 

Interpretation 

1 13y. male Parental Abuse Theme of ambivalence* often. Illustrates responses to life changes 

2 Adult female 

Psychotic (American Indian) 

3 70y. mute female - 49 year 

hospitalisation. 6m. art therapy, 

Paranoid Schizophrenia 

4 14y. male. 5 years of 

treatment. 

Emotional disorder 

5 21y. female Chronic 

Schizophrenia on 

lithium treatment 

6 Case studies mixed adults. 

Manic/Depressive tested on 

serial drawings of human 

figure 

7 36y. female 

Reactive Depression 

8 24y. male 

Brain Injury, car accident 

9 40y. male with 20y. hospital 

record psychosis. 

6 week mural program 

10 5 male 5 female adults 

Psychosis 

11 71 y. female Alzheimer's, 

diagnosed cancer 

12 10 mixed adults 

Manic/Depressive 

13 Family, 2 adults 1 male 11y. 

conjoint team 6 pics evaluated.. 

14 72y. male 

Aphasic 

15 Mixed adults over many years/ 

variety of settings. 

Depression 

16 Nearly 2000 pics from Multiple 

Personality Disordered patients 

Static and sparse Impoverished and incongruent with 

instructions 

Hostility,* suspicious, disorientated 

to well orientated, thoughtful. 

Selected from 1,250 drawings 

almost all circular forms, comments 

referred to mouth, cat, dragon and 

star. 

Religious themes and sexual 

conflicts*, from threatening and 

dark to lighter 

Results indicate directional trendsmutilated 

figures in depressive 

phase, strong dense lines in manic. 

Regression in primitive childlike 

characteristics/ younger figures. 

Pictures contained personal 

information, self disclosure 

Empty simple pictures, repeated 

theme broken land, disruption* 

became unified with colour as 

progress toward normal 

consciousness 

Symbol formation which resulted in 

new, more balanced, less 

egocentric, more differentiated 

schema than at start of project 

Separation/individuation symbols 

especially when representation of 

'three' occurred repeatedly 

Loss metaphors similar to cancer 

patients 

Depressed: less freq. creative, 

sombre gloomy themes /colour, 

summary drawings. Manic: 

rapid/expansive euphoric, warm 

bright colour 

Kwiatkowska methods. Unusual 

family portraits - other indicators 

Difficult to recognise complex 

imagery 

Bright colours, complete scenes, 

happy. Repeated symbols - yellow 

sun, flowers, trees, houses, grass 

extracted 10 thematic, structural and 

process, categories: system, 

Illustrates progress of therapy 

Mouth as archetypal image. Early drawings 

show the struggle* to rise out of the dark 

chaos of unconscious, become more focused. 

Preocc with mouth in autism. Theory mouth 

is primary site of psycho -sexual - social 

injury. Analogy of myth motifs and rituals to 

symbolic themes of mouth and transition from 

autistic phase ego development to symbiotic 

phase. 

Shows changes of affect, ego functions 

strengthened 

Minus phenomena in dep., plus properties in 

mania. Dynamic drawing tests useful for 

tracing changes in patient's state during 

therapy or as a prognostic tool 

Paralleled and contributed to improvement, 

more precise diagnosis 

Broken land symbolises disruption of brain 

damage. Body image relates to figures. 

Primary benefit relationship with therapist 

Through internalisation, S experienced a 

holding environment, now able to verbalise 

feelings 

Significance of numbers may relate to the 

number of visual symbols produced. 

Work expresses present situation of patient 

Unconsciously knew she was dying 

Illustrates illness, reflects disturbance in 

activity and thought 

Focus treatment and understand problem. 

Focus changed from boy to mother 

Requires different techs communication to 

interpret expression 

Symbolic of realistic hopes expressed in 

artwork, starting point for therapy 

To aid therapist's diagnosis of multiple 

personality disorder, but all indicators not

over 9 years fragmentation, barrier*, switching, 

threat*, alert, deception*, therapy, 

trance, abreaction 

355 

present. 

Table 5: summarising general signs of psychiatric disturbance reported in case studies. 

No. Case description/ 

diagnosis 

29 39 adult psychiatric 

inpatients 

30 177 16-71y. psychiatric 

outpatients 

31 34 adult inpatients 

depression & 

Schizophrenia 

Dot-to-dot geometrical 

figure 

Summary description of form reported in 

artwork 

Tendency to circle in a clockwise direction 

(torque) 

Constricted or expanded figures, drawn 

along edges of paper, disorganised placing 

Right hemispheric inhibition, deformation of 

the whole perceptive space with 

compression of the right and extension of the 

left. Left hemispheric inhibition caused 

initial and final parts shift to right. 


Closely associated with childhood 

psychosis, existing sensorimotor 

deficits and early cognitive 

dev'ment 

Drawing styles were found to 

correlate with personality traits 

Deformation might be based on a 

nonlinear distortion of the 

perceptive space with 

displacement of the initial 

coordinate point to the right from 

its geometrical centre.

Table 6: summarising changes or signs predominantly reported in the form of the artwork. 

S 

T 

U 

D 

Y 

No. 

Case description/ 

diagnosis 

17 30y. male 

decline in behaviour 

function/ 

psychological 

decompensation 

18 58y. female 

dementia (Alzheimer 

type) 

19 Adult female artist 

Borderline personality 

disorder 


Depressed 

21 Adolescent female 

Anorexia 

22 24y. male 

Impaired short term 

memory and Brain 

Damage 


Nervous Depression 

art and music therapy 

24 3 female Adults 

Depression + other 

psychiatric state 

25 100 mixed sex Adult 

Alexythymia 

(depression) 

26 Adult male 

Schizophrenia 

Adult male 

Schizophrenia 

27 13 mixed sex 

Schizophrenia 

28 10 Adult (19-55) 

Manic Depressive 

Summary description of form 

reported in artwork 

2 sets of figure drawings 10 years 

apart. Regression, lack detail, 

simpler shapes, omissions etc. 

Degeneration of image, childlike 

forms 

Childlike forms, fragmentation, 

affect, disorganisation, splitting 

Black & white or pencil rigid, well 

defined. Post therapy 

impressionistic, realistic with 

fantasy images in colour 

Poor verbal interaction, good 

quality complete drawings/paintings 

with colour and subject matter 

Subtle differences in 30 self 

portraits 

Wild, random, uncontrolled, 

incoherent drawings showing lack 

of connections, no centre of focus. 

Post-therapy structured, focused, 

coherent 

Dark, sombre, gloomy pictures 

depressive, bright colours not 

depressed 

Patients asked to draw illness, no 

correlation with scores on TAS 

1. Ossified, static, fragmentary. 

2. Clear structure 

Distortion of form, perseveration, 

simplification, proportion errors, 

disconnections, limited colour, 

confusion from directions 

Improvement with treatment on 

quality of drawing; head, mouth, 

essential detail, richness of 

356 


Detailed scoring of elements 

demonstrating decline intellectual & 

behavioral function for later pics 

Severe regression, intrapsychic reactions 

Art reflects mental state over years - 

strength/ego impairment and marked 

improvement reflected in drawings 

Trauma in self relates to object relation, 

mother not good enough, no internal 

models. Therapist plays different 

mothers. Drawings represent possibility 

of new more satisfying object relations 

illustrated 

Art can be a bridge to verbal interaction 

illustrates issues, conflicts and defenses 

Important learning took place although 

patient couldn't recall. Paintings provide 

access to patient's personality 

Express disorientation, turbulence, lack 

of connections, coherence, etc. shows 

state of mind. Progressive focus, 

structure and organisation of art 

promotes form and order in other areas 

and dialogue. Contributes to the healing 

process. Creative art therapy is not 

psychological but artistic 

Reflect mood state of patient 

All were able to graphically 

communicate illness but drawing 

promotes therapeutic alliance provides 

symbolic visual means to express 

recognise discuss feelings 

Drawing type agrees with formal 

symptoms therefore diagnosis correct. 

The formal symptoms disagree with 

drawing puts diagnosis in doubt 

These signs show evidence of initial 

diagnosis but also suggest organic 

disorder. 

11/13 further tested showed organic signs 

Some patients show typical features and 

pictures reflect improvement or 

deterioration in patient

features, execution 

Table 7: summarising information for case studies which considered the therapeutic relationship as the most 

important feature of art therapy 

No. case description/ 

diagnosis 

1 15y. male 


(fostered, firesetting) 

'Acting out' 

2 23y. female 

multiple personality 

disorder + childhood 

sex abuse by father 

3 30y. male 

Chronic Schizophrenia 

4 lesbian couple, 

deaf+suicidal, other 

hearing 

5 22y. female 

Anxiety Neurosis 

6 14y. male 

Behavioral Emotional 

Disturbance 

7 25y. female 

Schizophrenia 

8 24y. male 

Catatonic 

Schizophrenia 

severely regressed 

9 27y. male black 

Chronic Paranoid 

Schizophrenia 

10 15y. male 

Paranoid 

Schizophrenia 


Borderline personality 

+ suicidal 

12 26y. male black 

Alcoholic. Afraid of 

treatment + emotional 

problems 

Therapy type/ patient reaction art benefits explained by study relationship 

type 

Individual art sessions, initial 

resistance but progressed to 

good relations 

357 

greater sense of mastery and insight to 

focus primarily on reality 

Painting together providing empathetic response denied 

as child 

art, writing and verbals helped 

the therapist to understand S 

more clearly and recognize and 

work with his ego defenses, 

deficits and strength 

Drawing, psychodrama and clay 

sculpture with S's written 

afterthoughts 

Drawing together, therapist and 

subject experience 'merging 

with another person' 

Drawing and Painting to reverse 

narcissism and ego regression 

clay molding and drawing to 

reorganise and restructure the 

pathological development 

experience of the subject and 

encourage growth of ego 

functions. 

through visual imagery and mirroring, 

art helped the subject and therapist 

establish a symbiotic relatedness and 

nonverbal modality conducive to a 

therapeutic holding envm't 

psychodynamic - from the notes by 

patient, countertransference had 

taken place 

art provides graphic record of merger 

and increases receptivity to treatment, 

enhances participation, corrective 

experience, continues psychological 

growth 

Artwork and therapist served as selfobjects 

that helped nourish his inner 

self and emotional needs, promote 

growth 

helped to unite the subject and 

therapist and provides a 

nonthreatening environment for 

mutual trust and therapeutic alliance. 

Drawing and interaction help patient express suffering and 

observing interaction good for staff 

relations, accept patient human-being 

Drawing sexualised transference and use of 

energy toward relationship 

Drawing images of growth and 

mourning for termination of 

therapy 

Use of materials, control over 

materials 

Drawing and painting in self 

situations for fear. 

Treatment incomplete but 

Gesticulations showed S knew the 

therapist was separate and imperfect. 

Efforts at separation accelerated as 

termination progressed. Disruptive 

behaviour coincided feelings of 

disorganisation and despair. 

growing mastery of materials 

generalised to mastery of her 

environment 

Supported patient emotionally for eye 

operation and detox clinic. S became 

aware of himself in nonthreatening 

manner and art clarified vaguely 

nurturing 


nurturing 


nurturing non 

intrusive 


nurturing 


nurturing - 


nurturing - 


communicative 

communicative 

contact 

communication 

and 

release to 

indepen-dence 

supportive of 

goal directed 

interaction 

Supportive 

emotionally

13 22y. male 

Violence and 

substance abuse 

14 institutionalised 

retardates: 30y. male 

profound quadriplegic; 

10y. female, severe; 

27y. male, mild 

16 4 16-25y. males 

Autistic 

17 17y. male black Mild 

Retardation 

18 3 males 22y., 29y., 

32y. Retarded. 

progressed further than other 

approaches 

combined cognitive behavioral 

and expressive therapy. 

combined art modalities not 

psychoanalytical. 

providing open, accepting, 

respecting atmosphere for 

expression. Subjects progressed 

from inhibition to spontaneity 

and from overactivity to self 

control 

Drawing/painting self issues. 

Subject demonstrated improved 

functioning and more successful 

negotiation of the behaviour 

mod system 

358 

perceived situation 

Goal to alter self-image of violent 

patients helps develop alternative 

response patterns 

participation changes subject's 

perception of internal control by 

providing opportunity express or 

reflect on inner perceptions and 

feelings 

both processes reflected underlying 

growth in self confidence and 

autonomy. Reflected commonality in 

all human beings 

S achieved a sense of mastery through 

art, resulting in praise and 

encouragement improved self-esteem, 

supported ego-building, reorganisation 

and improved behaviour 

Opportunity for creativity environment values divergent 

thinking, subjects considered rigid and 

concrete thinkers successfully engage 

in creative process, no rewards/punish 

and natural interactions 

Supportive 

emotionally 

Supportive 

emotionally 

supportive 

emotionally 

supportive - 

opportunity for 

creative 

interaction 

supportive 

opportunity for 

creative 

interaction

Table 8: summarising reported behaviour changes for case studies. 

No. case description/ 

diagnosis 

1 group 14y. mixed sex 

Emotional/ behavioral 

problems 

2 28y. female Mild 

retardation 

3 2 females 13 and 15y. 

Disorganised 

Schizophrenia 

summary description of reported 

method 

video-taped early later art sessions. 

Unstructured art sessions. Sharing 

noted, minimal displacement 

activity 

Guided imagery and art 

experiences. Used beh observation 

form, better; work production 

average, increase; and House Tree 

Person drawing test 

Storytelling and drawing tasks. 

Verbal deficits form and content of 

speech and nonverbal deficit in 

logical thinking and drawing. 

4 24y male Schizophrenia Exercise left parieto-occipital 

function, verbal expression of 

spatial relations. Exercise right 

hemisphere; drawing. 

359 

Interpreted 

Greater awareness of needs/feelings of 

others. Showed greater co-operation non 

interference behaviour and more focused 

activity 

S achieved sense of accomplishment and 

internal control less feeling helpless. 

Blocking revealed deficiency in carrying 

out plans, poverty of content of speech 

reflected central deficit in planning. 

Central cognitive processing deficits 

sensitive to relative social/cognitive 

demands of context. 

Lowest levels of hallucinatory behaviour, 

aggressive verbal outbursts and physical 

aggression in right hem exercises.

Crosstabulations 1-6: contingency tables for Chi-square calculation to 

indicate associations between method of study, form of expression and benefits 

for categorised commonalities of 67 studies from the literature which claimed 

'expression of feelings' as main benefit for art therapy. 

Crosstabulation 1: ORIENTATION By METHOD OF STUDY METHOD 

OF STUDY -> 1.Illustrative; 2. projective/express; 3. behaviour; 4. psychoanalytic; 5. 

educational/experiential 

Std Res 1 2 3 4 5 Row Total 

______________________________________________________ 

ORIENTATION 0 _ 0 _ 1 _ 0 _ 1 _ 1 _ 3 

_ .0% _ 33.3% _ .0% _ 33.3% _ 33.3% _ 4.5% 

unknown _ .0% _ 2.6% _ .0% _ 14.3% _ 7.7% _ 

_ -.4 _ -.6 _ -.4 _ 1.2 _ .5 _ 

______________________________________________ 

1 _ 1 _ 1 _ 1 _ 1 _ 2 _ 6 

cognitive _ 16.7% _ 16.7% _ 16.7% _ 16.7% _ 33.3% _ 9.0% 

_ 25.0% _ 2.6% _ 25.0% _ 14.3% _ 15.4% _ 

_ 1.1 _ -1.3 _ 1.1 _ .5 _ .8 _ 

______________________________________________ 

2 _ 2 _ 28 _ 2 _ 1 _ 4 _ 37 

projective _ 5.4% _ 75.7% _ 5.4% _ 2.7% _ 10.8% _ 55.2% 

_ 50.0% _ 71.8% _ 50.0% _ 14.3% _ 30.8% _ 

_ -.1 _ 1.4 _ -.1 _ -1.5 _ -1.2 _ 

______________________________________________ 

3 _ 0 _ 0 _ 0 _ 0 _ 1 _ 1 

phenomen'l _ .0% _ .0% _ .0% _ .0% _ 100.0% _ 1.5% 

_ .0% _ .0% _ .0% _ .0% _ 7.7% _ 

_ -.2 _ -.8 _ -.2 _ -.3 _ 1.8 _ 

______________________________________________ 

4 _ 0 _ 3 _ 1 _ 1 _ 4 _ 9 

social/ _ .0% _ 33.3% _ 11.1% _ 11.1% _ 44.4% _ 13.4% 

occupational _ .0% _ 7.7% _ 25.0% _ 14.3% _ 30.8% _ 

_ -.7 _ -1.0 _ .6 _ .1 _ 1.7 _ 

______________________________________________ 

5 _ 1 _ 6 _ 0 _ 3 _ 1 _ 11 

analytical _ 9.1% _ 54.5% _ .0% _ 27.3% _ 9.1% _ 16.4% 

_ 25.0% _ 15.4% _ .0% _ 42.9% _ 7.7% _ 

_ .4 _ -.2 _ -.8 _ 1.7 _ -.8 _ 

______________________________________________ 

Column 4 39 4 7 13 67 

Total 6.0% 58.2% 6.0% 10.4% 19.4% 100.0% 

Chi-Square D.F. Significance Min E.F. Cells with E.F.< 5 

26.29640 20 .1562 .060 26 OF 30 ( 86.7%) 

Number of Missing Observations = 0 

360

Crosstabulation 2: ORIENTATION By FORM OF EXPRESSION 

FORM OF content style content behav.l verbal other 

EXPRESSION -> + style Row 

Std Res 1 2 3 4 5 6 Total 

_______________________________________________________________ 

ORIENTATION 0 _ 2 _ 0 _ 0 _ 1 _ 0 _ 0 _ 3 

_ 66.7% _ .0% _ .0% _ 33.3% _ .0% _ .0% _ 4.5% 

unknown _ 6.1% _ .0% _ .0% _ 5.9% _ .0% _ .0% _ 

_ .4 _ -.2 _ -.5 _ .3 _ -.6 _ -.3 _ 

_______________________________________________________ 

1 _ 2 _ 0 _ 0 _ 3 _ 1 _ 0 _ 6 

_ 6.1% _ .0% _ .0% _ 17.6% _ 11.1% _ .0% _ 9.0% 

cognitive _ 33.3% _ .0% _ .0% _ 50.0% _ 16.7% _ .0% _ 

_ -.6 _ -.3 _ -.7 _ 1.2 _ .2 _ -.4 _ 

_______________________________________________________ 

2 _ 21 _ 0 _ 3 _ 10 _ 3 _ 0 _ 37 

projective _ 56.8% _ .0% _ 8.1% _ 27.0% _ 8.1% _ .0% _ 55.2% 

_ 63.6% _ .0% _ 60.0% _ 58.8% _ 33.3% _ .0% _ 

_ .7 _ -.7 _ .1 _ .2 _ -.9 _ -1.1 _ 

_______________________________________________________ 

3 _ 0 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1 

phenomenological _ .0% _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.5% 

_ .0% _ .0% _ 20.0% _ .0% _ .0% _ .0% _ 

_ -.7 _ -.1 _ 3.4 _ -.5 _ -.4 _ -.2 _ 

_______________________________________________________ 

4 _ 3 _ 0 _ 1 _ 3 _ 1 _ 1 _ 9 

social/ _ 33.3% _ .0% _ 11.1% _ 33.3% _ 11.1% _ 11.1% _ 13.4% 

occupational _ 9.1% _ .0% _ 20.0% _ 17.6% _ 11.1% _ 50.0% _ 

_ -.7 _ -.4 _ .4 _ .5 _ -.2 _ 1.4 _ 

_______________________________________________________ 

5 _ 5 _ 1 _ 0 _ 0 _ 4 _ 1 _ 11 

analytical _ 45.5% _ 9.1% _ .0% _ .0% _ 36.4% _ 9.1% _ 16.4% 

_ 15.2% _ 100.0% _ .0% _ .0% _ 44.4% _ 50.0% _ 

_ -.2 _ 2.1 _ -.9 _ -1.7 _ 2.1 _ 1.2 _ 

_______________________________________________________ 

Column 33 1 5 17 9 2 67 

Total 49.3% 1.5% 7.5% 25.4% 13.4% 3.0% 100.0% 


35.43668 25 .0806 .015 33 OF 36 ( 91.7%) 


361

Crosstabulation 3: ORIENTATION By BENEFIT 

BENEFIT -> 1. cathartic/reflective; 2. communication; 3. healing/symptom relief; 4. 

developmental/social; 5. relationship 


______________________________________________________ 

ORIENTATION 0 _ 1 _ 1 _ 0 _ 0 _ 0 _ 2 

_ 50.0% _ 50.0% _ .0% _ .0% _ .0% _ 3.4% 

unknown _ 6.3% _ 5.0% _ .0% _ .0% _ .0% _ 

_ .6 _ .4 _ -.6 _ -.5 _ -.4 _ 

______________________________________________ 

1 _ 2 _ 3 _ 0 _ 1 _ 0 _ 6 

cognitive _ 33.3% _ 50.0% _ .0% _ 16.7% _ .0% _ 10.2% 

_ 12.5% _ 15.0% _ .0% _ 12.5% _ .0% _ 

_ .3 _ .7 _ -1.0 _ .2 _ -.7 _ 

______________________________________________ 

2 _ 12 _ 11 _ 6 _ 3 _ 3 _ 35 

projective _ 34.3% _ 31.4% _ 17.1% _ 8.6% _ 8.6% _ 59.3% 

_ 75.0% _ 55.0% _ 60.0% _ 37.5% _ 60.0% _ 

_ .8 _ -.3 _ .0 _ -.8 _ .0 _ 

______________________________________________ 

3 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1 

phenomen'l _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.7% 

_ .0% _ 5.0% _ .0% _ .0% _ .0% _ 

_ -.5 _ 1.1 _ -.4 _ -.4 _ -.3 _ 

______________________________________________ 

4 _ 0 _ 1 _ 3 _ 3 _ 0 _ 7 

social/ _ .0% _ 14.3% _ 42.9% _ 42.9% _ .0% _ 11.9% 

occupational _ .0% _ 5.0% _ 30.0% _ 37.5% _ .0% _ 

_ -1.4 _ -.9 _ 1.7 _ 2.1 _ -.8 _ 

______________________________________________ 

5 _ 1 _ 3 _ 1 _ 1 _ 2 _ 8 

analytical _ 12.5% _ 37.5% _ 12.5% _ 12.5% _ 25.0% _ 13.6% 

_ 6.3% _ 15.0% _ 10.0% _ 12.5% _ 40.0% _ 

_ -.8 _ .2 _ -.3 _ -.1 _ 1.6 _ 

______________________________________________ 

Column 16 20 10 8 5 59 

Total 27.1% 33.9% 16.9% 13.6% 8.5% 100.0% 


20.57888 20 .4223 .085 27 OF 30 ( 90.0%) 


362

Crosstabulation 4: METHOD OF STUDY By BENEFIT 




______________________________________________________ 

METHOD 1 _ 1 _ 2 _ 0 _ 0 _ 0 _ 3 

_ 33.3% _ 66.7% _ .0% _ .0% _ .0% _ 5.1% 

illustrates _ 6.3% _ 10.0% _ .0% _ .0% _ .0% _ 

progress _ .2 _ 1.0 _ -.7 _ -.6 _ -.5 _ 

______________________________________________ 

2 _ 9 _ 11 _ 7 _ 3 _ 4 _ 34 

projective _ 26.5% _ 32.4% _ 20.6% _ 8.8% _ 11.8% _ 57.6% 

expressive _ 56.3% _ 55.0% _ 70.0% _ 37.5% _ 80.0% _ 

_ -.1 _ -.2 _ .5 _ -.7 _ .7 _ 

______________________________________________ 

3 _ 3 _ 0 _ 0 _ 0 _ 0 _ 3 

behaviour _ 100.0% _ .0% _ .0% _ .0% _ .0% _ 5.1% 

_ 18.8% _ .0% _ .0% _ .0% _ .0% _ 

_ 2.4 _ -1.0 _ -.7 _ -.6 _ -.5 _ 

______________________________________________ 

4 _ 2 _ 1 _ 2 _ 1 _ 0 _ 6 

psycho- _ 33.3% _ 16.7% _ 33.3% _ 16.7% _ .0% _ 10.2% 

analytic _ 12.5% _ 5.0% _ 20.0% _ 12.5% _ .0% _ 

_ .3 _ -.7 _ 1.0 _ .2 _ -.7 _ 

______________________________________________ 

5 _ 1 _ 6 _ 1 _ 4 _ 1 _ 13 

education/ _ 7.7% _ 46.2% _ 7.7% _ 30.8% _ 7.7% _ 22.0% 

experience _ 6.3% _ 30.0% _ 10.0% _ 50.0% _ 20.0% _ 

_ -1.3 _ .8 _ -.8 _ 1.7 _ -.1 _ 

______________________________________________ 

Column 16 20 10 8 5 59 

Total 27.1% 33.9% 16.9% 13.6% 8.5% 100.0% 


19.52039 16 .2426 .254 22 OF 25 ( 88.0%) 


363

Crosstabulation 5: FORM OF EXPRESSION By METHOD OF STUDY 

METHOD OF STUDY -> 1.Illustrative; 2. projective/express; 3. behaviour; 4. 

psychoanalytic; 5. ed.l/experiential 

Std Res 1 2 3 4 5 Total 

______________________________________________________ 

FORM OF 1 _ 3 _ 19 _ 1 _ 5 _ 5 _ 33 

EXPRESSION _ 9.1% _ 57.6% _ 3.0% _ 15.2% _ 15.2% _ 49.3% 

_ 75.0% _ 48.7% _ 25.0% _ 71.4% _ 38.5% _ 

content _ .7 _ -.0 _ -.7 _ .8 _ -.6 _ 

______________________________________________ 

2 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1 

style _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.5% 

_ .0% _ 2.6% _ .0% _ .0% _ .0% _ 

_ -.2 _ .5 _ -.2 _ -.3 _ -.4 _ 

______________________________________________ 

3 _ 1 _ 2 _ 0 _ 0 _ 2 _ 5 

content _ 20.0% _ 40.0% _ .0% _ .0% _ 40.0% _ 7.5% 

and style _ 25.0% _ 5.1% _ .0% _ .0% _ 15.4% _ 

_ 1.3 _ -.5 _ -.5 _ -.7 _ 1.0 _ 

______________________________________________ 

4 _ 0 _ 11 _ 2 _ 0 _ 4 _ 17 

behaviour _ .0% _ 64.7% _ 11.8% _ .0% _ 23.5% _ 25.4% 

_ .0% _ 28.2% _ 50.0% _ .0% _ 30.8% _ 

_ -1.0 _ .4 _ 1.0 _ -1.3 _ .4 _ 

______________________________________________ 

5 _ 0 _ 5 _ 1 _ 2 _ 1 _ 9 

verbal _ .0% _ 55.6% _ 11.1% _ 22.2% _ 11.1% _ 13.4% 

_ .0% _ 12.8% _ 25.0% _ 28.6% _ 7.7% _ 

_ -.7 _ -.1 _ .6 _ 1.1 _ -.6 _ 

______________________________________________ 

other 6 _ 0 _ 1 _ 0 _ 0 _ 1 _ 2 

_ .0% _ 50.0% _ .0% _ .0% _ 50.0% _ 3.0% 

_ .0% _ 2.6% _ .0% _ .0% _ 7.7% _ 

_ -.3 _ -.2 _ -.3 _ -.5 _ 1.0 _ 

______________________________________________ 

Column 4 39 4 7 13 67 

Total 6.0% 58.2% 6.0% 10.4% 19.4% 100.0% 


14.50528 20 .8040 .060 26 OF 30 ( 86.7%) 


364

Crosstabulation 6: FORM OF EXPRESSION By BENEFIT 




______________________________________________________ 

FORM OF 1 _ 9 _ 8 _ 4 _ 2 _ 4 _ 27 

EXPRESSION _ 33.3% _ 29.6% _ 14.8% _ 7.4% _ 14.8% _ 45.8% 

_ 56.3% _ 40.0% _ 40.0% _ 25.0% _ 80.0% _ 

content _ .6 _ -.4 _ -.3 _ -.9 _ 1.1 _ 

______________________________________________ 

2 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1 

style _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.7% 

_ .0% _ 5.0% _ .0% _ .0% _ .0% _ 

_ -.5 _ 1.1 _ -.4 _ -.4 _ -.3 _ 

______________________________________________ 

3 _ 1 _ 3 _ 1 _ 0 _ 0 _ 5 

content _ 20.0% _ 60.0% _ 20.0% _ .0% _ .0% _ 8.5% 

and style _ 6.3% _ 15.0% _ 10.0% _ .0% _ .0% _ 

_ -.3 _ 1.0 _ .2 _ -.8 _ -.7 _ 

______________________________________________ 

4 _ 4 _ 4 _ 3 _ 3 _ 1 _ 15 

behaviour _ 26.7% _ 26.7% _ 20.0% _ 20.0% _ 6.7% _ 25.4% 

_ 25.0% _ 20.0% _ 30.0% _ 37.5% _ 20.0% _ 

_ -.0 _ -.5 _ .3 _ .7 _ -.2 _ 

______________________________________________ 

5 _ 2 _ 3 _ 2 _ 2 _ 0 _ 9 

verbal _ 22.2% _ 33.3% _ 22.2% _ 22.2% _ .0% _ 15.3% 

_ 12.5% _ 15.0% _ 20.0% _ 25.0% _ .0% _ 

_ -.3 _ -.0 _ .4 _ .7 _ -.9 _ 

______________________________________________ 

6 _ 0 _ 1 _ 0 _ 1 _ 0 _ 2 

_ .0% _ 50.0% _ .0% _ 50.0% _ .0% _ 3.4% 

other _ .0% _ 5.0% _ .0% _ 12.5% _ .0% _ 

_ -.7 _ .4 _ -.6 _ 1.4 _ -.4 _ 

______________________________________________ 

Column 16 20 10 8 5 59 

Total 27.1% 33.9% 16.9% 13.6% 8.5% 100.0% 


12.29713 20 .9055 .085 27 OF 30 ( 90.0%) 


365

Reliability Study Chapter 4 - Methods. 

Tables and Plots 1-15. 

Tables 1-15 by variable showing: column 1, Raw data scores for each 

variable each rater( r1-7) over 7 pictures in sequence. 

Column 2, scoring differences between 6 raters and author on 7 rated 

pictures. 

Column 3, mean differences for raters 1-6 and standard difference to rater 

7 (author). 

Plots 1-15 by variable showing individual rater differences around average 

rating of 6 independent raters and author. 

366

Tables showing mean differences between 6 raters and author on 7 rated pictures. 

Raters R1-7 score for RED, 

pics 1-7 - R7 = author* 

R1 R2 R3 R4 R5 R6 R7* 

0 0 0 0 0 0 0 

6 6 6 6 6 6 6 

5 9 9 8 5 6 9 

10 15 12 12 8 11 14 

5 7 5 5 5 7 6 

0 0 0 5 0 0 0 

11 11 11 12 11 9 10 

Total 

Total % 

agreement exact 

(x); ±1 point (1); 

±2 points (2) 

x 1 2 

6 

6 

2 1 

0 1 2 

0 6 

5 

5 1 

---------- 

24 9 2 

57 21 5 

mean for raters 1-6 

and difference to 

R7 ratings 

mean diff. 

R1-6 R7 

.00 .00 

6.00 .00 

7.00 2.00 

11.33 2.67 

5.67 .33 

.83 -.83 

10.83 -.83 

1. Difference in mean interrater score/author score for RED (RATS - A) 

plotted against average (RATS + A)/2. 

________________________________________ 

d 4_ _ 

i _ _ 

f _ 1 _ 

f _ 1 _ 

e _ _ 

r 0_1__________2___________________________ 

e _ 1 1 _ 

n _ _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 

Average 6 rats + author 

Raters R1-7 score for YELLOW 


R1 R2 R3 R4 R5 R6 R7* 

5 5 8 5 5 5 5 

4 5 3 5 5 3 5 

6 6 6 5 6 6 6 

16 14 13 16 16 17 16 

13 13 10 13 13 13 13 

0 0 0 0 0 0 0 

8 10 10 11 8 9 12 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

5 

4 2 

5 1 

3 1 1 

5 

6 

0 1 2 

----------- 

28 5 3 

67 12 7 



R7 ratings. 

mean diff. 

R1-6 R7 

5.50 -.50 

4.17 .83 

5.83 .17 

15.33 .67 

12.50 .50 

.00 .00 

9.33 2.67 

fig 2. Difference in mean interrater score/author score for YELLOW (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ 1 _ 

f _ _ 

e _ 1 1 1 _ 

r 0_1__________1___________________________ 

e _ 1 _ 

n _ _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


367

Raters R1-7 score for ORANGE, 


R1 R2 R3 R4 R5 R6 R7* 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

19 18 18 19 19 18 19 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

6 7 8 0 3 0 3 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

6 

6 

3 3 

6 

6 

6 

1 

----------- 

34 3 

81 7 



R7 ratings. 

mean diff. 

R1-6 R7 

.00 .00 

.00 .00 

18.50 .50 

.00 .00 

.00 .00 

.00 .00 

4.00 -1.00 

fig 3. Difference in mean interrater score/author score for ORANGE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ 1 _ 

r 0_5______________________________________ 

e _ 1 _ 

n _ _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for PURPLE, 


R1 R2 R3 R4 R5 R6 R7* 

0 0 0 0 0 0 0 

0 0 0 1 0 0 0 

17 14 11 14 17 9 13 

15 12 12 15 12 11 11 

0 0 0 0 0 0 0 

5 5 5 3 5 5 5 

0 3 0 0 1 0 0 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

6 

5 1 

0 2 1 

1 3 

6 

5 0 1 

4 1 

----------- 

27 7 2 

64 17 5 



R7 ratings. 

mean diff. 

R1-6 R7 

.00 .00 

.17 -.17 

13.67 -.67 

12.83 -1.83 

.00 .00 

4.67 .33 

.67 -.67 

fig 4. Difference in mean interrater score/author score for PURPLE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ _ 

r 0_3________1_____________________________ 

e _ 1 1 _ 

n _ 1 _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


368

Raters R1-7 score for GREEN 


R1 R2 R3 R4 R5 R6 

R7* 

5 5 4 5 5 5 4 

12 14 13 11 13 13 13 

3 3 3 2 3 3 3 

0 0 0 0 0 0 0 

13 11 11 7 9 9 7 

10 10 10 10 10 10 

10 

5 5 3 4 4 5 4 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

1 5 

3 2 1 

5 1 

6 

1 0 2 

6 

2 4 

----------- 

24 12 3 

57 29 7 



R7 ratings. 

mean diff. 

R1-6 R7 

4.83 -.83 

12.67 .33 

2.83 .17 

.00 .00 

10.00 -3.00 

10.00 .00 

4.33 -.33 

fig 5. Difference in mean interrater score/author score for GREEN (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ _ 

r 0_1____1__1_________1____1_______________ 

e _ 1 _ 

n _ _ 

c _ _ 

e _ 1 _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for BLUE, pics 

1-7 - R7 = author* 

R1 R2 R3 R4 R5 R6 

R7* 

8 8 8 8 8 8 

8 

16 16 14 13 15 15 

13 

0 0 0 0 0 0 

0 

11 14 9 11 14 13 

9 

4 5 4 4 5 4 

4 

7 7 8 7 13 12 

7 

19 18 19 18 18 18 

16 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

6 

1 1 2 

6 

1 0 2 

4 2 

3 1 

0 0 4 

----------- 

21 4 8 

50 10 19 



R7 ratings. 

mean diff. 

R1-6 R7 

8.00 .00 

14.83 -1.83 

.00 .00 

12.00 -3.00 

4.33 -.33 

9.00 -2.00 

18.33 -2.33 

fig 6. Difference in mean interrater score/author score for BLUE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ _ 

r 0_1_______1______1_______________________ 

e _ _ 

n _ 1 1 _ 

c _ 1 _ 

e _ 1 _ 

369

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for BROWN, 


R1 R2 R3 R4 R5 R6 

R7* 

0 0 0 0 0 0 0 

1 2 0 0 0 0 0 

0 0 0 0 0 0 0 

8 0 0 8 7 12 0 

4 2 0 3 0 6 0 

10 10 9 10 4 4 10 

14 10 12 13 12 16 12 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

6 

4 1 1 

6 

2 

2 0 1 

3 1 

2 1 2 

----------- 

25 3 4 

60 7 10 



R7 ratings. 

mean diff. 

R1-6 R7 

.00 .00 

.50 -.50 

.00 .00 

5.83 -5.83 

2.50 -2.50 

7.83 2.17 

12.83 -.83 

fig 7. Difference in mean interrater score/author score for BROWN (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ 1 _ 

f _ _ 

e _ _ 

r 0_2______________________________________ 

e _1 1 _ 

n _ _ 

c _ 1 _ 

e _ _ 

-4_ _ 

_ _ 

_ 1 _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for WHITE, 

pics 1-7 – R7 = author* 

R1 R2 R3 R4 R5 R6 R7* 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

6 7 0 7 7 4 7 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

6 

6 

3 1 

6 

6 

6 

6 

--------- 

39 1 

93 2 



R7 ratings. 

mean diff. 

R1-6 R7 

.00 .00 

.00 .00 

5.17 1.83 

.00 .00 

.00 .00 

.00 .00 

.00 .00 

fig 8. Difference in mean interrater score/author score for WHITE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ 1 _ 

e _ _ 

r 0_6______________________________________ 

e _ _ 

n _ _ 

370

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for BLACK, 


R1 R2 R3 R4 R5 R6 R7* 

12 12 12 12 9 12 12 

14 15 14 14 14 14 14 

8 8 6 9 8 8 9 

19 20 18 20 18 19 20 

19 17 18 18 19 18 18 

1 1 1 0 0 0 0 

12 10 11 12 11 11 10 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

5 

5 1 

1 4 

2 2 2 

3 3 

3 3 

1 3 2 

----------- 

20 16 4 

48 38 10 



R7 ratings. 

mean diff. 

R1-6 R7 

11.50 .50 

14.17 -.17 

7.83 1.17 

19.00 1.00 

18.17 -.17 

.50 -.50 

11.17 -1.17 

fig 9. Difference in mean interrater score/author score for BLACK (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ 1 1 1 _ 

r 0___________________________1______1_____ 

e _1 1 _ 

n _ _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for INTENSITY, 


R1 R2 R3 R4 R5 R6 R7* 

11 14 14 17 19 14 19 

16 17 20 18 19 15 18 

20 15 20 20 18 20 20 

19 13 17 15 19 14 16 

14 12 13 15 15 12 15 

9 11 10 10 9 8 10 

20 18 20 19 18 20 18 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

1 0 1 

1 2 2 

4 0 1 

0 2 1 

2 1 1 

2 3 1 

2 1 3 

----------- 

12 9 10 29 21 

24 



R7 ratings. 

mean diff. 

R1-6 R7 

14.83 3.83 

17.44 .89 

18.83 1.17 

16.22 -.22 

13.44 1.89 

9.56 .44 

19.22 -.89 

fig 10. Difference in mean interrater score/author score for INTENSITY (RATS - A) 


________________________________________ 

d 4_ 1 _ 

i _ _ 

f _ _ 

f _ 1 _ 

e _ 1 1 1 _ 

r 0______________________________1_________ 

e _ 1 _ 

n _ _ 

c _ _ 

371

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


372

Raters R1-7 score for PAINTED 

LINE, pics 1-7 

R7 = author* 

R1 R2 R3 R4 R5 R6 R 

7* 

8 12 9 7 7 9 

11 

4 6 6 15 4 6 

7 

6 6 6 4 5 4 

7 

14 14 11 7 15 9 

13 

4 8 8 12 11 11 

12 

0 0 0 0 0 0 

0 

4 4 3 5 6 4 

4 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

0 1 2 

0 3 

0 3 1 

0 2 2 

1 2 

6 

3 2 1 

----------- 

10 13 6 

24 31 14 



R7 ratings. 

mean diff. 

R1-6 R7 

8.78 2.56 

6.83 .17 

5.22 1.78 

11.72 1.61 

8.94 2.72 

.00 .00 

4.33 -.33 

fig 11. Difference in mean interrater score/author score for PAINTED LINE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ 11 _ 

f _ 1 1 _ 

e _ _ 

r 0_1_______1____1_________________________ 

e _ _ 

n _ _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for DRAWN 

LINE, pics 1-7 - R7 = author* 

R1 R2 R3 R4 R5 R6 R7* 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

0 0 0 0 0 0 0 

5 4 4 10 6 5 5 

1 0 0 0 0 0 0 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

6 

6 

6 

6 

6 

2 3 

5 1 

------- 

37 4 

88 10 



R7 ratings. 

mean diff. 

R1-6 R7 

.00 .00 

.00 .00 

.00 .00 

.00 .00 

.00 .00 

5.61 -.28 

.17 -.17 

fig 12. Difference in mean interrater score/author score for DRAWN LINE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ _ 

r 0_6_________1____________________________ 

e _ _ 

n _ _ 

373

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for SPACE, 


R1 R2 R3 R4 R5 R6 R7* 

15 14 15 10 14 13 12 

10 9 9 5 10 9 8 

4 4 4 4 4 4 4 

6 7 8 7 6 6 6 

4 4 4 4 4 4 4 

16 15 15 15 14 16 14 

4 4 4 4 4 4 4 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

0 1 3 

0 3 2 

6 

3 2 1 

6 

1 3 2 

6 

----------- 

22 9 8 

52 21 19 



R7 ratings. 

mean diff. 

R1-6 R7 

13.37 -1.77 

8.67 -.87 

4.00 .00 

6.80 -1.00 

4.00 .00 

15.13 -.93 

4.00 .00 

fig 13. Difference in mean interrater score/author score for SPACE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ _ 

r 0________3_______________________________ 

e _ 1 1 1 _ 

n _ 1 _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for 

EMOTIONAL TONE, pics 1-7 - 

R7 = author* 

R1 R2 R3 R4 R5 R6 R7* 

11 11 18 14 12 13 15 

15 16 19 18 16 16 15 

19 18 20 17 19 16 20 

7 10 11 9 7 9 7 

10 14 10 8 9 8 8 

14 14 15 16 17 16 18 

15 14 16 13 8 13 13 

Total 

Total % 

Agreement exact 

(x); ±1 point (1); 


x 1 2 

0 1 1 

1 3 

1 2 1 

2 0 2 

2 1 2 

0 1 2 

2 1 1 

----------- 

8 9 9 

19 21 21 



R7 ratings. 

mean diff. 

R1-6 R7 

13.28 1.39 

16.56 -1.22 

18.17 1.83 

8.83 -2.17 

9.83 -1.83 

15.22 3.11 

13.28 .06 

fig 14. Difference in mean interrater score/author score for EMOTIONAL TONE (RATS - A) 


________________________________________ 

d 4_ _ 

i _ 1 _ 

f _ _ 

f _ 1 1 _ 

e _ _ 

r 0_________________________1______________ 

e _ _ 

n _ 1 1 _ 

c _ 1 _ 

e _ _ 

374

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


Raters R1-7 score for FORM, 


R1 R2 R3 R4 R5 R6 R7* 

0 0 0 0 0 3 0 

7 8 8 7 7 7 8 

5 7 5 7 7 5 5 

0 0 0 0 0 0 0 

8 0 0 0 0 0 0 

16 16 16 16 16 16 16 

3 3 3 3 3 3 3 

Total 

Total % 


(x); ±1 point (1); 


x 1 2 

5 

2 4 

3 0 3 

6 

6 

6 

6 

------------ 

34 4 3 

81 10 7 



R7 ratings. 

mean diff. 

R1-6 R7 

.50 -.50 

7.33 .67 

6.00 -1.00 

.00 .00 

1.33 -1.33 

16.00 .00 

3.00 .00 

fig 15. Difference in mean interrater score/author score for DOMINANT FORM (RATS - A) 


________________________________________ 

d 4_ _ 

i _ _ 

f _ _ 

f _ _ 

e _ 1 _ 

r 0_1____1_______________________1_________ 

e _1 1 _ 

n _ 1 _ 

c _ _ 

e _ _ 

-4_ _ 

R-A ________________________________________ 

0 5 10 15 20 


375

Appendix 3 

Table of Authorities 

1. Impressionistic/Theoretical Studies 

2. Case Studies of Artists 

3. Case Studies - change of theme or content elements 

4. Case Studies - change of objective or formal elements 

5. Case Studies - change of behaviour 

6. Case Studies - therapeutic benefit - relationship 

7. Case Studies - therapeutic benefit - expression of feelings 

8. Controlled Studies 

376

Table of Authorities 

Impressionistic studies 

Abraham, A. (1990), The projection of the inner group in drawing, Group Analysis , Dec., V.23(4):391- 

401. 

Adler, R.F., Fisher, P. (1984), My self ... through music, movement and art, Arts in Psychotherapy , Fall, 

V.11(3):203-8. 

Adelman, E., Castricone, L. (1986), An expressive arts model for substance abuse group training and 

treatment, Arts in Psychotherapy , Spr., V.13(1):53-9. 

Albert-Puleo, N. (1980), Modern psychoanalytic art therapy and its application to drug abuse, Arts in 

Psychotherapy , V.7(1):43-52. 

Albert-Puleo, N., Osha, V. (1976), Art therapy as an alcoholism treatment tool, Alcohol Health and 

Research World , Win., V.1[2]28-31. 

Allan, J., Clark, M. (1984), Directed art counselling, Elementary School Guidance and Counselling , Dec., 

V.19(2):116-24. 

Allen, P.B. (1983), Group art therapy in short-term hospital settings, Am. J. Art Therapy , Apr., 

V.22(3):93-5. 

Allen, P.B. (1985), Integrating art therapy into an alcoholism treatment program, Am. J. Art Therapy , 

Aug., V.24(1):10-12. 

Amos, S.P. (1982), The diagnostic, prognostic, and therapeutic implications of schizophrenic art, Arts 

in Psychotherapy , Sum., V.9(2):131-143. 

Arrington, D. (1991), Thinking systems-seeing systems: an integrative model for systematically oriented 

art therapy, Arts in Psychotherapy , V.18(3):201-11. 

Atlas, J.A., Smith, P., Sessoms, L. (1992), Art and poetry in brief therapy of hospitalized adolescents, 

Arts in Psychotherapy , V.19(4):279-83. 

Assael, M., Popovici-Wacks, M. (1989), Artistic expression in spontaneous paintings of depressed 

patients, Israel J. of Psychiatry and Related Science s , V.26(4):223-243. 

Assael, M. (1978), Spontaneous painting: means of communication, Confinia Psychiatrica , V.21(1-3):10- 

24. 

Avstreih, A.K., Brown, J.J. (1979), Some aspects of movement and art therapy as related to the analytic 

situation, Psychoanalytic R eview , V.66(1):49-68. 

Ba, G. (1988), Strategies of rehabilitation in the day hospital, Psychotherapy and Psychosomatics , 

V.50(3):151-6. 

Bender, L., Wolfson, W.Q. (1983), Boats in the art and fantasy of children, Am. J. Art Therapy , Jul., 

V.22(4):125-8. 

Benveniste, D. (1985), Picture-time: a nondirective approach to art psychotherapy, Arts in Psychotherapy , 

Fall, V.12(3):171-180. 

Betensky, M. (1978), Phenomenology of self-expression in theory and practice, Confinia Psychiatrica , 

V.21(1-3):31-36. 

Betensky, M. (1973), Patterns of visual expression in art psychotherapy, Art Psychotherapy , Fall, 

V.1(2):121-9. 

Billig, O. (1973), The schizophrenic "artist's" expression of movement, Confinia Psychiatrica , V.16(1):1- 

27. 

Bishop, J. (1978), Creativity, art and play therapy, Canadian Counsellor , Jan., V.12(2):138-146. 

Bowers, J.J. (1992), Therapy through art. Facilitating treatment of sexual abuse, J. of Psychosocial 

Nursing and Mental Health Services , Jun., V.30(6):15-24. 

Breslow, D.M. (1993), Creative arts for hospitals: the UCLA experiment, Patient Education and 

Counselling , Jun., V.21(1-2):101-110. 

Brown, R.J. (1993), The fishing image: a preliminary study, Arts in Psychotherapy , V.20(2):167-171. 

Buchalter-Katz, S. (1985), Observations concerning the art productions of depressed patients in a shortterm 

psychiatric facility, Arts in Psychotherapy , V.12:35-8. 

Buck, L.A., Kardeman, E., Goldstein, F. (1985), Artistic talent in "autistic" adolescents and young adults, 

Empirical Studies of the Arts , V.3(1):81-104. 

Buckland, A., Bennett, D.L. (1995), Youth arts in hospital: engaging creativity in care, International 

Journal of Adolescent Medicine and Health , Jan-Mar., V.8(1):17-27. 

Burgess, A.W., Hartman, C.R., Grant, C.A., Clover, C.L., Snyder, W., King, L.A. (1991), Drawing a 

377

connection from victim to victimizer, J. of Psychosocial Nursing and Mental Health Services , Dec., 

V.29(12):9-14. 

Burkett, A.D. (1974), A way to communicate, Am. J. Nursing, Dec., V.74(12)::2185-7. 

Cameron, C.O., Juszezak, L., Wallace, N. (1984), Using creative arts to help children cope with altered 

body image, Children's Health Care , Win., V.12(3):108-12. 

Carnes, J.J. (1979), Toward a cognitive theory of art therapy, Art Psychotherapy , V.6(2):69-75. 

Carney, S. (1986), Symbol building in schizophrenic disorders, Pratt Institute Creative Arts Therapy 

Review , V.7:31-42. 

Cheyne-King, S.E. (1990), Effects of brain injury on visual perception and art production, Arts in 

Psychotherapy , Spr., V.17(1):69-74. 

Clark, W.H. (1977), Art and psychotherapy in Mexico, Art Psychotherapy , V.4(1):41-4. 

Cohen, B.M., Mills, A., Kijak, A.K. (1994), An introduction to the Diagnostic Drawing Series: a 

standardized tool for diagnostic and clinical use, Art Therapy , V.11(2):105-10. 

Conroy, R.M., McDonnell, M., Swinney, J. (1986), Process-centred art therapy in anorexia nervosa, 

British Journal of Occupational Therapy , Oct., V.49(10):322-3. 

Cox, K.L., Price, K. (1990), Breaking through: incident drawings with adolescent substance abusers, Arts 

in Psychotherapy , Win., V.17(4):333-7. 

Creadick, T.A. (1985), The role of the Expressive Arts in therapy, J. of Reading, Writing, and Learning 

Disabilities International , Spr., V.1(3):55-60. 

Cuozzi, J.L., Kaplan, F.F. (1979), Surviving the death and dying of a treatment community, Art 


Dallin, B. (1986), Art Break: a 2 day expressive therapy program using art and psychodrama to further the 

termination process, Arts in Psychotherapy , Sum., V.13(2):137-42. 

Davis, C.B. (1989), The use of art therapy and group process with grieving children, Issues in 

Comprehensive Paediatric Nursing , Jul-Aug., V.12(4):269-80. 

De-Nobel, C.A. (1972), Creative therapy: an autonomous discipline, Confinia Psychiatrica, 

V.15(1):77-81. 

Docherty, F. (1986), Steps in the progressive treatment of depression in the elderly, Physical and 

Occupational Therapy in Geriatrics , Fall, V.5(1):59-76. 

Dougherty, C.A. (1974), Group art therapy: a Jungian approach, Am. J. Art Therapy , Apr., V.13(3):229- 

36. 

Eckardt, M.H. (1991), The ambivalent relationship of psychoanalysis and creativity: the contributions of 

Suzanne Langer to the formative process of our psyche, J. of the Am. Academy of Psychoanalysis , Win., 

V.19(4):620-9. 

Edelson, R.T. (1990), ART AND CRAFTS - not "arts and crafts": alternative vocational day activities 

for adults who are older and mentally retarded, Activities, Adaptation and Aging , V.15(1-2):81-97. 

Engle, P. (1997), Art therapy and dissociative disorders, Art Therapy , V.14(4):246-254. 

Erickson, J.M. (1979), The arts and healing, Am. J. Art T herapy , Apr., V.18(3):75-80. 

Farrelly, J., Joseph, A. (1991), Expressive therapies in a crisis intervention service, Arts in Psychotherapy , 

V.18(2):131-137. 

Feen-Calligan, H. (1995), The use of art therapy in treatment programs to promote spiritual recovery from 

addiction, Art Therapy , V.12(1):46-50. 

Feinstein, H. (1985), The metaphoric interpretation of art for therapeutic purposes, Arts in Psychotherapy , 

Fall, V.12(3):157-163. 

Fink, P.J., Levick, M.F. (1973), Sexual problems revealed through art therapy, Art Psychotherapy , Win., 

V.1(3-4):277-291. 

Fink, P.J., Levick, M.F. (1973), Goldman, M.J., Art therapy: a diagnostic and therapeutic tool, Int. J. 

Psychiatry , Mar., V.11(1):104-118. 

Finley, P. (1975), Dialogue drawing: an image-evoking communication between analyst and analysand, 

Art Psychotherapy , V.2(1):87-99. 

Ford-Sori, C.E. (1995), The "art" of restructuring: integrating art with structural family therapy, J. Family 


Forrest, G. (1976), An art therapist beside herself, Am. J. Art Therapy , Jul., V.15(4):105-111. 

Foulke, W.E., Keller, T.W. (1976), The art experience in addict rehabilitation, Am. J. Art Therapy , Apr., 

V.15(3):75-80. 

Friedman, A.S., Glickman, N.W. (1986), Program characteristics for successful treatment of adolescent 

378

drug abuse, J. Nervous and Mental Disease , Nov., V.174(11):669-679. 

Frye, B. (1990), Art and multiple personality disorder: an expressive framework for occupational therapy, 

Am. J. of Occupational Therapy , Nov., V.44(11):1013-1022. 

Fuhrman, N.L., Zingaro, J.C., Kokenes, B. (1990), A preliminary comparative study of drawings 

produced under hypnosis and in a simulated state by both MPD and non-MPD adults, Dissociation 

Progress in the Dissociative Disorders , Jun. V.3(2):107-112. 

Garai, J.E. (1973), Reflections of the struggle for identity in art therapy, Art Psychotherapy , Win., V.1(3- 

4):261-275. 

Garai, J.E. (1976), New Vistas in the exploration of inner and outer space through art therapy, Art 

Psychotherapy , V.3(3-4):157-167. 

Garai, J.E. (1984), New horizons of holistic healing through creative expression, Art Therapy , May, 

V.1(2):76-82. 

Gerber, J. (1994), The use of art therapy in juvenile sex offender specific treatment, Arts in Psychotherapy , 

V.21(5):367-374. 

Gerritsen, M. (1995), Art therapy: the real art is the process, Therapeutic Communities International J. for 

Therapeutic and Supportive Organizations , Spr., V.16(1):25-35. 

Ghadirian, A.M. (1978), Graphic art and its relation to conceptual thinking, Confinia Psychiatrica , V.21(1- 

3):165-169. 

Ghadirian, A.M. (1974), Artistic expression of psychopathology through the media of art therapy, 

Confinia Psychiatrica , V.17(3-4):162-170. 

Glaister, J.A., McGuinness, T. (1992), The art of therapeutic drawing: Helping chronic trauma survivors, 

J. Psychosocial Nursin g and Mental Health Services , May, V.30(5):9-17. 

Goldstein-Roca, S., Crisafulli, T. (1994), Integrative creative arts therapy: a brief treatment model, Arts 

in Psychotherapy , V.21(3):219-222. 

Golub, D. (1985), Symbolic expression in post-traumatic stress disorder: Vietnam combat veterans in art 

therapy, Arts in Psychotherapy , Win., V.12(4):285-296. 

Gorelick, K. (1989), Rapprochement between the arts and psychotherapies: metaphor the mediator, Arts 

in Psychotherapy , Fall V.16(3):149-155. 

Hagood, M.M. (1991), Group art therapy with mothers of sexually abused children, Arts in 


Halbreich, U., Assael, M. (1979), Drawings of cephalopods by schizophrenic patients, and their meaning, 


Halbreich, U. (1978), The application of principles of short-term, problem-oriented psychotherapy to art 

psychotherapy, Art Psychotherapy , V.5(4):181-9. 

Halbreich, U. (1978), A nonverbal dialogue as a treatment of schizophrenic patients, Confinia Psychiatrica , 

V.21(1-3):58-67. 

Harlan, J.E. (1990), The use of art therapy for older adults with developmental disabilities, Activities, 

Adaptation and Aging , V.15(1-2):67-79. 

Harlan, J.E. (1993), The therapeutic value of art for persons with Alzheimer's disease and related disorders, 

Loss, Grief and Care , V.6(4):99-106. 

Harms, E. (1973), Art psychotherapy and the prophylaxis of psychic healing, Art Psychotherapy , Win., 

V.1(3-4):185-192. 

Harvey, S. (1990), Dynamic paly therapy: An integrative expressive arts approach to the family therapy 

of young children, Arts in Psychotherapy , Fall, V.17(3):239-246. 

Head, V.B. (1975), Experiences with art therapy in short term groups of day clinic addicted patients, 

Ontario Psychologist , Oct., V.7(4):42-49. 

Heimlich, M., (1972), Paraverbal techniques in the therapy of childhood communication disorder Int. J. 

Child Psychotherapy , Jan. V.1(1):65-83. 

Heine, D., Steiner, M. (1986), Standardized paintings as a proposed adjunct instrument for longitudinal 

monitoring of mood states: a preliminary note, Occupational Therapy in Mental Health , Fall, V.6(3):31-7. 

Heineman, L. (1992), Seeking a good enough mirror: art therapy and mirroring in a prevention program's 

parent training group, Pratt Institute Creative Arts Therapy Review , V.13:23-30. 

Henley, D.R. (1992), Aesthetics in art therapy: theory into practice, Arts in Psychotherapy , V.19(3):153- 

161. 

Henley, D.R. (1989), Art therapeutic interventions using Lowenfeld's motivational techniques: stereotypes 

in children's art, Am. J. Art Therapy , May, V.27:116-125. 

379

Hodnett, M.L. (1973), A broader view of art therapy, Art Psychotherapy , Fall, V.1(2):75-79. 

Honig, S. (1975), Ideation in the artwork of suicidal patients, Art Psychotherapy , V.2:77-85. 

Hunyady, H. (1984), A report of a drawing therapy for children's nightmares, J. Evolutionary Psychology , 

Mar., V.5(1-2):129-30. 

Hymes, S.M. (1983), The therapeutic nature of art in self reparation, Psychoanalysis Review , Spr., 

V.70(1):57-68. 

Jakab, I. (1976), Comprehensive view of the creative process in psychopathological art: a panel discussion 

at the 7th International Congress of Psychopathology of Expression, Confinia Psychiatrica , V.19(4):177- 

206. 

James, R.T., Burrows, T.M. (1981), Right brain exercises and whole brain medicine, J. Holistic 

Medicine , Fall-Win., V.3(2):152-6. 

Jenkins, H., Donnelly, M. (1983), The therapist's responsibility: a systemic approach to mobilizing family 

creativity, J. Family Therapy , Aug., V.5(3):199-218. 

Johnson, C., Lahey, P.P., Shore, A. (1992), An exploration of creative arts therapeutic group work on an 

Alzheimer's unit, Arts in Psychotherapy , V.19(4):269-277. 

Johnson, D.R. (1987), The role of the creative arts therapies in the diagnosis and treatment of 

psychological trauma, Arts in Psychotherapy , Spr., V.14(1):7-13. 

Johnson, L. (1990), Creative therapies in the treatment of addictions: the art of transforming shame, Arts 

in Psychotherapy , Win., V.17(4):299-308. 

Jones, D. (1978), Art Therapy, Art Psychotherapy , V.5(1):11-12. 

Joraski, M.F. (1986), The role of creative arts in cognitive rehabilitation, Cognitive Rehabilitation , Mar- 

Apr., V.4(2):18-23. 

Kagin, S.L., Lusebrink, V.B. (1978), The expressive therapies continuum, Art Psychotherapy , V.5(4):171- 

180. 

Kaslow, N.J., Eichner, V.W. (1988), Body image therapy: a combined creative arts therapy and verbal 

psychotherapy approach, Arts in Psychotherapy , Fall, V.15(3):177-188. 

Kelly, C.R. (1988), Expressive therapy assessment, Arts in Psychotherapy , Spr., V.15(1):63-70. 

Kidd, J., Wix, L. (1996) Images of the heart: archetypal imagery in therapeutic artwork, Art Therapy , 

V.13(2):108-13. 

Killick, K. (1993), Working with psychotic processes in art therapy, Psychoanalytic Psychotherapy , 

V.7(1):25-38. 

Kivalo, A. (1978), Art therapy with children, Psychiatria Fennica p.93-102. 

Kramer, E.S. (1982), The history of art therapy in a large mental hospital, Am. J. Art Therapy , Apr., 

V.21(3):75-84. 

Kramer, E.S. (1977), Art therapy and play, Am. J. Art Therapy , Oct., V.17(1):3-11. 

Kramer, E. (1986), The art therapist's third hand: reflections on art, art therapy, and society at large, Am. 

J. Art Therapy , Feb., V.24(3):71-86. 

Kramer, E., Schehr, J. (1983), An art therapy evaluation session for children, Am. J. Art Therapy , Oct., 

V.23(1):3-12. 

Lachman, M., Stuntz, E.C., Jones, N. (1975), Art therapy in the psychotherapy of a mother and her son, 

Am. J. Art Therapy , Jul., V.14(4):105-116. 

Lachman-Chapin, M. (1985), Ericksonian hypnosis and art therapy, Am. J. Art Therapy , May, 

V.23(4):115-124. 

Lachman-Chapin, M (1983), Making verbal the nonverbal: a commentary, Art Therapy , Oct., V.1(1):47-9. 

Lanc, J. (1982), "Encapsulating" and "examining" schizophrenics: proposal for treatment within a short 

term framework, Pratt Institute Creative Arts Therapy Review , V.3:49-57. 

Landgarten, H., Junge, M., Tasem, M., Watson, M. (1978), Art therapy as a modality for crisis 

intervention: children express reactions to violence in their community, Clinical Social Work Journal , 

Fall, V.6(3):221-229. 

Landgarten, H. (1983), Art psychotherapy for depressed elders, Clinical Gerontologist , Fall, V.2(1):45-53. 

Landgarten, H. (1981), Family art psychotherapy, Int. J. Family Psychiatry , V.2(3-4):379-395. 

Landgarten, H. (1975), Adult art psychotherapy, Art Psychotherapy , V.2(1):65-76. 

Lawlor, E.M. (1992), Creativity and change: the two-tiered creative arts therapy approach to co-dependency 

treatment, Arts in Psychotherapy , V.19(1):19-27. 

Leedy, J.J. (1973), Poetry therapy and some links to art therapy, Art Psychotherapy , Fall, V.1(2):145-151. 

380

Lerner, A. (1984), Some observations and comments on symposium held June 22-24 1984: The creative 

arts in therapy as an integral part of treatment for the 90s: Looking ahead - planning together, Arts in 

Psychotherapy , Win., V.11(4):293-5. 

Levens, M. (1990), Borderline aspects in eating disorders: art therapy's contribution, Group Analysis , 

Sep., V.23(3):277-284. 

Levick, M. (1975), Transference and counter-transference as manifested in graphic productions, Art 


Levick, M. (1978), Response to paper by Dr. Edwin Hammer, Art Psych otherapy , V.5(1):31-33. 

Levine, S.K. (1994), Order and chaos in therapy and the arts: an encounter with Rudolf Arnheim, Arts in 


Levy, B. (1978), Art therapy in a women's correctional facility, Art Psychotherapy , V.5(3):157-166. 

Lewis, P.P. (1988), The transformative process within the imaginal realm, Arts in Psychotherapy , Win., 

V.15(4):309-316. 

Lincoln, L. (1987), Body image remediation through creative arts therapy, Pratt Institute Creative Arts 

Therapy Review , V.8:35-44. 

Linden, J. (1985), Insight through metaphor in psychotherapy and creativity, Psychoanalysis and 

Contemporary Thought , V.8(3):375-406. 

Linesch, D. (1994), Interpretation in art therapy research and practice: the hermeneutic circle, Arts in 


Loo, C.M. (1974), The self-puzzle: a diagnostic and therapeutic tool, J. Personality Assessment , Jun., 

V.38(3):236-242. 

Lorenzetti, M. (1994), (trans. A. Coffetti), Perspectives on integration between arts therapy areas, Arts in 


Lund, C., Ormerod, E., George, K. (1986), Art group psychotherapy in a psychiatric day unit, British 

Journal of Psychiatry , Oct., V.149:152-515. 

Lyon, J.G. (1995), Communicative drawing: an augmentative mode of interaction, Aphasiology, 

Jan-Feb., 

V.9(1):84-94. 

Lyon, J.G.; Helm-Estabrooks, N. (1987), Drawing: Its communicative significance for expressively 

restricted aphasic adults, Topics in Language Disorders , Dec. V.8(1):61-71. 

Maclagan, D. (1995), Fantasy and the aesthetic: have they become the uninvited guests at art therapy's 

feast? Arts in Psychotherapy , V.22(3):217-221. 

Macrae, M., Smith, G. (1973), Combining music with art psychotherapy, Art Psychotherapy , Win., 

V.1(3-4):229-241. 

Marion, P., Felix, M. (1980), From denial to self-esteem: art therapy with the mentally retarded, Arts in 


Mango, C. (1993), The oral matrix, Arts in Psychotherapy , V.20(50:403-10. 

Martin, E. (1997), The symbolic graphic life line: integrating the past and present through graphic 

imagery, Art Therapy V.14(4):261-267. 

McNeilly, G. (1983), Directive and non-directive approaches in art therapy, Arts in Psychotherapy , Win., 

V.10(4):211-219. 

McNeilly, G. (1990), Group analysis and art therapy: a personal perspective, Group Analysis , Sep., 

V.23(3):215-24. 

McNiff, S. (1979), From shamanism to art therapy, Art Psychotherapy , V.6(3):155-161. 

McNiff, S. (1975), On art therapy: a conversation with Rudolf Arnheim, Art Psychotherapy , V.2(3-4):195- 

202. 

McSweeney, M. (1990), The use of transitional space within an expressive therapy relationship, Pratt 

Institute Creative Arts Therapy Review , V.11:63-71. 

McWhinnie, H.J. (1985), Carl Jung and Heinz Werner and implications for foundational studies in art 

education and art therapy, Arts in Psychothe rapy , Sum., V.12(2):95-99. 

Melanson, G.M. (1985), Gesture drawing: an avenue to personal myth, Saybrook Review , Fall-Win., 

V.5(2):73-82. 

Miller, M.G. (1986) Art - a creative teaching tool, Academic Therapy , Sep., V.22(1):53-6. 

Mitchell, D. (1978), A note on art psychotherapy and poetry therapy: the coordination of art and poetry 

as an expressive technique, Art Psychotherapy , V.5(4):223-5. 

Mitzushima, K. (1971), Art therapies in Japan, Interpersonal Development , V.2(4):213-221. 

381

Muller-Braunschweig, H. (1975), Psychopathology and creativity, Psychoanalytic Study of Society , 

V.67:1-99. 

Mullins, J.B. (1973), The expressive therapies in special education, Am. J. Art Therapy , Oct., V.13(1):52- 

8. 

Nagaraja, J. (1975), Psycho-iconography and the mentally sick, Child Psychiatry Quarterly , Jan., V.8(1):6- 

13. 

Naitove, C.E. (1988), Arts therapy with child molesters: an historical perspective on the act and an 

approach to treatment, Arts in Psychotherapy , Sum., V.15(2):151-160. 

Naitove, C.E. (1985), Protecting our children: the fight against molestation, Arts in Psychotherapy , Sum., 

V.12(2):115-6. 

Naitove, C.E. (1978), Symbolic patterns in drawings by habitual users of street drugs: a pilot study, 

Confinia Psychiatrica , V.21(1-3):112-8. 

Nathan, T.S., Hesse, P.P. (1978), Developmental and interactional aspects of creative expression in the 

course of group therapy, Confinia Psychiatrica , V.21(1-3):119-132. 

Nez, D. (1991), Persephone's return: archetypal art therapy and the treatment of a survivor of abuse, Arts 

in Psychotherap y , V.18(2):123-130. 

Nielsen, K.E. (1982), Creative arts therapy as a tool in promoting ego integration in delinquent adolescent 

girls, Pratt Institute Creative Arts Therapy Review , V.3:21-31. 

Noah-Cooper, C.L., Richards, R.G. (1983), Art therapy for an angry child: a case study, Academic 

Therapy , V.18(5):575-81. 

Nystul, M. (1987), Strategies for parent-centred counselling of the young, Creative Child and Adult 

Quarterly , Sum., V.12(2):103-110. 

Obernbreit, R. (1985), Object relations theory and the language of art: tools for treatment of the borderline 

patient, Art Therapy , Mar., V.2(1):11-18. 

Obernbreit, R. (1980), Art Therapy: agent in education, Pratt Institute Creative Arts Therapy Review , 

V.1:59-66. 

Ormay, A.P. (1990), Art as communication: a group analytic view, Group Analysis , Dec., V.3(4):377- 

389. 

Parciack, R., Winnik, H.Z., Shmueli, M. (1975), Aggression in painting: painting as a means of release 

of aggression, Mental Health and Society , V.2(3-6):225-237. 

Percoskie, S. (1997) Art therapy with the Alzheimer's client, Humanistic Psychologist , Summer, 

V.25(2):208-11. 

Perry, J.W. (1973), The creative element in madness, Art Psychotherapy Apr., V.1(1):61-5. 

Pickford, R.W. (1974), Aspects of art therapy, British J. of Projective Psychology and Personality Study , 

Jun., V.19(1):16-20. 

Poldinger, W. (1987), The relation between depression and art. Psychopathology , Feb., V.19 

(Suppl.2):263-268. 

Poldinger, W., Krambeck, K. (1987), The relevance of creativity for psychiatric therapy and rehabilitation, 

Comprehensive Psychiatry , Sep-Oct., V.28(5):384-388. 

Poore, M. (1977), Art therapy in a vocational rehabilitation center, Am. J. Art Therapy , Jan. V.16(2):55-9. 

Potocek, J. Wilder, V.N. (1989), Art/movement psychotherapy in the treatment of the chemically 

dependent patient, Arts in Psychotherapy , Sum., V.16(2):99-103. 

Powell, L., Faherty, S.L. (1990), Treating sexually abused latency age girls: a 20 session treatment plan 

utilizing group process and the creative arts therapies, Arts in Psychotherapy , Spr., V.17(1):35-47. 

Powers, P.S., Langworthy, J. (1978), Art work: another dimension in the treatment of psychiatric patients, 


Prager, A. (1995), Paediatric art therapy: strategies and applications, Art Therapy , V.12(1):32-8. 

Pulliam, J.C. (1988), Three heads are better than one: the expressive arts group assessment, Arts in 


Rabinowitz, J. (1985), Time-lapse family portrait: the use of drawings in family therapy, Family Therapy , 

V.12(3):303-9. 

Reiner, E.R., Tellin, J.A., O'Reilly, J.B. (1977), A picture regression scale for adults, Art Psychotherapy , 

V.4:219-223. 

Rhinehart, L., Engelhorn, P. (1982), Pre-image considerations as a therapeutic process, Arts in 


Rhyne, J. (1973), The gestalt approach to experience, art and art therapy, Am. J. Art Therapy , Jul., 

382

V.12(4):237-248. 

Riley, S. (1997) Social Constructivism: the narrative approach to clinical art therapy, Art Therapy , 

V.14(4):282-284. 

Riley, S. (1993), Illustrating the family story: art therapy, a lens for viewing the family's reality, Arts in 


Riley, S. (1987), The advantages of art therapy in an outpatient clinic, Am. J. Art Therapy , V.26(1):21-29. 

Riley, S. (1994), Rethinking adolescent art therapy treatment, J. Child and Adolescent Group Therapy , 

Jun., V.4(2):81-97. 

Robbins, A. (1973), A psychoanalytic prospective towards the inter relationship of the creative process 

and the functions of an art therapist, Art Psychotherapy , Apr., V.1(1):7-12. 

Robbins, A. (1992), The play of psychotherapeutic artistry and psychoaesthetics, Arts in Psychotherapy , 

V.19(3):177-186. 

Robbins, A. (1973), The art therapist's imagery as a response to a therapeutic dialogue, Art Therapy , Win., 

V.1(3-4):181-184. 

Robbins, A. (1988), A psychoaesthetic perspective on creative arts therapy and training, Arts in 

Psychotherapy , Sum., V.15(2):95-100. 

Rogers, P. (1987), The healing evocation of beauty, Pratt Institute Creative Arts Therapy Review , V.8:1- 

13. 

Roje, J. (1994) Consciousness as manifested in art: a journey from the concrete to the meaningful, Arts 

in Psychotherapy , V.21(5):375-385. 

Rosling, L.K., Kitchen, J. (1992), Music and drawing with institutionalised elderly, Activities, 

Adaptation and Aging , V.17(2):27-38. 

Rosman, Y., Assael, M., Gabbay, F. (1975), Spontaneous group drawing, Mental Health and Society , 

V.2(3-6):238-242. 

Rothenberg, A. (1987), Empathy as a creative process in treatment, Int. Review of Psycho-Analysis , 

V.14(4):445-463. 

Rubin, J.A. (1985), Imagery in art therapy: the source, the setting and the significance, Journal of Mental 

Imagery , Win., V.9(4):71-81. 

Rubin, J.A. (1973), A diagnostic art interview, Art Psychotherapy , Apr., V.1(1):31-43. 

Rubin, J.A. (1988), Art Counselling: an alternative, Elementary School Guidance and Counselling , Feb., 

V.22(3):180-5. 

Rubin, J.A. (1981), Art therapy in a community mental health center for children: a story of program 

development, Arts in Psychotherapy , V.8(2):109-114. 

Rusek, J. (1991), A creative approach to the treatment of resistance, Pratt Institute Creative Arts Therapy 

Review , V.12:9-15. 

Rush, K. (1978), The metaphorical journey: art therapy in symbolic exploration, Art Psychotherapy , 

V.5(3):149-155. 

Sagal, R. (1990), Helping older mentally retarded persons expand their socialization skills through the use 

of expressive therapies, Activities, Adaptation and Aging , V.15(1-2):99-109. 

Scanlon, K. (1993), Art therapy with autistic children, Pratt Institute Creative Arts Therapy Review , 

V.14:34-43. 

Schaverien, J. (1994), The transactional object: art psychotherapy in the treatment of anorexia, British J. 

of Psychotherapy, Fall, V.11(1):46-61. 

Schmais, C. (1988), Creative arts therapies and shamanism: a comparison, Arts in Psychotherapy , Win., 

V.15(4):281-284. 

Seftel, L. (1987), Understanding destruction in art therapy with children, Pratt Institute Creative Arts 


Segal, R.M. (1984), Helping children express grief through symbolic communication, Social Casework , 

Dec., V.65(10):590-599. 

Shaughnessy, M.F., Tevelowitz, N. (1981), Creativity in art with the retarded, Creative Child and Adult 

Quarterly , Fall, V.6(3):141-146. 

Sheahan, M. (1974), Picture your problems, Menninger Perspective , Sum., V.5(2)::16-21. 

Sherr, C. (1973), Therapeutic use of artwork in a community mental health center, Am. J. Art Therapy , 

Apr., V.12(3):183-190. 

Shoemaker, R. (1978), The significance of the first picture in art therapy, Proceedings of the 8th Annual 

Conference of the American Art Therapy Association , p.156-162. 

383

Siegel, L. (1988), The use of mural and metaphor with a schizophrenic population for recovery in a trauma 

situation, Pratt Institute Creative Arts Therapy Review , V.9:40-53. 

Simon, E.G. (1989), An art therapy approach to dream interpretation, Pratt Institute Creative Arts Therapy 

Review , V.10:51-60. 

Simon, R.M. (1975), Art: a strategic and empirical therapy? Confinia Psychiatrica , V.18(3)::174-182. 

Simon, R. (1974), Pictorial style as a means of communication, Am. J. Art Therapy , Jul., V.13(4):275- 

292. 

Sizemore, C.C. (1986), "On my life with multiple personalities": comments by Chris Costner Sizemore, 

Art Therapy , Mar., V.3(1):18-20. 

Sladyk, K. (1992), Traumatic brain injury, behavioral disorder, and group treatment, Am. J. Occupational 

Therapy , Mar., V.46(3):267-270. 

Slap, J.W. (1976), A note of the drawing of dream details, Psychoanalytic Quarterly , V.45(3):455-6. 

Smith, D.D. (1983), The art evaluation: a triage function on a psychiatric emergency admissions unit, Arts 

in Psychotherapy , Fall, V.10(3):187-195. 

Smith, G.M. (1985), The Collaborative Drawing Technique, J. Personality Assessment , Dec., 

V.49(6):582-5. 

Spitz, E.H. (1989), The world of art and the artful world: some common fantasies in creativity and 

psychopathology, Arts in Psychotherapy , Win., V.16(4):243-251. 

Strand, S. (1990), Counteracting isolation: group art therapy for people with learning difficulties, Group 

Analysis , Sep., V.23(3):255-263. 

Swenson, A.B. (1991), Relationships: art education, art therapy, and special education, Perceptual and 

Motor Skills , Feb., V.72(1):40-42. 

Syristova, E. (1989), The creative potential of schizophrenic psychosis: its importance for psychotherapy, 

Studia Psychologica , V.31(4):283-294. 

Talerico, C.J. (1986), The expressive arts and creativity as a form of therapeutic experience in the field of 

mental health, J. Creative Behavior , V.20(4):229-247. 

Tate, F.B. (1989), Symbols in the graphic art of the dying, Arts in Psychotherapy , Sum., V.16(2):115- 

120. 

Tate, F.B., Allen, H. (1985), Color preferences and the aged individual: implications for art therapy, Arts 

in Psychotherapy , Fall, V.12(3):165-169. 

Taylor, J.W. (1990), The use of nonverbal expression with incestuous clients, Families in Society , Dec., 

V.71(10):597-601. 

Temple, S. (1988), Erickson's model of personality development related to clinical material, British J. 

Occupational Therapy , Nov., V.51(11):399-402. 

Tokuda, Y. (1973), Image and art therapy, Art Psychotherapy , Win., V.1(3-4):169-176. 

Tokuda, Y. (1980), Theory and practice of image art psychotherapy, Confinia Psychiatrica , V.23(4):193- 

208. 

Ulman, E. (1977), Art education for the emotionally disturbed, Am. J. Art Therapy , Oct., V.17(1):13-16. 

Vaccaro, V.M. (1973), Specific aspects of the psychology of art therapy, Art Psychotherapy , Fall, 

V.1(2):81-89. 

Van-Krevelen, D.A. (1975), On the use of the family drawing test, Acta Paedopsychiatrica, 

V.41(3):104-9. 

Vassiliou, G.A. (1983), Analogic communication as a means of joining the family system in therapy, Int. 

J. Family Psychiatry , V.4(3):173-9. 

Vogl, J.M., Vogl, G.M. (1983), Group art therapy: an eclectic approach, Am. J. Art Therapy , Jul., 

V.22(4):129-135. 

Wadeson, H. (1973), Separateness, Art Psychotherapy , Fall, V.1(2):131-3. 

Wadeson, H. (1975), Suicide: expression in images, Am. J. Art Therapy , Apr., V.14(3):75-82. 

Wadeson, H. (1976), Combining expressive therapies, Am. J. Art Therapy , Jan., V.15(2):43-6. 

Wadeson, H. (1976), The fluid family in multi-family art therapy, Am. J. Art Therapy , Jul. V.15(4):115- 

8. 

Wald, J. (1983), Alzheimer's disease and the role of art therapy in its treatment, Am. J. Art Therapy , Jan., 

V.22(2):57-64. 

Wald, J. (1986), Art therapy for patients with dementing illnesses, Clinical Gerontologist , Feb., 

V.4(3):29-40. 

Weininger, O. (1987), The Differential Diagnostic Technique, a visual motor projective test, Perceptual 

384

and Motor Skills , Aug., V.65(1):76-8. 

Weiss, J.C. (1984), Expressive therapy with elders and the disabled: Touching the heart of life, Activities, 

Adaptation and Aging, May, V.5(1-2):213. 

Wilkinson, S. (1985), Drawing up boundaries: a technique, J. Family Therapy , May, V.7(2):99-111. 

Willmuth, M., Boedy, D.L. (1979), The verbal diagnostic and art therapy combined: an extended 

evaluation procedure with family groups, Art Psychotherapy , V.6(1):11-18. 

Wilson, L. (1985), Symbolism and art therapy: I. Symbolism's role in the development of ego functions, 

Am. J. Art Therapy , Feb., V.23(3):79-88. 

Wilson, L. (1985) Symbolism and art therapy: II. Symbolism's relationship to basic psychic functioning, 

Am. J. Art Therapy , May, V.23(4):129-133. 

Wilson, L. (1977), Theory and practice of art therapy with the mentally retarded, Am. J. Art Therapy , 

Apr., V.16(3):87-97. 

Wittels, B. (1978), Jung, art therapy and the psychotic patient, Art Psychotherapy , V.5(3):115-121. 

Wittels, B. (1975), The use of art to master symptoms as demonstrated in the art work of acutely 

psychotic patients, Art Psychotherapy , V.2(3-4):217-224. 

Wittenberg, D. (1974), Art therapy for adolescent drug abusers, Am. J. Art Therapy , Jan., V.13(2):141-9. 

Wolf, R. (1979), Re-experiencing Winnicott's environmental mother: implications for art psychotherapy 

of anti-social youth in special education, Art Psychotherapy , V.6(2):95-102. 

Wolff, R.A. (1975), Therapeutic experiences through group art expression, Am. J. Art Therapy , Apr., 

V.14(3):91-8. 

Ziegler, R.G. (1976), Winnicott's squiggle game: Its diagnostic and therapeutic usefulness, Art 


Zigmund, J. (1986), Relating developmental level to art materials in work with paranoid and schizoid 

personalities, Pratt Institute Creative Arts Therapy Review , V.7:1-12. 

Zlatin, H.P. (1979), "I never had a chance": Art therapy at a geriatric center, Art Psychotherapy , 

V.6(2):119-123. 

Case studies of artists 

9 Bader, A. (1971), Psychopathological discovery of Charles Filiger, symbolist painter, Confinia 

Psychiatrica , V.14(1):18-35. 

1 Billig, O. (1972), Is schizophrenic expression art? Confinia Psychiatrica , V.15(1):49-54. 

26 Dreifuss, G. (1978), Artists in the creative process of Jungian analysis, Confinia Psychiatrica , V.21(1- 

3):45-50. 

16 Fernandez, A., Seva, A. (1994), A discovery throwing light on the illness of F. de Goya Lucientes, 

History of Psychiatry , Mar., V.5(17 part 1):97-102. 

14 Gaillard, J.M. (1992), The expression of psychodynamic forces in the paintings of Modigliani, 

International J. of Short Term Psychotherapy , Apr., V.7(2):109-122. 

4 Garai, J.E. (1974), The use of painting to resolve an artist's identity conflicts, Am. J. Art Therapy , Jan., 

V.13(2):151-164. 

28 Genser, L. (1985), Art as therapy with an aging artist, Am. J. Art Therapy, Feb. V.23(3):93-99. 

24 Junge, M.B. (1994), The perception of doors: A sociodynamic investigation of doors in 20th century 

painting, Arts in Psychotherapy , V.21(5):343-357. 

10 MacGregor, J.M. (1977), European collections of psychiatric art: A brief chronological and very 

personal account of a 1-month tour of collections in Switzerland, Italy, Germany and Austria undertaken 

in March and April, 1976, Confinia Psychiatrica , V.20(1):1-9. 

19 Martin, S.A. (1988), Martin Ramirez: Psychological hero, Arts in Psychotherapy , V.15(3):189-205. 

27 Meissner, W.W. (1994), Vincent Van Gogh as artist: a psychoanalytic reflection, Annual of 

Psychoanalysis , V.22:111-141. 

Miller, R. (1990), Empathy and hierarchy: a response to Sass, New Ideas in Psychology , V.8(3):305-7. 

29 Muenchow, D.C., Aresenian, J. (1974), An artist in turmoil during art therapy, Am. J. of Art Therapy , 

Oct., V.14(1):18-23. 

5 Or-Halbreich, T., Halbreich, U. (1977), A comparison between mental patients' paintings and the action 

painting movement, Art Psychotherapy , V.4(1):15-18. 

6 Parsons, P. (1986), Outsider art: patient art enters the art world, Am. J. of Art Therapy , Aug., 

V.25(1):3-12. 

25 Peto, A. (1979), The Rondanini Pieta: Michelanelo's infantile neurosis, International Review of 

385

Psycho-Analysis , V.6(2):183-200. 

3 Poldinger, W. (1986), The relation between depression and art, Psychopathology , V.19 suppl.2:263-8. 

11 Postma, J.U. (1993), Did Rembrandt suffer from depressive periods? A photo-analytic study of his self 

portraits, European J. of Psychiatry , Jul-Sep., V.7(3):180-184. 

21 Roman, M., Stastny, P. (1987), An inquiry into art and madness: The career of Jochen Seidel, Annual 

of Psychoanalysis , V.15:269-291. 

18 Sass, L.A. (1985), Time, space, and symbol: A study of narrative form and representational structure 

in madness and modernism, Psychoanalysis and Contemporary Thought , V.9(1):45-85. 

22 Schildkraut, J.J. (1994), Hirshfeld, A.J., Murphy, J.M., Mind and mood in modern art: II. Depressive 

disorders, spirituality, and early deaths in the abstract expressionist artists of the New York School, Am. 

J. of Psychiatry , Apr., V.151(4):482-488. 

12 Schildkraut, J.J., Hirshfeld, A.J. (1995), Mind and mood in modern art I: Miro and "melancholie", 

Creativity Re search J. , V.8(2):139-156. 

23 Simon, N. (1977), Primal scene, primary objects and nature morte: A psychoanalytic study of Mark 

Gertler, International Review of Psycho-Analysis , V.4(1):61-70. 

15 Starobinski, J. (1993), A modern melancholia: Van Gogh's portrait of Dr. Gachet (Trans. M. 

Bradshaw), Psychological Medicine , Aug., V.23(3):565-568. 

2 Syristova, Eve (1989) The creative potential of schizophrenic psychosis: its importance for 

psychotherapy, Studia Psychologica , V.31(4):283-294. 

13 Taylor, B. (1981), Picasso and the pathology of cubism, Arts in Psychotherapy , V.8(3-4):165-173. 

7 Wapner, W., Judd, T., Gardner, H. (1978), Visual agnosia in an artist, Cortex , Sep., V.14(3):343-364. 

20 Warick, L.H., Warick, E.R. (1984), Transitional process and creativity in the life and art of Edvard 

Munch, J. of the Am. Academy of Psychoanalysis , Jul., V.12(3):413-424. 

17 Wijsenbeek, H. (1978), The art of Pieter Mondrian, Confinia Psychiatrica , V.21(1-3):156-160. 

8 Wylie, M.L., Wylie, H.W. (1989), The creative relationship of internal and external determinants in the 

life of an artist, Annual of Psychoanalysis , V.17:73-128. 

Case studies - change of sign/theme - subjective measures 

14 Bauer, A., Kaiser, G.(1995), Drawing on drawings, Aphasiology , Jan-Feb., V.9(1):68-78. 

3 Benveniste, D.(1983), The archetypal image of the mouth and its relation to autism, Arts in 


15 Buchalter-Katz, S. (1985), Observations concerning the art productions of depressed patients in a shortterm 

psychiatric facility, Arts in Psychotherapy , Spr., V.12(1):35-38. 

16 Cohen, Barry M., Cox, Carol T. (1989), Breaking the code: identification of multiplicity through art 

productions, Dissociation Progress in the Dissociative Disorders , Sep. V.2(3):132-137. 

8 Dodd, F.G. (1975), Art therapy with a brain injured man, Am. J. Art Therapy , Apr., V.14(3):83-89. 

12 Enachescu, C. (1971), Aspects of pictorial creation in manic-depressive psychosis, Confinia 


7 Forrest, G. (1978), An art therapist's contribution to the diagnostic process, Am. J. Art Therapy , Apr., 

V.17(3):99-105. 

1 Galbraith, N. (1978), A foster child's pictorial expression of ambivalence, Am. J. Art Therapy , Jan., 

V.17(2):39-49. 

13 Garcia, V.L. (1975), Case study: Family art evaluation in a Brazilian guidance clinic, Am. J. Art 

Therapy , Jul., V.14(4):132-9. 

6 Hardi, I. (1972), Reflection of manic-depressive psychoses in dynamic drawing tests, Confinia 


10 Levinson, C.P. (1986), Patient drawings and growth toward mature object relations: Observations of 

an art therapy group in a psychiatric ward, Arts in Psychotherapy , Sum., V.13(2):101-6. 

2 Lofren, D.E. (1981), Art therapy and cultural difference, Am. J. Art Therapy , Oct., V.21(1):25-30. 

4 Lowe, M.E. (1984), Smoke gets in your eyes, sometimes, Arts in Psychotherapy , Win., V.11(4):267- 

277. mute 1912 

11 Mango, C. (1992), Emma: Art therapy illustrating personal and universal images of loss, Omega J. 

of Death and Dying , V.25(4):259-269. 

9 Martineau, M. (1986), From symptom to symbol: Group intervention as a catalyst in establishing an 

effective holding environment, Pratt Institute Creative Arts Therapy Review , V.7:22-30. 

5 Perez, L., Marcus-Ofseyer, B. (1978), The effect of lithium treatment on the behavior and paintings of 

386

a psychotic patient with religious and sexual conflicts, Am. J. Art Therapy , Apr., V.17(3):85-90. 

Case studies - change of sign theme - objective measure 

23 Aldridge, D., Brandt, G., Wohler, D. (1990), Toward a common language among the creative arts 

therapies, Arts in Psychotherapy , Fall, V.17(3):189-195. 

20 Cagnoletta, M.D. (1983), Art work as a representation of object relations in the therapeutic practice, 

Pratt Institute Creative Arts Therapy Review , V.4:46-52. 

26 Cronin, S.M., Werblowsky, J.H. (1979), Early signs of organicity in art work, Art Psychotherapy , 

V.6(2):103-8. 

19 Fink, P.J. (1973), Art as a reflection of mental status, Art Psychotherapy , Apr., V.1(1):17-30. 

27 Gerevich, J., Ungvari, G., Karczag, I. (1979), Further data on the diagnostic value of spontaneous 

drawing, Confinia Psychiatrica , V.22(1):34-48. 

28 Hardi, I. (1977), Alcoholic diseases in the light of dynamic drawing tests, Psychiatrica Fennica , p.47- 

61. 

25 Heiman, M., Strnad, D., Weiland, W. (1994), Art therapy and alexithymia, Art Therapy , V.11(2):143- 

6. 

24 Heine, D., Steiner, M. (1986), Standardized paintings as a proposed adjunct instrument for longitudinal 

monitoring of mood states: a preliminary note, Occupational Therapy in Mental Health , Fall, V.6(3):31-7. 

22 Hendrixson, B.N. (1986), A self-portrait project for a client with short-term memory dysfunction, Am. 

J. Art Therapy , Aug., V.25(1):15-24. 

30 Holmes, C.B. (1983), Memory For Designs drawing styles of psychiatric patients, J. Clin. 

Psychology , Jul., V.39(4):563-566. 

29 Kay, S.R. (1979), Significance of torque in retarded mental development and psychosis: relationship 

to antecedent and current pathology, Am. Psychologist , Apr., V.34(4):357-362. 

31 Nikolaenko, N.N., Menshutkin, V.V. (1993), Co-ordinate displacement and visual space compression 

during right hemisphere inhibition, Human Physiology , Mar-Apr., V.19(2):104-8. 

17 Roback, H.B., Gunby, L. (1984), A ten year comparison of human figure drawings by a 

psychologically decompensating patient, International J. Symbolo gy , Nov., V.8(3):103-111. 

18 Wald, J. (1984), The graphic representation of regression in an Alzheimer's disease patient, Arts in 

Psychotherapy , Fall, V.11(3):165-175. 

21 Wolf, J.M., Willmuth, M.E., Watkins, A. (1986), Art Therapy's role in treatment of anorexia nervosa, 

Am. J. Art Therapy , Nov., V.25(2):39-46. 

Case studies, behaviour change 

Bowen, C.A., Rosal, M.L. (1989), The use of art therapy to reduce the maladaptive behaviors of a 

mentally retarded adult, Arts in Psychotherapy , Fall, V.16(3):211-218. 

Gale, I.G. (1990), Neuropsychological rehabilitation technique with a chronic schizophrenic patient, 

Behaviour-Change , V.7(4):179-184. 

Goren, A.R., Fine, J. (1995), Manaim, H., Apter, A., Verbal and nonverbal expressions of central deficits 

in schizophrenia., J. Nervous and Mental Disease , Nov. V.183(11):715-719. 

Olive, J.S. (1991), Development of group interpersonal skills through art therapy, Maladjustment and 

Therapeutic Education , Win., V.9(3):174-180. 

Case studies - main therapeutic benefit - relationship 

7 Bondesen, C.L. (1984), Transference and countertransference in schizophrenia: The paranoic defense 

against homosexuality, Pratt Institute Creative Arts Therapy Review , V.5:22-32. 

8 Buck, L.A., Goldstein, F., Kardeman, E. (1984), Art as a means of interpersonal communication in 

autistic young adults, J. Psychology and Christianity , Fall, V.3(3):73-84. 

13 Davis, D.L., Boster, L. (1988), Multifaceted therapeutic interventions with the violent psychiatric 

inpatient, Hospital and Community Psychiatry , Aug., V.39(8):867-869. 

18 Dreifuss, E. (1978), Some notes on a relationship between art therapist and patient, Am. J. Art 

Therapy , Jan., V.17(2):57. 

17 Dunne, M. (1993), The integration of two theoretical models in treatment with art therapy, Pratt 

Institute Creative Arts Therapy Review, V.14:17-24. 

387

10 Fagin, I. (1983), Images of growth and mourning in the process of termination, Pratt Institute Creative 

Arts Therapy Review , V.4:53-60. 

6 Ferrara, N. (1992), Adolescent narcissism and ego regression: an art therapy case illustration, J. Child 

and Youth Care , V.7(1):49-56. 

12 Forrest, G. (1975), The problems of dependency and the value of art therapy as a means of treating 

alcoholism, Art Psychotherapy , V.2(1):15-43. 

9 Gunther, M. (1992), Eros and the ego: the use of ego assessment in creatively addressing a sexualized 

transference, Pratt Institute Creative Arts Therapy Review , V.13:31-40. 

4 Horovitz-Darby, E.G. (1992), Reflections: Countertransference: Implications in treatment and post 

treatment, Arts in P sychotherapy , V.19(5):379-389. 

3 Izhakoff, S. (1993), Symbiosis and symbiotic relatedness: A bridge to schizophrenia, Pratt Institute 

Creative Arts Therapy Review , V.14:25-33. 

5 Kaplan, F.F. (1983), Drawing together: Therapeutic use of the wish to merge, Am. J. Art Therapy , Apr., 

V.22(3):79-85. 

2 Shapiro, J. (1988), Moments with a multiple personality disorder patient, Pratt Institute Creative Arts 


14 Stamelos, T., Mott, D.W. (1983), Learned helplessness in persons with mental retardation: art as a 

client centred treatment modality, Arts in Psychotherapy , Win., V.10(4):241-249. 

19 Stamelos, T., Mott, D.W. (1986), Creative potential among persons labelled developmentally 

delayed:II. Meditation as a technique to release creativity, Arts in Psychotherapy , Fall, V.13(3):229-234. 

11 Teirstein, E.G. (1991), Developing: Art, mastery, self, Pratt Institute Creative Arts Therapy Review , 

V.12:16-29. 

1 Wolf, R. (1975), Art psychotherapy with acting-out adolescents: an innovative approach for special 

education, Art Psychotherapy , Vol.2(3-4):255-266. 

Case studies - main therapeutic benefit - expression of feelings 

Alanko, A. (1973), Psychosis and art, Psychiatria Fennica , p.153-158. 

Bemtovegna, S., Schwartz, L., Deschner, D. (1983), Case study: the use of art with an autistic child in 

residential care, Am. J. Art Therapy , Jan., V.22(2):51-6. 

Berkowitz, S. (1990), Art therapy with a Vietnam veteran who has post traumatic stress disorder, Pratt 


Bertoia, J., Allan, J. (1988), Counselling seriously ill children: use of spontaneous drawings, Elementary 

School Guidance and Counselling , Feb., V.22(3):206-221. 

Blasco, S.P. (1978), Case study: art expression as a guide to music therapy, Am. J. Art Th erapy , Jan., 

V.17(2):51-56. 

Branch, J. (1992), Depression and feminine personality development, Pratt Institute Creative Arts Therapy 

Review , V.13:9-15. 

Cardone, L., Marengo, J., Calisch, A. (1982), Conjoint use of art and verbal techniques for the 

intensification of the psychotherapeutic group experience, Arts in Psychotherapy , Win., V.9(4):263-268. 

Carozza, P.M., Heirsteiner, C.L.(1982), Young female incest victims in treatment: stages of growth seen 

with a group art therapy model, Clinical Social Work J. , Fall, V.10(3):165-175. 

Ciornai, S. (1983), Art therapy with working class Latino women, Arts in Psychotherapy , Sum., 

V.10(2):63-76. 

Cohen, F.W. (1974), Art therapy in the diagnosis and treatment of a transsexual, Am. J. Art Therapy , 

Oct., V.14(1):3-11. 

Cohn, R. (1984), Resolving issues of separation through art, Arts in Psychotherapy , V.11(1):29-35. 

Colli, L.M. (1994), Aims in therapy and directives in society: observations on individuation and 

adaptation (Trans. J. Leyland), Arts in Psychotherapy , V.21(2):107-112. 

David, I.R., Sageman, S. (1987), Psychological aspects of AIDS as seen in art therapy, Am. J. Art 

Therapy , Aug., V.26(1):3-10. 

Drachnik, C. (1978), Case study: art therapy with a girl who lived in two worlds, Am. J. Art Therapy , 

Oct., V.18(1):19-27. 

Eskridge, J.H. (1993), Healing the wounded female self, Pratt Institute Creative Arts Therapy Review , 

V.14:50-55. 

388

Evans, E. (1986), Facilitating the reparative process in depression: images for healing, Pratt Institute 

Creative Arts Therapy Review , V.7:43-53. 

Evans, E. (1984), Transpersonal aspects of transference and countertransference, a Jungian perspective, Pratt 


Fleming, M., Nathans, J. (1979), The use of art in understanding the central treatment issues in a female 

to male transsexual, Art Psychotherapy , B.6(1):25-35. 

Fogle, D.M. (1980), Art and poetry therapy combined with talking therapy with a family of four in an 

outpatient clinic, Arts in Psychotherapy , V.7(1):27-34. 

Gillespie, A. (1986), "Art Therapy" at the Familymakers project, Adoption and Fostering , V.10(1):19-23. 

Glaister, J.A. (1994), Clara's story: post traumatic response and therapeutic art, Perspectives in Psychiatric 

Care , Jan-Mar., V.230(1):17-22. 

Green, P., Bertrand, D. (1975), Art therapy with a schizophrenic patient, Bulletin of the Menninger Clinic , 

Jan., V.39(1):83-92. 

Greenspoon, D.B. (1984), The role of the art therapist as an adjunctive member of a residential treatment 

team, Residential Group Care and Treatment , Spr., V.2(3):15-31. 

Greenspoon, D.B. (1982), Case study: the development of self expression a severely disturbed adolescent, 

Am. J. Art Therapy , Oct., V.22(1):17-22. 

Halbreich, U., Assael, M., Dreifus, D. (1980), Premonition of death in painting, Confinia Psychiatrica , 

V.23(2):74-81. 

Harriss, M., Landgarten, H. (1973), Art therapy as an innovative approach to conjoint treatment: a case 

study, Art Psychotherapy , Win., V.1(3-4):221-228. 

Hatfield, F.M., Zangwill, O.L. (1974), Ideation in aphasia: the picture-story method, Neuropsychologia , 

Jul., V.12(3):389-393. 

Heiney, S.P. (1991), Sibling grief: a case report, Archives of Psychiatric Nursing , Jun., V.5(3):121-127. 

Hook-Wheelhouwer, J. (1991), Protective custody: a lifestyle in prison, Pratt Institute Creative Arts 


Jones, D.L., Rush, K. (1979), Treatment of psychotic patients with preoccupations of demon possession, 


Katz, S.L. (1987), Photocollage as a therapeutic modality for working with groups, Social Work with 

Groups , Win., V.10(4):83-90. 

Kornreich, S. (1988), An Alzheimer patient's use of art as a form of constancy, Pratt Institute Creative Arts 


Kunkle-Miller, C. (1978), Art therapy with mentally retarded adults, Art Psychotherapy , V.5(3):123-133. 

Landgarten, H. (1975), Art therapy as primary mode of treatment for an elective mute, Am. J. Art Therapy , 

Jul., V.14(4):121-5. 

Landgarten, H. (1975), Group art therapy for mothers and daughters, Am. J. Art Therapy , Jan., 

V.14(2):31-35. 

Levick, M., Herring, J. (1973), Family dynamics - as seen through art therapy, Art Psychotherapy , Apr., 

V.1(1):45-54. 

Lehtonen, K., Shaughnessy, M.F. (1992), Projective drawings as an aid to music therapy, Acta 

Paedopsychiatrica International J. of Child and Ad olescent Psychiatry , Dec., V.55(4):231-233. 

Lubart, L. (1985), The use of structured art and movement with chronic schizophrenic adults, Pratt 


Marinow, A. (1980), Symbolic self-expression in drug addiction, Confinia Psychiatrica , V.23(2):103-8. 

Mashiah, T. (1996), Painting as language for a stroke patient, Art Therapy , V.13(4):265-9. 

McIntyre, B.P. (1990), Art therapy with bereaved youth, J. Palliative Care , Spr., V.6(1):16-25. 

McNiff, S. (1975), Anthony: a study in parallel artistic and personal development, Am. J. Art Therapy , 

Jul., V.14(4):126-131. 

Mills, A. (1985), Art therapy on a residential treatment team for troubled children, J. Child Care , 

V.2(4):61-71 - reprint J. Child and Youth Care , 1991 V.6(4):49-59. 

Moffat, J.P., Friedman, I. (1973), Utilization of art therapy in the hospital management of a schizophrenic 

patient, Art Psychotherapy , Win., V.1(3-4):301-6. 

Musick, P.L. (1980), Creativity: abreaction for the therapist, Arts in Psychotherapy , V.7(3):197-199. 

Myers-Garrett, E.A. (1987), The role of contours in symbol building with a victim of sexual abuse, Pratt 

389


Naitove, C.E. (1986), "Life's but a walking shadow": treating anorexia nervosa and bulimia, Arts in 


Nelson, A. (1986), The use of early recollection drawings in children's group therapy, Individual 

Psychology Journal of Adlerian Theory, Research and Practice , Jun., V.42(2):288-291. 

Pitak, S. (1982), Bridging isolation: a synthesis of Eastern and Western perspectives in creative group 

work with addiction recovery unit patients, Pratt Institute Creative Arts Therapy Review , V.3:67-76. 

Potocky, M. (1993), An art therapy group for clients with chronic schizophrenia, Social Work with 

Groups , V.16(3):73-82. 

Quail, J.M., Peavy, R.V. (1994), A phenomenologic study of a client's experience in art therapy, Arts in 


Robbins, A. (1984), The struggle for self-cohesion: an analytically orientated art therapy case study, Art 

Therapy , Oct., V.1(3):107-118. 

Shennum, W.A. (1987), Expressive activity therapy in residential treatment: effects on children's behavior 

in the treatment milieu, Child and Youth Care Quarterly , Sum., V.16(2):81-90. 

Sikelianos, M. (1975), The use of symbolic drawing, metaphor and illusion in a therapeutic-creative 

process, Israel Annals of Psychiatry and Related Disciplines , Jun., V.13(2):142-161. 

Sinai, J. (1997) The use of metaphor by an artless first time psychotherapist, Am. J. Psychotherapy , 

Spring, V.51(2):273-88. 

Small, J., Greenway, M. (1988), The rediscovery of the lost twin: an account of therapy for a child and 

his parents, British J. of Psychotherapy , Fall, V.5(1):19-28. 

Stember, C.A. (1978), Change in maladaptive growth of abused girl through art therapy, Art 


Uhlin, D.M. (1977), The use of drawings for psychiatric evaluation of a defendant in a case of homicide, 

Mental Health and Society , V.4(1-2):61-73. 

Tyler, J. (1998), Nonverbal communication and the use of art in the care of the dying, Palliative Medicine , 

March, V.12(2):123-6. Ulak, B.J., Cummings, A.L. (1997) Using client's artistic experiences as metaphor 

in counselling: a pilot study, Can. J. Counselling , Oct., V.31(4):305-16. 

Vishup, E. (1985), Group art therapy in a methadone clinic lobby, J. of Substance Abuse Treatment , 

V.2(3):153-158. 

Vogli-Phelps, V. (1985), Letting the monsters out, Pointer , Spr., V.29(3):35-9. 

Weston, D. (1988), Development of a holding space for children hospitalized in a psychiatric unit, Pratt 


Wickersham, K. (1982), Imagery as a bridge to reorganizing secondary process skills in a ten year old 

aphasic child, Pratt Institute Creative Arts Therapy Review , V.3:56-7. 

Williams, S., Tamura, T.A., Rosen, D.H. (1977), An outpatient art therapy group, Art Psychotherapy , 

V.4(3-4):199-214. 

Williams, S. (1976), Short term art therapy, Am. J. Art Therapy , Jan., V.15(2):35-41. 

Zambelli, G.C., Clark, E.J., de-Jong-Hodgson, A. (1994), The constructive use of ghost imagery in 

childhood grief, Arts in Psychotherapy , V.21(1):17-24. 

67 

Controlled studies 

[C controlled studies; V Validity study; R Reliability Study; M Meta analysis] 

1. Aikman, K.G., Belter, R.W., Finch, A.J. (1992), Human figure drawings: validity in assessing 

intellectual level and academic achievement, J. of Clinical Psychology , Jan., V.48(1):114-120. [V] 

2. Anstadt, T., Krause, R. (1989), The expression of primary affects in portraits drawn by schizophrenics, 

Psychiatry , Feb., V.52(1):13-24. [C, V] 

3. Bergland, C., Moore Gonzalez, R. (1993), Art & madness: can the interface be quantified? (SPAR), 

Am. J. Art Therapy , Feb., V.31:81-90. [C, V, R] 

4. Brems, C., Adams, R.L., Skillman, G.D. (1993), Person drawings by transsexual clients, psychiatric 

clients and nonclients compared: indications of sex-typography, Archives of Sexual Behavior , Jun., 

V.22(3):253-264. [C, V] 

5. Brooke, S.L. (1995) Art Therapy: An approach to working with sexual abuse survivors, Arts in 

Psychotherapy , V.22(5):447-466. [C, V] 

6. Castilla, L.M., Klyczek, J.P. (1993), Comparison of the Kinetic Person Drawing Task of the Bay Area 

390

Functional Performance Evaluation with measures of functional performance, Occupational Therapy in 

Mental Healt h , V.12(2):27-38. [V] 

7. Cermak, S.A., Eimon, M. & P., Hartwell, A. (1991), Constructional abilities in persons with chronic 

schizophrenia, Occupational Therapy in Mental Health V.11(4):21-39. [C, V] 

8. Cohen, B., Hammer, J.S., Singer, S. (1988), The Diagnostic Drawing Series: A systematic approach 

to art therapy evaluation and research, Arts in Psychotherapy , Spr., V.15(1):11-21 [C, V] 

9. Cohen, F., Phelps, R.E. (1985) Incest markers in children's artwork, Arts in Psychotherapy Win. 

V.12(4):265-283. [V, R] 

10. Cohen, F.W., Phelps, R.E. (1985), Incest markers in children's artwork, Arts in Psychotherapy, 

Win., 

V.12(4):265-283. [R] 

11. Couch, J.B. (1994), Diagnostic Drawing Series: research with older people diagnosed with organic 

mental syndromes & disorders, Art Therapy , V.11(2):111-115. [C, V] 

12. Cressen, R. (1975), Artistic quality of drawings and judges' evaluations of the Draw-A-Person, J. 

Personality Assessment , Apr., V.39(2)132-137. [R] 

13. De Fazio, A. (1985), An abberant drawing sequence of the human figure and its relation to 

psychopathology, Perceptual Motor Skills , Dec., V.61(3pt1):785-802. [C, V] 

14. Dent, J.K., Kwiatkowska, H.Y. (1970), Aesthetic preferences of young adults for pictures drawn by 

mental patients and by members of their immediate families, Sciences de l'Art , V.7(1-2):43-54. [R] 

15. Dodrill, C.B. (1985), Incidence and doubtful significance of nonstandard orientations in reproduction 

of key, Perceptual Motor Skills , Apr., V.60(2):411-415. [C, V] 

16. Dudley, H.K. (1973), The Draw-A-Person Test and young state hospital patients, J. of Youth & 

Adolescence , Dec., V.2(4): 313-330. [V] 

17. Dykens, E. (1996), The Draw-A-Person task in persons with mental retardation: what does it 

measure?, Research in Developmental Disabilities , Jan-Feb., V. 17(1):1-13. [V] 

18. Ericson, R., Hill, K., Eras, P., Holmen, K., Jorm, A. (1994) The short human figure drawing scale 

for the evaluation of suspect cognitive dysfunction in old age, Archives of Gerontology & Geriatrics , Nov- 

Dec., V.19(3):243-251. [C, V] 

19. Feher, E., Vandecreek, L., Teglasi, H. (1983), The problem of art quality in the use of human figure 

drawing tests, J. Clin. Psychology Mar., V.39(2):268-275. [R] 

20. Forstl, H., Burns, A., Levy, R., Cairns, (1993) N. Neuropathological basis for drawing disability 

(constructional apraxia) in Alzheimer's disease, Psychological Medicine , V.23:623-629. [V, R] 

21. Gantt, L. (1990), A validity study of the Formal Elements Art Therapy Scale (FEATS) for diagnostic 

information in patients' drawing, unpublished Doctoral dissertation, University Pittsburgh, USA. [C, V, 

R, M] 

22. Gounard, B.R., Pray, R.C. (1975), Human figure drawings of learning disabled and normal children 

at three age levels, Perceptual and Motor Skills , V.40:914. [V] 

23. Green, B.L., Wehling, C., Talsky, G.J. (1987) Group art therapy as an adjunct to treatment for chronic 

outpatients, Health and Community Psychiatry , Sep., V.38(9):988-991. [C, V] 

24. Grodner, S., Braff, D.L., Janowsky, D.S., & Clopton, P.L. (1982), Efficacy of art/movement therapy 

in evaluating mood, Arts in Psychotherapy Fall V.9(3):217-225. [C, V] 

25. Grossman, M. (1993), Semantic evaluation of perceptual errors in aphasics' freehand category drawing, 

Neuropsychology , Jan.V.7(1):27-40. [C, V] 

26. Gustafson, J.L., Waehler, C.A. (1992) Assessing concrete and abstract thinking with the Draw-A- 

Person technique, J. Personality Assessment , V.59(3):439-447. [C, V] 

27. Heiman, M., Strnad, D., Weiland, W., Wise, T.N. (1994), Art therapy and alexythymia, Art Therapy , 

V.11(2):143-146. [V] 

28. Heine, D., Steiner, M. (1986), Standardized paintings as a proposed adjunct instrument for 

longitudinal monitoring of mood states: a preliminary note, Occupational Therapy in Mental Health , Fall, 

V.6(3):31-37. [V] 

29. Holmes, C.B., Wiederholt, J. (1982), Depression and figure size on the draw-a-person test, Perceptual 

and Motor Skills , Dec., V.55(3 pt.1):825-826. [C, V] 

30. John, K.B. (1974), Variations in bilateral symmetry of human figure drawings associated with 2 levels 

of adjustment, J. Clin Psychology Jul., V.30(3):401-404. [C, V] 

31. Kaplan, F.F. (1991), Drawing assessment and artistic skill, Arts in Psychotherapy , V.18:347-352. [V, 

R] 

32. Kay, S.R. (1980), Progressive figure drawings in the developmental assessment of mentally retarded 

391

psychotics, Perceptual and Motor Skills , Apr., V.50(2):583-590. [V] 

33. Kay, S.R. (1978), Qualitative differences in human figure drawings according to schizophrenic 

subtype, Perceptual and Motor Skills , 47:923-932. [C, V, R, M] 

34. Kessler, K. (1994), A study of the Diagnostic Drawing Series with eating disordered patients, Art 

Therapy , V.11(2):116-118. [C, V] 

35. Kirk, A., Kertesz, A. (1989), Hemispheric contributions to drawing, Neuropsychologia , 

V.27(6):881-886. [C, V, R, M] 

36. Knapp, N.M. (1994), Research with diagnostic drawings for normal and Alzheimer's subjects, Art 

Therapy , V.11(2):131-138. [C, V, R, M] 

37. Langevin, R., Raine, M., Day, D., Waxer, K. (1975), Art experience, intelligence and formal features 

in psychotics' paintings, Arts in Psychothera py (study 1), V.2(2):149-158. [C, V, R] 

38. Langevin, R., Raine, M., Day, D., Waxer, K. (1975), Art experience, intelligence and formal features 

in psychotics' paintings, Arts in Psychotherapy (study 2), V.2(2):149-158. [C, V, R, M] 

39. Langevin, R., Hutchins, L.M. (1973), An experimental investigation of judges' ratings of 

schizophrenics' and non-schizophrenics' paintings, J. Personality Assessment , Dec., V.37(6):537-543. [V, 

R] 

40. Larrabee, G.J., Kane, R.L. (1983), Differential drawing size associated with unilateral brain damage, 

Neuropsychologia , V.21(2):173-177. [C, V] 

41. Lehman, E.B., Levy, B.I. (1971), Discrepancies in estimates of children's intelligence: WISC and 

human figures drawing, J. Clin Psychology , V.27:74-76. [V] 

42. Lerner, C., Ross, G. The magazine picture collage: development of an objective scoring system, Am. 

J. of Occupational Therapy , Mar., V.31(3):156-161. [C, V] 

43. Levy, B.I., Ulman, E. (1974), The effect of training on judging psychopathology from paintings, Am. 

J. Art Therapy , Oct., V.14:24-25. [C, V] 

44. McGlashan, T.H., Wadeson, H.S., Carpenter, W.T., Levy, S.T. (1977), Art and recovery style from 

psychosis, J. Nervous and Mental Disease , V.164(3):182-190. [C, V, R, M] 

45. McNiff, S., Oelman, R. (1975), Images of fear, Arts in Psychotherapy , V.2(3-4):267-277. [C, V] 

46. Miljkovitch, M., Irvine, G.M. Comparison of drawing performances of schizophrenics, other 

psychiatric patients and normal schoolchildren on a draw-a-village task, Arts in Psychotherapy , 

V.9:203-216. [C, V, R, M] 

47. Miller, A.L., Atlas, J.A., Arsenio, W.F. (1993), Self-other differentiation among psychotic and 

conduct-disordered adolescents as measured by human figure drawings, Percep Motor Skills , Apr., 

V.76(2):397-8. [C, V] 

48. Mills, A., Cohen, B.M., Meneses, J.Z. (1993), Reliability and validity tests of the Diagnostic 

Drawing Series, Arts in Psychotherapy , V.20:83-88. [R] 

49. DDS study 77 naive raters, unpublished reported in Mills, A., Cohen, B.M., Meneses, J.Z. (1993), 

Reliability and validity tests of the Diagnostic Drawing Series, Arts in Psychotherapy , V.20:83-88. [R] 

50. Phillips, E.L., Geller, S.K. (1983), Ireland, M., Research on the use of art therapy in a university 

setting, Am. J. Art Therapy , Oct., V.23(1):26-29. [R] 

51. Phillips, W.M., Phillips, A.M. (1976), Similarity between complexity on Role Construct Repertory 

Tech and articulation of Draw-A-Person test for patients and nonpatients, Perceptual Motor Skills , Dec. 

V.43(3):1256-1258. [C, V] 

52. Rankin, A. (1994), Tree drawings and trauma indicators: a comparison of past research with current 

findings from the DDS, Art Therapy , V.11(2):127-130. [C, V, R] 

53. Robins, C., Edward, B., Sidney, J., Ford, R.Q. (1991), Changes in human figure drawings during 

intensive treatment, J. Personality Assessment , Dec. V.57(3):477-97. [C, V] 

54. Rosal, M.L. (1993), Changes in locus of control in behaviour disordered children, Arts in 

Psychotherapy , V.20(3:231-241. [C, V] 

55. Rubin, J.A., Ragins, N., Shachter, J., Wimberly, F. (1979), Drawings by schizophrenic and 

non-schizophrenic mothers and their children, Arts in Psychotherapy , V.6(3):163-175. [C, V] 

56. Russell-Lacy, S., Robinson, B., Benson, J., Cranage, J. (1979), An experimental study of pictures 

produced by acute schizophrenic subjects, B. J. Psychiatry , V.134:195-200. [C, V, R, M] 

57. Sidun, N.M., Rosenthal, R.H. (1987), Graphic indicators of sexual abuse in Draw-A-Person tests of 

psychiatrically hospitalized adolescents, Arts in Psychotherapy , Spr., V.14(1):25-33. [C, V, R, M] 

8. Silver, R., Ellison, J. (1995), Identifying and assessing self-images in drawings by delinquent 

adolescents, Arts in Psychotherapy , V.22(4):339-352. [R] 

392

59. part 2. Silver, R., Ellison, J. (1995), Identifying and assessing self-images in drawings by delinquent 

adolescents, Arts in Psychotherapy , V.22(4):339-352. [R] 

60. Simmonds, D.W., Koocher, G.P. (1973), Perceptual rigidity in paranoid schizophrenics; use of 

projective animal drawings, Perceptual Motor Skills , Aug., V.37(1):247-250. [C, V] 

61. Sims, J., Bolton, B., Dana, R.H. (1983), Dimensionality & concurrent validity of the Handler DAP 

anxiety index, Multivariate Experimental Clinical Research , V.6(2):69-79. [V, R] 

62. Sullivan, E.V., Mathalon, D.H., Nim Ha, C., Zipursky, R.B., Pfefferbaum, A. (1992), The 

contribution of constructional accuracy and organizational strategy to nonverbal recall in schizophrenia and 

chronic alcoholism, Biological Psychiatry V.32(4):312-333. [C, V] 

63. Tharinger, D.J.; Stark, K.D. (1990), A qualitative versus quantitative approach to evaluating the Draw- 

A-Person and Kinetic Family Drawing:a study of mood and anxiety disorder children, Psychological 

Assessment , V.2(4):365-375. [V] 

64. Van Hoof, J.J., Hulstijn, W., Van Mier, H., Pagen, M. (1993), 

Figure drawing and psychomotor retardation: preliminary report, J. of Affective Disorders , Dec., 

V.29(4):263-6. [C, V] 

65. Verinis, J.S., Lichtenberg, E.F., Henrich, L. (1974), The Draw A Person in the rain technique: Its 

relationship to diagnostic categories and other personality indicators, (experiment 1), J. Clin. Psychology , 

Jul. V.30(3):407-414. [C, V] 

66. Verinis, J.S., Lichtenberg, E.F., Henrich, L. (1974), The Draw A Person in the rain technique: Its 

relationship to Drawing categories and other personality indicators (experiment 2), J. Clin Psychology Jul. 

V.30(3): 407-414 [C, V] 

67. Verinis, J.S Lichtenberg, E.F., Henrich, L.(1974), The Draw A Person in the rain technique: Its 

relationship to Drawing categories and other personality indicators (experiment 3), J. Clin Psychology Jul. 

V.30(3): 407-414 [C, V] 

68. Wadeson, H., Carpenter, W.T. (1976), A comparative study of art expression of schizophrenic unipolar 

depressives and bipolar manic-depressive patients, J. Nervous Mental Disease , May, V.162(5):334-344. 

[C, V] 

69. Wadlington, W.L., McWhinnie, H.J. (1973), The development of a rating scale for the study of formal 

aesthetic qualities in the paintings of mental patients, Arts in Psychotherapy , Win., V.1(3-4):201-220. [C, 

V, R, M] 

70. Waldman, T.L., Silber, D.E., Holmstrom, R.W., Karp, S.A. (1994), Personality characteristics of 

incest survivors on the draw-a-person questionnaire, J. Personality Assessment , V.63(1):97-104. [C, V] 

71. Walsh, F.W. (1979), Breaching of family generation boundaries by schizophrenics, disturbed and 

normals, Int. J. of Family Th erapy , Fall, V.1(3):254-75. [C, V] 

72. Walsh, S.M. (1993), Future images: an art intervention with suicidal adolescents, Applied Nursing 

Research , Aug., V.6(3):111-8. [C, V] 

73. Wittels, B. (1982), Interpretation of the 'body of water' metaphor in patient artwork as part of the 

Diagnostic process, Arts in Psychotherapy , Fall, V.9(3):177-182. [C, V] 

74. Wittlin, B.W., Augusthy, R. (1988), Comparison of art psychopathology and discharge diagnoses of 

diagnostic unit patients, Art Therapy , Dec., V.5(1):94-98. [V] 

75. Wright, J.H., Macintyre, M.P. (1982), The family drawing depression scale, J. Clin. Psychology , 

V.38(4): 853-861. [C, V, R, M] 

76. Wright, S.K., Ashman, A.F. (1991), The use of symbols in drawings by children, nondisabled 

adolescents and adolescents with an intellectual disability, Developmental Disabilities Bulletin , 

V.19(2):105-128. [C, V] 

77. Yaguchi, K. (1981), A study of tree drawings in aged groups: An examination of formal indices of 

the drawings, J. Child Development , Jan., V.17:32-34. [C, V] 

78. Young, N.A. (1975), Art therapy with chronic schizophrenic patients of a low socio-economic class 

in a short term treatment facility, Arts in Psychotherapy , V.2(1):101-117. [C, V] 

79. Zucker, K.J., Finegan, J.K., Doering, R.W., Bradley, S.J. (1983), Human figure drawings of gender 

problem children: A comparison to sibling, psychiatric, and normal controls, J. Abnormal Child 

Psychology , 11:287-298. [V] 

393

Appendix 4 

Development of the Descriptive Assessement for Psychiatric Artwork 

(DAPA) 

DAPA version 3: the rating guide used in the main study. 

Rating sheet for DAPA version 3. 

Helpsheet for DAPA rating guide version 3. 

Rating sheet for casenotes (main study). 

DAPA version 2: the rating guide used in the pilot study. 

Research questionnaire on dominant form for artists. 

Research rating sheet on dominant form for re-rating of form version 3. 

394

Page 1. Rating guide 

DAPA Version 3. The rating guide used in the main study 

DESCRIPTIVE ASSESSMENT FOR PSYCHIATRIC ART 

RATING GUIDE 

S. HACKING AND D. FOREMAN 1999. 

395

D.A.P.A. DESCRIPTIVE ASSESSMENT OF PSYCHIATRIC ARTWORK - S. 

HACKING AND D. M. FOREMAN © 1999. 

RATING GUIDE 

The pictures must be rated for the presence of 15 elements on 6 scales: colour, intensity, 

line, space, emotional tone and form. 

A 5 column x 4 row grid drawn on acetate lies over the picture dividing it 

into 20 squares whatever the size of the paper. Borderlines done by the 

painter are ignored. This is laid according to the intended ‘right way up’ 

of the picture. The rating is done on the rating sheet which corresponds to 

the grid. Each scale in each division offers a choice which is marked off 

by the rater. Colour rating forces a present/absent in that square decision 

on each of 9 colours; the other scales use gradations of high/medium/low. 

A total of 300 decisions are required to rate one picture. However, time 

for picture rating typically varies from 5-15m. 

Each of the 20 scoring squares on the rating sheet contains 5 rows of boxes. Rows are 

identified left. Colour; Intensity; Line; Space; Emotional Tone. Example below. To score 

a box use diagonal line corner to corner. 

Each rating square scores the same grid square on the picture. If a picture square is unused, 

cross the whole rating square completely through. 

COLOUR 

R Y O P G B N W K 

INTENSITY H N L 

PAINTED H 

LINE 

V N 

1 2 3 4 5 

DRAWN LINE H 

N 

V 

396

COLOUR 

COLOUR R Y O P G B N 

W K 

Colour is simple, one you know what the letters mean! Red, Yellow, Orange, Purple, 

Green, Blue, browN, White, blacK. 

DEFINITION: Colours are defined by their hue. Mark the letter of any colour appearing 

in the grid square no matter how little. Writing by the painter is included. Grey and 

pencil marks are scored ‘blacK’. The colour of the paper is not scored. See HELP for 

more information on colour description and examples. 

397

INTENSITY 

DEFINITION: Firstly, the brightness or pureness of the media used; secondly, the 

densit over the area covered by the media (not the unused portion of the square). If two 

intensities occur in the same square, use whichever covers the most area. If there is equal 

cover, score the highest. 

H – High strong, dense saturated colour – e.g. thick pure paint or very heavy pressured 

pencil or crayon. 

N – Neutral. ‘Muddy’ colour; e.g. the colour has been ‘greyed’ or toned down, perhaps 

mixed to darker or lighter shades. Medium pressure pencil lines are scored as ‘neutral’. 

L – Low intensity or ‘watery’ colour (especially paint), little pigment over a large area, 

e.g. light pressured crayon or pencil. See HELP for examples. 

If colour is used in a single intensity or pressure, i.e. felt pen, pencils, 

crayon, neutral is scored when lines are deliberately overmarked in 

different colours. I.e. yellow overscored with black forms a ‘muddy 

yellow’ as it would if mixed together. 

LINE 


L 

I 

N 

E 

PAINT H 

V 

N 

DRAW 

H 

V 

Line is scored for Paint (media which fill the area; paint, pastel) and Draw (media which 

use marks such as crayon, pencil, felt tip). Both lines or one line can be used. 

DEFINITION: A line must be a distinct drawn or painted mark, loose scribble covering 

an area, pattern marks such as dots, outlines and writing ARE lines. Two areas of colour 

which come together or thin filled shapes or areas of colour tightly filled by drawing 

media ARE NOT lines. Leave blank if no lines appear in the square. 

Guideline: Scan the whole picture to identify the range of line. If the line appears 

constant, do not make very sensitive discriminations. Differences should be apparent. 

Lines such as pencil or felt pen used at the same pressure over the whole picture score 

as thin. Thick lines must be distinct. If the line is emphasised, i.e. redrawn 2 or 3 times, 

even at the same pressure, mark as thick. Refer to HELP for examples of varied lines. 

398 

N

H – Majority of tHick, or heavy lines with high pressure. 

V – Varied lines when both thick and thin lines are present in roughly the same quantity. 

N – ThiN, or the majority at light pressure. 

399

SPACE 

>10% >25% >55% >80% >100% 

DEFINITION: The largest UNUSED area of the square. 

Guideline: Identify the largest UNMARKED area in the square. It doesn’t matter if 

there are 2 or 3 unmarked areas, use only one. Imagine drawing a bubble shape around 

this space (bubbles can bend, be triangular, circular, square or elipse, but if you have a 

bubble with a narrow waist, you have two areas!). Does the bubble represent (1) 0-10%; 

(2) 10-25%; (3) 25-55%; (4) 55-80%; (5) 80-100% of the area of the square. 

Simply by quarters. (1-2) up to _; (3) up to _; (4) _ to _ ; (5) more than _ . Empty 

squares score 5. 

EMOTIONAL TONE 

E-TONE + 

0 - 

Guideline: Scan the picture as a whole, decide which elements of the picture, taking 

account of what communicates TO YOU of the maker’s intent in content, colour, 

intensity, line and form. (+) positive or (-) negative. Mark the squares containing these 

elements first. The other squares are (0) neutral. Leave empty squares blank. 

DOMINANT FORM 

DEFINITION: A shape enclosed by a boundary, explicit or implicit. It should be 

exceptional in, size or colour (contrasting hue, intensity or saturation). It is not always 

a recognisable shape or person. It is a LARGE SINGLE SHAPE. When multiple, 

400

there is NO dominant form! The shape may be repeated, but repetitions will be smaller 

or less intense. 

Guideline: Scan the picture as a whole, decide where the dominant form is. Use closure 

for open forms. If more than 25% of the square is covered by the form, shade the 

corresponding square in the small grid at the top of the rating sheet . 

Half Rating sheet for DAPA. Template. 1999 Hacking and Foreman © 

COLOUR 

INTENSITY 

L 

PAINT I 

N 

DRAW 

SPACE 

E-TONE 

COLOUR 

INTENSITY 

L 

PAINT I 

N 

DRAW 

SPACE 

E-TONE 

COLOUR 

INTENSITY 

L 

I 

N 

DRAW 

SPACE 

E-TONE 

COLOUR 

INTENSITY 

L 

PAINT I 

N 

DRAW 

SPACE 

E-TONE 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 

R 

Y O P G B N W K 

H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 401 - 

FORM --- 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 -

Part 2 Rating Sheet for DAPA: Hacking and Foreman 1999 © 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 

402 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0 - 


H N L 

H V N 

H V N 

1 2 3 4 5 

+ 0

Help Sheet for DAPA version 3. Main study. Hacking and Foreman 1999 © 

403

Rating Sheet for Casenotes DAPA version 3. 1999. 

KEELE UNIVERSITY STAFFORDSHIRE. DEPT. OF PSYCHIATRY, SCHOOL OF 

P.G. MEDICINE. ICHRC. N. STAFFORDSHIRE HOSPITAL. 

UNIT NAME 

WARD M / F MARRIED/SINGLE/SEP RACE AGE 

ICD-10 MEDICATION 

DIAGNOSIS 

OCCUPATION/TRADE 

ED LEVEL 

ECT YES/NO INPATIENT/OUT EVER SECTIONED 

404

Rating Guide Version 2. S. Hacking and D. Foreman 1994. © 

Descriptive Assessment for Psychiatric Art. 

Rating Guide Descriptive Assessment for Psychiatric Art 

V.2 

Used in the Pilot Study 1996. 

405

D.A.P.A. DESCRIPTIVE ASSESSMENT OF PSYCHIATRIC ARTWORK Pilot Study 

- S. HACKING AND D. M. FOREMAN © 1994. 

RATING GUIDE 

The pictures must be rated for the presence of 13 elements on 5 primarily structural 

areas: colour, intensity, line, area, emotional tone. These items are designed to describe 

the picture as objectively as possible. A grid is drawn over the picture forming 20 

squares. Rating looks at each category one at a time in each division. Colour rating offers 

two options forcing a present/not present decision; the others offer optional descriptors 

of the form high, medium or low. A total of 260 decisions are required to rate one 

picture. However, time for picture rating typically varies from 5-15m. A transparent 

overlay divides the picture into 20 squares; 5 across and 4 down, taking account of the 

intended ‘right way up’. The squares are drawn from the edge of the paper, ignoring 

borderlines done by the painter. 

Each of the 20 scoring squares on the rating sheet contains 5 rows of boxes. Each row is 

identified on the left; Colour; Intensity; Line; Area; Emotional Tone. See the example 

below 

COLOUR 


LINE H V 

N 

10 20 30 40 50 60 70 80 90 

100 

AREA 

Colour 


COLOUR R Y O P G B N 

W K 

406

Colour is simple, one you know what the letters mean! Red, Yellow, Orange, Purple, 

Green, Blue, browN, White, blacK. 

DEFINITION: Colours are defined by their hue. It doesn’t matter if the shade is dark 

or See HELP for more information on colour description and examples. If the colour 

appears anywhere in the square mark the identifying letter. Only the media on the paper 

is scored, not the colour of the paper. Writing on the picture done by the painter is 

scored in the same way. Pencil is scored black. 

407

Intensity 

DEFINITION: The brightness or pureness of the media used, not the surrounding 

space. If a hgih intensity dot sits in the middle of an otherwise empty square, the square 

is scored high. If the surrounding area is slightly tinted, however, the square is scored 

low. Durll and strong mixes of colour occurring in the same square are scored on 

whichever covers most of the area. If there is equal cover, score whichever colour is 

highest. Leave blank if the square is empty. 

H – High strong, dense saturated colour – e.g. thick pure paint or very heavy pressured 

pencil or crayon. 

N – Neutral or neither, also ‘muddy’ colour; e.g. the colour has been ‘greyed’ or toned 

down, perhaps mixed to darker shades. 

L – Low intensity or ‘watery’ colour especially paint, little pigment, e.g. light pressured 

crayon or pencil or thinly scattered media over the area. See HELP for examples. 

Line 

DEFINITION: - Refer to help for examples. A line must be a distinct drawn or painted 

mark. A line is not two areas of colour which come together. Line can be used for 

scribble covering an area or pattern marks, but is not used to describe thin shapes filled 

with paint. Leave blank if no lines appear in the picture. 

Scored as H – Majority of tHick, or heavy lines with high pressure; V – Varied lines 

when both thick and thin lines are present; N – ThiN, or light pressure. 

Area 


AREA 

LINE H V 

N 

10 

20 

30 

40 

Guidelines: Estimate how much of the square is covered by the media and mark the 

coverage on the scale in tenths or by 10%. A used area has media over it, no matter how 

408 

50 

60 

70 

80 

90 

100

thin or scattered. An unused area is completely empty. 

Emotional Tone 

E-TONE + 

0 - 

DEFINITION: subjective overall assessment of whether the square, its colour, intensity, 

line and content TO THE RATER seems (+) positive or happy; (0) neutral or neither 

(-) negative or sad. This is the only category where if the square is empty, score as 0 or 

neutral. DO NOT LEAVE BLANK. 

409

Form sheet for Artists. Side 2. DAPA development 1994 © sue Hacking. 

Age Sex m/f 

Art Training (tick) A level; Foundation; Degree; Post Grad. 

Currently practising? 

Media most used: paint; print; sculpture; 3d; design; other write 

This test takes about 5 minutes. 

Thank you for your co-operation in this test. I am seeking to understand what is meant 

by artistic terms in practice. Please answer both questions as clearly as possible. 

1. Look at the sheet of reproductions of works of art (other side). 

For each picture, delineate in red, the dominant form, as closely as you can to the 

contours of what you see as the single most dominant form in that picture. If the 

question is inapplicable to the picture, write ‘none’ at the bottom. 

2. What do the words ‘dominant form’ mean to you in the above sentence? Give a brief 

definition of your understanding of what a form is. You may refer to the pictures if 

you wish. You can take from 2 to 3 sentences to half a page. 

410

3. Research Questionnaire on Dominant Form for Raters. Test sheet1. DAPA Hacking 

and Foreman 1999 © 

Dominant Form 

This study is part of an experiment to find ways of describing a picture. This is not the 

whole of the study but one of the elements being tested. Please try to understand the 

explanation given by the experimenter as if you were part of a group trying to score 

exactly the same as everyone else. 

DEFINITION: 

An object or space enclosed by a boundary, explicit or implicit. 

It should be exceptional in 

Size and/or 

Colour 

Contrasting hue/intensity/saturation. 

It should be single (there must not be two opposing forms). 

The shape may be repeated, the repetitions will be smaller or less intense. It is usually 

a regular shape. 

What is going on in the picture (the content or narrative) is secondary to the structure. 

It need not be a recognisable shape or a person. 

When you have understood the explanation to the experimenter’s satisfaction, you will 

be asked to rate some pictures. Keep this explanation by you and refer to it every time. 

The experimenter will now describe the grid system. 

Please look at the picture as a whole first, can you see a shape which is large, singular and 

whose outline is generally echoed throughout the picture? 

Point out to the experimenter which squares the shape occupies. Cut off extremeties 

which are not integral to the regular shape. The shape must occupy more than 25% of 

the square to be counted. 

411

Appendix 5 

Permission for study, information for participants, and instructions for group leaders 

on treatment of pictures 

Consent forms for all participants in the pilot and for those in the main study who were 

saving their pictures from therapy groups were the same, pages 2 and 3 (oral and written). 

Information sheet for pilot study and for those in the main study who gave consent were 

the same (p.4). 

Instructions for group leaders in pilot study (p.5). 

Instructions for group leaders in main study (p.6). 

412

North Staffordshire Health Authority 

Research Ethics Committee 

PERSONAL CONSENT TO THE CONDUCT OF A RESEARCH 

INVESTIGATION 

STUDY TITLE Describing pictures by different groups of patients 

NAME OF CLINICIAN Dr. D. Foreman and Ms. S. Hacking 

The aims and procedures of the clinical investigation in which I have been asked to take 

part have been explained to me by ward staff. I have read and understood the patient 

leaflet set out overleaf, and have been informed about the possible benefit to myself and 

about any foreseeable risks or discomfort. 

I have had the opportunity to ask questions and to consider the answers given. 

I understand that participation in the study is voluntary and that I may withdraw from the 

study at any time of my own accord. If I do withdraw it will not affect the future care and 

attention which I will receive from my doctors. 

I agree that the relevant parts of my medical records may be disclosed to Dr. Foreman 

provided they agree not to reveal my name. 

I hereby freely give my fully informed consent to taking part in this clinical investigation. 

Name ……………………………….. Signature ……………………………. 

Date …………………………………. 

I confirm that I have explained the nature of the above investigation to the above named 

patient. 


Date …………………………………. 

413

North Staffordshire Health Authority 

Research Ethics Committee 

ORAL CONSENT TO THE CONDUCT OF A RESEARCH INVESTIGATION 

STUDY TITLE Describing pictures by different groups of patients 

NAME OF CLINICIAN Dr. D. Foreman and Ms. S. Hacking 

NAME OF PATIENT 

I have explained the aims and procedures of the above clinical investigation to the above 

named patient. He/she was informed of the possible benefits to him/herself and about any 

foreseeable risks or discomfort (and the information in the patient leaflet was also 

explained). 

He/she was given the time and opportunity to ask questions and to consider the answers 

given. 

The voluntary nature of participation in the study was emphasised, as was the right to 

withdraw from the study for any reason without prejudicing his/her relationship with 

myslef or any other of his/her medical advisors. 

I have explained that relevant parts of my medical records may be disclosed to Dr. 

Foreman. Names will not be disclosed. 

On this basis, I declare that the above named patient freely gave his/her consent to taking 

part in this clinical investigation. 

Witness to Oral Consent 


JOB TITLE OR RELATIONSHIP TO PATIENT …………………………….. 

Date …………………………………. 

414

Information sheet. Research into Art Therapy 

Painting for pleasure can have healing effects. Paintings may express what is deep inside 

the mind, that may not be easily put into words. 

Our understanding of a picture is often brought about through talking to people about it, 

but people's comments about their paintings are sometimes not helpful. This research is 

trying to discover a way of looking at the pictures themselves rather than what is said 

about them. 

We will be looking at a lot of pictures by people with the same kinds of problems, or with 

no problems at all. So any picture will be just one of a group. We do not just want 'special' 

pictures or particularly good pictures. It is more important to have a variety, so we would 

like a picture from anyone willing to do one. It does not matter if anyone cannot draw as 

well as they would wish as this is not an artistic project. 

You will be asked to paint a picture in a group. The picture will be numbered. Your name 

will not appear on it. No-one will see the picture but the people doing research. We have 

no connection with any treatment or ward. 

You will not be asked to discuss the pictures with anyone. The pictures will be taken 

away and used as a group study. We will keep a list of pictures for the time of the study 

and then the list will be destroyed. 

If you do not wish to help, it will not affect any treatment or care. I you want to do a 

picture, and then decide not to after all, or take your picture out of the study once it is 

done, this is your choice. 

Thank you for your help and co-operation. 

415

Psychiatry Dept., School P.G. Medicine. 

Researcher Sue Hacking. 

Research Project - DRAW A PICTURE. Study 1. 

PROTOCOL. 

If something goes wrong, or there is some alteration to the procedure, would you please 

write on the back of this paper what it was - and return it with the completed pictures. 

Allow about one hour for the session. 

Obtain consent from individuals before the series, using the information sheets and consent 

forms provided, if someone refuses, they may still attend their usual sessions with the 

group. 

On the reverse of this paper write ward no. and group leader. Give every participant a 

number beginning ______ so the first one would be ___1. Write the number and their 

names on the back of this paper, so they can be identified. 

Note the refusers like this: male/female who chose not to take part, no 

names. 

1. Make sure that each person has access to the following materials on their table: 

RED YELLOW ORANGE PURPLE GREEN BLUE BROWN WHITE BLACK, available 

for use, i.e. red and yellow do not provide orange, orange must be mixed and available. 

2. Facilities to make thick and thin lines, preferably with different colours. 

3. One piece of paper, A3 size - as big as 2 sheets of photocopy paper. 

Themed Sessions, one theme per session. 

1. Draw yourself as you usually are. 

2. Draw yourself as you might look if you were an animal. 

3. Draw a picture of yourself doing something you like to do. 

4. Draw a picture of your life with the past and the future on it. 

5. Draw a picture of yourself as you are feeling now. 

Other instructions to the group: 

You can put anything in the picture and you can use any colours that you want to use. 

You will not have to show it to anyone, or talk about it, you have up to one hour to finish 

the picture. 

Function of the researcher as helper to the group leader. To ensure that the participants 

make as free a choice as possible as to what colours they should use, and what kind of 

picture they should draw. To encourage participants and discourage dropout if possible. 

Participants who finish early may do something else. 

416

Psychiatry Dept., School P.G. Medicine. 

Researcher Sue Hacking. 

Research Project - DRAW A PICTURE - PROTOCOL. Study 2. 

KEEP THIS PAPER 

Instructions for group leader. Please save the paintings from your themed or recreational 

sessions with patients. So that we can identify patients please follow these instructions. 

If something goes wrong, or there is some alteration to the procedure, would you please 

write on the back of this paper what it was - and return it with the completed pictures. 

Allow about one hour for the session. 

Obtain consent from individuals before the series, using the information sheets and consent 

forms provided, if someone refuses, they may still attend their usual sessions with the 

group. 

On the reverse of this paper write ward no. and group leader and the date. Give every 

participant, including staff who provide a picture, a number beginning ______ so the first 

one would be ___1. Write the number and their names on the back of this paper, so they 

can be identified. 

Note the refusers like this: male/female who chose not to take part, no 

names. 

Try to provide these materials on every table: 

RED YELLOW ORANGE PURPLE GREEN BLUE BROWN WHITE BLACK, available 

for use, i.e. red and yellow do not provide orange, orange must be mixed and available. 

2. There should be facilities to make thick and thin lines, in colour, best achieved with 

paint and preferable for this research. 

3. One piece of paper, A3 size - as big as 2 sheets of photocopy paper, placed so that the 

top (furthest away from the artist) is the longer side (landscape format). 

If there are limitations, please note them on the back of this paper. 

You can use any type of sessions for this research, themed or free sessions or personal 

work. Self portraits are particularly useful. Do not direct the participants as to colours 

used, or suggest a type of picture they should draw for the research. Participants should 

not do anything different than they usually do in their art session (i.e. talk about their 

pictures or show them to anyone else if they usually do not). Be encouraging and 

supportive and discourage dropout if possible. 

Write on the back of the picture, the numbers and not the names of all participants 

including staff. Keep for collection. Thankyou for your co-operation. 

417

Bibliography 

418

Primary Sources 

Journals and papers 

Bibliography 

Adler, H.M. (1997), Towards a multimodal communication theory of art therapy: the 

vicarious coprocession, Am. J. Psychotherapy, Win., V.51(1): 54-66. 

Aikmanm K.G., Belter, R.W., and Finch, A.J. (1992), Human Figure Drawings: Validity 

in assessing intellectual level and academic achievement, J. Clin. Psychol., V.48(1): 114- 

120. 

Aldridge, D. (1994), Single-CAse Research Designs for the Creative Art Therapist, Art 

Psychotherapy, V.21(5), pp.333-342. 

Amos, S. (1982), The Diagnostic, Prognostic, and Therapeutic Implications of 

Schizophrenic Art, Art Psychotherapy, V.9:131-43. 

Anastasi, A., Foley, J.P. (1941) A survey of the literature on artistic behavior in the 

abnormal: Historical and theoretical background, J. Gen. Psychol., V.25: 111-142. 

Anastasi, A., Foley, J.P., (1940) A survey of the literature on artistic behavior in the 

abnormal: Spontaneous productions. Psychol. Mon., V.52(6): 1-71. 

Anastasi, A., Foley, J.P. (1941) A survey of the literature on artistic behavior in the 

abnormal: Experimental investigations, J. Gen. Psychol., V.25:187-237. 

Anastasi, A., Foley, J.P. (1944) An experimental study of the drawing behavior of adult 

psychotics in comparison with that of a normal control group, J. Exp.l Psychol. V.34: 

169-94. 

Arnheim, R. The Thoughts That Made Me Move, Art Psychotherapy V.21(4):245-6. 

Arrington, D. (1991), Thinking Systems - Seeing Systems: an integrative model for 

systemically oriented art therapy, Art Psychotherapy, V.18:201-211. 

Bachant, J.L., and Adler, E. (1997), Transference: Co-constructed or brought to the 

interaction? J. Am. Psychoanalytic Assessment, V.45(4): 1097-1120. 

Ballentino, R.C. (1998), The Need for a New Ethical Model in Medicine: a challenge for 

conventional, alternative and complementary practitioners, Advances Win., V.14(1): 6- 

16. 

Bergland, C., and Gonzalez, M. (1993), Art and Madness, can the interface be quantified? 

Am. J. Art Therapy, Feb., V.31: 81-90. 

Billig, O., (1971) Is Schizophrenic Expression Art? A comparative study of creativeness 

and schizophrenic thinking, J. Nervous Mental Dis. V.153(3): 149-64. 

Birchtnell, J. (1981), Is Art Therapeutic? Inscape, V.I, p.10-13. 

Borrowsky Junge, M. and Linesch, D. (1993), Our Own Voices: new paradigms for art 

therapy research, Art Psychotherapy,V.20: 61-7. 

Bradley, M.T. R.D. Gupta (1997), Estimating the Effect of the File Drawer Problem in 

Meta Analysis, Perceptual and Motor Skills, V.65(2):719-22. 

Buchalter-Katz, S. (1985), Observations concerning the art productions of depressed 

patients in short term psychiatric facilities, Art Psychotherapy, Spring, V.12(1):35-8. 

Burke, J. (1988), Field trials of the 1987 draft of Chapter V. (F) of ICD-10, British J. 

419

Psychiatry, 152(suppl.1): 33-57. 

Cagnoletta, M.D. (1983), Artwork as a representation of object relation in therapeutic 

practice, Pratt Institute Creative Arts Therapy Review, V.4:46-52. 

Champernowe, J. (1971) Art and Therapy: an uneasy partnership? Am. J. Art Therapy, 

April, X(3): 131-143. 

Cohen, B.M., Cox, C.T. (1989), Breaking the code: identification of multiplicity through 

art productions, Dissociation Progress in the Dissociative Disorders, Sep., V.2(3): 132- 

137. 

Cohen, B.M., Hammer, J., Singer, S. (1988), The Diagnostic Drawing Series: a systematic 

approach to art therapy evaluation and research, Art Psychotherapy, V.15(1): 11-21. 

Cohen, B.M., Mills, A., Kijak, A.K. (1994), An introduction to the DDS: a standardised 

tool for diagnostic and clinical use, Art Therapy, V.11(2): 105-110. 

Cooper, J.E. (1988), The structure and presentation of contemporary psychiatric 

classifications with special reference to ICD9 and 10. British Journal Psychiatry, 

V.152(suppl.1):21-8. 

Couch, J.B. (1994), DDS research with older people diagnosed with organic mental 

syndrome and disorders, Art Therapy,V.11(2):111-5. 

Crane, R.R., Levy, B.I. (1962), Color scales in responses to emotionally laden situations, 

J.Consulting Psychol V.26(6):515-9. 

Cressen, R., Artistic quality of drawing and judges evaluations of the DAP, J. Personality 

Assessment, 1975, V.39: 132-137. 

Cupchik, G.C., and Gebotys, R.J. (1988), The search for meaning in art: interpretive 

styles and judgement of quality, Visual Arts Research V.14:138-50. 

Dalley, T. (1980), Assessing the therapeutic effects of art: an illustrated case study, Art 

Psychotherapy, V.7: 11-17. Abell, S.C., Heiberg, A.M., and Johnson, J.E. (1994), 

Cognitive evaluation of young adults by means of human figure drawings: an empirical 

validation of 2 methods, J. Clin. Psychol., Nov., V.50(6):900-905. 

D'Andrade, R., Egan, M. (1974), The colours of emotion, Am. Ethnologist, Feb. 

V.1(1):49-63. 

Dent, J.K., and Kwiatkowska, H.Y. (1970), Aesthetic preferences in young adults for 

pictures drawn by mental patients and by members of their immediate families, Sciences 

de L'art (English Abstract), V.7(1-2): 43-54. 

Ellenberger, H.F. (1968), The Concept of Creative Illness, Psychoanalytic Review, 1968, 

V.55, pp.442-456. 

Enachesu, C. (1971) Aspects of pictorial creation in manic-depressive psychosis, Confina 

Psychiatrica, V.14(2): 133-142. 

Engels, G.L. (1977), The Need for a New Medical Model: a challenge for biomedicine? 

Science, April 8, V.196:129-37. 

Fabry, G.H., and Bertinetti, J.E. (1990), A Construct Validation Study of the Human 

Figure Drawing Test, Perceptual and Motor Skills, V.70:465-466. 

Feher, E., Vandicreek, L., Taglasi, H. (1983), The problem of art quality in the use of 

human figure drawings, J. Clin. Psychol., March, V.39(2): 268-275. 

Franklin, M., and Plitsky, R. (1992), The Problems of Interpretation: Implications and 

420

strategies for the field of art therapy, Art Psychotherapy, V.19(3): 163-175. 

Gantt, L., and Schmal, M. (1974), Art Therapy, A Bibliography (1940-73), George 

Washington University and National Institute of Mental Health, U.S.A. (unpublished 

report). 

Gantt, L. (1986), Systematic investigation of art works: some research models drawn 

from neighboring fields, Am. J. Art Therapy, May, V.24(4): 111-118. 

Gantt, L., and Howie, J. (1979), Chart of correspondences in diagnostic characteristics 

of mental disorder and artwork (unpublished 1979). 

Garvey, M.J., Luxenberg, M. (1987), Comparison of color preference in derpressives and 

controls, Psychopathology, V.20:268-271. 

Gertler, L. (1985), Art as Therapy with an aging artist, Am. J. Art Therapy, Feb., 

V.23(3): 93-9. 

Gibson, J.J. (1971), The information available in pictures, Leonardo, V.4, p.27-35. 

Goodman, R., Agell, L., Gantt, L., and Williams, K. (1994), Are there Doctors in the 

House? Does Art Therapy Need a Cure? Am. J. Art Therapy, August, V.33:3-13. 

Gorelick, K. (1989), Rapproachement between the arts and psychotherapies: Metaphor 

the mediator, Art Psychotherapy, Fall, V.16(3): 149-155. 

Gregorian, V.S., Azarian, A., DeMaria, M.B., and McDonald, L.D. (1996), Colors of 

disaster: the psychology of the "black sun", Art Psychotherapy, V.23(1): 1-14. 

Gruber, H.E. (1988), Coping with multiplicity and ambiguity of meaning in works of art, 

Metaphor and Symbolic Activity, V.3(3): 183-189. 

Gulbro-Leavitt, C., Schimmel, B. (1991), Assessing Depression in children and 

adolescents using the Diagnostic Drawing Series modified for children (DDS-C), Art 

Psychotherapy, V.18(4): 353-356. 

Hacking, S., Foreman, D., Belcher, J. (1996), The Descriptive Assessment for Psychiatric 

Artwork (DAPA): a new way of quantifying paintings by psychiatric patients, J. 

Nervous and Mental Disease, V.184(7):425-430. 

Hagood, M. (1990), Art Therapy Research in England: impressions of an American art 

therapist, Art Psychotherapy, V.17(1): 75-9. 

Healy, D. (1998), Commentry: meta analysis of trials comparing anti-depressants with 

active placebos, British J. Psychiatry, V.17:232-4 

Heine, D., and Steiner, M. (1986), Standardised paintings as a proposed adjunct 

instrument for monitoring mood states: a preliminary note, Occupational Therapy in 

Mental Health, Fall, V.6(3): 21-27. 

Johnson, D.R. (1987) The role of the creative arts therapies in the diagnosis and 

treatment of psychological trauma, Art Psychotherapy V.14: 7-13. 

Johnson, F.A., and Greenberg, R.P. (1978), Quality of Drawing as a Factor in the 

Interpretation of Figure Drawings, J. Personality Assessment, 1978, V.42(5):489-495. 

Kahill, S. (1984), Human Figure Drawing in Adults: an update of the empirical evidence 

1967-1982, Canadian Psychol. V.25(4):269-292. 

Kamphaus, R.W., Pleiss, K.L. (1991), Draw-A-Person techniques: tests in search of a 

construct, J. Sch. Psychol., Win. V.29(4):395-401. 

Kaplan, F.F. (1994), The imagery and expression of anger: an initial study, Art Therapy, 

421

V.11: 139-143. 

Kaplan, F.F. (1996), Positive Images of Anger in an Anger Management Workshop, Art 

Psychotherapy, V.23(1): 69-75. 

Kaplan, F.F. (1991), Drawing assessment and artistic skill, Art Psychotherapy, 

V.18:347-52. 

Kay, S.R. (1978), Qualitative differences in human figure drawings according to 

schizophrenic subtype, Perceptual Motor Skills, V.47: 923-932. 

Kirk, A., Kertesz, A. (1989), Hemispheric contributions to drawing, Neuropsychologia, 

V.27(6):881-6. 

Knapp, N.M., (1994), Research with diagnostic drawings for normal and Alzheimer's 

subjects, Art Therapy, V.11(2):131-8. 

Koppitz, E. (1983), Projective Drawings in Children and Adults, School Psychol. 

Review, V.12: 421-427. 

Kramer, E.S., and Iager, A.C. (1984), The use of art in assessment of psychotic disorders: 

changing perspectives, Art Psychotherapy, V.11:197-201. 

Kris, E. (1953) Review of Schizophrenic Art by Margaret Naumberg, Psychoanalytic 

Quarterly, V.22:98-101. 

Kulik J. (1983), Review of G.V. Glass et al. (1981) Evaluation News, V.4:101-5. 

Langevin, R. and Hutchins, L.M. (1973), An experimental investigation of judges ratings 

of schizophrenic and non-schizophrenic's paintings, J. Personality Assessment, Dec., 

V.37(1): 537-543. 

Langevin, R., Raine, M., Day, D., and Waxer, K. (1975), Art experience, intelligence and 

formal features in psychotics' paintings, Art Psychotherapy, V.2(2):149-158. 

Levy, B.I. (1980), Research into the psychological meaning of colour, Am. J. Art 

Therapy, V.19: 87-91 and reprint V.23 (1984). 

Levy, A.J., Barowsky, E.I. (1986), Comparison of computer-administered Harris- 

Goodenough Draw-A-Man Test with standard paper-and-pencil administration, 

Perceptual and Motor Skills, Oct., V.63(2, pt.1): 395-398. 

Levy, B.I. and Ulman, E. (1967), Judging Psychopathology from Paintings, J. Abnormal 

Psychol., V.72(2): 182-7, reprinted 1975, 1984, 1992. 

Levy, B.I. and Ulman, E. (1974), The effect of training on judging psychopathology from 

paintings, Am. J. Art Therapy, Oct. 1974, V.14: 24-25 reprinted 1984, 1992. 

Linesch, D. (1994), Interpretation in Art Therapy Research and Practice: The 

Hermeneutic Circle, Art Psychotherapy, V.21(3): 185-195. 

Maclagan, D. (1995), Fantasy and the aesthetic: have they become the uninvited guests 

at art therapy's feast? Art Psychotherapy, V.22(3): 217-221. 

Maclagan, D. (1989), The Aesthetic Dimension of Art Therapy: luxury or neccessity?, 

Inscape, Spring, pp.10-13. 

Maitland-Gholson, J.C. (1985), Implications of selected studies in psychology for visual 

arts research, Visual Arts Research, Fall, V.11(2), issue 22): 21-30. 

Malchiodi, C. (1993), Introduction to special issue on art therapy and professionalism, 

Is there a crisis in Art Therapy Education? Art Therapy, 10(3): 122. 

422

Males, B. Is it right to carry out scientific research into art therapy? Therapy, 3 May 

1979:5. 

Males, B. (1980), Art Therapy: Investigations and implications, Inscape, 4(2): 13-15. 

Martin, I.G. (1982), Universal vs learned emotional responses to colors: afterthoughts 

to thesis research, Art Psychotherapy, V.9:245-7. 

McNiff, S. (1979), From Shamanism to Art Therapy, Art Psychotherapy, V.6(3):155-61. 

McNiff, S. (1986), Freedom of Research and Artistic Inquiry, Art Psychotherapy, V.13: 

279-284. 

McNiff, S. (1987), Research and Scholarship in the Creative Arts Therapies, Art 

Psychotherapy, V.14: 285-292. 

McNiff, S. (1994), Celebrating the life and work of Rudolf Arnheim, Art Psychotherapy 

V.21(4): 247-248. 

McNiff, S. (1994), Rudolf Arnheim, A Clinician of Images, Art Psychotherapy V.21(4): 

249-260. 

Miljkovitch, M., Irvine, G.M. (1982), Comparison of drawing performances of 

schizophrenics, other psychiatric patients and normal schoolchildren on a draw-a-village 

task, Art Psychotherapy, V.9: 203-216. 

Mills, A., Cohen, B.M., Meneses, J.Z. (1993), Reliability and Validity tests of the 

Diagnostic Drawing Series, Art Psychotherapy, V.20: 83-88. 

Moon, B. (1994), What Kind of Art Therapy, Art Psychotherapy V.21(4): 295-298. 

Moore, R.W. (1983), Art Therapy with Substance Abusers: a review of the literature, 

Art Psychotherapy, V.10: 251-260. 

Morris, M.B. (1995), The Diagnostic Drawing Series (DDS) and the Tree Rating Scale: 

an isomorphic representation of Multiple Personality Disorder, Manic Depressive and 

Schizophrenic populations, Art Therapy, V.12(2): 118-128. 

Muenchow, D.C., Aresenian, J. (1974) An artist in turmoil during art therapy, Am. J. Art 

Therapy, V.14(1):18-23. 

Naglieri, J.A., Pfeiffer, S.I. (1992), Performance of disruptive behavior disordered and 

normal samples on the Draw A Person: Screening Procedure for Emotional Disturbance, 

Psychological Assessment, Jun., V.4(2): 156-159. 

Neale, E.L. (1994), The Childrens' Diagnostic Drawing Series (CDDS), Art Therapy, 

11(2): 119-126. 

Nodine, C.F., Locher, P.J. and Krupinski, E.A. (1993), The role of formal art training on 

perception and aesthetics in the making of art comparisons, Leonardo, V.26: 219-27. 

Phillips, E.L., Geller, S.K., and Ireland, M. (1983), Research on the use of art therapy in 

a university setting, Am. J. Art Therapy, Oct., V.23(1): 26-29. 

Politsky, R.H. (1995), Towards a Typology of Research in the Creative Arts Therapies, 

Art Psychotherapy, V.22(4): 307-314. 

Quail, J., Peavy, R.W. (1994) A Phenomenological Research Study of a Client's 

Experience in Art Therapy, Art Psychotherapy, V.21(1): 45-57. 

Regier, D.A., Kaelver, C.T., Roper, M.T., Rae, D.S., Sartorius, N. (1994), The ICD-10 

Clinical Field Train for Mental and Behavioral Disorders: results in Canada and the 

United States, Am. J. Psychiatry, V.151(9):1340-1350. 

423

Reuven, S.K. (1998), Reversal of a body image disorder (Macrosomatognosia) in 

Parkinson's disease by treatment with AC pulsed electromagnetic fields, Int. J. of 

Neuroscience, V.93:1-2. 

Riley, S. (1997), Conflicts in Treatment Issues of Liberation, Connection and Culture: 

Art therapy for women and their families, Art Therapy, V.14(2): 102-8. 

Rogers, S. and Costall, A. (1983), On the Horizon: Picture perception and Gibson's 

concept of information, Leonardo, V.16(3): 180-2. 

Russell-Lacy, S., Robinson, V., Benson, J., Cranage, J. (1979), An Experimental Study 

of Pictures Produced by Acute Schizophrenic Subjects, British Journal of Psychiatry, 

V134: 195-200. 

Sartorius, N. (1991), The classification of mental disorders in the Tenth Revision of the 

International Classification of Diseases. European Psychiatry, V.6: 315-322. 

Sartorius, N., Bedirhan Ustan, T., Korten, A., Cooper, J.E., Van Drimmelen, J. (1995), 

Progress toward achieving a common language in psychiatry, II: results from the 

international field trials of the ICD-10 diagnostic criteria for research for mental and 

behavioral disorders, Am. J. Psychiatry, V.152(10):1427-1437. 

Schmidt, J.A., McLaughlin, J.P., Leighten, P. (1989), Novice strategies for understanding 

paintings, Applied Cognitive Psychology, Jan-Mar., V.3(1): 65-72. 

Scott, R. (1981), Measuring intelligence with the Goodenough-Harris drawing test, 

Psychological Bulletin, V.89:483-505. 

Shoemaker, R.H. (1978), The significance of the first picture in art therapy, Proceedings 

of the 8th Annual Conference of the American Art Therapy Association, pp.156-62. 

Silver, R. and Ellison, J. (1992), Identifying and Assessing Self-Images in Drawings by 

Delinquent Adolescents, Art Psychotherapy, V.22(4): 339-352. 

Sims, J., Dona, R.H., and Bolton, B. (1983), The validity of the DAP as an anxiety 

measure, J. Pers. Assessment, V.47:250-7. 

Smith, M. & G. Glass, (1980) Meta Analysis of research on class size and its 

relationship to attitudes and instruction, Am. Educational Research J., V.17:419-33. 

Smitskamp, H. (1995), The Problem of Professional Diagnosis in the Arts Therapies, Art 

Psychotherapy, V.22, No.3, p.181-187. 

Slansky, L., and Short-Degraff, M. (1989), Validity and Reliability Issues with Human 

Figure Drawing Assessments, Physical and Occupational Therapy in Paediatrics, 

V.9(3):127-142. 

Sohn, D. (1997), Questions for meta analysis, Psychological Reports, V.81(1):3-15. 

Sternlicht, M., Rosenfeld, P., Siegel, L. (1973), Retesting with graphic production: 

resolution of a diagnostic dilemma, Art Psychotherapy, Win., V.1(3-4): 299-300. 

Strube, M. (1985) Combining and comparing significance levels from non-independent 

hypothesis tests, Psychological Bulletin V.97:334-341. 

Swenson, C.H. (1957), Empirical Evaluations of Human Figure Drawings, Psychological 

Bull., V.54: 431-466. 

Swenson, C.H. (1968), Empirical Evaluations of Human Figure Drawings, Psychological 

Bull., V.70: 20-44. 

Syristova, E. (1989), The creative potential of schizophrenic psychosis: Its importance 

424

for psychotherapy, Studia Psychologica, V.31(4): 283-294. 

Tate, F.B., Allen, H. (1985), Color preferences and the aged individual: implications for 

art therapy, Art Psychotherapy, Fall, V.12(3): 165-169. 

Trevisan, M.S. (1996), Review of the Draw a Person: Screening Procedure for Emotional 

Disturbance, Measurement and Evaluation in Counseling and Development, Jan., V.28(4): 

225-8. 

Trowbridge, M.M. (1995), Graphic indicators of sexual abuse in children's drawings: a 

review of the literature, Art Psychotherapy, V.22(5): 405-93. 

Ulman, E. and Levy, B.I. (1968), An Experimental Approach to the Judgement of 

Psychopathology from Paintings, Bull. Art Therapy, Oct., V.8(1): 3-12 reprinted 1975, 

1984, 1992. 

Ulman, E. and Levy, B.I. (1973), Art Therapists as Diagnosticians, Am. J. Art Therapy, 

Oct., V.13: 35-38 reprinted 1984, 1992. 

Wadeson, H. and Bunney W.E. (1970), Manic Depressive Art: a systematic study of 

differences in a 48 hour cyclic patient, J. Nervous and Mental Disease V.150:215-31. 

Wadeson, H. (1975), Is interpretation of sexual symbolism necessary? Art 

Psychotherapy, V.2(3-4): 233-239. 

Wadeson, H. (1975) Suicide: Expression in Images, Am. J. Art Therapy V.14:75-82. 

Wadeson, H. and Carpenter, W.T. (1976), A Comparative Study of Art Expression of 

Schizophrenic, Unipolar Depressive and Bipolar Manic-Depressive Patients, J. Nervous 

and Mental Disease, May, V.162(5): 334-344. 

Wadeson, H. (1978), Some Uses of Art Therapy Data in Research, Am. J. Art Therapy, 

Oct., V.18(1): 11-18. 

Wadlington, W.L. and McWhinnie, H.J. (1973), The development of a rating scale for the 

study of formal aesthetic qualities in the paintings of mental patients, Art 

Psychotherapy, Win., Vol.1(3-4): 201-220. 

Woddis, J. (1986), Judging by Appearances, Art Psychotherapy, V.13(2):147-149. 

Wright, H. and McIntyre, M.P. (1982), The Family Drawing Depression Scale, J. Clin. 

Psychol., V.38(4): 853-61. 

Primary sources 

Books 

Adair, J.G. and Bellanger, D., Dish, k., Sabourin, M. (eds.) Advances in Psychological 

Science: international congress of Psychology, Montreal 1996,, V.1, Hove: Psychological 

Press. 

Altman, D.G (1991). Practical Statistics for Medical Research, 5th ed. 1994, London: 

Chapman and Hall. 

American Psychiatric Association (1987), Diagnostic and statistical manual of mental 

disorders (3rd ed. rev.), Washington D.C.: Author. 

Armitage, P. and Berry, G. (1987), Statistical Methods in Medical Research, Oxford: 

425

Blackwell. 

Arrington, D. (1992), Art-based Assessment Procedures and Instruments used in 

Research, in Wadeson, H., (ed.), A Guide to Conducting Art Therapy Research, 

Mundelein, Ill: Am. Art Therapy Ass., pp.157-178. 

Banker, S.G. (1998), The Power of Art and Story: women therapists create their own 

fairy tales, in Robbins, A. (ed.) Therapeutic presence: Bridging expression and form, 

London: Kingsley. 

Barker-Bausell, R. (1986), A Practical Guide to Conducting Empirical Research, New 

York: Harper Row. 

Bartal, L., and Ne'eman, N. (1993), The Metaphoric Body: Guide to expressive therapy 

through images and archetypes, London: Kingsley. 

Baynes, H.G. (1940), Mythology of the Soul, London: Tindall Cox. 

Borrowsky Junge, M., Pateracki Asawa, P. (1994), A History of Art Therapy in the 

United States, Illinois, Mundelein: Am. Art Therapy Assn. 

Cox, M. (1992) Children's Drawings, Harmondsworth, Penguin. 

Dalley, T. and Case, C. (1992), Handbook of Art Therapy, London: Routledge. 

Cunningham-Dax, E. (1953), Experimental Studies in Psychiatric Art, London: Faber 

Faber. 

Dalley T. And Gilroy, A. (eds.) (1989), Pictures at an Exhibition London: Routledge. 

Dalley, T. (1984), Art as Therapy London: Tavistock. 

Dalley, T., Case, C., Schaverien, J., Weir, F., Halliday, D., Nowell-Hall, P., Waller, D., 

(eds.) (1987), Images of Art Therapy, London: Tavistock. 

Dondis, D.A. (1973), A Primer of Visual Literacy, Cambridge: MIT Press. 

Dunn, G. (1989), Design and Analysis of Reliability Studies: the statistical evaluation of 

measurement errors, London: Arnold. 

Edwards, D. (1987), Evaluation in Art Therapy, in Milne, D. (ed.), Evaluation in Mental 

Health Practice, Beckenham: Croom Helm, pp. 53-69. 

Ellenberger, H.F. (1970), The Discovery of the Unconscious - The History and Evolution 

of Dynamic Psychiatry, Harmondsworth: Penguin. 

Eysenck, H. (1961), The Effects of Psychotherapy in H.J. Eysenck, (ed.), Handbook of 

Abnormal Psychology, London: Basic Books, pp.697-725. 

Farrell, B.A. (1955), The Standing of Psychoanalysis, Oxford reprint 1981: Oxford 

University Press. 

Fink, B. (1995), The Lacanian Subject, Oxford: Princeton University Press. 

Fuller, P. (1980) Art and Psychoanalysis, London: Writers Readers. 

Gantt, L. (1990), A Validity Study of the Formal Elements Art Therapy Scale (FEATS) 

for diagnostic information in patients' drawings, Unpublished Doctoral Dissertation, 

University of Pittsburgh, Pensylvania. 

Gibson, J.J. (1980), forward in Hagen, M.A. (ed.), The Perception of Pictures, V.1, New 

York: Academic Press. 

Gilroy, A. (1992), Research in Art Therapy, in Waller, D. and Gilroy A. (eds.), Art 

Therapy, A Handbook, Bristol, pp.229-247. 

426

Gilroy, A. and Dalley, T. (1989) Pictures at an exhibition, London: Routledge. 

Glass, G.V., McGraw, B., Smith, M.L. (1981) Meta Analysis in Social Research, 

Beverley Hills, CA: Sage. 

Gombrich, E. (1960) Art and Illusion: a study in the psychology of pictorial 

representation, 5th ed. 1960, Princeton, NJ: Phaidon. 

Goodenough, F.L., and Harris, D.B. (1963), The Goodenough-Harris Drawing Test, New 

York: Harcourt Brace and World. 

Hagen, M.A. (ed.), The Perception of Pictures, V.1, New York: Academic Press. 

Hammer, E.F. (ed.) Clinical Applications of Projective Drawing, Springfield: Thomas. 

Harris, D. (1963), Children's Drawings as Measures of Intellectual Maturity, New York:, 

Harcourt Brace and World. 

Hill, A.(1945), Art Versus Illness, London: Allen Unwin. 

Hill, A.(1951), Painting out Illness, London: Allen Unwin. 

Hogg, J. Some Psychological Theories and the Visual Arts, in Hogg, J., (ed.), Psychology 

and the Visual Arts (Harmondsworth 1969) Penguin pp.78-81. 

Hopkins, J. (1992), Psychoanalysis, interpretation and science in Hopkins, J. and Saville, 

A. (eds) Psychoanalysis, Mind and Art: perspectives on Richard Wollheim, Oxford: 

Blackwell. 

Hunter, J.E., F.L. Schmidt and G.B. Jackson (1982), Meta Analysis: cumulating research 

findings across studies, Beverley Hills, CA: Sage. 

Jaspers, K. (1963), General Psychopathology, Manchester, 7th Ed. trans: Manchester 


Jung, C.G., and Wilhelm, R. (1931) The Secret of the Golden Flower, London: 

Macmillan. 

Kris, E. (1964), Psychoanalytic Explorations in Art, New York: International University 

Press. 

Kusbit, D. (1993), Signs of Psyche in Modern and Postmodern Art, Cambridge 


Lacan, J. (1988), The topic of the imaginary, in J. A. Miller (ed.) The Seminar of Jacques 

Lacan, Book 1 (trans. Forrester), Cambridge University Press. 

Leger, F.L. (1998), Beyond the therapeutic relationship: behavioural, biological and 

cognitive foundations of psychotherapy, New York: Haworth Press. 

Liebmann, M. (1990), Art in Practice, London: Tavistock. 

Levens, M. (1989), Working with defence mechanisms in art therapy, in Gilroy, A. and 

Dalley, T., Pictures at an Exhibition, London: Routledge, pp.143-6. 

Little, M.I. (1997), Miss Alice M. and Her Dragon, New York: Binghampton. 

Lombroso, C. (1891), Man of Genius, London: Scott. 

Lusebrink, V. (1990), Imagery and Visual Expression in Therapy New York: Plenum. 

Luzzatto, P. (1989) Drinking problems and short-term art therapy: working with images 

of withdrawal and clinging in Gilroy, A. and Dalley, T. (eds.) Pictures at an exhibition, 

London: Routledge, pp.207-219. 

Machover, K. (1949), Personality Projection in the Drawing of the Human Figure, 

Springfield Ill., reprint 1978 10th ed: Charles C. Thomas. 

427

MacGregor, J.D. (1989), The Discovery of the Art of the Insane, New Jersey and 

Oxford: Princetown University Press. 

McClelland, S. (1992), Brief Art Therapy in Acute States: a process oriented approach 

in Waller, D. and Gilroy, A. Handbook of Art Therapy, London: Routledge, pp.189-207. 

Milner, M. (1969), In the Hands of the Living God, London: Virago. 

Miller, J.A. (ed.) The Seminar of Jacques Lacan, Book 1 (trans. Forrester), Cambridge 


Milne, D. (ed.), Evaluation in Mental Health Practice, Beckenham: Croom Helm. 

Moon, B. (1992), Essentials of Art Therapy Training and Practice, Springfield, Ill: 

Charles C. Thomas. 

Moore, R. (1981), Art Therapy in Mental Health, Rockville, MD: NIMH. 

Naumberg, M. (1947), Studies of the free art expression of behaviour disturbed children 

as a means of diagnosis and therapy, New York: J. Nervous and Mental Disease 

Monographs, Cooleridge. 

Naumberg, M. (1950), Schizophrenic Art, Its Meaning in Psychotherapy, New York: 

Grune Stratton. 

Naumberg, M. (1950), Art Therapy: Its Scope and Function in Hammer, E.F. (ed.) 

Clinical Applications of Projective Drawing, Springfield: Thomas. 

Naumberg, M. (1966) Dynamically Orientated Art Therapy: Its Principles and Practices, 

New York: Grune Stratton. 

Oster, G.D., and Gould, P. (1987), Using Drawings in Assessment and Therapy: A guide 

for mental health professionals, New York: Brunner Mazel. 

Parsons, M.J. (1987), How we understand art. A cognitive developmental area of 

aesthetic experience, 2nd ed. 1989: Cambridge University Press. 

Payne, H., (ed.), (1993), Handbook of Inquiries into the Art Therapies: One river, many 

currents, London and Bristol, PA: Kingsley. 

Pickford, R. (1967) Studies in Psychiatric Art, London: Tavistock. 

Plokker, J.H. (1964), Artistic Self Expression in Mental Disease, London: Littlebrown. 

Prinzhorn, H. (1922), Artistry of the Mentally Ill, Berlin: Springer Verlag. 

Pollock, G. (1988), Women and Sign: psychoanalytic readings, in Pollock, G., Vision and 

Difference, London: Routledge and Kegan Paul. 

Pollock, G. and Ross, J.M. (eds), (1988) The Oedipus Papers, Conn: Madison. 

Reber, A.S. (1985), Dictionary of Psychology, Harmondsworth: Penguin. 

Reitman, F. (1950), Psychotic Art, London: Routledge Kegan Paul. 

Robbins, A., (ed.) (1998) Therapeutic Presence: Bridging Expression and Form, London: 

J. Kingsley. 

Rosenthal, R. (1984), Meta Analytic Pocedures for Social Research, Beverley Hills, CA: 

Sage, p.9-10. 

Rosenthal, R. (1998) Meta analysis: concepts, corollaries and controversies, in J.G. Adair 

et al. (eds.) Advances in Psychological Science, Hove: psychological press. V.1:371-384. 

Ross, R. (1963) Symbol Systems and Civilisation, New York: Harcourt Brace and 

Johanovich. 

Schafer, R. (1958) Regression in the service of the ego: the relevance of a psychoanalytic 

428

concept for personality assessment in G. Lindzey (ed.) Assessment of Human Motives, 

London: Grove. 

Schaverien, J. (1992), The Revealing Image: analytical art psychotherapy in theory and 

practice, London: Routledge. 

Schilder, P. (1942), Mind: perception and thought in their constructive aspects, reprint 

1981, Oxford University Press. 

Schneider-Adams, L. (1993) Art and Psychoanalysis, New York: Harper Collins. 

Sims, A. (1988), Symtoms in the mind: an introduction to descriptive psychopathology, 

London: Tindall. 

Strupp, H. (1973), Psychotherapy: Clinical, Research and Theoretical Issues, New York:. 

Taylor Fitzgibbon, C. and Lyons Morris, L. (1987), How to Analyse Data, Beverley 

Hills, CA: Sage. 

Thomas, G.V., Silk, A. (1990), An Introduction to the Psychology of Children's 

Drawings, Herts: Harvester Wheatsheaf. 

Thorburn, J.M. (1925), Art as the relation of outer and inner, in Thorburn, J.M., Art and 

the Unconscious: a psychological approach to a problem of Philosophy, London:Kegan 

Paul, pp.151-6. 

Thorburn, J.M. (1925), Is Art Symbolic, in Thorburn, J.M., Art and the Unconscious: 

a psychological approach to a problem of Philosophy, London: Kegan Paul, pp. 73-9. 

Wadeson, H. (1980), Art Psychotherapy, New York: Wiley. 

Wadeson, H. (1987), The Dynamics of Art Psychotherapy, New York: Wiley. 

Wadeson, H. (1992), A guide to conducting art therapy research, Mundelein, Ill: Am. Art 

Therapy Assn. 

West, R. (1991), Computing for Psychologists, London: Harwood. 

Winnicott, D.W. (1971), Playing and Reality, London: Tavistock. 

Waller, D., and Dalley, T. (1992), Art Therapy: A theoretical perspective, in Waller, D. 

and Gilroy, A., Art Therapy: A Handbook, Bristol: Open University Press. 

Waller, D. and Gilroy, A. (1992), Art Therapy: A Handbook, Bristol: Open University 

Press. 

Waller, D. (1991), Becoming a Profession: the history of art therapy 1940-1982, London: 

Routledge. 

Waller, D. (1992), The Training of Art Therapists in Waller, D. and Gilroy, A., Art 

Therapy: A Handbook, Bristol: Open University Press. 

Winner, E. (1982) Invented Worlds: the psychology of the arts Cambridge, Mass: 

Harvard University Press. 

Woddis, J. (1992) Art therapy: New problems, new solutions, in D. Waller and A. Gilroy 

(eds.) Art Therapy: a handbook, Bristol: Open University Press. 

Wolf, F.M. (1986), Meta Analysis: quantitative methods for research synthesis, 


Wollheim, R. (1964), Art and Its Objects, Cambridge reprint 1980: Writers Readers. 

World Health Organisation, Division of Mental Health of the (1993), International 

Criteria for Diagnoses in the Mental and Behavioral Disorders: Diagnostic Criteria for 

429

Research (ICD-10 DCR), Geneva: Author. 

Secondary Sources 

From Amos, S. (1982). The Diagnostic, Prognostic, and Therapeutic Implications of 

Schizophrenic Art, Art Psychotherapy, V.9: 131-143. 

Pasto, T. (1968) The Biomythology of Colour: a theory, in Jakob, I., (ed.), Psychiatry 

and Art: art of interpretation and art therapy, V.2, New York: Karger. 

Billig, O., Burton Bradley, B.G., (1968) The Painted Message, New York: Wiley. 

Rapaport, D., Gill, M., Schafer, R. (1946), Diagnostic Psychological Testing Chicago: 

Year Book Publishers. 

From Dalley, T. and Case, C. Handbook of Art Therapy, London: Routledge. 

Meares, A. (1958) The Door of Serenity. 

Ehrensweig, A. (1967), The Hidden Order of Art, London: Paladin. 

Fuller, P. (1980) Art and Psychoanalysis, London: Writers Readers. 

From Goodenough, F.L., and Harris, D.B. (1963), The Goodenough-Harris Drawing 

Test, New York: Harcourt Brace and World. 

Goodenough, F. (1926), Measurement of Intelligence by Drawings, New York: Harcourt 

Brace and World. 

From Hogg, J. (1970) Some Psychological Theories and the Visual Arts, in Hogg, J., 

(ed.), Psychology and the Visual Arts, Harmondsworth: Penguin pp.78-81. 

Nagel, E. (1959), Methodological issues in psychoanalytic theory in S. Hook, (ed.), 

Psychoanalysis: Scientific Method and Philosophy: A Symposium, Grove Press pp.38- 

56. 

Nagel, E. (1952), Wholes, Sums and Organic Unities, in Lerner, D., (ed.), Parts and 

Wholes: The Hayden Colloquium on Scientific Method and Concept, London: 

Macmillan. 

Petermann, B. (1932), The Gestalt Theory and the Problem of Configuration, London: 

Kegan Paul. 

From MacGregor, J.M. (1989) The discovery of the art of the insane, New York: 

Princetown University Press. 

Kraepelin, E. (1883) Lehrbuch der Psychiatrie. 

Jaspers, K. (1932) Strindberg und Van Gogh. 

From Schneider Adams, L. (1993) Art and Psychoanalysis, New York: Harper Collins. 

Freud, S. (1910), Leonardo Da Vinci - a memory of his childhood, V.XIV, 

Harmondsworth: Penguin. 

430

Freud, S. (1914) The Moses of Michelangelo, Harmondsworth: Penguin. 

From Wolf, F.M. (1986), Meta Analysis: quantitative methods for research synthesis, 


Cohen, J. (1977) Statistical Power Analyses for the Behavioural Sciences, New York: 

Ac.Press. 

L.V. Hedges and I. Olkin (1985) Statistical methods for meta analysis, New York: Ac. 

Press 

431

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