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Visual Expression and Resilience of Art
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Sheila Lorenzo De Peña
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FLORIDA STATE UNIVERSITY
COLLEGE OF FINE ARTS
VISUAL EXPRESSION AND RESILIENCE OF ART THERAPISTS
By
SHEILA LORENZO DE LA PEÑA
A Dissertation submitted to the
Department of Art Education
in partial fulfillment of the
requirements for the degree of
Doctor of Philosophy
2015
© 2015
SHEILA LORENZO DE LA PEÑA
All Right Reserved
Sheila Lorenzo de la Peña defended this dissertation on June 29, 2915.
The members of the supervisory committee were:
David Gussak
Professor Directing Dissertation
Carolyn Henne
University Representative
Marcia Rosal
Committee Member
Sara Scott Shields
Committee Member
The Graduate School has verified and approved the above-named committee members, and
certifies that the dissertation has been approved in accordance with university requirements.
ii
I would like to dedicate this dissertation to my husband and best friend, Gabriel
Alcibiades de la Peña. Neither of us knew just what it meant to head in this path nor all that
would transpire throughout it. Thank you for loving me and sticking by my side through the
highs and lows of it all. Thank you for understanding my anger and frustration was not usually of
your creation but nevertheless being able to handle it gracefully. You have an annoying knack
for knowing when I need a hug the most and stubbornly don’t ask, and you give it anyways.
Without you I would not have had to scare the cats as I tip-toed through the house with a Nerf
gun to catch you off-guard. I would not have to keep foam hatchets in the kitchen for when you
got out of hand, nor foam bokens for when the smaller tools just wouldn’t do the job. Let’s face
it, without you I would have been one frustrated, aggravated, stressed-out, disheveled, unfed grad
student. Thank you for being there when I didn’t think it was possible, and reminding me it was
(I knew you didn’t know what you were talking about, but we made it anyhow).
I would also like to dedicate this dissertation to my familia. Gracias por soportar este
antojito. Los quiero muchisimo y siento no haber podido visitar mas frecuentemente durante
estos años. Nos vemos pronto: Angela Rosa Lorenzo Fraga, Rolando Anecio Lorenzo Brito, and
my sis Marien Lorenzo.
iii
ACKNOWLEDGMENTS
This dissertation would not have been possible without the encouragement and support of
so many people over these last few years. Of special mention is my dissertation committee chair,
Dr. David Gussak, without whom I would not have made it this far. He offered encouragement
and motivation when I was at my best as well as my lowest. Through the stress, tears, and
heartache he always seemed to find just the right words, even if he had no Kleenex. Thank you
also to the tireless efforts of my committee, Dr. Marcia Rosal, Dr. Carolyn Henne, and Dr. Sara
Scott Shields, who muddled through all the pages to find those pesky things I overlooked. I
would also never have come this far if it weren’t for the wise words of Dr. Tom Anderson,
whose advice early-on set me on the right path, thank you.
None of this would have been possible without the dedication and timely contributions of
those art therapists who took time from their busy schedules to respond to a call for research
participation. Thank you.
I also need to thank Dr. Victoria Huston and Dave Huston for their tireless and faithful
guidance throughout. It was their vigilante efforts that kept me caffeinated and my sanity in
check by reminding me it would get way worse before it got better. Thank you also for the
tireless efforts at translating and decoding my well meaning committee chairs’ scribbled notes; I
wouldn’t have made it very far without you.
Thank you to all the others who throughout these last few years have kept me together
and moving forwards through all the rough patches, Maria Eugenia, Eric, Adriane, Mareta,
Christine, Gwendolyn, and my co-workers through it all Kathy, Lisa, and Ellen.
iv
TABLE OF CONTENTS
LIST OF FIGURES ................................................................................................................... xiii
ABSTRACT ................................................................................................................................ xiv
CHAPTER 1: INTRODUCTION TO THE STUDY ................................................................. 1
Background of the Problem ......................................................................................................... 3
Burnout ............................................................................................................................... 5
Art Therapy Profession ....................................................................................................... 7
Statement of the Problem ........................................................................................................... 11
Purpose of the Study ......................................................................................................... 11
Research Questions ........................................................................................................... 12
Significance of the Study .................................................................................................. 12
Research Design................................................................................................................ 13
Limitations ........................................................................................................................ 13
Definitions of Terms ......................................................................................................... 14
Summary ...................................................................................................................................... 16
CHAPTER 2: REVIEW OF RELATED LITERATURE....................................................... 19
Act of Expression: As Experience ............................................................................................. 19
Visual Expression as Personal Elaborative Process.......................................................... 23
Visual Expression as Ritual Acts ...................................................................................... 26
Visual Expression an Elaborative Community Process .................................................... 28
Visual Expression as a Tool for Processing with the Self ................................................ 30
v
Burnout as Process ...................................................................................................................... 32
Propensity of Burnout in the Mental Health Field ............................................................ 34
Role of the Work Environment ......................................................................................... 35
Empathetic Attunement as a Risk Factor .......................................................................... 38
Newness in Field as a Risk Factor .................................................................................... 39
Social Factors as Risk Factors .......................................................................................... 40
Preventative Measures ...................................................................................................... 41
Visual Expression as a Means of Curating Experiences ......................................................... 44
Bringing Preventative Measures in Line With Practice .................................................... 47
Response art as experience ........................................................................................... 47
Expanding our roles as clinicians ......................................................................... 47
Understanding the therapeutic encounter.............................................................. 48
Visual expression towards resonance and reflection .................................................... 49
Summary ...................................................................................................................................... 50
CHAPTER 3: RESEARCH METHODS .................................................................................. 53
Problem and Purposes Overview .............................................................................................. 53
Research Questions ..................................................................................................................... 54
Research Design .......................................................................................................................... 54
Participants and Setting ............................................................................................................. 57
Instrumentation........................................................................................................................... 58
Phase I Demographic and Informational Survey .............................................................. 58
vi
Phase II Artifact Review and Upload Form ...................................................................... 59
Phase II Artifact Review Document ................................................................................. 60
Image resolution ........................................................................................................... 61
Phase II Interview Questions and Notes Document ......................................................... 61
Safekeeping of Instruments............................................................................................... 62
Research Procedures .................................................................................................................. 62
Phase I ............................................................................................................................... 62
Phase II.............................................................................................................................. 63
Interview ....................................................................................................................... 64
Data Analysis ............................................................................................................................... 66
Constant Comparative Analysis ........................................................................................ 66
Organization of Visual Data ............................................................................................. 67
Coding of Transcripts ....................................................................................................... 68
Limitations of the Study ............................................................................................................. 70
Summary ...................................................................................................................................... 71
CHAPTER 4: RESULTS ........................................................................................................... 72
Phase I: Demographic and Informational Survey ................................................................... 73
Recruitment Outcome ....................................................................................................... 73
Participation ...................................................................................................................... 74
Demographics ................................................................................................................... 74
Education and Credential Status ....................................................................................... 75
Employment Status ........................................................................................................... 75
vii
Primary Work Setting ....................................................................................................... 75
Perception of Stress and Preparedness .............................................................................. 76
Perceived Stress Level ...................................................................................................... 78
Response Art and Creative Engagement........................................................................... 78
Art Share ........................................................................................................................... 79
Phase II: Introduction of Participants ...................................................................................... 81
Adrian ............................................................................................................................... 81
Anchor & Self-Care Mantra ......................................................................................... 82
Self-Care & Gratitude .................................................................................................. 83
Self-Care Affirmation & Strengths .............................................................................. 84
Blair................................................................................................................................... 84
In My Bones ................................................................................................................. 84
Eclectic Growth ............................................................................................................ 85
Energy Source .............................................................................................................. 86
Camie ................................................................................................................................ 87
Germination .................................................................................................................. 88
Labels ........................................................................................................................... 89
Untitled ......................................................................................................................... 90
Devon ................................................................................................................................ 91
Friday September 5th ................................................................................................... 91
Pimbi ............................................................................................................................ 93
Professional Life........................................................................................................... 93
Mari ................................................................................................................................... 93
viii
Response Art 6 13 ........................................................................................................ 95
Response Art 12 12 ...................................................................................................... 95
Contained Fire .............................................................................................................. 96
Leisy.................................................................................................................................. 96
Hope for Recovery ....................................................................................................... 98
I Will Listen.................................................................................................................. 98
Elephant in the Room ................................................................................................... 99
Phase II: Interviews .................................................................................................................. 100
Participant Beliefs ........................................................................................................... 101
Workplace ....................................................................................................................... 102
Novelty in the workplace ........................................................................................... 103
Structure, culture, and boundaries .............................................................................. 104
Losing a patient .......................................................................................................... 106
Supportive practices in the workplace........................................................................ 107
Boundaries .................................................................................................................. 109
Stress ............................................................................................................................... 111
Signs of emerging stress ............................................................................................. 112
Red flags ..................................................................................................................... 113
Self-Care ......................................................................................................................... 114
Response Art ................................................................................................................... 116
Relationship with the visual response ........................................................................ 117
Intentionality .............................................................................................................. 119
Traditional art-making as a response practice ............................................................ 121
ix
Using collage as a media and restorative process ...................................................... 122
Accessibility ............................................................................................................... 124
Responsive to the process........................................................................................... 125
The creative process is responsive to novelty ............................................................ 126
Communities as Part of the Process ................................................................................ 128
Local, familial and social support system .................................................................. 128
Communal art-making for accountability and social support .................................... 129
The traditional gallery art show within the local community .................................... 130
Bridging local with online communities .................................................................... 131
Social networking platforms as components in the process ....................................... 132
Summary .................................................................................................................................... 135
CHAPTER 5: DISCUSSION ................................................................................................... 137
Expression as Experience ......................................................................................................... 138
Field Demographics .................................................................................................................. 138
Research Question 1: Is Art Used as Self-Care by Art Therapists and If So, How? .......... 140
Being Responsive............................................................................................................ 141
Exposure ......................................................................................................................... 142
Flexible Approach ........................................................................................................... 142
Developing Intimacy....................................................................................................... 143
Importance of the Creative Process ................................................................................ 144
Traditional art process ................................................................................................ 144
Collage as a contemplative practice ........................................................................... 145
x
Intuitive approach to the creative process .................................................................. 146
Research Question 2: Does Personal Visual Expression Mitigate Perceived Burnout?..... 148
Identification of Increased Stress .................................................................................... 148
Changes in process as red flag ................................................................................... 149
Residual Material ............................................................................................................ 149
Traditional community support .................................................................................. 150
Social networking platform communities .................................................................. 151
Research Question 3: Does Responsive Art-Making Influence Art Therapists’ Professional
Identity, and If So How? .......................................................................................................... 154
A Case for Flexible Boundaries ...................................................................................... 155
Visual Expression as a Positive Investment of Time ...................................................... 155
Novel Experiences .......................................................................................................... 157
Community Role ............................................................................................................. 159
Main Question: How Do Selected Art Therapists Employ Personal Visual Expression To
Sustain Their Practice? ............................................................................................................ 161
Conclusions ................................................................................................................................ 165
Limitations of the Study ........................................................................................................... 168
Implications of Findings ........................................................................................................... 171
APPENDIX A: PHASE I DEMOGRAPHIC & INFORMATIONAL SURVEY ............... 174
APPENDIX B: PHASE II ARTIFACT REVIEW & UPLOAD FORM ............................. 179
APPENDIX C: SOCIAL MEDIA POST ................................................................................ 183
xi
APPENDIX D: PHASE I SURVEY INVITATION............................................................... 184
APPENDIX E: PHASE I CONSENT FORM ........................................................................ 185
APPENDIX F: PHASE II CONSENT FORM ....................................................................... 187
APPENDIX G: PHASE II ARTIFACT REVIEW DOCUMENT ........................................ 189
APPENDIX H: PHASE II INTERVIEW QUESTIONS & NOTES DOCUMENT ........... 193
APPENDIX I: PHASE II INTRODUCTION & OVERVIEW............................................. 194
APPENDIX J: IRB APPROVAL LETTER ........................................................................... 196
REFERENCES .......................................................................................................................... 197
BIOGRAPHICAL SKETCH ................................................................................................... 204
xii
LIST OF FIGURES
1.
Research process. ........................................................................................................55
2.
Anchor & Self-Care Mantra. Mixed media in journal ...............................................82
3.
Self-Care & Gratitude. Mixed media in journal ........................................................83
4.
Self-Care Affirmation & Strengths. Mixed media in journal ....................................83
5.
In My Bones. Collage of magazine images ...............................................................85
6.
Eclectic Growth. Collage of magazine images ..........................................................86
7.
Energy Source. Collage of magazine images ............................................................87
8.
Germination. Oil pastel on black paper .....................................................................88
9.
Labels. Mixed media collage of magazine images and news paper text ...................89
10
Untitled. Mixed media on map ..................................................................................90
11.
Friday September 5th. Mixed media in journal .........................................................92
12.
Pimbi. Digital photo ..................................................................................................92
13.
Professional Life. Mixed media.................................................................................93
14.
Response Art 6 13. Mixed media assemblage ...........................................................94
15.
Response Art 12 12. Collage of magazine images ....................................................95
16.
Contained Fire. Acrylic & Tempera ..........................................................................97
17.
Hope for Recovery. Mixed media on masonite .........................................................97
18.
I Will Listen. Mixed media on masonite. Artist name removed ..............................98
19.
Elephant in the Room. Mixed media on masonite. Artist name removed ................99
xiii
ABSTRACT
The objective of this research is to elicit and analyze the use of visual response created by art
therapists and its implications for their resiliency. As part of the mental health community, art
therapists are exposed to trauma histories and traumatic events, their empathetic nature making
them susceptible to the negative effects stress, which over time can accumulate and lead to
clinician burnout. Although there is ample literature on the detrimental effects of the burnout
syndrome on the helping professions, the literature is limited when it comes to art therapists and
their distinct needs and resources. The current study used mixed methods to better understand
the role of visual response art as it was used by participating art therapists in building and
maintaining resilient and restorative self-care practices.
Keywords: artifact, burnout, compassion fatigue, constant comparative method,
mindfulness, mixed methods, photo elicitation, response art, resiliency, secondary traumatic
stress, self-awareness, self-care
xiv
CHAPTER 1
INTRODUCTION TO THE STUDY
Art therapists must address personal issues in addition to those of their clients: burnout of
the empathetic professional is a serious threat to clinicians and their clients. In one of the first
mentions of the term burnout, elements from the work environment, peers, and the clinician’s
own background were identified as contributing to the syndrome (Freudenberger, 1974). Since
then, others have expanded on the connections between the mental health professional and the
symptoms of burnout (Chernizz & Krantz, 1983; Farber, 1983a; Figley 2002b; Maslach, 1982;
Maslach & Leiter, 1997; Maslach, Schaufeli, & Leiter, 2001; Meier, 1983; Pines, 1983). Ample
literature also exists on the benefits of incorporating protective practices into clinician daily
routines (Farber, 1983a; Figley, 2002b; Harrison & Westwood, 2009; Iliffe & Steed, 2000;
Maslach, Schaufeli, & Leiter, 2001; Mullenbach & Skovholt, 2011). While not exclusive to the
mental health field, professional burnout has been a prevalent topic in the psychology literature
(Barnett, ed., 2011; Figley, 1995, 2002a, 2002b; Harrison & Westwood, 2009; Johnson, W.,
Johnson, S., Sullivan, G., Bongar, B., Miller, L., & Sammons, M., 2011; Lee, Cho, Kissinger, &
Ogle, 2010; Mullenbach & Skovholt, 2011; Saakvite, 2002). Art therapists are just as vulnerable
to the development of burnout as other mental health professionals; being invariably exposed to
trauma narratives and symptoms of traumatic experiences. However, art therapists have access
to tools for effectively addressing emotive distress, which can be employed toward sustaining a
healthy practice. By engaging in visual expression themselves, art therapists are able to process
distressful material; in essence using art as therapy for self-care. Unfortunately, the use of visual
expression by art therapists toward the development of a sustained practice is under-studied
(Kapitan, 2003; McNiff, 2004; Pakula, 1997; Robbins, 2000; Wadeson, 2003).
1
The purpose of the present research was to answer the following questions:
•
How do selected art therapists employ personal visual expression to sustain their
practice?
a. Is art used as self-care by art therapists and if so, how?
b. Does personal visual expression mitigate perceived burnout?
c. Does responsive art-making influence art therapists’ professional identity, and if
so how?
The rationale for this research is presented by first providing a background from the
psychology literature indicating the chronic nature of the burnout syndrome. According to the
literature (Bride, Radey, & Figley, 2007; Chernizz & Krantz, 1983; Farber, 1983a; Figley 2002b
Freudenberger, 1974; Heifetz & Bersani, 1983; Maslach, 1982; Maslach, Schaufeli, & Leiter,
2001; Meier, 1983; Pines, 1983; Skovholt & Trotter-Mathison, 2011), the complexity of the
syndrome is in part due to the accumulation of pre-existing and current factors. These are
encountered in all areas of the clinicians’ life, including their workplace; it is not an isolated
phenomenon. The syndrome has a pervasive and chronic effect on the clinicians’ mental and
physical functioning, which in turn, impact their workplace and social functioning. As an art
therapist, working at a state forensic mental health facility, I encounter burnt-out clinicians on a
daily basis.
As clinicians, art therapists are at risk of accruing stress, and becoming burned-out. As
masters level mental health professionals, art therapists often work in direct contact with clients
in medical hospitals, psychiatric facilities, and forensic settings to name a few. In the line of
work they become routinely exposed to the traumatic stories of their clients, by verbal and
illustrative means. The art therapy literature is replete with studies and case examples of the
2
value of creative expression. However, there is a gap in the literature when it comes to the
implementation of creative practices by clinicians. This chapter will introduce the concepts
leading to the research questions; providing a brief background on the field of art therapy and
what makes these clinicians vulnerable in the practice of their profession.
Background of the Problem
Art is necessary because, it serves a purpose greater than itself (Anderson, Gussak,
Hallmark, & Paul, 2011; Anderson & Milbrandt, 2005). Art is a necessary mediator between the
self and the world of experiences; it seeks to express a personal truth (Arnheim, 1986). It is the
means through which individuals explore, communicate, and process their world.
The act of visual expression is a personal elaborative process, one through which the
individual can regain access to elements of an experience. In the creative process content is
sifted through and elaborated, by doing so the experience can be augmented or toned-down
(Dissanayake, 2000). The overall process is elaborative and transactive; it allows for an
expansion of themes and associations through media interaction. By means of learning and
reflecting, conceptual ideas are expanded as they are manipulated and given form (Dewey,
1980). The creative process is elaborative, the resulting artifact serving to cue particular
experiences and corresponding emotive content. Creative expression is therefore an innate and
personal means through which to make sense of the world (Dissanayake, 2000); it is a means of
making sense of the chaos (Arnheim, 1971).
In the act of making, amorphous ideas take shape as they are given form and are
crystallized (Dissanayake, 2000; Levitin, 2009; Lusebrink, 1990; Robbins, 2000). Through
media manipulation information is synthesized, order is created (Arnheim, 1971), and decisions
are made. The process of giving an idea, concrete form, is transactive, requiring a certain degree
3
of vulnerability. Such moments of vulnerability are necessary to the process in order to grant
access to the emotive and amorphous ideas that were the experience.
Further manipulation of the media and the consideration of ideas narrow the individuals’
focus to what is needed. This includes past and current understanding of the self, as well as the
experience being processed. As many have indicated, it is only what has already been
experienced that can enter awareness in order to be expressed (e.g. Arnheim, 1986; Dewey,
1980; Dissanayake, 2000; May, 1965, 1975). It is this prior experiencing that allows for
recognition of similarities (Anderson & Milbrandt, 2005; Arnheim, 1986; Langer, 1953) for
extrapolating knowledge that supports, or discounts personal truths. Creative expression is an
integral system of knowing, it connects the internal and external world (Dissanayake, 2000;
Langer, 1953; Lusebrink, 1990; May, 1975), and it is through intentional acts of making that
experiences are granted concrete form.
The individual, their world (i.e. internal or external), and the media being manipulated,
are necessary elements in the reciprocal exchange that is visual creative expression. It is through
this tactile exchange that burdensome emotive content can be sublimated to a more innocuous
state, until the experience is recalled anew. The acts can be said to be innately nurturing,
becoming ritualized with repetition. The raw content is given purpose through intentional acts
(Dewey, 1980). Sublimation of raw emotive content is processed one motion at a time; they are
shaped to reflect preferences through choices, actions and exclusions.
The resulting artifact embodies the truth, as it was before and during the acts of creative
expression (Dewey, 1980; Dissanayake, 2000; Levitin, 2009; Lusebrink, 1990; & Robbins,
2000). Both artifact and process are revealing. Through the processes individuals capture and
communicate their personal truth (Arnheim, 1986; Dewey, 1980; May, 1965): their world,
4
culture, emotions, and struggles as they understand them to be (Dissanayake, 2000; Hegel, 2004;
May, 1975). The process and artifact serving as a feedback system, one created by the individual
that holds singular meaning for them (Pakula, 1997). Such artifacts, when created by art
therapists after a session, serve as tangible records of the material that was processed (Betensky,
1995; Fish, 2006, 2008; Hinz, 2009; Kapitan, 2003; Kaufman, 1996; Levine, 1995; Lusebrink,
1990; Pakula, 1997; Robbins, 2000).
Under such contemplative states, what is not noticed, and what is not done, can be as
important as what is actively being transformed. Without the hands-on knowledge inherent in
the creative process, art therapists would be devoid of an integral part of their practice. Through
the transactive interaction that takes place in the creative process, the art therapist gains access to
what may otherwise be unprocessed emotive content. In the case of their clients, this may refer
to material that surfaces in session, but could not be addressed at the time. When left unchecked,
the surfacing emotive content may be shouldered by the therapist, and unknowingly left to
accumulate. Accumulation of un-processed stress over time, can lead to the syndrome of
burnout (Freudenberger, 1974; Heifetz & Bersani 1983; Maslach, 1982; Pines, 1983).
Burnout
Burnout relates to a complex interaction of pre-existing, and environmental factors,
which over time cause the mental, and physical exhaustion, of an individual (Chernizz & Krantz,
1983; Farber, 1983a; Freudenberger, 1974; Maslach, 1982; Maslach, Schaufeli, & Leiter, 2001;
Meier, 1983; Pines, 1983). As such, burnout is seen as a chronic condition that affects both work
and social dynamics (Meier, 1983). Burnout involves emotional exhaustion, depersonalization,
and the perception of reduced accomplishment (Maslach, 1982; Maslach & Leiter, 1997;
5
Maslach, Schaufeli, & Leiter, 2001). It is a natural response with repercussions in all areas of
life, affecting work performance, and inevitably the clinician’s self-worth.
The literature shows that mental health professionals, who are considered to be in a hightouch (Skovholt, 2001) field due to their interactions with traumatized individuals, have a higher
propensity for developing symptoms of burnout at some point in their careers (Bride, Radey, &
Figley, 2007; Heifetz & Bersani, 1983; Maslash, 1982; Skovholt & Trotter-Mathison, 2011;
Figley 2002b). They often engage in repeated and sustained interactions relating to crises, and,
may have no scheduled recovery time to process the emotional distress. Clinicians may
minimize accumulating stress as coming with the territory, versus something needing to be
addressed.
The creative process allows art therapists to develop, and nurture, an informed sense of
self-awareness (Levine, 1995; Pakula, 1997; Robbins, 2000). Self-care has been identified as a
protective practice (Baker, 2003). The acts of creative expression have ramifications beyond the
visual artifact. They align the internal systems of knowing with the external world through the
transactive interactions taking place between the environment, the media, and the individual, in
the creation of an artifact (Dewey, 1980; Dissanayake, 2000; Langer, 1953; Lusebrink, 1990;
May, 1975). These properties and transactions would then have value for anyone engaging in
creative acts, art therapists included.
As clinicians, art therapists are at risk of burnout, seen in the chronic disparity between
the empathetic desire to help their clients, and the lack of resources to do so (Barnett, ed., 2011;
Figley, 1995, 2002). Overtime, the inability to effectively cope with the emotional and physical
demands of work leads to exhaustion (Maslach, 1982), and consequently a decline in clinical
performance. Such decline in the clinician’s performance may include the inability to notice
6
changes in their clients, or within themselves (Baker, 2003). As clinicians, art therapists are
exposed to the trauma stories of both staff and clients. Individuals processing trauma using art
therapy modalities actively engage their stories, giving them shape and color. Exposure to such
images of violence can further negatively impact the art therapist. Clinicians are not immune to
the risks of repeated exposure, as they can figuratively take the images with them, exacerbating
the distressing memory by inadvertently adding concurring imagery. Such a compilation of
distressing emotive content, concurring visual artifacts, and a lack of professional support, can
lead to burnout of the clinician (Baker, 2003; Barnett, ed., 2011; Cherniss, 1980; Farber, 1983;
Figley, 1995, 2002; Harrison & Westwood, 2009; Johnston et al., 2011; Maslach, 1982; Paine,
1982; Saakvite, 2002).
Art Therapy Profession
According to the American Art Therapy Association (AATA) (2013), art therapy became
a profession in the 1940’s. Art therapists are masters and doctoral level mental health clinicians,
who have successfully completed coursework in the field through accredited programs. After
program completion, new art therapist professionals enter the work force in a myriad of work
settings: medical hospitals, psychiatric facilities, substance abuse treatment centers, forensic
facilities, school systems, private practice, and other settings.
Approved masters programs must adhere to the education standards set forth in 2007 by
the AATA in order to obtain, and retain their approval. Content areas that are covered include,
but are not limited to: history and theory of art therapy, direct experience with processes in
various treatment settings and age groups, utilizing art therapy for assessments, ethical issues of
practice, standards, and cultural and social diversity. In addition, programs are also to provide
coursework in psychopathology, human growth and development, counseling and psychological
7
theories. Coursework is augmented by the required minimum of 600 hours of supervised
internship. While the internship component can vary per state depending on licensure
requirements, the AATA indicates that the internship experience must be varied in terms of age
ranges, practice, settings, and types of interventions.
Art therapy graduates are then faced with the hardships of finding and securing a job.
With an extensive portion of the required coursework rooted in the mental health profession,
mental healthcare is an area of possible employment. The art component tends to be heavily
weighed down by societal notions of art teachers and artists. Depending on training and personal
choice, art therapists can be both or neither, educators or artists. While neither on its own serves
as an accurate depiction of what an art therapist is, aspects of both, may contribute to the role an
art therapist eventually takes-on. A recent search by the principal investigator for “art therapy
jobs,” yielded many more results than it did a few years ago, but it does not mean that employers
have developed an inherent understanding of what art therapy is, or how it can be used.
From the start, art therapy job seekers have to educate prospective facilities as to how
they could be a good-fit for the workplace. They often must work to demonstrate their skills,
and abilities to perform the job, in the hopes that over time they can incorporate increasing
amounts of the art therapy practices they cultivated as students. For employers taking a chance
on someone who does not readily fit the job description creates the risk of the new hire not being
able to fulfill all the job requirements. As such, institutions may only make exceptions for one or
two art therapists to be hired, and often this is under various job titles, such as creative arts
therapist or rehabilitation therapist. In practice, this near-fit for the job is a partial success for the
art therapist, attaining access to a facility, but not necessarily being recognized as members of
the mental health profession.
8
Exacerbating the situation, art therapists often practice in isolation (Wadeson, 1983).
Practicing their profession under institutional titles such as rehabilitation specialist or therapist,
their presence at times can be overlooked. On the other hand, when institutions write job
descriptions that are specific to a profession such as art therapy, they are fixed on having to hire
an individual with particular credentials. Such positions may be hard to fill because, if there are
no qualified clinicians available, the position goes unfilled. Because of this, art therapists often
find themselves serving as ambassadors to the profession (Chilton, Gerity, LaVorgna-Smith, &
MacMichael, 2009), having to pave their own way into an institution. Applying for positions
that may be only marginally related to their field, and within which they may practice their
profession. Practicing alone, versus within a group of like-minded professionals, the art therapist
is a novelty; they shoulder the burden of representing what art therapists everywhere are like.
New professionals are faced with the need to manage a caseload, while adjusting to unfamiliar
routines, and developing a professional identity as an art therapist. As professionals transition
from the often nurturing scholarly arena, into the realities of the workplace, some professional
decline may be expected (Robbins, 2000; Wadeson, 2003). After graduation from an approved
program, and adjustment into the workplace culture, professional art therapists still have careerlong battles to contend with. They continue to change and develop their art therapist identity
(Levick, 1995). Changes may occur in the bureaucracies of the work site (Robbins, 2000), as
well as in the nature of the client population. Professional isolation and issues related to
budgetary constraints are additional sources of difficulty. In order to prevent burnout, art
therapists must develop sustaining practices for the realities facing the profession.
Literature within the field of art therapy that focused on the specific needs and abilities of
art therapists is limited. There are few practitioners who have discussed their personal use of art
9
after unsettling traumatic experiences (Kaufman, 1996; Pakula, 1997; Rosen, 2009). Kaufman
(1996) used visual expression extensively after the death of her son, as a means to process loss
and grief. Pakula (1997) found drawing alleviated her post-traumatic stress symptoms, and
allowed her to regain control, after a workplace incident where she was held hostage by an
inmate. Rosen (2009) used autobiographical cartoons to distract, and unintentionally process,
open heart surgery. Campbell (2002) approached art-making as a means to reflect on past
relationships, she found that with increased practice, she became more at ease with the creative
process, which became an avenue for connecting with others.
Over thirty years ago, the first journal of art therapy provided discourse on sustained
creative practices (Jones, 1983; Wadeson, 1983). Working for extended shifts in the early days
of deinstitutionalization, Jones (1983) relied on his visual explorations to communicate with
patients, and process witnessed abuses. At the same time, Wadeson (1983) drew attention to the
dangers of practicing in isolation, and forgetting that art allows art therapists to do what they do.
In recent years, discussions relating to transactions between therapists and the creative
process as a means of self-reflection and professional development, have for the most part, been
relegated to theses (Brosnan, 2012; Fish, 2006), and book publications (Kapitan, 2003; Levine,
1995; McNiff, 2004; B. Moon, 2002; C. Moon, 2002; Robbins, 2000). Brosnan (2012) and Fish
(2006), elaborated on the topic of response art as part of their masters’ theses. They referred to
response art, as the art made by art therapists in response to, or in the processing of, an event.
Other authors’ contributions appeared in books directed primarily at the practice of art therapy
(Kapitan, 2003; Levine, 1995; McNiff, 2004; B. Moon, 2002; C. Moon, 2002; Robbins, 2000).
Brown (2008) surveyed 45 New York creative arts therapists and indicated that of those who
participated in her research, all continued to engage in the creative process outside of work.
10
However, it was not clear whether art therapy clinicians were involved. A few years earlier,
Campbell (2002) described in detail her failed relationships and finding herself through her
paintings. Through the years, Fish (2006; 2008; 2012) has steadily expanded on the use of
response art by art therapists. Nonetheless, current publications in peer-reviewed journals that
discuss such concepts of continuing creative engagement by art therapists are fairly limited.
Statement of the Problem
Much of what is known about the syndrome of burnout stems from other helping
professions such as psychology, social work, nursing, and education. The literature in these
fields is replete with theories on contributing factors (Heifetz & Bersani, 1983; Maslach, 1982;
Maslach & Leiter, 1997; Maslach, Schaufeli, & Leiter, 2001), and ongoing discussion of best
practices to prevent or alleviate burnout (Farber, 1983a; Figley, 2002b; Harrison & Westwood,
2009; Iliffe & Steed, 2000). Literature specific to the field of art therapy is lacking in
publications regarding both the identification and prevention of burnout. This is the gap that is
being addressed by this study. The existing research from adjacent fields serves as the impetus
for the research. Art therapists’ work is distinctive, its practice centers on the interaction with
the creative process. In using the creative process to reach their clients, art therapists bring
unique attributes to how they address workplace distress. It is important to explore how, art
therapists are engaging the creative process for themselves, and to what extent they benefit from
doing so.
Purpose of the Study
The present research examined whether art therapists currently use, or have used, visual
expression to create, and maintain, a sustained practice of self-expression as a means to address,
and process workplace distress. This was done through a demographic online survey, and by
11
interviewing a subset of the survey participants using a self-selected sample of their art work.
The current study contributes to the art therapy literature regarding clinician self-care and
perceptions of the creative process.
Research Questions
The primary question guiding this study is:
•
How do selected art therapists employ personal visual expression to sustain their
practice?
Supporting questions that lead to developing answers to the guiding question of this study are:
a. Is art used as self-care by art therapists and if so, how?
b. Does personal visual expression mitigate perceived burnout?
c. Does responsive art-making influence art therapists’ professional identity, and if so how?
Significance of the Study
Increasing awareness of the need for more literature on the topic of burnout and the
personal visual expression of art therapists, the research results have implications for the field of
art therapy. Graduate programs may incorporate the discussion on art therapist creative practices
to inform student and clinician program of studies and protective practices. Results may also be
of particular benefit to those professionals already in the field who have yet to develop selfsustaining visual response practices. Chapter 4 provides a detailed account of the interviewed art
therapists varied use of art practices, including aspects of their practices that contribute to their
resiliency. Some of the findings discussed in chapter 5 shed light on particular attributes of
creative practices that were perceived as beneficial when time was of importance. Finally, by
increasing awareness of the need for additional research and publishing in relevant publications,
this study may entice other art therapists to pursue similar lines of inquiry.
12
Research Design
This research used a mixed method design (Johnson and Onwuegbuzie, 2004) to collect
data in 2 sequential phases. The first of which is an online survey collecting demographics and
perceptions on the personal use of creative expression. Participants who progressed to the
second phase provided response art images and corresponding information, before taking part in
a voice over internet protocol (VOIP) facilitated interview.
Participants for the study were professional art therapists, who have worked or are
currently working in that capacity. Data was collected by means of an online survey, semistructured interviews (Knox & Burkard, 2009; Qu & Dumay, 2011), and photo elicitation
(Collier, 1957; Harper, 2002; Holm, 2008; Stanczak, 2007). Photographs of participant created
response art were used as a component of the interview process, to serve as story cues and
expand the dialogue beyond the scripted questions. It was assumed that participants taking part
in the proposed research answered questions honestly and to the best of their abilities. It was
also assumed that images that were uploaded for inclusion were participant originals. Research
data was analyzed using the constant comparative method of grounded theory (Charmaz, 2000;
2006; Charmaz & Henwood, 2008); collecting and evaluating the data as it was obtained.
Interview data was organized into a visual map of relatedness. Research design information will
be provided in detail in chapter 3.
Limitations
This study was developed in response to personal inquiries made pertaining to the
creative practices of art therapists. An art therapist myself since 2007, I am often faced by some
of the same lines of inquiry presented here. I consider my proximity to the topic as an asset in
providing access to subtleties of the practice that may be overlooked by non-art therapists. One
13
example being the media properties and its manipulation, over the final product of expression.
Researcher subjectivity will be unavoidable; however, the quantitative portion of the mixed
methods design may provide some objectivity to the otherwise qualitative narratives and images.
According to Johnson and Onwuegbuzie (2004) in using a mixed method model, the strengths
and weaknesses of one model may help offset the same in the other. Although this study will
likely provide discipline specific insights, due to its small size, the information distilled will not
be generalizable to the field as a whole.
The study was purposefully limited to art therapists who had the prior indicated
qualifications, and who also knew about, and used response art. The number of participants
choosing to take part in the online survey may have been further limited by the time of year the
study was active, in the Fall of 2014. Participation was further limited to art therapists who were
users of social networking platforms (SNP), or who were otherwise sent the survey link by peers
who saw the survey post on an SNP. Participants completing the phase I online demographic
survey were used as the base for phase II. The number of participants who chose to continue for
possible inclusion in the pool for interviews was further limited by the time and resource
commitments needed. Furthermore, a lack of timely communication with the researcher was
cause for participants to be dropped from the pool of viable interviewees. Interviews were
primarily carried out through the use of VOIP. VOIP refers to the technology that enables the
transfer of voice and data using internet protocols. Participation in the research was further
limited by a lack of access to the needed software, hardware, or unreliable bandwidth.
Definitions of Terms
Artifact – this term is used often in place of the term “artwork”; it refers to the concrete
visual response that emanates from engagement in the creative experience. It is understood to be
14
the outcome of said experience, but it does not always mean the piece itself is complete or
finished. The artifact can be a work in progress.
Burnout – According to Maslach (1982) burnout is a syndrome resulting from chronic
high contact emotional fatigue, usually from high demand and low resources.
Compassion Fatigue- while at times used interchangeably with the term burnout.
Compassion fatigue is a form of burnout that specifically relates to changes in the cognitive
schema of the therapist which adversely affects their practice (Figley, 1995).
Constant Comparative Method – a method of analyses used in grounded theory for
comparison between all data and across stages of research towards the development of a theory
that is based on the data that is collected. It calls for the comparison between similar and
dissimilar data, codes, and categories through all stages of review; this leads to sequentially
narrower concepts until saturation is reached (Charmaz, 2000, 2006).
Photo Elicitation- the use of photographs in the process of eliciting information from
identified participants (Collier, 1957; Harper, 2002; Holm, 2008; Stanczak, 2007). The photos
pertain to the topic of study and are reviewed by both participants and researcher by means of
open-ended interview questions. Photos may be taken by the researcher or by the participants.
As the photo(s) are reviewed with the researcher the participant accesses a correlating narrative
which may or may not be readily discernible from the image. In this way photo elicitation
provides the researcher with relevant and new information that would not have been otherwise
ascribed to the image (Stanczak, 2007).
Response Art- a term used to indicate the art process and outcome that seeks to process an
experience, usually related to the work environment and client interactions (Fish, 2006; 2008;
2012).
15
Resiliency- the ability to recover after distress by returning to baseline time after time.
Secondary Traumatic Stress- is indicative of stress that is a result of becoming exposed to
traumatic material, as when a therapist is exposed to clients’ narratives of emotional reactions to
traumatic experiences.
Summary
The creative process is not only natural, but a necessary as a means of processing
experiences, and of self-reflection. It is an active and transactive process, reflecting the reality of
the individual undertaking the process. As such, it reflects the individual’s truth, and holds
meaning that is particular to that person, in that moment. For art therapists, this has two
implications. First, that art therapists can be exposed to visual representations that are client, and
experience specific, visualizations of how the client sees the world. Second, that because of such
particular exposure, art therapists may benefit from a means of processing that is particularly
their own. According to the literature, since art reflects the truth as experienced, post-session art
has the potential of holding associations, and reflections, that are particular to transpired events.
Such visual processing after a session could sublimate experienced emotive content for the
therapist.
In spite of this, creative engagement by art therapists is not a topic commonly seen in the
art therapy literature, which also has minimal mention of art therapist burnout or protective
practices. While there is related literature from neighboring fields, there is no equivalent
research specific to the art therapist, in our literature. Although art therapists often practice in
the same facilities as other healthcare providers, their exposure to potentially traumatic and
stressful material is somewhat different, and few publications address this difference.
16
While chapter 1 provided an introduction to the research, indicating the gaps in the
literature, and the need for further research, chapter 2 will review the literature in support of the
topics to be examined. In chapter 2 the case will be made for the importance of using creative
expression as a means to process experiences, and as a self-soothing behavior that contributes to
the clinicians’ self-care. A more thorough description of the history of burnout will also be
explored, with particular interest towards the propensity of mental health professionals to be
affected by the work they do. Lastly, chapter 2 will review the literature from the field of art
therapy that makes mention of how the creative process has been used by art therapists through
the years; once again highlighting gaps as well as illustrating the benefits of creative expression.
The research design will be explained in detail in Chapter 3; including the rationale for
the use of a mixed methods design, and the implementation of the constant comparative method
of analysis for the image facilitated interviews. The breakdown of participant recruitment,
participation, and retention will be outlined along with the rationale for the two phases of
research and the various means of data collection and analyses.
The data collected from all phases of the research will be presented in chapter 4, this
chapter is organized into three sections respectively named: Phase I Demographic and
Informational Survey, Phase II Introduction to Participants, and Phase II Interviews. Beginning
with recruitment observations, results from the demographic survey will be summarized and
compiled into categories of responses. Phase II participants will be introduced along with the
visual artifacts they uploaded. Interview results were compiled and organized by emerging
themes versus individual participant contributions; these are presented at length with supporting
quotes and stories.
17
In chapter 5 the results described in the previous chapter are weighed in reference to the
literature reviewed in chapter 2, and presented as a discussion. The chapter was organized in
such a fashion as to answer the supporting questions and building up to the main question of:
How do selected art therapists employ personal visual expression to sustain their practice? As
part of the discussion several observed limitations were discussed along with possible
implications of findings and suggestions for the field of art therapy.
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CHAPTER 2
REVIEW OF RELATED LITERATURE
In exploring the relationship between art therapists and art as it is used for self-care, I will
first contextualize the role of visual expression. I will then provide a brief overview of the
history of burnout and its relation to the mental health clinician. Considerations for the art
therapist will then examine the necessity of engaging the act of creative expression as a means of
building resiliency. Exercising the resource of making, as a means of processing experiences is
an innate means of communication (Dissanayake, 2000; Langer, 1953; Lusebrink, 1990; May,
1975); as such, it is accessible regardless of the level of the clinicians’ expertise. Facilitating
communication through elaboration and ritual, the maker is able to exert control over
experiences and recall, as needed. While visual expression is an integral part of the profession of
art therapy, it is not broadly used by therapists themselves as a means to process through
contentious events.
Act of Expression: As Experience
The creative act is an experience (May, 1975); such an encounter fully absorbs the
individual into the content by means of the process. Creating art is an instinctual way of making
connections; individuals seek experiences such as the act of visual expression as a means of
communication (Dissanayake, 2000). Dissanayake (2000) referred to this often intimate
connection as having mutuality, a give-and-take between the participant and the process,
whereby an experience can be explored and expanded on. People fail to know that which has not
been experienced (Langer, 1953), as living itself is a dynamically interacting series of tensions
and resolutions that are informed and react to the sensory emotive self. Indeed, the act of
expression in and of itself can be seen as an engagement in experience towards the exploration of
19
an idea. It is a necessary means of communication between internal systems of knowing and the
external world (Dissanayake, 2000; Langer, 1953; Lusebrink, 1990; May, 1975), and such
experiences give the individual knowledge of the world around them (Dewey, 1980).
Bandura’s (1999, 2001, 2012) theory of triadic reciprocity facilitated an understanding of
the exchange taking place between the individual, the environment, and behavioral variables,
needed in the development of an idea into an artifact. In brief, the theory of triadic reciprocity
pertains to the interaction taking place between 3 variables which facilitate attainment of
knowledge. In this case the environment stands for more than just the immediate surroundings,
it also includes the materials and media which cannot be forgotten, as they also affect both
process and outcome. In being actively involved in the creative process, the individual is
experiencing and learning. In the creation of the visual artifact, the maker initiates the
experience, guides the process, and declares when it has reached its completion. The process of
making is therefore informed by the reciprocal dynamics taking place between the maker, the
environment, and the media towards the expression of an emotion or concept.
Taking part in the creative process enhances the initial experience, allowing for physical
interaction that is concurrent with cognitive engagement (Dissanayake, 2000). The act of visual
expression as such does not require spoken language. It is within this nonverbal exchange
between cognition, behavior, and environment that the maker is able to familiarize with the
process of expression that at times is referred to as creativity. Yet, as disclosed by May (1975),
creativity is not something for the weekend practitioner, the once-in-a-while hobbyist, or elusive
maker. Creativity as it is referred to here, and similar to what May described, is something that
permeates through the acts and experiences of the individual, unrestrained by the immediacy of a
particular task. Furthermore, it is not something to be called-upon only during moments of need,
20
but more of a skill set, needing to be honed throughout the lifespan in order to increase its
effectiveness.
All elements present within the creative process interact towards the experience:
individual, environment, and behavior. Integrating all experiences to varying degrees, it is in the
act of expression that the elements of triadic reciprocity can be said to be tethered (Bandura
1999, 2001, 2012). In the process of creating, the individual is receiving immediate and constant
feedback through the tactile manipulation of the media, which they are responding to in-vivo. In
creating a visual expression, the artist reconnects with the memory of the experience and further
explores it (Arnheim, 1986). Visual creative expression, serves as a means of processing the
emotive content of an experience by eliciting said content, noticing the change, and choosing a
response.
Emotive content is the raw impetus for action; it provides the starting point from which
the maker expands upon. Providing both spark and fuel to experiences, emotions are raw and
self-perpetuating, needing external boundaries to be adequately expressed (Dewey, 1980).
Active engagement between maker, media, and conceptual ideas are clarified through the process
(Rita & Cosson, 2004). The maker sublimates raw emotive impulsions into ordered experiences
by modifying the expression. While there can be a crude discharge of emotive content through
visual expression, true expression needs to have forward momentum (Dewey, 1980). Without
purpose, the opportunity that is presented by an experience falls short of its potential.
Visual expression presents the means to expand on an experience. Serving as a concrete
representation of the creative process between maker and lived experience, the visual artifact in
turn incites a concurring experience. The reciprocal act of making allows for the unfolding of
particular experiences, allowing for adaptation through expansion (Dewey, 1980; Dissanayake,
21
2000). Naturally occurring tensions in the process serve to enhance essential aspects of
creativity, their inherent energy giving momentum to the creative process (Dewey, 1980; Langer,
1953; May, 1975). Such expansion of the experience is not without conflict, as there would be
no reflection or change.
In creating, the maker is expending energy to communicate an idea by giving the
experience tangible form. In the process of creating, the maker’s focus narrows onto the tools
and means of expression. In this microcosm of creation, all elements present undergo change,
the media, the concept, and the maker. While everything in life is experience, it is within the
creative process that conflicting elements are able to come together and inhabit the same space
(Dewey, 1980).
The inherent reciprocity present in the act of making facilitates the development of
critical thinking and discriminating faculties in the maker (Dissanayake, 2000). The internal
process emerges out of the give and take of the creative acts, becoming evident in the tangible
artifact (Dewey, 1980). While experience in the arts is transferable (Dissanayake, 2000) to other
experiences, it is ephemeral, and after the experience has passed, it is the artifact that serves as a
concrete representation of what has transpired. In spite of this, some who take part in the
creative process develop an increased appreciation for the acts versus the final outcome
(Dissanayake, 2000).
The creative process is an aesthetic experience (Dewey, 1980; May, 1975). It is one that
must be entered into with purpose. It is much more than a coordination of limbs towards the
completion of a task; the process requires awareness and dedication. There is a necessary
connection between the resources of the maker and the external objects from which the artifact is
to be created. Skill alone will be insufficient for providing a complete experience (Dewey, 1980)
22
just like the mere presence of art media will not result in one. Expanding on this concept, the
experience demands the full presence of the maker, the absorption into the moment, and the idea.
Without the idea and presence of mind, the process and artifact are unable to elicit a full
experience (Dewey, 1980; May, 1975).
Immersion into the experience then, is not only a prerequisite, but also the means through
which the individual elevates the moment into an experience commensurate with the act of
expression. Furthermore, it is the tactile awareness of the experience that elevates the process
from habit to experiential encounter. Processing of content in this way facilitates increased
sensibility toward similar future events (Dewey, 1980). It is in the creative process that elements
of an experience can be fused together and expanded upon while remaining true to their nature
(Dewey, 1980). The reciprocal variables of an experience are additive rather than restrictive.
Visual Expression as Personal Elaborative Process
The creative expression of an experience is innate and personal (Dissanayake, 2000). It
is an internal process, sparked and driven by the emotive content of the experience, which
becomes concrete only after being given form (Levine, 1995). However the experience itself is
not contingent on form. Engagement in the media requires intentionality on the part of the
maker (Arnheim, 1986; Dewey, 1980; May, 1965). Requiring the entirety of the maker’s
attention for media engagement, intentionality further indicates that by doing so the maker also
accesses and utilizes sociocultural knowledge (Dissanayake, 2000; May, 1965). In this state of
intimate contemplation, the maker would be consumed by the task at hand, aware of what lies
before her, and of little else. With heightened and focused attention, the maker is able to utilize
raw materials towards an expansion of her experience.
23
Emanating from the maker’s experience, visual expression is a means of communicating
first with the self, and ultimately with others. From the beginning, raw material intermingles
with the personal, and through the creative acts it undergoes change, and then is once more
internalized. In making, both the maker and the artifact undergo change, as the moment is
captured in memory, and within the artifact.
Due to its modality and accessibility, visual expression can be used in making sense of
non-verbal material stored in memory. Personal experiences can be manipulated through the
physical acts of creating, in order to gain new perspectives, or in preparation to be shared with
others. In a similar fashion, when an experience is unknown, it too can be developed through the
media and process. While the process of expression can raise anxieties (May, 1963), it also
sublimates the experience through its acts (Levine, 1995; Lusebrink, 1990; McNiff, 2004). In
conveying an experience, the maker is working from the personal to the concrete, by means of
the media, and the processes involved.
In transforming the idea, concepts are enriched, and the understanding of the experience
expanded (Robbins, 2000). Utilizing visual expression as the means through which to develop
the experience requires reciprocity between media, intentionality, and environment. Such give
and take between the elements of the process is crucial in the transition, between experience and
artifact. In order to express what there are no words for, it must be made concrete (Dissanayake,
2000; Robbins, 2000). Doing so, affords the maker new opportunities to review the experience
under changing circumstances. Expanding the experience through the manipulation of media,
the maker engages with the inherent properties, utilizes their senses, triggers associations, and
makes new connections. The process is reciprocal, in that as one element affects another, the
change that is enacted affects all elements in the chain (Bandura, 1999, 2001, 2012).
24
With the dynamic engagement between physical, cognitive, and environmental elements,
the maker cannot help but be absorbed into the creative process. Sensory engagement with the
media is intimate, allowing for the development of the non-verbal feedback system that sustains
the creative process. The repetitive give-and-take of the process is akin to the concept of
mutuality (Dissanayake, 1988, 1992, 2000), which develops between the maker, and the means
of expression. An intimate dialogue takes place between the media and the developing concept.
Serving as both stimulus and reference, the feedback received from the creative process serves to
motivate continued engagement (Dissanayake, 2000).
Visual expression, as a dynamic process requires the elaborative interaction that takes
place between the individual and their environment. Herein the maker is seeking to order the
chaos, and find meaning that is otherwise absent from her environment (Dissanayake, 1992,
2000; May, 1985). In making sense of the world, the creative process provides for exploration of
novel concepts, and containment of dissonant ideas. While the visual artifact serves as container,
it does so by means of reciprocity between the concepts. This is where elaboration aids the
maker in clarifying, and crystallizing the experience (Dissanayake, 2000), through repetition, and
addition of both behavior, and media.
As an evolutionary adaptation, elaboration of an experience serves to build a sense of
competence, in the maker (Dissanayake, 2000). In memorable actions and artifacts, attention is
captured, and communication is effective. Through elaboration of action, the experience is made
special (Dissanayake, 2000; Hinz, 2013). By elaborating the artifact or artistic act, the
experience is made distinct; it is afforded conviction and memorability above other similar
expressions (Anderson, 2004; Anderson & Milbrandt, 2005; Dissanayake, 2000). On the other
25
hand, that which lacks distinction quickly fades from memory. In the process, operations are
repeated and actions are refined.
While reciprocity explains the kind of relationship that is present within the elements that
are part of the creative process, elaboration refers to how each is expanded in the process.
Elaboration is seen through movement as well as alteration of given materials towards the
expression or clarification of the idea (Dissanayake, 2000). It is instinctual to want to “make
sense” (Dissanayake, 2000) of the environment; those things that feel right are those which are
repeated in order to be remembered. Through the creative encounter, the maker seeks to put
things in order as she sees it, and make sense of both her internal and external worlds. It is in the
ritual of elaboration that the maker is able to organize, and crystallize the story (Dissanayake,
2000), relating the new with the past, and vice-versa. It is through such a dynamic give-and-take
process that an experience is elaborated, metaphorically and concretely.
Elaboration in this sense involves both the cognitive processing, and turning-over of an
idea or concept, as well as the physical interaction with the raw material (Dewey, 1980;
Dissanayake, 2000) within an environment. The varying qualities of media influence the process
of expression (McNiff, 2004). In shaping the media, order and control, may be gained by the
maker (Dewey, 1980; Dissanayake, 2000). Interaction with the media affords a physical
exchange that is responsive to, and corresponds with, the maker’s emotive state, thereby
augmenting that which is of importance. As one responds to the other, both undergo change.
Visual Expression as Ritual Acts
Setting the creative act apart from daily life, through distinctive actions (Dissanayake,
1992), and emotive responses, leads the maker towards repetition. With continued engagement,
the acts of the creative process have the propensity of being developed into rituals. These rituals
26
emerge from the elaboration of familiar, and preferred movements, ranging from minor acts, to a
series of actions, that when sequenced, can be referred to as a process. With repetition, acts gain
or lose preference, and those which are identified as more efficient, are increasingly repeated and
maintained. Acts involved in the creative process are responsive to external and internal
feedback, and through repetition they are refined, altered, elaborated, and retained.
The act of creative expression is in itself an exploratory experience (Dewey, 1980;
Dissanayake, 2000), requiring the intention of the maker to engage the media with purpose
(Dewey, 1980; May, 1965). Interacting with the media brings about a responsive turn-taking:
acting on the media, observing the result, and responding. Visual expression necessitates a
sequence of such repetitive actions, in order to achieve a desired result. Having familiarity with
these acts, allows for a more efficient sequencing of movements in response to an event. While
at times the ebb and flow of the movements acquire a rhythmic pulse, there is still reciprocal
communication taking place that makes the elements of the interaction become interdependent
for the duration of the act.
Consider the allocation of time, and cognition, devoted to the collection, and organization
of media prior to its application towards a creative act. Distinction is afforded by means of
selection, preparation, and use. Media selection is thereby a part of the ritual act of making,
versus a behavior apart. In physically engaging the media, the maker feels rewarded; it is a
means of innate learning, and of being connected to others, of intimacy (Dissanayake, 2000).
Such ritualized acts give form to psychological concerns (Dissanayake, 1992, 2000), expressing
the stress and anxiety.
In ritualized acts, the maker can be afforded control over the experience (Dissanayake,
1992), and can also use the ritual towards disconnecting (McNiff, 2004) from daily strife.
27
Knowing the process and how it will end, the maker is comforted by a sense of control
(Dissanayake, 1992). Herein it is through the sequencing, and repeating of movements, that the
maker gains control over the experience, and a sense of mastery (Dissanayake, 2000). By
performing familiar movements in response to novel situations, the maker continues to foster a
sense of control they would not otherwise have. In time, successful acts of creative engagement
can become ritualized. Personal rituals aiding in the amelioration of perceived distress, can be
entered into unconsciously or purposefully.
While there is a familiarity to the creative process, if the actions were to become
automatic, the experience would lose meaning (Dewey, 1980). It is the rhythms of creation that
encourage the change and elaboration, that are a prized aspect of the creative experience (Dewey,
1980). Without the ebb and flow of the process, the experience would remain one-dimensional,
lacking the depth, and maturation, necessary for an effective means of expression. Ritual also
extends beyond the individual, as a means of social communication.
Visual Expression an Elaborative Community Process
Through the arts, communities come together, strengthening cooperation and affiliations
(Dewey, 1980; Dissanayake, 1988, 2000). Human mutuality evolved out of the intrinsic human
disposition for survival (Dissanayake, 2000). Utilizing visual expression as a means to
communicate where language was insufficient, or inadequate, yet dependent on communication,
hominids have been hardwired for attunement to their counterparts and their sustaining
environment (Dissanayake, 2000). The natural desire to communicate observed at infancy
(Dissanayake, 1988, 2000), was integral to the development and maintenance of visual culture.
Such visual culture would then evolve and expand from the individual towards communicating
with the sociocultural group (Dissanayake, 1988, 1992). Taking place in private or public
28
domains, the creative act and the resulting artifact, could be personally used, and socially shared
as a means to communicate ideas and experiences. Furthermore, by engaging in acts of
expression with others, the maker gained an identity within the group (Dissanayake, 2000); they
were set apart while being embraced.
Gaining identities through their skill and craft, makers are recognized as valuable
contributing members of the group (Anderson, 2004). In the act of making, concepts and
behaviors are elaborated. Experiences and concepts are made special, through embellishment of
action and artifact (Dissanayake, 2000). The time devoted to the process of making special
within the creative acts, is itself indicative of distinction (Anderson, 2004; Dissanayake, 2000).
Reminiscent of other human activity, it is the creative endeavor from beginning to end
that inextricably connects the maker to their community (Becker, 1982). A symbolic
construction demarking concepts, the visual artifact serves as a means to connect with others
through the resonance of experiences (Rosen, 2009). While it is not exhaustive, the artifact is
indicative of a collective of events, and communities, that directly and indirectly were present
throughout the time the visual expression was being made. The artifact connects the maker to an
experience, and is itself a reminder of the collective of moments that transpired in its making.
Visual expression as such is a means through which communication can be expanded,
from the personal to the social, and vice-versa. It is a communal activity, comprised of a
network of participants (Becker, 1974, 1976, 1982, 2007), who are connected to societal
conventions through media and tools (1982). Indicating that the acquisition of the necessary
skills is as contextual as the final outcome, and as such, it can be seen throughout the processes
and the artifact. Therefore, the artifact is a reflection of the time and place it was created, and
through recognizable conventions, viewers are able to identify with it (Becker, 1974, 1976,
29
1982). As society is a reflection of its organizational structures (Becker, 2007), so too is it
manifested in both processes and resulting artifact. Just as language used serves as a reflection
of the times, and cultural identification, so does the expression of an experience through media,
and elaboration, have contextual traces for the maker, and those who later observe it (Becker,
1982).
It is this resonance between the community and the artifact, or expressive act, which
draws one towards the other. For the observer, emotive associations evoke reflection over
memories, while at the same time creating a new experience. Everything is captured in the
artifact through the elaborative act, and it is by means of those acts that the maker is connected to
the artifact, and through it to their community, and so on (Anderson, 2004; Dessanayake, 2000).
As indicated earlier (May, 1975), the maker is able to tune into experiences with
dedication, and purpose. They are able to utilize raw materials in the visual expression of an
idea, as a means of communication. Inasmuch as they are able to reflect their inner world
through media, and process, they similarly cannot disconnect from the outside world they know.
This connection is present in the environment that is the temporary host to the creative process,
and as such, has a reciprocal influence on the outcomes of the experience as a whole.
Visual Expression as a Tool for Processing with the Self
As previously indicated, visual expression is a tool most often used for communication.
It is a vehicle for the transformation of an experience from one mode of understanding into
another. It is a means of condensing information from the communal to the personal, and of
expansion from the personal to the universal. In the process of visual expression, the maker
consolidates their knowledge of being in the world. At every step of the way, the process is
30
transformative; it undergoes changes that can both enrich, and filter content. At its core, visual
expression is personal, emanating and suffusing through the individual maker.
Many have (Dissanayake, 2000; Malchiodi, 2012; May, 1975) proposed that creative
expression provides the maker with an increasing awareness of themselves, one based on
reflection of experience (Malchiodi, 2012). Humans are innately drawn to creative expression
(Dissanayake, 2000; Malchiodi, 2012), the resulting artifacts commemorating special events, and
themselves being endowed with particular desirable qualities.
By creating, awareness is raised over a multitude of possibilities (May, 1975); in making
mistakes, the individual is able to go further, and explore options they would not have had access
to otherwise. May (1975) proposed that if individuals are only interested in being right, they
block themselves from all other possibilities. The dialectic exists when they are fully committed
and able to experience a variety of options, including being wrong. Such psychological intimacy
requires vulnerability and courage, which over time, increases openness (May, 1975).
Visual expression is inevitably influenced by the experiences of the individual. Engaging
in the process of visual expression requires a reciprocal interaction of individual, environment,
and material. It is an active process that brings about both an internal and external change. Such
reciprocal relationships may over time bring about ritualized engagements serving the particular
needs of the individual.
As noted earlier, individuals have an innate propensity to process experiences through
visual expression. It is a means of expression that does not require the use of language for
communication to take place. It is a filter that is capable of capturing snapshots of the
experiences in the moment of time within which they were made, and which reflect the
subjective experiences of the maker. These are the premises for the use of art as a therapeutic
31
tool, extending beyond spoken language as a means of communication and processing. The acts
that are part of the creative process are purposeful, and elaborative. As experiences are given
form, they reveal and expand, from their original concept. Herein the applicability of visual
expression towards the identification, and processing of felt distress. The following section will
present some of the reviewed literature on the syndrome known as burnout; contributing factors
to its prevalence in mental health clinicians, as well as selected protective factors.
Burnout as Process
Often related to experiencing high levels of stress with inadequate support over extended
periods of time, burnout is a cumulative process (Chernizz & Krantz, 1983; Farber, 1983a;
Maslach, Schaufeli, & Leiter, 2001; Paine, 1983), it is not a response to a singular event. Having
exhausted conventional means of coping with stressful events, burnout serves as a warning
system (Farber, 1983a; Maslach, 1982). Comprised of both environmental and individual
influences, burnout incrementally effects both cognitive, and behavioral functioning, as well as
affective elements in clinicians (Meier, 1983). Burnout symptoms and its effects, along with
preventative acts, appear throughout the psychology literature. It is a chronic condition that sets
in over time, versus an acute response to a precipitating event, or particular client. Under the
chronically draining demands of high-touch relationships, burnout is a natural response, allowing
for detachment from sources of significant prolonged stress (Maslach, 1982; Maslach, Schaufeli,
& Leiter, 2001). According to Maslach & Leiter (1997) high-touch relationships are those that
involve large amounts of direct human interaction, which in turn, can be the most physically and
mentally draining. Skovholt & Trotter-Mathison (2011) further explained that in high-touch
encounters, professionals endure repeated caring attachments and detachments from client to
client; these encounters are by their very nature depleting. In one of the first mentions of the
32
term burnout, factors identified included the contributing environment, peers, and the dedicated
clinician (Freudenberger, 1974). Most readily identified as the final step in a series of failures,
burnout represents the inability to reconcile a lack of resources and stressors, leading to a state of
fatigue (Farber, 1983a). In part, the difficulty of defining burnout lies in it being a process that
develops over an extended period of time, with contributing factors emanating from within, and
outside the workplace, the effects of which are far-reaching (Farber, 1983a).
Early on, it was noted that burnout had repercussions in all areas of life, manifesting in
physiological and emotional changes (Freudenberger, 1983). In example, having a stressful
work milieu can have ramifications in the clinicians’ social life, and vice versa. The cycle
repeats, as negative consequences in social environments are then dragged into the workplace.
Being dedicated to help, and then taking on more responsibilities, leaves the individual out of
balance, and at risk of burnout (Freudenberger, 1974). Once the job and its duties cease to
engage the clinician, the routine becomes a chore, and a source of drain rather than
replenishment. The empathetic clinician then continues to give of themselves in ever-increasing
amounts, in order to reach a previously attained level of performance, but without the payoff.
In the existing literature on burnout, similar terms often appear: compassion fatigue,
secondary traumatic stress, and secondary traumatization. While burnout has been used
interchangeably with compassion fatigue, there are some distinguishing factors (Figley, 2002b).
Although both can develop from empathetic attunement to emotionally demanding events,
compassion fatigue tends to have a more rapid onset, and once identified, responds faster to
treatment (2002b). Figley (2002a) identified compassion fatigue as a form of burnout, relating to
changes in the cognitive schema of the therapist, which adversely affects their practice.
33
Secondary traumatic stress, though at times used interchangeably with compassion
fatigue, is similar to secondary traumatization. In recent years, the literature has focused less on
burnout, and has emphasized recognition of specific hazards in relation to secondary traumatic
stress (O’Halloran and Linton, 2000). Research suggests that while there may be similarities in
symptomatology, the distinguishing factors lie in the cause of the distress.
Maslach (1982) (Maslach & Leiter, 1997; Maslach, Schaufeli, & Leiter, 2001) identified
a pattern of behaviors that were associated with the burnout syndrome: emotional exhaustion,
depersonalization, and the perception of reduced personal accomplishment. While feeling
physically and mentally drained, exhaustion enables distancing from the perceived cause of
distress. Depersonalization causes emotional detachment from others in attempts to safeguard
oneself. Over time the individual loses self-worth, and with it, the confidence to perform her job.
Propensity of Burnout in the Mental Health Field
In mental health care, clinicians are effective when they are able to make an emotional
connection, between themselves and the client (Skovholt & Trotter-Mathison, 2011). Problems
arise when the clinician becomes unable to separate the “other” from the self, at which point
practice itself wounds the provider (Skovholt & Trotter-Mathison, 2011; Figley 2002b). With an
increasing number of clients, the relationships suffer, as the therapist is stretched to form a
sustainable means of engaging in therapeutic alliances, and separations. It is by means of the
same porous emotional boundaries that allow for healthy boundary development through
repeated attachment, and detachment, from short-term relationships that unhealthy boundaries
develop (Skovholt & Trotter-Mathison, 2011).
Mental health professionals engage in high-touch relationships, in which the
circumstances that bring the professional, and client, together are those of distress and need
34
(Maslash, 1982; Skovholt & Trotter-Mathison, 2011). Those in the helping professions tend to
have notoriously skewed relationship dynamics with their clients, and workplace environments
(Heifetz & Bersani, 1983). There is a prevalent trend of hopelessness, and helplessness to be
found in the helping professions (Skovholt and Trotter-Mathison, 2011). Processing these, quite
often requires repeated, and sustained exposure, to precipitating events. Once the precipitating
issue is resolved, the relationship ends, and the professional moves on to the next crisis. Such
realities provide a skewed scope of interactions, which over time can color expectations, and
cause lasting changes in the clinician (Bride, Radey, & Figley, 2007).
According to Maslach (1982), in high-touch relationships where adequate reciprocity is
limited, or non-existent, the therapist feels de-humanized. The etiquette of appropriate conduct
delineated for those in high-touch fields contributes to their distress. Communication between
clinicians, and clients, becomes an added burden, as the therapist is expected to maintain
emotional control throughout the duration of all interactions (Farber, 1983b; Maslach, 1982).
Leaving personal responses unvoiced, in order to be objective with clients, can leave the
therapist feeling bottled-up following a session (Maslach, 1982). Depending on the work
environment, and access to peers, the clinician’s emotive response to a client may at times need
to remain repressed indefinitely.
Role of the Work Environment
It should be noted that not all individuals working in demanding circumstances
experience burnout (Cherniss & Krantz, 1983; Harrison & Westwood, 2009). However, several
authors have proposed that dedication, and commitment, play a key role in the burnout of mental
health clinicians (Freudenberger, 1974; Heifetz & Bersani 1983; Pines, 1983). Cherniss and
Krantz (1983) suggested that neither work-related stress nor excessive involvement could
35
independently lead to burnout. Instead, they found that a loss of commitment and purpose on the
part of the professional was key. Although increased commitment was often equated with higher
chances of burnout (Freudenberger, 1974; Heifetz & Bersani 1983; Pines, 1983), this was not the
case when clinicians worked within a like-minded community with shared goals (Cherniss &
Krantz, 1983), and adequate support. Ideological communities tended to have an increased sense
of direction and structure which often reduced ambiguity (Cherniss & Krantz, 1983). However,
it was also noted that public institutions tended not to be ideologically minded communities,
possibly a result of having a diverse workforce (1983). However, a unified ideology may be
simply unrealistic for some settings, and may be the cause of increased frustrations that lead to
employee burnout.
Therapists need be cautioned against the cycle that develops between increasing
pressures in the work environment, and decreasing energy for external supports, leading some
therapists to rely on their work as a source of approval (Maslach, 1982). However, an
invalidating work culture can hinder progress, and adversely affect productivity. When
outcomes are not consistent on the actions taken, there is a sense of losing control, and of being
helpless to dependably produce results. With increasing lack of control over rewards, and
punishments, therapists could inadvertently be led towards learned helplessness, and eventual
burnout (Meier, 1983); becoming unable to avoid encounters with distressing stimuli.
Adding to feelings of isolation, and inadequacy, therapists have indicated they have little
or no control over the rules that govern their work structure (Maslach, 1982; Meier, 1983;
Maslach, Schaufeli, & Leiter, 2001). Research indicates that the organizational structure of the
institution could have a beneficial or detrimental effect, on both the clinician, and client
(Harrison, 1983; Maslach, 1982). In addition, regulatory policies, and politics, can inadvertently
36
promote co-worker rivalry for self-promotion. Some regulations also leave professionals feeling
trapped between what they have to do, and what they are able to do. At other times clinicians
may seek refuge behind institutional rules in order to keep a safe distance from the client’s
issues. For example a clinician may provide scripted responses for particular questions or
situations. Once again the clinician becomes caught between the demands of the institution,
obligations to the profession, and personal needs.
Many have pointed out that motivational conflicts emanating from facility rules, and
functions could impact the clinician (Harrison, 1983; Maslach, 1982; Meier, 1983; Maslach,
Schaufeli, & Leiter, 2001; Skovholt and Trotter-Mathison, 2011). Most commonly referring to
cases where as soon as treatment effectiveness is noted, the client’s services are changed, and
either or both incur a loss. Thus, the professional incurs a loss, due to provision of beneficial
services. Not only are there losses incurred by means of client, and facility changes, but also due
to ambiguity itself. Ambiguous loss herein referred to the intangible losses that are encountered
in the line of work, over which there is little, or no control, and for which closure may not be
accessible. Skovholt and Trotter-Mathison (2011) indicated that having clients in a state of
limbo was an ambiguous loss for the clinician, and a source of increased stress. Further clinician
drain, being a result of accumulating losses, and workplace ambiguities.
Whether a personal preference or the result of the workplace culture, professional
isolation could further adversely affect the ability to process job stresses (Iliffe & Steed, 2000;
Maslach, 1982; Leiter & Maslach, 1988). Isolation could stem from a lack of positive co-worker
and supervisor interactions. The physical arrangement of the facility, as well as its governance,
can also adversely contribute, by inadvertently, or purposefully limiting clinicians’ fraternization
37
with peers (Maslach, 1982). By making it difficult to meet with other clinicians, institutions are
exacerbating professional isolation.
Empathetic Attunement as a Risk Factor
While empathetic attunement is a desirable attribute for those in the helping profession, it
has also been identified as having a predominant role in clinician burnout (Figley, 1995, 2002b;
Maslach 1982; Saakvitne, 2002; Skovholt & Trotter-Mathison, 2011). Being able to focus on the
lives of others versus one’s own for measured amounts of time is necessary for empathetic
attunement. The process allows for the effective exchange that takes place between the therapist,
and the client. Having porous emotional boundaries opens the clinician to the emotional needs
of the client (Skovholt & Trotter-Mathison, 2011). Such connections are porous because the
exchange is dynamic, ebbing, and flowing, as needed in order to build relationships with each
client; it is necessary in order to be empathetic, and compassionate.
Having effective empathy allows the therapist to understand the distress of the client,
from an outsider’s perspective (Maslach, 1982). Becoming emotionally attuned to the client’s
distress costs the therapist her objectivity, and effectiveness. However, realistically there are
situations of resonance between the helper, and the client, wherein the events in discussion have
relevance for both. Resulting in a possible loss of objectivity, the higher the resonance of events,
the shorter the distance between the clinician and the client.
While it is necessary for the mental health professional to find and nurture, a connection
with their client, in order for empathy to emerge, it is by means of such a connection that
negative emotions may be transferred onto the therapist (Figley 2002b; Maslach 1982, Skovholt
& Trotter-Mathison, 2011). While these connections can be seen as a source of accomplishment
(Lee, Lim, Yang, & Lee, 2011), they also make the therapist particularly vulnerable to
38
exhaustion. The clinician becomes vulnerable to vicarious traumatization (VT) (Saakvitne,
2002) as a result of their empathetic attunement to the client. This occurs when the therapist’s
exposure to traumatic content through their client has caused a change in the therapist. This is
often the outcome of the tendency, and capacity, to focus on the well-being of another
(O’Halloran & Linton, 2000). Clinicians are vulnerable to burnout by the very nature of the
work they do.
Newness in Field as a Risk Factor
In contrast to scholarly work during college years, where value is placed on reflection
and feedback, work in the human service professions is often repetitive and measured by volume
(Skovholt & Trotter-Mathison, 2011). When entering the helping profession, novices have a
tendency of glamorizing their work roles (Farber, 1983b; Skovholt & Trotter-Mathison, 2011),
expecting to perform at full ability, all of the time, and possibly even being consistently
recognized for such arduous work. Despite years spent seeking a degree, when empathetic
scholars enter the work force, they may not be ready for what awaits them. This lack of
preparation is often exacerbated by inadequate onsite training, and professional isolation (Iliffe
& Steed, 2000).
One type of culture clash between the clinician, and the work environment, is the lack of
return on one’s investment. Engaging in one crisis after the next, with minimal resources, and
outcomes, the pattern becomes normative over time. As a result, clinicians expect less, and less,
from their workplace, in reference to outcomes, and resources. Furthermore, mental health
professionals, were likely to receive minimal positive feedback and attention, when doing their
job well, and were additionally likely to be given negative feedback when things went wrong
(Maslach, 1982). For the empathetic novice, the lack of effective feedback, and already skewed
39
relationships in a high-touch environment, can further strain identity development as a viable
clinician.
While developing a professional identity, the clinician may struggle with the ability to
distinguish between a success, and a failure (Skovholt & Trotter-Mathison, 2011). Furthermore,
there is an inherent vulnerability among newer clinicians to take on the wins, and losses, of their
clients, as their own; it is through experience, and supervision, that distinctions can be made over
the ownership of session outcomes (2011). Additionally, extensive caring is an emotional strain
when not balanced by the facility (i.e., co-workers, supervisors, administrators), and this strain
can easily be exacerbated by excessive paperwork, and bureaucratic hurdles (Maslach, 1982;
Maslach, Schaufeli, & Leiter, 2001).
Unrealistic expectations can also lead to early-career onset of burnout (Maslach,
Schaufeli, & Leiter, 2001) that may serve as a wake-up call (Maslash, 1982), propelling the
clinician into remediating action. The first wave of burnout can send new professionals
searching for different careers, as motivation does not compensate for experience (Harrison,
1983). Moreover, burnout is not isolated to early-career mental health professionals. Some have
speculated that the decrease in reported stress with increased experience may be related to,
distressed clinicians having left the field early in their careers (Maslach 1982, Skovholt &
Trotter-Mathison, 2011). However, mid-career therapists were comparably strained at work, and
home (Farber, 1983b).
Social Factors as Risk Factors
Freudenberger (1983) warned that following the medical model, and using overly
inclusive definitions of burnout, would not serve to grasp the complexities of the syndrome.
Therefore, when considering the etiology of the burnout process, the values, and social systems
40
of the individual, must also be seen as contributing factors (1983). While adding to the problems
created by emotional exhaustion, dehumanizing relationships are not confined to the work
environment (Maslach, 1982). Spending long hours on the job is also not isolated to those in the
helping professions, however, the energy expended in the fulfillment of job expectations can
leave clinicians exhausted (Maslach, 1982), further diminishing the scope of stress-reducing
outlets. In treating marginalized populations, the job itself can have negative social stigma
attached; this adds to the level of perceived job-related stress, while outside of work (Maslach,
1982).
Preventative Measures
The literature on work-related stress, discusses some preventive measures. In their
research on preventing vicarious traumatization, Harrison & Westwood (2009) identified
protective practices that sustain clinicians in their work; these will be supplemented, and
corroborated by others found in the literature, such as diverse social support, supervision, peer
validation, professional development, and spiritual practice. Although there are social factors
that increase the contributing stressors leading to burnout, social support can serve towards the
effective mediation of stress (Farber, 1983a; Figley, 2002b; Mullenbach & Skovholt, 2011). As
a means of countering the negative effects of their work, clinicians benefited from fostering a
variety of relationships (Figley, 2002b; Harrison & Westwood, 2009; Maslach, 1982).
Professionals with families fared better than their single counterparts; those in relationships and
those who were married were less emotionally exhausted and had a greater sense of
accomplishment (Maslach, 1982). A diverse social support system ideally gave the mental
health clinician a more expansive sense of self (Figley, 2002b), by having more opportunities for
41
experiencing positive aspects of life (Harrison & Westwood, 2009). Such external relationships
serve to balance the otherwise skewed interactions that dominate daily work.
Consistent with findings regarding the maintenance of a social network, clinicians
endorsed benefiting from supervision, in order to increase therapist self-awareness (Harrison &
Westwood, 2009; Iliffe & Steed, 2000; Maslach, Schaufeli, & Leiter, 2001; Skovholt & TrotterMathison, 2011). Counselors identified that being validated by peers, and supported by their
team, was especially beneficial when making difficult decisions in relation to their clients (Iliffe
& Steed, 2000). Continued training and professional development, that conforms to the
profession’s best practices, and that is supported by the organization, may also provide a
buffering effect to feelings of isolation (Harrison & Westwood, 2009). Professional
development activities may also lead to an expansion of roles, which creates a sense of
interconnection with others in the field (Harrison and Westwood, 2009). Such professional
pursuits may keep the mental health clinician from stagnation (Skovholt & Trotter-Mathison,
2011).
The sense of interconnectivity was found to increase with an integrated practice of
spirituality (Harrison & Westwood, 2009). Such spiritual connections, though subjective,
provided therapists with a greater sense of hope, and meaning both within and outside their work
roles (Skovholt & Trotter-Mathison, 2011). Similarly, Skovholt & Trotter-Mathison (2011)
proposed that in employing focused attention, such as a practice of mindfulness, the clinician
developed increased self-awareness. The concept of mindfulness has been described as
intentional, and focused attention on the present (Brown & Ryan, 2003; Germer, 2005; KabatZinn,1994); although it has Buddhist roots, its practice is not tied to a specific religion.
According to Skovholt & Trotter-Mathison (2011), having a mindfulness practice also served as
42
an early warning mechanism alerting the clinician of a probable imbalance in their self-care
practices.
Awareness of dialectics allows for an expanded world view, where the clinician is able to
consider multiple contradictory truths: there is pain, and suffering in the world, but there is also
comfort, and joy (Harrison & Westwood, 2009). The clinician needs to be able to identify the
work environment as both, a source of meaning, and as a drain, on personal resources (Skovholt
& Trotter-Mathison, 2011). Such appreciation of differing views may play a role in the overall
proactive approach to problem-solving, and provide the clinician with the ability to monitor how
she is being affected by her work. In order to be prepared, clinicians need to exhibit a proactive
practice of self-care (Harrison & Westwood, 2009), involving the ability to disconnect from
work, and clients, as needed (Figley, 2002b; Skovholt & Trotter-Mathison, 2011). Since
empathetic attunement is part of the cycle of burnout and fatigue, it is necessary for clinicians to
learn how to disengage, as a means of self preservation (Figley, 2002b). Clinicians need to be
able to set aside the thoughts and feelings associated with clients, and events, between sessions,
and this practice needs to be seen as part of a larger self-care plan. Where active problemsolving can take place and problems can be concretely defined. Such instances of disconnection
for restoration must have a habitual presence in the practice of the mental health professional, as
they are often linked with self-renewal and boundary maintenance (Harrison & Westwood,
2009). Self-management tools, when employed routinely, aid in clinician resiliency by
clarifying, and maintaining boundaries, that allow meaningful empathetic connections to be
made, and terminated as needed.
Mental health clinicians need to be prepared by knowing as much about a situation as
possible, before making decisions (Skovholt & Trotter-Mathison, 2011). Clinicians can also
43
benefit from making intangible losses and gains tangible (Skovholt & Trotter-Mathison, 2011).
Doing so can make the difference between feeling lost and without closure, and feeling
grounded, and with a grasp of what has transpired, and how it is affecting the practice. Nurturing
an integrated practice where the clinician is able to acknowledge, and incorporate the realities of
clinical practice with personal identity, and seek the necessary resources to remain viable
(Harrison and Westwood, 2009). Therefore, in order to remain psychologically available to
clients, there is an ethical imperative towards an ongoing self-care routine (Barnett, Baker,
Elman, and Schoener, 2007).
Visual Expression as a Means of Curating Experiences
Art therapists are mental health clinicians, observers, and guides, utilizing the creative
process as a tool in the practice of the profession. In working with clients to develop a repertoire
of visual dialogue, these clinicians become exposed to emotive, and intimate graphic depictions.
Facilitating the creative process, art therapists are attuned to, and respond to, the needs of their
clients, effectively containing the emerging emotive content. As the client is in touch with their
inner world when engaged in creative expression, the art therapist is attuning to them, and
responding as therapeutically necessary. By engaging in these connections, and disconnections,
mental health clinicians are able to facilitate change. It is common that upon hearing a client’s
story, the clinician experiences some correlating, and often lingering visual imagery (Iliffe &
Steed, 2000). An example would be a clinician imagining what it would be like to be present at
the time the memory took place. Such daily transactions with clients, however beneficial, have a
depleting effect on the mental health professional (Figley, 1995, 2002b; Iliffe & Steed, 2000;
Maslach 1982; Saakvitne, 2002; Skovholt & Trotter-Mathison, 2011), art therapists included.
44
The accumulation of distressing experiences can transform the therapist, and result in
negative consequences to her work, and personal life. Work roles with an emphasis on
intellectual, versus emotive processing, may ultimately work against the therapist (Saakvitne,
2002). Deconstructing the complexities of felt experiences, empathic therapists must increase
their understanding over their own vulnerabilities, and find the means to process through them
(2002). To nurture periods of being disconnected from others, and attuned to the self (Skovholt
& Trotter-Mathison, 2011), solitude might be provided by habitual interaction with creative
expression, such as visual arts.
Over 30 years ago, Wadeson (1980) identified institutional dynamics affecting art therapy
practice, which in the long-term could either be a challenge, or prove fruitful. Workplace
politics and culture dynamics dictating the value placed on the treatments being administered. It
appears not much has changed. Reiterating some of the aforementioned factors affecting mental
health clinician resilience, art therapists as clinicians, are also confronted by the workplace
environment and culture, which dictate scheduling, access to supplies, space, and method of
practice. As ambassadors of the profession, art therapists often work in isolation (Wadeson,
1983), with minimal support from management, and often geographically isolated from a
supportive peer network. Those who are the first to be hired for particular agencies, tend to
practice in a vacuum, and can be sought out within their agencies as personifying what art
therapy is, and is not. Such external pressures add to the daily challenges that are posed by the
clients served. This creates the perfect storm, of increased pressure to achieve goals, diminishing
resources, and a lack of acknowledgement for roles taken-on by the art therapist. Over the years,
some have speculated that such limitations and expectations cause the separation between the art,
and the art therapist (Kramer, 2000; McNiff, 2004; Wadeson, 1983).
45
Throughout the history of the profession, art therapists have had a contentious
relationship with personal visual expression (Allen, 1995; Fish, 2006; McNiff, 2004), as to
whether it needs to hold a primary role in the personal life of the art therapist, or be exclusively
part of their clinical role. In spite of this, many professionals have engaged in visual expression
as a means of processing through a variety of experiences (Campbell, 2002; Fish, 2006, 2012;
Jones, 1983; Kapitan, 2003; Kaufman, 1996; McNiff, 2004; B. Moon, 2002; C. Moon, 2002;
Pakula, 1997; Robbins, 2000; Rosen, 2009; Wadeson, 2003). While for some, creative
expression is part of their self-identity, and has been present throughout their lives (Campbell,
2002; Kaufman, 1996; Kramer, 2000; McNiff, 2004: C. Moon, 2002; Robbins, 2000), for others
it emerges as a sustaining practice after marked distress (Pakula, 1997; Robbins, 2000; Rosen,
2009). However, it can fade out of favor due to clinical and life demands (Fish, 2006).
Response art is the term used to describe art made by art therapists as a result of, or in
direct relation to, particular distressing events (Fish, 2006, 2008). Response art has been used
towards increasing understanding of an experience, or as a means of facilitating containment of,
emotionally-arousing material (Fish, 2006, 2012). While at times it serves as a tool in the
supervisory exchange, the process may be undertaken in solitude. Emerging from, and
contributing to the clinician’s experiences, it is a means of expanding upon, and communicating
concepts, that emerge from the practice of art therapy (Fish, 2006). Although some therapists
have indicated the use of some form of visual expression prior to encountering difficult situations
(Fish, 2008), the important factor once again, is the focus on responding to a distressing event.
To that end, some art therapists have indicated an intuitive, if not impulsive need, to visually
respond to adverse situations (Jones, 1983; Pakula, 1997). While there is variability in the means
employed in creative expression, response art is more than the final artifact; throughout the
46
process of making, the visual-sensory media engagement allows for emotive processing of the
experience, and is in and of itself, an experience.
Bringing Preventative Measures in Line With Practice
Response art as experience. As clinicians, the work performed seeps into our lives, and
art, felt experiences, and their aftereffects, rarely if ever remain neatly contained within the
therapeutic session (Fish, 2006; McNiff, 2004). Response art facilitates change through the
transaction taking place between the therapist, the media, and the process. The creative
undertaking is shaped, and transformed by, the therapist’s prior experiences, as well as the
process at hand. Sublimating intense emotive content through response art provides for
expanded experiences (Dissanayake, 2000; Kaplan, 2000; McNiff, 2004). Each engagement
effectively capturing the moment (Fish, 2012), which if desired, can be returned to at a later
time. Through the process of making, the artifact is imbued with ideas pertaining to an event,
and its corresponding emotional content, it can be used to sublimate, or as a means of recall
(Dissanayake, 2000). Directly expressing emotional content through creative expression aids in
understanding it, and purposefully bringing about change (Dewey,1980; May,1975).
Expanding our roles as clinicians. Often a component of supervision sessions (Fish,
2006, 2008, 2012), responsive art can be a part of the clinicians sustainable practices (McNiff,
2004; B. Moon, 2003; C. Moon, 2002). Regular practice of mindfulness allows therapists to
remain in the present, and be less reactive to stressors (Harrison & Westwood, 2009). Similarly,
art therapists have at times advocated for engagement in personal art-making to develop, and
sustain their roles as clinicians (Fish, 2012; Kramer, 2000; McNiff, 2004; C. Moon, 2002;
Robbins, 2000). Engaging in visual expression is a concrete means of processing through the
sessions content (Fish, 2012). While it is particularly informative, and often necessary as a form
47
of debriefing following charged exchanges with clients (Fish, 2012), some have advocated for a
more routine engagement in the creative process (Kramer, 2000; Levine, 1995; McNiff, 2004; B.
Moon, 2003; C. Moon, 2002; Robbins, 2000). It is vital to know the process, before attempting
to assist others through it (McNiff, 2004; Robbins, 2000).
Another common argument within the profession suggests that, the sustained use of art
by the art therapist is a means of honing their skills (Arnheim, 1986; Kramer, 2000; McNiff,
2004; B. Moon, 2003; Robbins, 2000). With sustained practice, the clinician becomes familiar
with their baseline visual responses, and processes, and is then ideally able to distinguish
changes when they occur. Familiarity with the creative process translates into flexibility, as
therapists are better equipped to respond in vivo to clients’ needs (Kramer, 2000; B. Moon,
2003). Serving as a warning system, clinicians have indicated that engagement in art, as a
response to particular clients, or situations, has helped triage distressing events, and thus clarify
what has transpired (Fish, 2006, 2008, 2012; Malchiodi, 2012). Thus, in nurturing the creative
process as a means of self-expression, the therapist is in turn contributing to their knowledge
base, towards expanding their in vivo contributions to the therapeutic encounter.
Understanding the therapeutic encounter. Assuming a multitude of roles within the
agency often means a splitting of allegiances between those served. It is therefore not difficult to
see clinicians losing focus on their own needs (Skovholt & Trotter-Mathison, 2011). In such
cases, the creative process, and subsequent artifact, allow for the therapist to fuse, and then
separate, from the work as needed to process the dynamics encountered while on the job
(Robbins, 2000). Such dynamics can then be applied to similar situations in which the mental
health clinician must attach and detach from those served, while remaining true to their role, and
profession. Familiarity in the process also fosters use of visual expression outside the regularly-
48
scheduled session (Fish, 2008), and for content that goes beyond the scope of the workplace. It
is therefore crucial for art therapists to be well-versed in the means of creative expression
through personal explorations (McNiff, 2004; B. Moon, 2003), as post-session artwork can
provide reflective distancing from contentious clients, but also from evocative non-client
interactions (Levine, 1995; Robbins, 2000). In this way, visual expression is used to inform
treatment, by expanding the clinicians’ conceptualization of events (Fish, 2012; Kramer, 2000;
Levine, 1995), which can serve to inform practice. All in all, the art process is itself an
experience; it naturally fosters variability from which new acquisitions can be made (McNiff,
2004).
Visual expression towards resonance and reflection. Responsive art-making is an
experience, serving as a means of externalizing emotional laden content through the transactional
process of creating. The process has been used to communicate with clients, and supervisees, to
document events, and effectively process workplace distress (Fish, 2006, 2012; Robbins, 2000).
Both the artifact, and the process, serve as a means of containment, neither surpassing the other
in importance (Kramer, 2000).
Providing a means of sublimating strong emotions that may not be appropriate for
discourse under different circumstances, the process of art-making is grounding (Fish, 2008,
2012; Levine, 1995). In times of upheaval, giving concrete form to otherwise variable emotional
content serves as both, tool and means, through which the clinician is able to condense, and
contain the experience (Levine, 1995; Malchiodi, 2012; McNiff, 2004; B. Moon, 2003; Robbins,
2000). Through the use of the creative process, such contentious emotive content can be
sublimated into a more acceptable means of expression (Dewey, 1980; Dissanayake, 2000).
49
Serving as a marker of the captured event, the resulting artifact can later be examined for further
insights (Fish, 2008, 2012; Levine, 1995; Robbins, 2000).
Going beyond words, the creative encounter allows for dissonance of abstract ideas, to
simultaneously exist within the context of the process and artifact (Dissanayake, 2000; Levine,
1995; Lusebrink, 1990; McNiff, 2004). Serving as a mirror for reflection of material that is
otherwise hard to access, the creative process entails the rituals of set-up, and take-down
(Levine, 1995). As long as the clinician derives a benefit, effectiveness of the process is not
contingent on clearly defined goals (Fish, 2006, 2012). As Baker (2003) reminds the clinician, it
is the accumulation of short-term distresses, that tend to have a cumulative effect; therefore
learning to recognize when such accumulation is taking place, and taking appropriate action, can
be the difference between burnout, and sustainability. In addition, through visual expression, the
clinician creates a concrete representation that serves as a repository of the otherwise ambiguous
events. The process, and artifact, provides the clinician with closure, by giving form, to what
would have otherwise been an ambiguous loss.
Summary
The literature is rich when it comes to a discussion of the many aspects of burnout, its
causes, its symptoms, and sustainable practices from adjacent human service fields, such as
psychology, social work, counseling, nursing, etc. Burnout is a byproduct of the helping
professions, it is an accumulation of depleting experiences occurring over an extended period of
time, and therefore, it makes sense for it to be present within all the helping professions. It is an
exhaustion of the therapists’ resources, which in the long run have both mental and physical
manifestations, and affect all areas of life. Art therapists, as clinicians of mental health services,
50
are not immune to the detrimental effects of burnout. However, there is minimal, if any,
literature in the field of art therapy that engages the topic of professional burnout within the field.
Looking back through the history of the art therapy profession, the literature is replete
with articles on the therapeutic use of art with various populations. While mention of using the
tools of the trade for self-reflection towards role sustainability is bestowed to the fringes.
Mention of the duality of the role art therapists have, between mental health clinician, and artist,
tended to be present early in the history of the profession. In time these arguments, and opinions,
on the role the art part plays within the practice, and development of the art therapist, have
relocated away from peer reviewed journals, and into other forms of publications such as blogs,
and social media posts.
Visual expression, as used by the art therapist, was reserved for supervision sessions,
individual engagement, and traumatic experiences. As a scholarly directive to facilitate
discussion and reflection, art in this sense is part of the dynamics of the supervision session. In
the literature reviewed, those professionals advocating for individual engagement in the creative
process did so in the auspices of a sustained role as artist. While infrequent, some publications
made the connection between art therapists who used the art to process through particular
distressing events. When it comes to utilizing visual expression towards the habitual practice of
responding to particular events, the literature once again comes up short. However, few
publications within the art therapy profession addresses the sustainably of the art therapist role.
In summary, the act of expression is an innate act serving to process experiences. The act
is personal in that it takes on experiences as perceived by the individual, and allows for it to be
elaborated, and made sense of. The acts involved in the breakdown and re-processing of events
51
can become an experience unto themselves, a ritualized sequencing of acts leading to expression.
As a tangible means of processing experiences, visual expression serves the individual.
As part of the mental health community, art therapists are just as vulnerable to the effects
of burnout. In some cases art therapists are embattled between their clinician roles, and that of
the more creative artist side. Often working in professional isolation, their resources for
processing through work related stressors seem to be limited. In spite of this, the literature in the
profession is lacking when it comes to discussions on the sustainability of the role of the art
therapist. The proposed research will serve to gather data on the current artistic practices
employed by art therapists for the purposes of self-care, with an emphasis on the sustainability of
the practice towards maintained resilience. Chapter 3 will present the methodology used, and a
step by step breakdown of procedures.
52
CHAPTER 3
RESEARCH METHODS
This chapter will provide an overview of the methods used to structure the study (see
Figure 1). This was a mixed methods research, conducted in 2 sequential phases; the results of
which were analyzed using a constant comparative analysis (Boeije, 2002; Charmaz, 2000,
2008). Semi-structured individual interviews (Knox & Burkard, 2009; Qu & Dumay, 2011)
expanded on the themes of the survey and provided individual perspectives. Photo elicitation
(Collier, 1957) was used as part of the interviews to further expand on themes through associated
narratives, and will be discussed at that point. I will first give a brief overview of the problem
and the purpose of the research. The research design will be discussed next, followed by
participant recruitment, and participation throughout both phases of the research. An overview
of the instruments, and when they were used throughout the study will follow. Due to the
importance placed on the images provided by participants, the criteria for inclusion, the means of
transfer, and the means of safekeeping, and use, will also be delineated.
Problem and Purposes Overview
This study examined how art therapists use visual self-expression as a means to construct
resiliency. As a member of the art therapy community I have come to realize that although
clients are encouraged to use visual expression as a means to cope with their life, art therapists
are often not comfortable with using visual expression as a means to process distress. While
some art therapists have advocated for visual self-expression (Fish, 2006, 2008, 2012; Kramer,
2000; Levine, 1995; McNiff, 2004; C. Moon, 2002; Robbins, 2000), the literature supporting
engagement towards a sustainable practice is limited. In expanding the understanding of how art
53
therapists are using visual expression, it was important to include both their work and their
beliefs about it.
Research Questions
1. How do selected art therapists employ personal visual expression to sustain their
practice?
a.
Is art used as self-care by art therapists and if so, how?
b. Does personal visual expression mitigate perceived burnout?
c. Does responsive art-making influence art therapists’ professional identity, and if
so how?
Research Design
A mixed methods approach provided broader data collection, leading to stronger
corroboration of findings, and ultimately a better understanding of the participants (Yardley &
Bishop, 2008). The study was approached from the understanding that individuals are active
composers of their experience. It is through the participants’ subjective experiences that they
know, and make sense of the world around them (Bandura, 1989, 2000, 2001, 2006; Dewey,
1910, 1922, 1980; Dissanayake, 2000; May, 1975, 1985; Palmer, 2005). The acquisition,
processing, and expression of knowledge, is therefore based on the personal subjective
experience (Palmer, 2005; von Glasersfeld, 1989).
Individuals such as art therapists construct their understanding of the world based on
subjective interpretations of experiences, and through it, their understanding of their clients and
of themselves. Using a quantitative survey based on Baker’s Therapist Self-Care Questionnaire
(2003) to obtain numerical data provided only a partial answer to the research questions.
Incorporating an interview component into the research design then made it possible to access
54
personal experiences through narrative. Unable to separate experiences from one area of life to
another, the art of these art therapists served as a visual record of a transpired life event, or series
of events. As such, data derived from images, and accompanying narratives was subjective.
Therefore, in order to gain a more complete understanding of the experiences leading to the use
of response art by art therapists, a mixed method approach using both qualitative and quantitative
components was used (see Figure 1). As presented by Johnson and Onwuegbuzie (2004) and
Yardley and Bishop (2008) a mixed methods approach provides access to varied information for
a more complete understanding of the subject under review.
Data Analysis
Research
question
Recruitment
Phase I
Phase II
Interviews
Visual
map
Results
Data collection
Figure 1. Research process.
The study took place in 2 sequential phases of research, with each process serving to
inform the next. The focus of Phase I was the recruitment of participants, and completion of an
online survey (see Appendix A). In Phase II, the focus was the collection of data through a brief
questionnaire (see Appendix B), in preparation for participant interviews. In Phase I,
55
participants were asked to complete an online survey and given the option to volunteer for the
next phase. Those who indicated having an interest in the following phase were asked to select
and upload up to 3 response art images.
The aim of this study was not to make generalizations of the art therapy field as a whole,
but to begin to build an understanding of how creative expression has been used by those art
therapists who chose to participate in the study, who currently use, or have used their art for
responsive expression, or self-care. Using a mixed methods approach was therefore necessary,
in order to best answer the research questions. Quantitative data was collected from the
anonymous online survey, while qualitative data was obtained from interviews with art
therapists. While various quantitative data was gathered from the Phase I survey, on its own it
lacked the individuals’ perspective. It was reductionist in its presentation and may be difficult to
connect with. By having a qualitative component such as thorough interviews, participant stories
added complexity through personal narrative.
In order to expand and clarify on some of the themes from the Phase I survey, participant
interviews were used as part of Phase II. The interviews provided a personal and subjective
point of view, on the identification and management of work induced stress, and the use of the
creative process. In order to establish trust with participants and increase their commitment to
tell their story, photo elicitation method was used. The photo elicitation (Collier, 1957)
component in Phase II of the research initially served as an icebreaker, and then ensured a more
comprehensive narrative during the interview. By having the participants self-select images
pertaining to the topic being researched, the typical power dynamics were disrupted (ClarkIbáñez, 2007; Harper, 2002) and the participants were empowered (Goldstein, 2007) to tell their
story.
56
Participants and Setting
Participation in this study was voluntary, comprising of a convenience sample (Robinson,
2014). Participants were practicing art therapists with at least a masters’ level degree from an
academic program adhering to the guidelines set forth by the American Art Therapy Association
(AATA). At the time of the survey, participants needed to have at least 6 months of consecutive
experience providing art therapy services.
Participants were initially recruited through social media posts (see Appendix C) inviting
them to participate in the Phase I online survey. Facebook was the primary social networking
platform (SNP) through which the survey link was distributed. However, adjunctive social
media cites such as LinkedIn, and Google+ (1 post in each) were initially used and later
discontinued. Social media cites, such as the ones mentioned above, offered the fastest and most
cost-effective method for distributing the survey link. Additionally, all state chapters listed
through AATA at the time were contacted and asked to forward the Phase I survey link and
introductory letter (see Appendix D) to their membership rosters. Snowball sampling (Baltar &
Brunet, 2012; Robinson, 2014) was used for increased participation; participants were
encouraged to forward the survey link to other art therapists. Snowball sampling was necessary
in this case due to the target audiences’ geographical separation, and possible decreased
likelihood of responding to an SNP research request. Three to four weeks after the initial post
the researcher re-posted the survey link as a way to increase participation; re-posting was done
several times over the span of the 3 months the data was collected.
For the most part, participation took place from anywhere the participant was able to
access the internet. The Phase I online survey was accessible through portable media devices
such cell phones, but it might have been more comfortable to view on larger screens such as
57
tablets, laptops, or other large interfaces. However, for Phase II, in order to complete the online
questionnaire participants needed access to digital image files of their response art. Those taking
part in the interview option required access to a reliable internet connection and a Skype account.
Since Skype has a mobile version of its software, participants were able to complete the
interview from any device which hosted their Skype account. Those who did not use Skype
were called by the principal investigator.
Instrumentation
Phase I Demographic and Informational Survey
The initial data was collected in Phase I, through a web-based demographic and
informational survey hosted by Qualtrics. This initial survey was accessible through a hyperlink.
Basic information was requested from the participants in relation to their professional status,
employment status, and perceptions of work related burnout as well as their belief and behavior
towards response art, through the Phase I demographic and informational survey. The survey
began with a letter of consent (see Appendix E) and the entire survey and reading of the consent
process took about 30 minutes to complete.
The Phase I survey obtained information regarding the professional and employment
status of the participant (Baker, 2003). Some of the generic questions were adapted from
Baker’s (2003) Therapist Self-Care Questionnaire and from the AATA membership survey as
reported by Elkins & Deaver (2013). Questions pertained to the length of time in practice, levels
of perceived stress, and whether creative expression was used as a means of processing stress.
Questions related to visual artifacts and creative expression were composed by the principal
investigator with art therapists in mind. Further questions asked if participants felt valued in
58
work site relationships, and about their engagement in professional endeavors within the field of
art therapy. This particular arrangement of questions was not piloted.
Phase II Artifact Review and Upload Form
The first portion of Phase II was an image upload form and artifact review. The initial
part of Phase II prompted participants to review a second consent (see Appendix F), delineating
image retention and interview specifics, before proceeding to the actual questionnaire. The
questionnaire prompted participants to upload at least one image of previously completed
response art, and requested information about each.
The form contained sufficient fields for 3 image files of up to 3072 Kilobytes (KB), the
equivalent of 3 Megabytes (MB) each. Participants were asked to review and prepare up to 3
images they felt illustrated their use of response art. Each participant in Phase II could submit up
to 3 images. One of the 3 images could be of the work space; these were counted as part of the 3
allotted. Participants were encouraged to submit images that were free of identifiable signatures
and names any signatures were removed or otherwise obscured to retain anonymity. Images
needed to be in a digital format, either by scanning or photographing. Only image file formats
such as JPEG, BITMAP, and TIFF were accepted.
All uploaded images were digital in nature and were printed for the purposes of review,
as part of the Phase II artifact review document (see Appendix G). Upon receiving the artifact
image files the researcher moved and re-named the files onto the portable hard drive designated
for research purposes and encrypted with BitLocker. A copy of the original files was left on the
Qualtrics server. Image files names were changed to reflect the titles, a note was made of the
original file name in the respective artifact review document. All images submitted were kept
59
for possible future follow-up research unless expressly indicated otherwise by the participants.
These images, as with all of the research material will only used for scholarly purposes.
Access to this Qualtrics hosted form was through invitation only, and for a delineated
period of time. The link was generated by Qualtrics and was only for participants who had
completed the Phase I survey; the link could not be shared with others. The amount of time the
link remained active ranged from 30 to 60 days, depending on when the participant completed
Phase II.
Phase II Artifact Review Document
The artifact review document and all its sections were created as a means to catalogue,
and organize, the artifact image information; this document was not shared with participants.
Three multi page review documents were generated for each participant; one per artifact file
uploaded. Source material emanated from the participants answers during the Phase II artifact
review, and from their interview. For cataloguing purposes, all pages of the artifact image
review documents indicated the artifact title, artifact ID, and participant ID. Static identifiers on
each page decreased errors of identification; these included a thumbnail of the artifact image,
title, and ID. Microsoft Publisher was used to generate and edit the forms used for artifact
review. This allowed for pre-formatted pages to be easily added to the document as the data
expanded.
Also, part of the artifact review document, the observation of characteristics page listed
the elements and principles of design. Initially created to be a systematic means of reviewing the
images and documenting findings, the page did not provide pertinent information. Its use was
discontinued early-on; a brief discussion can be found in chapter 5 under the section heading for
limitations of the study.
60
Researcher observations that were outside of the specified parameters of the form were
annotated in the blank notes section. Any such entries were identified by date of the entry.
Whenever pertinent, the type of artifact format being referenced was also annotated: printed full
size printed thumbnail, full size image on laptop, or on duplicate screen. Providing this
information was important when digital versions of images provided clearer details than the
printed image. Regardless of its redundancy, cataloging of the visual data was useful when
conducting the interviews.
Image resolution. While printing of the images was only necessary for cataloguing, it
was never the less important to discuss image quality and resolution. When dealing with image
files from various sources, variation in size was a concern. Discussing image print resolution
was determined by the principal investigator to be the most common language with which to
describe image clarity. Digital images needed to have at least a minimum print resolution
allowing for a clear image at a 4”x5” print size. Images with the resolution supporting larger
prints were also accepted, as long as the file was not larger than 3MB.
Phase II Interview Questions and Notes Document
Interview questions (see Appendix H) were developed from a small sample of Baker’s
(2003) Therapist Self-Care Questionnaire. The selected questions were rephrased to allow for
open-ended dialogue. The pre-scripted questions were used to clarify and gain further narrative
on topics explored in the Phase I survey. After the questions, participants were prompted to “tell
a little bit” about their selected images.
Memo writing, took place throughout the entirety of the research. Memos were part of
the documentation maintained throughout the research process, and a necessary part of
maintaining traceability of findings (Boeije, 2002). Memo writing also allowed for a pause, to
61
reflect on the data being collected and analyzed (Boeije, 2002; Charmaz & Henwood, 2008). All
memos were dated, they catalogued reviews of the data, communications with participants,
social media posts, reflections, findings, codes, hypothesis, etc; they ranged from brief notes to
long memos.
Safekeeping of Instruments
All records of the study were kept private and confidential. Research records were stored
securely and only the researcher and university professors had access to the records. Recorded
files as well as any research documents were saved and accessed through a password protected
personal computer. Non-digital material was kept in a locked file cabinet when not in use. All
digital data created as a result of the study was downloaded at various points and saved on a
dedicated external hard drive encrypted with BitLocker To Go. BitLocker encrypted the entire
disk drive versus individual files requiring a passkey in order to access the drives’ contents.
Research Procedures
Phase I
Consent for participation in the Phase I survey was the first screen needing participant
acknowledgement. This first survey provided basic demographic and informational data on
sentiments in regards to stress, work, and on using response art and creative expression. At the
end of the survey participants had the opportunity to read about Phase II and the optional
interview. Those wishing to continue assisting with the study, were to provide an email for
further contact. Those participants who did not wish to continue onto Phase II were re-directed
through a link to the end of the survey. The researcher reviewed submissions of Phase I surveys
on an ongoing basis in order to respond in a timely fashion to those who volunteered for Phase
II.
62
Phase II
Interested participants were emailed with a Phase II introduction and overview (see
Appendix I) letter. The overview also contained a participant specific, and time sensitive, link to
the Phase II artifact review and upload form. The email communication informed participants to
open the hyperlink using their primary computer, the one primarily hosting image files. It was
important for the participant to know what was required before they proceeded; information such
as the number of images to be uploaded, the length of time for the interview, and other technical
requirements. Consent for participation in the second stage of the study was provided with the
Phase II artifact review and upload form.
Consenting to participate allowed participants to proceed to the rest of the Phase II image
questionnaire and upload form. It was through the online questionnaire that participants were
able to answer identifying questions for each image, before uploading the corresponding file(s).
Phase II questionnaires with corresponding image files were processed as they were submitted.
Participants were advised to complete the consent, and the image upload, in one session taking
approximately 15 to 30 minutes. When issues arose, the participant was contacted using the
provided email, and informed of the technicality, then given a secondary method of submitting
the files (ie. emailing the image files). This phase contained the photo elicitation component and
the interview component; both of these were sequential data collection methods.
The principal investigator checked 1-2 times per week for newly completed Phase II
questionnaires and uploaded image files, in order to keep the lapse of time between completion
and contact, to a minimum. Once the images were processed, participants received a second
email, thanking them for completion of Phase II and inviting them to participate in the interview
63
at their discretion and convenience. This began negotiations for a date and time for the
interview. Participants were also informed that they were free to decline the interview.
Interview. Due to budgetary and time constraints, it was anticipated that there would be
no less than 5, and no more than 8 participants taking part in the interviews; at the culmination of
the study there were 6 completed interviews. Due to the low number of participants completing
Phase II, all 6 participants who volunteered to take part in the interviews were contacted for
participation, and all were eventually interviewed.
The individual semi-structured interviews were conducted using voice over internet
protocol (VOIP). In this type of interview protocol, the questions prepared were open-ended,
and based on the study’s central themes (Knox & Burkard, 2009; Qu & Dumay, 2011). This
interview format allowed for flexibility within the interview to deviate from, and return, to the
main themes in order to build rapport, and freely pursue any leads that come-up (Knox &
Burkard, 2009). Furthermore, in the semi-structured interview format both interviewee and
interviewer contributed to the emerging narrative (Qu & Dumay, 2011), this dynamic was
enhanced by the inclusion of photo elicitation (Collier, 1957).
In preparation for the interview, participants were asked to select, and submit images, of
visual artifacts they associated with being response art. The images submitted by each
respondent were later reviewed during the interviews. This was done in order to elicit a richer
narrative of experiences from the participants. The use of images during the interview served as
a center of focus for both the participant and the researcher, effectively introducing a secondary
subject.
Photo elicitation was used as a method of requesting, reviewing, and expanding dialogue.
This was done in order to gain a more complete understating of how art therapists utilize visual
64
expression. Incorporating personal visual artifacts into the interviews served as an icebreaker,
and as a means of facilitating recall of related past experiences (Collier, 1957) ; snapshots of
particular moments in time when the pieces were created (Stanczak, 2007). Using images during
the interview also had the added effect of quickly establishing rapport between the interviewer
and the interviewee. By incorporating the images into the dialogue, the participant was brought
to the forefront as expert in their own narrative, and as conductor of the story being told
(Charmaz, 2006; Clark-Ibáñez, 2007; Collier, 1957; Harper, 2002; Reavey & Johnson, 2008). In
the image facilitated semi-structured interviews the emerging narratives were allowed to
fluctuate. Proceeding in this way, fostered trust, variability, and a wider range of themes than
would have been elicited by interviewing using only the scripted questions. Participant images
can be found in chapter 4.
By using the images, participants were cued to the specific events which corresponded
with the visual response and related circumstances. The inclusion of images encouraged
spontaneous narrative, and provided for a wider range of associations that would not have been
previously or otherwise considered by the researcher, or the interviewee for discussion. Image
use also kept the discussion centered on the experiences of each participant.
Before each interview the researcher generated a hard copy of the corresponding artifact
index for each file uploaded; this increased familiarity with the content. In preparation for each
interview, the corresponding Phase I survey was also reviewed. Identification was possible by
matching the emails provided by the participant at each of the questionnaires. Such organization
systematized the initial data gathering, leaving traces between the sources of information for later
review.
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VOIP was the preferred form of communication due to its accessibility, negligible cost,
and inherent secure socket layer level (SSL) of encryption which allowed for voice, video, or
data to be transferred between users. A benefit to using VOIP, much like phone interviews, was
the reduced need to travel for both interviewee and interviewer. According to Knox and Burkard
(2009), such interviews could also provide improved access to note-taking and focused
interviews, due to decreased external distractions.
Skype version 7.5.85.102 was the primary means of communication software used.
Skype audio was recorded using Callnote Premium version 3.0.26. Whilst face to face meetings
were not ruled-out they were not the primary method for interviews due to limited accessibility.
The use of Skype software to conduct VOIP calls expanded the pool of possible participants to
anywhere in the United States; while the use of the Callnote Premium allowed for the calls to be
digitally recorded on the same computer conducting the call and with access to all related
documents (i.e., image files, survey results, notes, etc.). All interviews were digitally recorded
using Callnote Premium as agreed upon in the consent form for Phase II and transcribed by the
researcher for coding, omitting any identifying information. Interviews took an average of 52
minutes. After each interview was transcribed, the resulting document was compared to the
original recording for accuracy. Transcribing the interviews provided the researcher with an
increased familiarity of the raw data.
Data Analysis
Constant Comparative Analysis
Grounded theory’s constant comparative method was used in the analysis of the collected
data. This allowed the researcher greater flexibility to gather, and analyze, the subjective data as
it was collected (Charmaz, 2006; Charmaz & Henwood, 2008); allowing for responsive
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flexibility throughout the course of the study. As the researcher became familiar with the
participant, and their particular narrative, adjustments were made that were in direct response to
the emerging phenomena. Use of in vivo codes (Charmaz, 2006) aligned the researcher within
the narrative being told by the participant.
Furthermore, using participant provided images as part of the Phase II interview further
clarified the narrative (Reavey & Johnson, 2008). As described by Collier (1957) when
participants are presented with their images, the inquiry expands thru a natural progression. The
process also serves as a means of empowering participants to tell their story (Goldstein, 2007).
Mirroring by the researcher, served to further ease the participant and let them know that their
story was being heard.
Acknowledging that both the participants and the researcher brought their own subjective
views into the research (Charmaz, 2006; Charmaz & Henwood, 2008; Reavey & Johnson, 2008)
also fostered awareness to the need of carefully maintaining and reviewing memos. Field notes
and memos were an essential tool for the researcher. Notes were used to collect extraneous data,
and towards noticing patterns within said data (Charmaz, 2006). They also allowed the
researcher to annotate observations, comparisons, and personal reflections throughout the
development of the research. Maintaining procedural notes was particularly helpful in the recall
of events from an earlier stage of research.
Organization of Visual Data
Before and after each interview, the visual artifacts and their corresponding
documentation were reviewed, in order for the principal investigator to increase familiarity with
the material and make any necessary annotations. Details provided during the interview were
combined with previously acquired information. According to Hennie Boeije (2002) in order to
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increase traceability when conducting subject comparisons it was crucial that the researcher keep
careful notations on the phase of research in which the observation took place, the reason for the
comparison, as well as the results. This cycle repeated throughout the study as needed until no
new information was found, thereby reaching saturation.
Coding of Transcripts
All interview transcriptions were formatted using the columns feature, leaving half the
page blank. This allowed for notes to be written on the right side of the page, adjacent to the
content in reference. Printed transcriptions were first reviewed for themes using a yellow pen;
darker colors indicated 2nd or 3rd reviews. Due to saturation, only some interviews were
reviewed twice or more. As soon as multiple interview data was available the comparison
naturally expanded to include comparisons between interviews. With the emergence of
repetitive themes between interview narratives, and supporting images, patterns or clusters were
identified, and an axial coding applied. In order to organize and group the emerging themes,
pieces of data were compared to one another and across interview narratives with the
implementation of a visual map. At this point all emerging themes and quotes were transferred
onto small pieces of paper for grouping.
Impressions of the interviews and corresponding visual artifacts was initially annotated in
memos, then color coded and transferred onto post-it notes for further organization. Each of the
six interviews was assigned a color for quick identification. All notes pertaining to Adrian were
written in orange, Blairs’ were red. Camies’ were identified by a teal blue, while Devons’ notes
were bright pink. Green denoted Maris’ contributions and purple was assigned to Leisy. There
was no particular reason for color assignment other than pen availability. Notes were organized
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on 2 sheets of white butcher paper, each about 3 feet by 9 feet long; the pieces were taped
together to form approximately a 6 foot by 9 foot rectangle.
One collection of notes, now identified by color, was organized at one time. At the onset
there were only loose associations grouping the notes, such as art related or work related. As the
notes from more interviews were added, the groups both expanded and contracted. Relationships
between the data pieces allowed for a natural organization process. Relationships between
categorical groupings of data pieces were relational. For example, under the category of work,
peers and communication lead to the emergence of a separate but related category of community
support systems.
Interview data was coded and grouped into categories. The categories showed
relationships with or because of other categories, the relationships were expressed by placement
proximity to one another. The visual arrangement begun with one interview and was expanded
as data from successive interviews was added. Throughout the process categories expanded and
contracted or merged as needed. When data pieces contained themes from more than 1 group,
they served as connectors between groups. The organizational scheme employed resulted in an
organic representation of relatedness.
Due to the scale of the final map, XMind 6 software (version 3.5.1.201411201906) was
used to digitize the data and make it more transportable. An open source mind mapping and
brainstorming software, XMinds’ basic free version with limited features was used for the initial
map. Following the original pattern of the paper map, categories were organized around a
central point. As it was entered, each piece of data was color coded and organized under the
respective category. These pieces could then be reorganized as needed by dragging and
dropping into other categories. This allowed for further organizational categories to emerge as
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subtopics of main categories. For example, the self-care category was further organized into
descriptive subsections titled: challenges, spiritual practice, environment and other activities.
The software allowed for more information to be added to the map, and for it to be reorganized
as needed without incurring data loss, as a result the final map was substantial in size.
Limitations of the Study
As previously indicated in chapter 1, researcher subjectivity was unavoidable, the issue
was addressed by breaking-up the study design; having sequential quantitative and qualitative
phases. The mixed methods design however, took longer to create, collect, and analyze the data
versus using one or the other on its own. The study itself was purposefully limited to art
therapists, who had the prior indicated qualifications, but who also knew about response art. The
number of participants choosing to take part in the online survey may have been further limited
by the time of year the data collection phases took place. Had it taken place in conjunction with
the national art therapy conference, it could have served as a direct venue for recruitment.
Participation was further limited to art therapists who were users of social networking platforms
(SNP), or who were otherwise sent the survey link directly by peers who saw the survey post on
an SNP.
Those participants completing the phase I online demographic survey were used as the
base for phase II. The number of participants who chose to continue for possible inclusion in the
pool for interviews was further limited by the time and resource commitments needed.
Furthermore, a lack of timely communication with the researcher was cause for participants to be
dropped from the pool of viable interviewees. Interviews were primarily carried out through the
use of VOIP. VOIP refers to the technology that enables the transfer of voice and data using
internet protocols versus land lines which use cables and are only able to carry voice. Lack of
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access to the needed software, hardware, or reliable bandwidth therefore also limited
participation in the research. Overall, due to the size and nature of the study, its findings would
not be generalizable, but serve to expand the knowledge base on the topics presented.
Summary
In order to comprehensively answer the research questions, a mixed method approach
(Bishop, 2008; Johnson & Onwuegbuzie, 2004) was used. The combination of quantitative and
qualitative methods provided ample and varied data for a more complete analysis. Individual
semi-structured interviews (Knox & Burkard, 2009; Qu & Dumay, 2011) helped expound on the
themes from the survey and provided personal narratives. Collier’s (1957) photo elicitation
method was incorporated into the interview in order to help focus the interview, and give
participants a sense of familiarity, and control. As data was collected through the questionnaires
it was reviewed, and compared to other data using the constant comparative method of analyses
(Boeije, 2002; Charmaz, 2000, 2008). Participant recruitment and advancement through the
sequential phases of research was also addressed. Lastly, the need to employ a visual map as a
means to organize and consolidate the interview data was presented.
Chapter 4 will follow with detailed summaries of the data gathered from the Phase I
survey, the image uploads, and the interviews. Chapter 5 will then present a discussion of the
findings.
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CHAPTER 4
RESULTS
This chapter will be organized into 3 sections representing the phases of research. Phase
I of the research will be discussed first; it includes participant recruitment, online survey,
demographics, and perceptions on visual expression and response art. Phase II will present the
demographics of the 6 interview participants, and introduce the image elicitation results. Data
gathered from the 6 interviews will be presented in the last section of the chapter. Beliefs held
by participants, relating to how they conceptualize their relationship with the creative process,
will be discussed first. The influence of the workplace is where novelty will first be introduced
as a factor. Workplace structure, culture, and boundaries, also emerged as areas of importance,
which greatly affect one of the key themes, that of losing a patient. Supportive practices at the
workplace will also be discussed, as well as physiological signs of building stress. Red flags in
the creative process alerting the individual to the presence of stress will be presented as a
contributor to self-regulation, and developing awareness. How interviewees’ defined self-care,
which activities they considered effective, and what challenges they faced, will lead to a section
on response art. Interviewee’s relationship with the visual response, intentionality, and methods
of working, such as traditional, or other, will explore the importance of the creative process as a
restorative practice. Factors of accessibility and responsiveness, to said creative process, will
lead into a discussion on the role of novelty. Toward the end of the chapter, the role of
communities will include viewpoints on the traditional gallery show, bridging local with online,
and social networking platforms as components in the process. The information collected and
summarized in this chapter will answer the following questions:
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1. How do selected art therapists employ personal visual expression to sustain their
practice?
a. Is art used as self-care by art therapists and if so, how?
b. Does personal visual expression mitigate perceived burnout?
c. Does responsive art-making influence art therapists’ professional identity, and if
so how?
Phase I: Demographic and Informational Survey
The Phase I survey was created in order to attain basic demographic and descriptive
statistics. As a result, data collected will not be weighed to show cause and effect. The Phase I
survey containing informed consent was accessible through a hyperlink. The pre-survey
introduction page indicated that participants needed to have at least a master’s level degree, and
6 months practicing as an art therapist for the present research. The purpose of the research was
identified as: to learn about the contributing factors of responsive art-making by art therapists,
and its perceived contribution to their professional practice. Recruitment began immediately
after IRB approval (see Appendix J) by reaching out to the American Art Therapy Association
(AATA) and its affiliate chapters through email.
Recruitment Outcome
All state chapters listed through the AATA were contacted, and requested to forward the
introductory letter to their membership rosters, along with the Phase I survey link. Only a
handful of chapters responded to the email entitled: Art Therapy Research Participation Request.
One forwarded the link and survey invitation to their membership, the others directed the
researcher to their FaceBook page for posting as a message. On social network platforms (SNP),
due to cite traffic, there was variability in post visibility. As other users created posts, the one
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created for the survey became buried and out of sight. In spite of this, the link was opened 32
times in a 3 month span; of those, 2 did not meet criteria.
Participation
The research was conducted in 2 sequential phases, with participants beginning at Phase
I, and choosing to proceed to Phase II, with the possibility of an interview. Of the 30 who
consented, 2 others met criteria, but left the survey blank and were not included in the results
(N=28). Over the course of the survey, respondent numbers decreased as questions pertaining to
creative engagement were negatively endorsed. Those who identified as not engaging in
response art or any other form of visual expression, were excluded from further questions that
directly related to those topics. These respondents arrived at the end of the survey faster than
those who did endorse creative engagement. Twenty-two respondents reached the question
providing an introduction to Phase II, and the option to provide an email for further details on
continued participation.
Demographics
All respondents were female (N=28), between the ages of 25 and 65, at the time they
completed the survey in the fall of 2014. The majority of respondents (87.5%, n=24) identified
as “White/Caucasian.” Two identified as “Asian,” one as “Multiracial,” and one as “Other.”
Except for 2, respondents were residing in the United States when they took the survey. Of the
2, one accessed the survey from an east African country and the other from Australia. Overall,
the state with the highest concentration of Phase I survey access was Florida (n=7), representing
25% of all respondents.
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Education and Credential Status
Participants also needed to have acquired a master’s level degree from an AATA
approved program in order to begin the survey. Criteria for participation in the Phase I survey
also indicated that participants needed to have at least 6 months practicing as an art therapist. All
respondents had a master’s degree, of which only 5 (17.9%) went on and completed their
doctorate. The majority of respondents had either their ATR (21.4%, n=6), or their ATR-BC
(39.3%, n=11), no respondents had their ATCS credentials. Eight participants indicated having
“no licensure.” “Other licensure held” was endorsed by 5 survey respondents.
Employment Status
Only one participant indicated being unemployed at the time they completed the survey;
71.4% (n=20) were employed full-time, while 25% (n=7) were employed part-time. No survey
respondents identified as being retired or a student at the time. In the previous 5 years just under
half of respondents (46.4%, n=13) indicated having applied for a job, while 4 indicated having
lost, having been fired, or having quit a job. The overwhelming majority of endorsements
(60.7%, n=17) were hired for an art therapy, counseling, rehab, or related area position. Nearly a
quarter of respondents (21.4%, n=6) indicated no change to their employment status, while 5
indicated the “other” option. None of the respondents indicated having retired in the last 5 years.
Survey participants’ years in the field ranged from 6 months to 24 years.
Primary Work Setting
Survey respondents were asked to identify their primary work setting by selecting from a
list of 28 categories that included the option of “other.” In order to better reflect the complexity
of roles possible within the art therapy field multiple selections were permitted. Of the 28
categorical options for primary work setting 19 were selected at least once. Three respondents
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used the fill-in option to more accurately capture their primary work setting. There were two
categories with the highest endorsements “Outpatient Mental Health” (21.4%, n=6) and
“Nonprofit Association/Foundation” (21.4%, n=6). Followed-up by three work setting
categories which were just as prevalent (17.9%, n=5): counseling center, education
college/university, and hospital (psychiatric/adult).
Perception of Stress and Preparedness
In order to better understand how stress was perceived by those art therapists who took
part in the survey, a likert scale was used. Where 1 indicated they completely disagreed with the
statement provided and 5 meant they completely agreed; a 3 indicated a neutral response.
Participants could also choose ‘decline to answer’ or ‘does not apply’. Of the 27 who completed
the likert scale questions, 22 (81.5%) indicated they either completely or somewhat felt graduate
school adequately prepared them for real-world application. While 4 (14.8%) indicated they felt
their preparation in graduate school had not adequately prepared them for real-world application.
One participant indicated they felt neutral, and one did not answer the question at all.
The next several questions pertained to job and career satisfaction. The majority of
respondents (85.2%, n= 23) indicated they felt qualified for the job they were hired for, while
two disagreed with the statement and two indicated the statement did not apply to them. The
majority of art therapists taking the survey (81.5%, n= 22) indicated they were gratified by the
work they were doing. Two indicated they were not gratified by their current work, and two
indicated the statement did not apply to them. One indicated neither agreeing, nor disagreeing,
with the statement pertaining to feeling gratified by the job they are currently doing. Eight
participants indicated having considered leaving the field in the last 12 months.
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Using the same likert scale, participants were asked about workplace perceptions on
relationships, about half of participants (55.6%, n= 15) indicated having their concerns heard by
their supervisors or department heads. Four respondents (14.8%) indicated complete or partial
disagreement with the statement. While 2 indicated the statement did not apply to them, and 6
marked being neutral about the statement.
Nearly three-fourths of respondents (74.1%, n= 20) who were given the statement “my
work load is proportional to what I can handle,” indicated they agreed either completely or
somewhat with the statement. Five respondents disagreed with the statement (18.5%), while 1
indicated the question did not apply and 1 was neutral. Seventy-seven percent of respondents
(77.8%, n= 21) felt valued by their workplace peers, and 11% (n= 3) did not. Three respondents
were neutral, neither agreeing nor disagreeing with the statement.
Twenty out of 27 participants indicated feeling their work was valued by their supervisor,
while only 18 felt their work was valued by their agency. For both statements, two participants
indicated the statement did not apply to them, while 3 indicated being neutral about whether or
not, their supervisor valued their work. Two participants felt their supervisors did not value their
work, whereas 4 felt their agencies did not.
Twenty-two participants indicated using art directives on a weekly basis, while 17
indicated doing so on a bi-weekly basis and 17 did so on a daily basis. Only 2 indicated not
using art directives on a weekly basis, and 3 noted the statement did not apply to them. The
number of respondents who did not agree with the statement increased to 3 respondents for the
bi-weekly and daily options. Four participants indicated being neutral to the statement of using
art directives on a daily basis, and 2 indicated the statement did not apply to them. Four
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participants indicated the statement about using art directives on a bi-weekly basis did not apply
to them.
Perceived Stress Level
When participants were asked to indicate their perceived work-stress level in a typical
work week by choosing a number between 0 and 10; where 10 was the maximum possible the
majority of respondents (63%, n= 17) indicated feeling a moderate (between 5 and 7) amount of
stress. On the same scale, 3 respondents indicated feeling higher levels of work stress, in the
range of 8 to 10. While only 6 respondents indicated low work stress in the range of 1 to 4.
Response Art and Creative Engagement
The overwhelming majority of respondents (85.2%, n= 23) identified as being a member
in a creative group. Twenty-one of the 23 participants indicated they were active participants
within their creative group. The concept of response art was “very familiar” to 15 survey
respondents; another 7 indicated being “somewhat familiar.” Only 2 individuals had “heard the
term before” but they were not familiar with it and 3 indicated not being familiar with the term at
all.
Overall, response art was described by survey participants as a visual response made by
an art therapist as a means to understand and process clinical work. Such visual response could
include reactions to clients, particular sessions, events or other clinical issues. It was further
described as “witnessing and responding to one’s personal and professional experience as a
therapist, in visual form.” The practice was understood by some to serve as a means of “selfcare and personal reflection.” In the art therapy profession, response art has referred to both art
made in session and post session. Survey respondents voiced both applications indicating that
response art could be created during the session in the presence of the client, and it could also
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take place after the session or precipitating event. The choice to use response art at all varied in
the field, and could be seen as a “self-centered practice” as was expressed by one survey
respondent.
The majority of respondents however, indicated using response art or visual expression
for self-care (81.5%, n= 22). There were 6 individuals who in a previous question indicated not
using response art or visual expression for self-care; they were not shown questions in regard to
frequency of art engagement. Of the 5 respondents who indicated not employing the practice, 3
indicated they “saw a value” in its use, while 2 “did not.” Of those participants who indicated
using response art or visual expression for self-care, 17 did so at least once monthly, or with
more frequency. Of those who did engage in response art or visual expression of some form, 13
did so “on the spot,” “as soon as feasible,” or “within the work week.” Six did make art, but they
did not categorize it as “response art.” Taking both of those groups into consideration, about
86.4% of respondents routinely engaged in some form of art-making, while the other 13.6%
(n=3) indicated seldom creating response art.
The overwhelming majority of those who indicated engaging in responsive art-making,
chose to create while either at home (91%, n=20), or at work (66.6%, n=14). Survey
respondents were opportunistic in their choice of when to create, with 13 indicating they did so
during “idle time.” Only 3 respondents indicated making art during transit or commuting, while
4 actually scheduled their art-making sessions.
Art Share
When respondents were asked as to whether they shared their art with others, 8 affirmed
they did, a majority of 10 indicated maybe, and only 4 indicated no. All those who indicated
even a remote possibility of sharing their art, were asked to identify who they shared it with.
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When the art was shared, the overwhelming majority of individuals chose to do so with friends
(72%, n=13), or art therapy colleagues (77.8%, n=14). About half of respondents were likely to
share it through the use of SNP, with family, or with non-art therapy professional peers. Sharing
within local networks of individuals was endorsed by 8 respondents. Five individuals indicated
sharing while at conferences or workshops. Only 3 participants indicated sharing with the
general public.
When participants were asked how they felt sharing their response art with others
contributed to their self-care practice, 8 participants provided a typed response. Seven of the
eight respondents indicated having a positive association between sharing of their work, and
perceived contributions to their self-care practices. Five of the eight statements included
language indicating that response art provided witness, validation, and a sense of being
connected. Sharing of the art provided alleviation from isolation, and a sense of belonging. The
art provided alternate perspectives, and feedback on themes being explored, towards increased
insight. In spite of this, as indicated by a survey participant, the line between art and response art
was anything but clear.
In order to gain a better understanding of how art therapists used visual expression to
sustain their practice, those survey participants who made it to the end of the survey were
provided with information on continuing with the research. After reviewing the information on
Phase II, 13 participants indicated interest to continue by providing their email address. The 6
participants who completed Phase II and their submitted visual artifacts will be reviewed in the
next section, before expanding on the data collected from the interviews.
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Phase II: Introduction of Participants
In the first part of Phase II, participants were emailed with individually generated links
directing to an online questionnaire. The questionnaire contained a second consent form
detailing the specifics of the Phase II image submitting process, and optional interview, this link
was time sensitive. Of the 13 who were contacted by email with an introduction to Phase II
research letter and links, 6 completed the online questionnaire which included a consent form.
All 6, also consented to take part in the optional interview component.
As part of Phase II, participants were asked to select and submit from 1 to 3 images of
their choosing to the principal investigator. If selected for an interview, the images were to be
used as part of the dialogue. Otherwise, the images and the corresponding information would be
reviewed in support of the research. Each of the 6 participants selected and uploaded the
maximum of 3 image files. One participant’s Phase II questionnaire was received without
images; an exception was made in her case to accept emailed image files due to the technical
error. The interviewee was contacted by email and notified of the issue needing correction. The
participant emailed the 3 images that initially failed to upload with her Phase II questionnaire.
The next section will provide some details on the 6 Phase II participants, and the image
files uploaded by each. All names used were pseudo names assigned to maintain anonymity.
The last section will discuss at length the data collected from the interviews.
Adrian
A Caucasian female from the Mid-West, Adrian was in her 40s at the time of the survey
in the fall of 2014. Having practiced art therapy for 15 years, she currently indicated working in
the areas of higher education, private practice, and a domestic violence shelter. On a weekly
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basis she indicated experiencing a moderate amount of stress, rating it a 6 on a scale from 1 to
10, where 10 represented the highest level of stress possible.
She voiced being familiar with the concept of response art, and engaging in it about 2-3
times per month. Whenever something came up that needed visual processing, she attempted to
do so within that work week, whether at work, home, or otherwise idle. She began using
creative expression for self-care in 2011; sharing her response art with art therapy colleagues and
through SNPs as a means of validating, normalizing, and promoting a sense of belonging. For
Phase II she uploaded 3 images respectively titled Anchor & Self-Care Mantra (see Figure 2),
Self-Care & Gratitude (see Figure 3), and Self-Care Affirmation & Strengths (see Figure 4). The
images selected were all part of a self-care journal made out of folded brown paper bags, the
journal measured 4.5x5 inches.
Figure 2. Anchor & Self-Care Mantra. Mixed media in journal.
Anchor & Self-Care Mantra. This piece (see Figure 2) was completed sometime in
2013; the mixed media piece covered 2 pages in her self-care journal, when open it measured
9x10 inches. She indicated that in this journal, the purpose was to “explore self-care” in
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response to her “work in trauma as an art therapist.” In the visual response she used paint, paper,
and quotes in her exploration of the topic. She indicated that the “spread [was] dedicated to
anchoring and honoring the importance of a self-care mantra.”
Figure 3. Self-Care & Gratitude. Mixed media in journal.
Self-Care & Gratitude. This piece (see Figure 3) was also part of the mixed media
journal exploring self-care and her role as art therapist. She used a similar style as in the
previous selection and incorporated writing, quotes, paint, and sewing. This particular piece
was” dedicated to the role of gratitude and balance in professional self-care.”
Figure 4. Self-Care Affirmation & Strengths. Mixed media in journal.
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Self-Care Affirmation & Strengths. This last double-page entry (see Figure 4) was also
part of the mixed media self-care journal created in 2013. The thematic content of this one
explored the roles of identifying and remembering affirmations and her “strengths to
manage/cope [at] work.” In this piece she used paper, paint, quotes, writing, and sewing, with
the addition of oil pastels and heart puff stickers.
Blair
Blair, a Caucasian woman from a Southern state working full-time as an art therapist was
in her 30s at the time she completed the survey. She had been in the field for 7 years and
identified her current work setting as a psychiatric day treatment facility; working with both
inpatient and outpatient adults. She identified as having a weekly stress level of 5 on a scale
from 1 to 10 where 10 represented the highest level of stress possible.
She identified being very familiar with the concept of response art, as a tool used by art
therapists to process interactions and therapy issues. On average engaging in response art about
once per week, at a scheduled time and place such as at home. She has been using creative
expression for self-care since entering the field in 2007. When she chooses to share her response
art, she does so through SNPs with friends, art therapy colleagues, and with non-art therapy
professionals and peers. She believes that sharing of the art provides her with feedback and
increased self-reflection which can “ultimately [lead her to a] better understanding of [her]
professional self.” All of the pieces she contributed were completed in the same art-making
session on October 2014 on 5”x8” matte board using collaged magazine images. They were her
response to being hired into a new art therapy position.
In My Bones. These pieces were “created following [her] second week in a new art
therapy position, after returning to the art therapy field after 1 year respite.” The piece (see
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Figure 5) contrasts female figures on a vague landscape with architectural pillars and a
wishbone. During the interview she voiced identifying with the symbolic elements of all the
pieces. They represented aspects of herself she was exploring through the imagery. She created
this piece in response to Eclectic Growth.
Figure 5. In My Bones. Collage of
magazine images.
Eclectic Growth. This piece (see Figure 6) was created prior to In My Bones, but it was
uploaded second. The pieces’ primary element is a disjointed figure created by the assemblage
of a skirt and legs wearing oversized pumps, an arm chair, and a leaf-less tree. She voiced that
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“Eclectic Growth is an interpretation of professional rebirth; finding and maintaining a balance
between preserving individual and professional identity.”
Figure 6. Eclectic Growth. Collage
of magazine images.
Energy Source. The 3rd piece (see Figure 7) created and uploaded contained “multiple
symbols and images related to nourishment and feeding the soul.” In it she overlaid images of a
female figure drinking water from a fountain in an outdoor scene with bowls, books, fruits, and
birds, one with a fish in its beak. The imagery represented her developing relationships with her
clients.
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Camie
A Caucasian female in her 30s, residing in a Southern state, Camie had been in the art
therapy field for the last 7 years. At the time of the survey she had a full time job in a medical
setting with children and adolescents with a higher education component. She identified her
weekly stress level to be at 5, on a scale from 1 to 10, where 10 represented the highest level of
stress possible.
Figure 7. Energy Source. Collage of magazine images.
She was very familiar with the concept of response art, further indicating that it was an
art response to the work done with clients “as a form of self-care and personal reflection.”
Although she only seldom engaged in art-making for this purpose, she indicated being able to do
so at home or most often at work, during pre-scheduled creative staff activities. She began using
creative expression as a means of self-care in 2005. If she were to share her art responses she
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would do so locally, at conferences and workshops, with non-art therapy peers, friends, and by
using SNPs.
Germination. This first uploaded piece (see Figure 8) was completed in May of 2012,
the piece measured 12x18inches. Oil pastels on a piece of black paper were used to design a
mandala in exploration of her “identity as an art therapist.” Having been “out of the field for 2
years and 2 months,” she created the piece soon after becoming the first art therapist hired in that
program. She indicated using the piece to reconnect with her art therapy skills, but also in
“trying to navigate the widely different environment of both arts in medicine and practicing in a
medical setting,” which was new to her at the time. She recalls the piece being made in an
“unconscious and unscripted” way; the piece went untitled for several years after being
completed. The accompanying poem is included below:
My beginnings are a seed. All that I need to become is within me. My next, my home is
created from my insides. I am made of water, soil, ashes, memories, air, life. Only when
I realize I have all I need - I am all I need - do I rise from the barriers and turn my face to
the stars.
Figure 8. Germination. Oil pastel on black paper.
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When the piece and poem were reviewed for inclusion in this study she gave it the name,
Germination. In review, she concluded that the piece had “incredible significance to [her]
practice and what was to come.” She also reflected themes’ recurrence when she transitioned
into another work role.
Labels. Labels (see Figure 9) was a piece completed in January of 2011. It was a mixed
media mandala where magazine images of people were layered with printed words using tape on
an 8x12 piece of paper. Labels evolved “after a particularly frustrating set of weeks when our
team of volunteers was helping support a teenager who had a severe medical condition due to
drug use,” he was labeled a "bad kid" from the start. She believed this affected the care he
received while at the hospital. The piece was used to help her “resolve” her feelings in a
“constructive way,” about the “labels” assigned to people “before really taking a chance to
understand.”
Figure 9. Labels. Mixed media collage of
magazine images and news paper text.
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Untitled. Her last piece (see Figure 10) measuring 5x7 inches was completed in
November 2014 and remained untitled. She described it as a mixed media piece using a map,
watercolor, sharpie, and glue. This particular piece was made during a staff art-making session.
After receiving news of a client passing, she voiced that the “art became a response to the grief
[she] was feeling at that moment.” The piece was reminiscent of themes the client explored in
his own art:
The last few pieces of art he'd made me in his lifetime had themes of stars and infinity.
Neither he nor his mom were talking about death, but in retrospect, he was signaling to
me his exploration of this theme. The map, although a nautical map about water, looked
also like an astrological map to me and reminded me of our final works together.
Figure 10. Untitled. Mixed media on
map.
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Camie, further indicated that she found the process of reviewing and selecting the pieces
for participation in the research as “valuable.” It made her realize how long it had been since she
last made art, she considered response art, reflecting on her professional life. For her, the review
process allowed her to reminisce and reflect on work completed when she became an art
therapist in 2007 to 2012, and up to her most recent piece.
Devon
A Caucasian female in her late 20s, Devon, had only been in the field 1 year when she
participated in the research. At the time she was working part-time in a setting she described as
having components of an art center and foundation in an east African country. Within her recent
past, she graduated from an art therapy program, had applied for and been hired into an art
therapy role. When responding to the survey, she identified her weekly stress level to be at a 2
on a scale from 1 to 10 where 1 represented the lowest level of stress possible.
She indicated being somewhat familiar with the concept of response art and using it on a
daily basis. When distressed she would attempt to engage in creating a response art piece as
soon as feasible. This meant working at work or home and during idle time. Making art for selfexpression and self-care for most of her life prior to becoming an art therapist, she indicated
sharing it provided “alternate perspective” and at times lead to “insight” on the work and the
related distress. She indicated sharing her art locally with family, friends, colleagues, peers, and
the general public. At the time of the survey she shared work with others at conferences and
workshops but she did not feel comfortable sharing her art using SNPs.
Friday September 5th. She completed this piece (see Figure 11) as the name indicates,
on September 5th 2014. The piece was completed in a journal measuring 8x5 inches when open,
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using pen, colored pencils, a cutout magazine image, and glue. According to Devon, “the image
was created in response to anxiety about an upcoming plane flight.”
Figure 11. Friday September 5th. Mixed media in journal.
Figure 12. Pimbi. Digital photo.
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Pimbi. This photograph (see Figure 12) was taken later in September of 2014 with the
camera on her phone. She indicated selecting the image as response art “because [she] was
taking pictures of everything excitedly in [her] new work environment, [and] the pimbis seemed
especially interesting and different.”
Professional Life. The last piece (see Figure 13) uploaded was completed in October
2013 using an 8x8 inch square piece of paper, pencil, magazine images, fortune cookie fortunes,
string, modpodge, and watercolors. Professional Life, was created “when my ATR supervisor
asked me to create a piece about my professional life.” At the time she was considering work
stressors such as “the need to maintain balance, poise, persuasiveness, maternal nature, etc.”
Figure 13. Professional Life. Mixed media.
Mari
At the time she participated in the survey, Mari was in her early 50s. A Caucasian female
working full-time as an art therapist in a Midwestern state, she had 1 year of post graduate
experience. Initially, she described her job site as a wellness center and during the interview she
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explained it more as a hospital setting. She identified her weekly stress level to be at a 6 on a
scale from 1 to 10 where 10 represented the highest level of stress possible.
She indicated being very familiar with the concept of response art, using it with the
intention of processing her own experience with clients. However, she only engaged in response
art less than once per month, but when she did it was an “on the spot” action; taking place at
work or home. She began using creative expression as a means of self-care in 2008. She shared
her art with those around her such as friends, family, colleagues, and peers; from time to time
this also included workshops and conferences. At the time of the survey she did not use SNPs
for art sharing but she voiced that “having witnesses helps alleviate [a] sense of isolation,
loneliness, and despair.”
Figure 14. Response Art 6 13. Mixed media
assemblage.
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Response Art 6 13. Completed while at the national art therapy conference in June of
2013 and measuring 14x17 inches, Response Art 6 13 (see Figure 14) was described as an
“assemblage made with paper, tissue paper, feathers, pebbles, [and] watered down Elmer’s glue
as sealing medium.” It was her visual response to her first ever art therapy conference and all the
stress and excitement that entailed for her.
Figure 15. Response Art 12 12.
magazine images.
Collage of
Response Art 12 12. The second piece (see Figure 15) was a collage mandala completed
in December of 2012, the piece is about 8 inches in diameter. The collaged words create a poem
that reads: "You've been / soft color/ Ready/ To create the lighter, brighter / Dreaming/ To see
the world / With fresh/ Courage encouraged / Welcome/ Secret for Happiness.” It was created
after relocating to the Midwest from the Northeastern US, before she began working full-time.
During that time she volunteered at a local behavioral hospital, working with adults and senior
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citizens. She described the piece as “suggesting” of the “safety and tenderness of
wanting/having nurturing from family/mother, and feelings of vulnerability but also thrilling
possibilities unfolding in [her] life at the time.”
Contained Fire. In December of 2014, Mari completed Contained Fire (see Figure 16)
using metallic acrylic and tempera paints leftover after a client session, the piece measured 9x10
inches. The population and atmosphere at her site of employment still felt “new” and as such
was “full of unexpected at every turn,” an “adrenaline rush.” “I love the work that I do, I believe
it to be my calling and while some days are better than others, on the whole I feel blessed to have
found this work.”
Leisy
A Caucasian female in her early 30s, Leisy was working full-time at an inpatient
psychiatric hospital in a southern state at the time of her participation in the research. She had 4
years working in the role of an art therapist. She indicated that on a weekly basis her stress level
was about a 2 on a scale from 1 to 10 where 1 represented the lowest level of stress possible.
She was very familiar with the concept of response art. She described it as art made by
the therapist in order to “explore counter transference and gain clarity about emotional reactions
to a client.” She further explained that it could be used as a means of having a client visually
respond “to something they themselves have created.” She noted engaging in response art about
2-3 times per month; usually getting to the art within the same work week of the distressing
event. She has engaged in response art at work, but preferred doing so at home in her art space.
Using creative expression as a means to self-care since 2001, Leisy does not post her art on
SNPs. When she chooses to share her art, it is with friends, family, colleagues, peers, and the
general public.
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Figure 16. Contained Fire. Acrylic & Tempera.
Figure 17. Hope for Recovery. Mixed media
on masonite.
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Hope for Recovery. Using magazine images and acrylic paint on masonite, the first
uploaded piece (see Figure 17) was completed in September of 2013 measuring 11x14 inches.
According to Leisy, the mixed media piece was “created in response to working with eating
disorder population.” The piece shows a female figure balancing on a pile of food and reaching
up to the sky, a silhouette of a bird in flight above her hand.
Figure 18. I Will Listen. Mixed media on masonite. Artist
name removed.
I Will Listen. On September of 2014, Leisy completed I Will Listen (see Figure 18),
using acrylic paint, text, pen, and magazine images on masonite. Measuring 18x24 inches, this
piece was created in response to working with an eating disorder population. The image shows
two figures inhabiting the same space, but each encircled in a distinctive color and separate from
the other, in the space between them a pie clock marking 5:00 o’clock.
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Elephant in the Room. The Elephant in the Room (see Figure 19), completed in
October of 2013, also uses magazine images and acrylic paint on a masonite board measuring
18x24 inches; a response to working with an eating disorder population. The masonite surface is
predominantly black, with a large stripped arm chair off-center. Three small elephants were
positioned near or on the chair; a female figure peering at a book leans back on the oversized
chair. There is writing throughout the background and tracing the stripped pattern on the chair.
The background writing reads:
Figure 19. Elephant in the Room. Mixed media on
masonite. Artist name removed.
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Warning: What you see before you may look like just a small girl in a chair. What you
don’t know is that underneath this chair are five other paintings that each got covered up
because I thought they were ugly and stupid.
All 6 of the participants in Phase II, submitted the maximum of 3 images each; basic
information was provided for all pieces. Due to the low number of participants who completed
the Phase II image uploading component, all were invited to be interviewed. Individual
interview details were coordinated through email contact and 5 of the 6 were completed through
Skype to Skype calls, while 1 used Skype to phone. All 6 of the Phase II interview participants
were in the United States at the time of their interviews. In the following section the Phase II
interviews will be discussed. Due to the amount of data that emerged from each of the
interviews the information was organized by emerging themes, not by individual participants.
Phase II: Interviews
Phase II participants coordinated a feasible time for the interviews through email; all
interviews were recorded using CallNote, and then transcribed. One participant used the
optional comments box to communicate to the researcher that she would not use Skype for the
interview, but would be willing to interview using other accommodations. For that instance the
Skype-to-phone feature was enabled and used. Lower phone quality made it difficult to
understand some of the discussion, as such there were some blanks in the transcription. On
average the interviews took 52 minutes, the briefest conversation taking under 45 minutes and
two others about 59 minutes. Three participants asked for the video option to be enabled, and of
the other 3, 1 chose not to enable to video, 1 did not have the video option, and 1 was using her
cell for the Skype call and I asked that the video feature not be enabled.
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Interviews were transcribed and coded, before being further compiled using axial coding
into a visual map. Quotes, paraphrased statements, and stories about the art, were grouped into
loosely arranged sections. Some data pieces contained themes from more than 1 group, these
served as connectors between groups. Organizing the data pieces in relation to the others
resulted in an organic representation of relatedness. Interview results were then summarized
based on this organization scheme.
Presentation of findings will begin with a discussion of participant beliefs. Workplace
factors will be reviewed before discussing signs of emerging stress and self-care. The role of
response art, including intentionality, accessibility, responsiveness, and type of creative
engagement will also be discussed. The various roles of communities and their influence on the
creative process and the mental health of the clinician will lead to a discussion on the influence
of SNP.
Participant Beliefs
Throughout the interviews participants voiced certain opinions and beliefs that did not fit
into other categories, these will be presented first, as participant beliefs. These personal tenets
were important because they emerged throughout the interviews as components of interviewee
self-concept, or understanding of creative practices. One key belief was that interviewees voiced
being connected to the art, before becoming art therapists, using their knowledge to nurture
themselves and others. Blair phrased it this way, “we kind-of came to the field because those are
the things we love to do,” she was referring to the personal practice of art-making. Overtime
finding the connection to the art changed with their career and overall life; “As you change
yourself you change others around you,” indicated Mari. Making art accessible to those they
work with helps bring the clients out of their routine, whether it is new coping skills, or skills for
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self-expression and communication. “There’s something really unique…special about being an
art therapist,” continued Mari as she attempted to clarify in several instances the drain and
replenishment she felt were part of being an art therapist. What these individuals offer would not
have been otherwise accessible to the client or the team of providers. With the client as the
primary beneficiary of art therapy services there is an outward ripple of benefits, affecting others
with direct contact to the client. This observation was most presently noted in the conversations
with interviewees who provided services at medical hospitals, or small mental health facilities.
They described a session as affecting their client, then any nearby family, and rippling out to
staff. Therapists themselves seemed to mirror their perceived session outcomes, in the shortterm noticing emotional changes, and effects on perceived energy; feeling energized or drained
by particular interactions. In the long-term indicating that as you helped change a client you also
incurred changes. In spite of being singular providers of art therapy services, the interviewees
described systems of connectedness. These systems influenced their beliefs, creative practices,
and interpersonal interactions. Passion for the profession or esteem for the wellbeing of clients
served only as contributing factors to the actual work environment and culture where the services
were provided.
Workplace
Art therapists work in a variety of fields as was evident from the Phase I survey results.
With 5 out of 6 interview participants working with high risk populations in medical, mental
health, or community centers. Overall, participants indicated that the health of the therapist was
important for effective work; some chose to compartmentalize between their various roles while
others didn’t. On the whole, therapists indicated needing to remain focused within highly
stimulating work environments in order to be effective for their clients. Despite experience, they
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expressed at times, “feeling out of the water;” the ability to work through those moments was
seen as pivotal to both client and therapist. In those moments of uncertainty there seemed to be
opportunity for change, adaptation, and personal development; in such instances of novelty there
was distress, but there was also opportunity.
Novelty in the workplace. One key theme that arose in several categorical groups was
the idea and driving force of a novel experience. It emerged in the areas of role identification,
work environment, stress, visual response, and possibly in a more subtle way in other groups. In
the personal application there’s a sense of excitement that surfaces during novel events, such as
when entering a new role, employment, or duty. The novelty of the situation is coupled with
increased opportunities for learning, an increase in self-reflection, and accompanying stress.
Several interviewees identified that novel experiences could be exciting with unexpected
challenges, and rewards; in many ways serving as a motivational force.
As a non-official representative of the profession, art therapists have an added pressure to
“do right,” says Devon. Often times as the sole providers of art therapy at their respective sites
there’s a budgetary burden placed on the hiring department, which they may or may not be aware
of at the time of hire. Furthermore, an extended period of acclimation beyond learning the basic
layout of the institution, its rules, and cultural nuances, can also be expected in order for the
practice to be tailored to the particular needs of the setting. Each place and role having its own
nuances, requiring accommodations, in order to be an effective part of the services offered.
Accommodations such as media adaptation for application in a medical setting, versus that of an
acute mental health facility, or within a community centre. These workplace and treatment
specific needs were oftentimes intertwined with, personal and professional identity, and
boundary formation.
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Structure, culture, and boundaries. Structure, culture, and overall work environment,
influenced employee performance and retention. Those working in medical hospitals described a
fast paced, loud, stimulating environment, with a plethora of rules and restrictions, for client
safety. While other settings posed difficulties in the reliable acquisition of media, and
sustainability of practices, after the session has culminated; all required resourcefulness and
flexibility in planning. The variation in settings and structure also influenced the overall work
culture, which in conjunction with the art therapists history, and personality, shaped their
boundaries.
Inherent structure of work environment could aid, or hinder, healthy boundary formation
and maintenance. Boundaries were particularly mentioned in reference to mitigating daily stress
due to client interactions. Although 5 of the 6 interviewees discussed not finding their client
interactions as stressful, it was clear that all believed their interactions were tailored to the
particular needs and abilities of the individual or group being served. All indicated that working
with their clients was fulfilling or purposeful, but nevertheless, brought about some degree of
burden or heaviness. Mari pointed out that “it takes time and effort…it [work] is draining and
restorative.” Camie voiced a similar opinion indicating that “it is draining [but] it keeps me
fresh.” Leisy pointed at the underlying truth for the majority of interviewees, which was that
“work is a big part of my life.” As will be expanded upon later under workplace culture,
boundaries, self-care and visual responses to name a few, it was challenging to draw distinct
lines between the personal scope and workplace, as they often overlapped.
Individuals working in medical settings indicated that due to their clients’ individual
health needs, art therapy services had to be individually tailored. "Every patient you see is
giving you something of themselves," expressed Camie. Each setting and client population
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presenting with particular needs, that from time to time required research, testing or exploration
of activities, during the therapists’ off-duty hours. The customization of services afforded the
therapist both a challenging and rewarding work experience.
While some of the most challenging clients refuse mandated treatment, for the most part
therapists found themselves tested by their clients in ways they could not have expected. “It
always surprises me at how creative and how much energy they can have towards art-making
even in the most terrible of circumstances…they’re in severe pain and the one thing they want to
do is make art,” expressed Camie. Sometimes clients themselves served as unexpected role
models, by working through adversity, while the therapist served as a container for their stories.
Some therapists found their place working along-side their client for the purpose of
accomplishing something together. Other interviewees voiced using the art process as a means
of trying to explore aspects of their clients’ stories, finding an effective means to relate, or a
mechanism of processing major events.
Those interviewed voiced that stress in the workplace most frequently emanated from
peer to peer interactions, from the work environment itself, or from the administrative political
environment. “It was the way that the manager went about informing me that made me feel like
a child; it was condescending,” explained Blair as we looked at her image “Eclectic Growth”
(see Figure 6), her voice conveying remnants of the original emotion. In essence, the culture and
peer behaviors that were encountered routinely at work, could prove significant contributors of
stress. Devon voiced at several moments that “there’s a practical stress…but a lot of excitement
about what I’m learning everyday…I mean it’s like a constant awareness of the assumptions
you’re bringing to the table.” This was especially poignant in the first year or two after a change
in employment, such as being hired into a facility or transferring into a new role; where the
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feeling of being lost, or of being in a different country, was at its peak. During such moments of
novelty, the concurring experience would emerge in the art, as Blair put it, “lately, because the
position is so new that most of my artwork tends to do with work in one way or another.” All
three of the pieces she submitted expressed this theme (see Figures 5, 6, & 7). . At times the
excess stress found its way into the art practices of the therapist, and this too served as a means
of mitigating the distress. The anxiety and stress decreased over time as the therapist received
validation from clients, peers and supervisors; becoming a contributing part of the facility.
Earning the role of student mentor was viewed as a positive change, and contributed to the
feeling of being a part of the workplace community. While additional responsibilities could be a
source of stress, it was also positively viewed as a reflection of doing well. Attaining and
sustaining the role of an art therapist, took time and effort, and was described as being both
depleting and heavy, but it was also restorative and positive.
Those who came to the field early in their career search, or those who have found it after
several careers, voiced how connected they are with what they currently do. While those
interviewed did not express absolute love for every aspect of their work roles, they indicated
feeling like they were doing what they were supposed to be doing. Interviewees spoke about the
inherent stresses of their duties as well as the ways in which some aspects of the job ameliorated
the stress. In most cases it was subset by having a variety of client contact, being able to vent
with colleagues, being appreciated for services rendered, and by being able to exercise some
control over how art therapy services were conducted. When therapists incurred a loss,
regardless of what measures were taken, there would be excess stress needing further attention.
Losing a patient. Major distressing events can happen both outside and inside the work
space, and can spill through boundaries and roles, even when it is an expected part of the job.
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On the job losses can be felt differently depending on the work role identification; an interviewee
indicated there were differences for her between the administrative role and that of being a
therapist. As a therapist, she had increased contact and closer involvement with her patients.
Likewise, how a work loss was felt by the therapist was also influenced by the facility culture,
level of attachment, and other events in the therapists’ life. The loss of a patient, even when
expected posed unexpected challenges. For instance, Camie questioned herself after the loss of a
patient she had felt close to; “should I be more sad, should I be less sad?” (see Figure 10). The
passing of a patient regardless of whether it was expected or not, is always difficult, and the way
in which the loss is communicated can also influence how it affects the staff.
Clear boundaries increased distance and separation, which could be crucial for day to day
functioning in the presence of workplace losses. A daily sense of increased heaviness and being
burdened over losses of life, or of security, can bring-up existential doubts in the most capable of
therapists. Adrian noticed herself asking, “why do I do the work that I do?,” to no one in
particular. While workplace loss can be a shared experience amongst staff, individual and
professional boundaries will have it affecting everyone differently, from administrators, to front
line staff, to other clients. Knowing they are not alone, that someone else has gone through
similar struggles, or that their concerns are being heard, may be a step in the right direction.
Some administrators and supervisors go beyond the basics and have normalized the routine use
of protective practices for their staff.
Supportive practices in the workplace. After incurring a workplace loss, the awareness
and ability to seek out a means of purposeful processing will have far reaching ramifications.
Regular day-to-day workplace stresses routinely make it into non-workplace conversations.
Needing a means of ‘get it out,’ while being careful not to violate the Health Insurance
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Portability and Accountability Act (HIPPA). Processing can take the shape of weekly workplace
meetings, which some identified as their place to be heard and to check-in with peers. Taking it
a step further, some interviewees indicated their workplaces facilitated participation in staff
retreats, workshops, or lunch groups. Camie indicated that work peer collaborations were open
to creative processing, in order to safely express work loss, to commemorate, and to make
special. “At one of our staff meetings we were making art [for a particular project]…and um, the
patient had passed away that day or the day before. So it was on my mind…the theme was
journeys…and I was thinking about his journey,” expressed Camie (see Figure 10). She went on
to say that, within the peer group others had also worked with her client, and the group was both
welcoming and supportive. In some instances, a workplace loss can be a motivating drive for
change.
Adrian and Camie spoke about being inspired by peers or speakers, who propelled them
towards a positive change in their lives. In exploring creative self-care practices Adrian
discussed having come across a book that inspired her, “the whole book was about putting
yourself first. Even though our society doesn’t always agree with that.” Attending motivating
workshops with peers who encountered similar workplace losses was also seen as beneficial.
These engaged participants, and made them feel connected most often also spurring attendees
into action. Adrian continued, “after seeing [the speaker] I started to pay attention…even more
to self-care…reminding yourself that it’s sort of an honor to do this work” (see Figure 3)
Taking-on practical advice on how to include simple daily acts that are restorative and balancing
(see Figure 2 & 4). Acts with the most potential seemed to be those which increased awareness
of the moment, and had the capacity of connecting the individual with a supportive community.
This theme will be expanded upon when discussing creative acts and community engagement.
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Some of the stories given as examples were of inspirational peers, who although they were not
art therapists themselves or artists, were nevertheless regularly creating and sharing through
social networks. Throughout the interview Camie shared brief stories about those peers she
found inspiring, who although they were not identified artists, were still propelled to create and
share within the community.
It’s really hard in our daily lives to sit down and make art…one of my colleagues
posts…daily drawings…photographs and stuff…its interesting…he definitely
does self-care, they are actually not beautiful works of art but he still posts
them…My other friend, which again she’s not an art therapist [was inspired by a
TED video about 30 days to change]…She made a commitment to take 1 good
picture every day just with her iphone…she talked about how it made her excited
to wake up every day and think about when she would take the next shot.
As therapists there is a need to routinely process, and effectively eliminate the residual
material generated from working with clients, and from any accumulating stress. Burnout was
mentioned in conjunction with graduate school preparation, as something spoken about by
professors although not necessarily personally endured. Burnout was seen as something that was
present within the field of art therapy, and something to stay away from by implementing selfcare practices, and having healthy boundaries.
Boundaries. Those interviewed were aware of the duality between needing to be open,
empathetic clinicians, and keeping themselves safe. Participants offered personal stories from
their past illustrating boundary crossings, and how such events influenced their current behavior.
With decreased awareness, boundaries suffered, and residual material was retained. Camie
explained it this way:
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It’s a really fine balance for counselors…I think especially for art therapists that on the
one hand we need to be these really open empathetic people but on the other hand we
can’t let it penetrate us, because if we let all of that muck into ourselves we would just be
distraught.
Depending on the environment and the individual, some blurred boundaries could be
expected, and may not raise alarm. Interviewees indicated that because they loved what they
were doing they sometimes brought work home, and the boundaries could become somewhat
blurry. “If you really love what you do…you’re also going to want to bring your work home…to
share it…and you can’t just, like cut it off,” explained Camie. Such boundary crossing was not
seen as depleting unless it became a habitual pattern, depriving the therapist of other selfnurturing activities. All in all, having some boundary flexibility was seen as beneficial.
Individuals interviewed voiced some level of boundary elasticity. There was an
awareness of sometimes carrying a “work-mind” while outside of work, which at times
facilitated an increase in judgment of the public. Although unintentional, those moments of
disquieting judgment at times served as red flags; something that needed further attention.
Boundary flexibility between professional and personal roles could be informative as well as
challenging as Camie explained:
There’s times where I pulled from my clinical work and it gives me tools to help
cope…but there’s also times when things going on…makes me really adverse to
dealing with things at work.
Providing the therapist with access to tools from one area to another and vise versa;
clinical tools could be used for personal improvement and personal tools could be used in
clinical applications. “It’s not the black and white that we were taught in school,” continued
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Camie; requiring adaptive responses that are in line with the therapists’ views and beliefs as well
as the cultural amplitude of the employing facility. The gray areas are vast, and each interviewee
traversed it using their best judgment.
Art therapists interviewed indicated making art at some point in their career, if not for
themselves, then in their daily activities. Some referred to the art as self-care, others as
response-art, and others still, considered it more in line with a craft, or making something
decorative. Even when time was short, and there was no time for personal art-making, exploring
a technique or media for a client, while at home would be seen as permissible. Camie voiced
such sentiments with the adage that “I love what I do and that makes the boundaries blurry.” It
was also seen as a positive activity versus a stressful one, due to the conceptualization of the
career-work role.
In the instances discussed, the culture and environment were large contributors to the
boundary formation, and maintenance. Taking a cue from the cultural norm of the setting, and
holding in balance with the therapists’ ethical beliefs and history, new boundaries were shaped in
response to novel situations. Interviewees described it as a “fine balance,” and were aware of
differences between art therapists, counselors, nurses, doctors, supporting staff and clients.
Individuals had their own conceptualization of discipline specific boundaries. This translated
into differing levels of felt distress for clinicians, and opportunities for interdisciplinary
communication whenever possible. Due to the presence of stress in the interviewees’ lives, they
were asked to provide descriptors alerting them to the areas of concern.
Stress
In various instances, interviewees were asked to describe how they knew they were
stressed, how it was felt, perceived, or even expressed. After all the interviews were completed
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and analyzed, two major areas surfaced: physical signs and mental or emotive signs.
Interviewees described what it was like for them to be stressed, or more accurately, they
indicated the nuances that alerted them to being stressed. All in all, regardless of how an
individual first became aware of their rising stress level, it rose in awareness once it interfered
with either work, or personal life. The more it interfered, the more it was noticed as something
to be addressed. In most cases, interviewees expected a certain level of stress due to their
positions; a hazard of the job.
Signs of emerging stress. Interviewees voiced a myriad of ailments they attributed to
increased work related stress. These physical manifestations were identified as beyond that of
the daily encounter. Behavioral changes in routine such as speeding-up or slowing-down. Half
of interviewees indicated an increase in migraines, headaches, and muscular strains or aches in
the shoulders. Excessive enduring tiredness or even occasional dizziness was common. An
escalation in overall sickliness, either in frequency or duration was noticed after particularly
stressful events. Having difficulties ‘turning-off’ the mind, or waking up in the middle of the
night were contributors to sleep disturbances.
Participants also indicated having an overall increased emotional reactivity. In
conjunction with the physiological drain, interviewees voiced not feeling like themselves, as
Mari indicated, being “down,” “not [as] usual,” or in a mental “fog.” At times feeling like they
were “spread thin,” as voiced by Camie. On such occasions they reported decreased patience
with peers and clients. Camie also indicated an “increased grumpiness,” and a generalized
decrease in ability to manage emotions, which at times proved ineffective in the work setting.
Interviewees were aware that such behaviors could adversely affect their professional and
personal relationships and these behaviors were often seen as red flags.
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Red flags. When minor things began to become larger problems interviewees took
notice. Beginning with physiological and emotive markers, accumulating stress would then
surface in the creative process. Changes in their regular art-making processes, media selection,
and visual artifacts in conjunction with the rest, served as red flags. Adrian noted that increases
or decreases in speed of engagement from her norm would alert her to changes in stress levels.
Further changes in routines or in methods of working would alert the individual to pay closer
attention. Dreams about work, or clients, were for the most part seen as distressing, and also
accepted as red flags, indicative of an area needing attention. Workplace culture impacted selfcare and reflective practices, both within, and outside, the workplace. At times increasing
awareness of the need for self-reflection, and being mindful of said needs.
One of the interviewees voiced that the stress-distress pattern was continuous, it did not
stop, and it required action each time it came into awareness. “Making sure I’m not losing hope
[and] not getting drawn into the clients’ distress,” voiced Leisy, as an important aspect of taking
care of herself. Stress wasn’t automatically in awareness; it was through the individuals’
reactions that they became alerted to its presence. Both Blair and Leisy voiced similar opinions,
that overtime, with developing self-awareness we could “catch” the “off balance” sooner. When
the distress became personal the mitigating actions could also bring its presence further into
awareness, as could happen with visual expression and will be discussed later. For now it was
important to voice that most participants indicated that “when feeling low” or “when concerns
are more emotional” or “when it can’t be pin-pointed” visual art engagement tended to become
spontaneous. The stress-distress dynamic could be augmented by environmental factors in both
work and personal spaces. Changes in routine, social dynamics, environment or culture could
also affect felt distress and pose significant challenges to the self-care routine.
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Self-Care
Self-care was endorsed by all the interviewees as an ongoing practice that was crucial for
any therapist, and which practice extended beyond the workplace. Amount of effort needed in
order to follow through invariably was commensurate with the distressing event. In spite of
knowing that, Adrian adamantly voiced that, “you are worth it in time and effort” (see Figure 2).
Leisy also identified that there was a continual struggle to “ensure time for taking care of me.”
The interviews revealed a generalized notion that while in a graduate program, there was an
external demand, and an inherent structure which made it easier to engage in self-restorative
practices. However, as Devon shared, “with decreased external demand there’s decreased
structure and decrease schedule of making; [and it was] easier to talk self out of it.”
“Lack of time,” and the challenges of “making time,” or “finding time,” surfaced as the
most likely causes of decreased clinician self-care. Those interviewed indicated not having a lot
of time, and because of it, said Blair, needing to “adapt and let go of a few things.” One practice
or activity displaced another, and when engagement in a self-care practice felt like work,
engagement decreased until it was replaced by something else. Being able to “find-your-thing”
said Camie, was important for clinicians as they balanced expectations, abilities, and their own
needs. The implication of self-care was perceived as having enough energy for both work and
personal life.
Having awareness of individual needs, and being able to respond to changing
circumstances, also required developing an increased sense of self. Knowing that a break was
needed, as well as the means of ‘taking a break;’ several of the interviewees voiced needing time,
or space for “adjustment,” or a “balancing out,” after changes or major events, whether they were
planned or not. Being able to recognize, accept, and adapt to changing circumstances especially
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when regularly scheduled means of self-care were inaccessible, was seen as crucial for continued
clinician resilience. Activities used needed to contain or process the distress, needed to involve
both physical and mental wellness, and had to be restorative, versus depleting.
Scheduled activities were a core component of the self-care routine for those interviewed.
While some participants attended weekly religious services, for others it was a spiritual practice
that needed to be maintained. Balanced eating, and regular physical exercise, was seen as
routine care as well. Some took part in counseling, or other scheduled therapeutic interventions,
continuing education in areas of interest, and meditative practices were also mentioned. Having
a separate space for personal or private practice, afforded both the physical separation, and in
some instances even provided variety to otherwise routine schedules. Self-care activities needed
to provide a physical separation, a distraction, or a change from the workplace routine.
While “finding a balance,” was mentioned by all those interviewed, they were not
necessarily speaking about the same thing. Leisy reflected that she was currently
“developmentally and emotionally,” in a more stable place in her life. She was now more aware,
of needs as well as other external contributing factors that lead towards such self-nurturing
experiences as her yoga practice. Putting it succinctly, she said “self-care is practicing what I
preach.” Shifting attention as needed to the present, and being grounded, finding that balance,
and maintaining a support system whether that be communal, social, professional, or familial.
While for some, it would involve an increase in action, for another it could be the opposite.
Finding the time to be still and engage in an activity processing the chaos of the workplace was a
maintenance practice.
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Response Art
As indicated earlier, for some, visual expression could serve to illuminate and mitigate
stress. Interviewees voiced that response art could be responsive to all aspects of the workplace,
to include administrative, peer, and patient care. According to Adrian and Blair, the art becomes
‘responsive when work distress surfaces in its content,’ as such response art was not always
intentional. In other instances response art was used as a tool for the therapist to connect with
the clients and increase empathy.
The extent to which any of the respondents was utilizing response art at the time of the
interview varied greatly. All interviewees had prior experience with visual expression, and all
indicated having used response art at some point in their career. Adrian, Devon, Mari, and Leisy
all indicated that with increased emotional distress, the desire to create a visual response was
augmented. It was noticed that when creating, the emerging themes counter-balanced current
life events. “If there’s content that needs to come out it will” voiced Camie; the art is reflective
to the current place, moment, and needs.
Visual responses served as cues for transpired events. The creative process in providing
exposure can lead to desensitization. Devon shared an image where she purposefully illustrated
and processed her growing anxiety over a pending trip (see Figure 11). Another interviewee
noticed that in her experience, with increased art practice there’s a decrease in un-mediated work
responses. Adrian observed that with decreased instances of creative engagement, work content
had a higher tendency of surfacing in her art. However, as she increased her art-making
practices, visual indicators and behavioral changes in her creative process decreased along with
felt distress. Indicating that at least for her, with frequent visual engagement there was less
unsolicited thematic emergence in the art. While Camie indicated the opposite, voicing that in
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years past when she created on a more consistent schedule, unsolicited material had a tendency
of surfacing. It remained unclear whether it was the frequency or the very act of creating that
allowed the content to emerge in one interviewees art and not in the other. Camie admitted that
her engagement in visual responses had greatly decreased, and she seldom does what she would
call “response art” anymore. It is mostly crafty gifts for friends or art-based experiments needed
to acquiesce to her patient’s requests and needs. From time to time she fondly recalls when she
had more time to make her own art.
Adrian, Blair, Devon, and Leisy were engaged in more frequent visual responses, they
talked of an increase in flexibility in how the creative engagement tended to unfold for them.
For the most part, they did not have set schedules or topics to work-on, they simply began the
process with a theme, and they allowed the process to develop organically. Participants’
methods of creating will be expanded upon when processes are reviewed later-on. However,
everyone had a sense of attunement with the thematic content and chronology of the artwork
discussed, even months or years after it was made. Some participants brought up for discussion
art they completed years prior, and without hesitation they were able to voice the events leading
up to or resulting in the visual response. Such as when Camie discussed the workplace
interactions leading her to create Labels (see Figure 9) and the Untitled (see Figure 10) piece
created to process and memorialize her relationship with a deceased client. At times there was
even a noted change in the interviewees’ voice pitch and intonation as they described the visual
response and the events leading up to its creation.
Relationship with the visual response. The ‘maker’ of the visual response identified
with the piece or a component therein; for them, it served as a reminder of something important.
“Art is central to the practice of an art therapist,” voiced Adrian. Similarly, Leisy indicated that
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“it is personal” (see Figure 19), and may even have agreed with Blair, when she indicated that
“art is intimate [and] not shared indiscriminately.” This intimacy was present during the process
of creating, as Blair explained, “the pieces become extensions of yourself” (see Figure 5, 6, & 7);
serving as direct links to particular memories and emotive content. Adrian and Mari saw making
art as being “helpful,” and a contributing factor to “keeping healthy,” as Blair put it.
As indicated earlier while all the response art may not have been created with that
particular intent, its outcome could nevertheless serve as a reflection of the maker’s underlying
needs. Serving as a mirror, visual responses were described as inadvertently echoing distress
from any source, be it work related or personal. Camie indicated that inevitably “any art
endeavor would have some connection to work.” Due to the nature of the art therapy profession
the emotive intensity of each day was bound to be reflected in any expressive endeavor
undertaken by the therapist.
Art-making was seen as “a positive investment of time and resources” according to
Adrian; the process was “containing, harnessing, and changing” for those involved stated Mari.
As will be discussed later, when the process of creating was purposeful, creative engagement
could become a contemplative practice. Adrian advocated that “art-making is a time to be still
and decrease worries” (see Figure 2). Everyone had their own timetable for creating; both
Adrian and Blair indicated creating regularly, Camie and Mari created only as needed, while
Devon and Leisy, had a semi-regular schedule of creative engagement. Although method of
creative engagement, time allocation, and media varied basic themes of containment, processing,
and embellishment seemed to repeat regardless of the frequency of creative engagement.
The process of creating a visual response served to slow things down and for the most
part increase awareness within the individual. Engagement with the media involved the whole
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individual, body and mind. While Blair described the creative process as being “fun,” that was
not usually the case. Adrian maintained that “making art is a mindful practice.” One that Blair
identified as “bring[ing] you face to face with [the current] stressor…[and] gaining some
reflection” (see Figure 5 & 6). It was also indicated by Leisy, that an individual may “not [be]
fully aware when it’s happening [as in] having a decreased conscious awareness” (see Figure 19)
which then made it difficult to put into words.
As indicated earlier although there were a great deal of similarities there also was some
diversity in the creation-transformation-reflection cycle of the interviewees. Most of the
variations could be attributed to their particular creative processes which in some cases extended
beyond the acts of visual response. Throughout the 6 interviews, 3 creative processes emerged
which opened discussions further into topics of community, artist, and purpose which will be
discussed later. In the next section each of the 3 processes will be discussed as well as some of
the concepts or beliefs interviewees voiced in relation to the creative process in general.
Intentionality. Although Betensky (1995) defined intentionality as having to do with
seeing and relating to something, for the purposes of this research intentionality, refers to an
individuals’ urge to create, becoming more pronounced as concepts accumulate. Scheduling
time to create daily was a challenge most did not subscribe to. However, those interviewed
expressed there was a difference between having a scheduled art practice or not. Some indicated
having had a scheduled practice in the past, but having stopped; that it was both, time consuming
and rewarding. Noticing the benefits only after no longer taking part in frequent acts of selfexpression. Finding and taking the time each day to create although “beneficial” according to
Adrian, was a huge undertaking. This was especially true, when taking into account that almost
all the interviewees identified their main self-care challenge as “not having enough time.”
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For those who were already engaged in a daily or weekly art practice, the time committed
was necessary. None had a specific block of time or criteria to create, but creative engagement
was nonetheless routinely spontaneous. Those individuals with a routine for creating voiced
noticing when too much time had elapsed between creative engagements; the building urge
becoming an added tension, needing to be processed. They all seemed to have back-up routines,
or brief creative deeds to pull them through disruptions. Blair described herself as engaged in
creative preparation whenever her time or physical resources were limited. Preparation for her,
entailed small or brief creative acts that eventually came together in a finished piece. Her
process lent itself well to this method of working and it worked for her; it will be expanded
further under the collage as process section.
Camie volunteered that years prior she had committed herself to a scheduled art practice.
Looking back, she indicated that while the practice was usually engaging, from time to time it
was difficult to get to the art part. On those weeks when she struggled and fell-back from her
routine she was often encouraged by her blog subscribers. Looking back, she now attributed the
success of this endeavor to having made the commitment to keep a routine schedule of creative
engagement as well as those subscribers who took an interest in her and the work she was doing.
As will be discussed later in broader terms, those individuals who followed her progress
provided encouragement for continued engagement, and support. These sentiments were echoed
by others whose creative practices extended into social networking platforms (SNPs).
Adrian offered that her initial commitment to a daily creative practice was greatly
facilitated by the use of technology. She began with a daily photo practice which she then posted
to SNPs. Although brief, she recalls these moments fondly as “moments of reflection.” She
later changed her daily practice to include more traditional visual expressive acts, which she
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maintains years later. After all, she indicated that the length of time needed for creative
engagement continuously varies from day to day, but nonetheless the act serves as a reflective
practice; an inventory of events.
Creative engagement serves as a means of documentation. Those who practiced it on a
regular basis indicated that in spite of the media used, and outcome, the process was akin to a
ritual. Creative engagement was described as a reflective practice that when observed in
retrospect ‘documents’ and ‘archives’ life events. All interviewees indicated regular or
intermittent review of their visual artifacts, which afforded them with glimpses into the events
that lead to their creation. These artifacts were storehouses of emotive content serving as visual
cues to particular memories.
Traditional art-making as a response practice. The process of creating varies from
person to person, and from one act of engagement to another. Each interviewee had an idea of
what their creative methods entailed, and even when they created in an unplanned organic style,
there was a sense of awareness of what was needed. For instance, Leisy indicated her primary
media and method of expression was painting. She explained beginning only with a vague idea
or theme, a span of 2 to 3 hours, and a quiet space usually at her home. Although the process
varied from time to time, she advocated for the alone and quiet space in order to “get into the
zone.” Within a single session, paintings were not always completed, and some needed multiple
sessions. Leisy conveyed that when she “gets into it,” the process of creating become physically
strenuous. Spending a large part of her day indoors, she often would lose track of time, but
tended to stop only once physically, and mentally exhausted. The process as a whole was
consuming and rewarding, she described it as a ‘relationship’.
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The process of creating was described as a relationship. Exploring the initial thematic
content within the space and media of choice, Leisy indicated it was a lot like “getting to know
each other.” Once there was some directionality and the media was unpacked and strewn around
her workspace, not being particularly careful, but not being neat either, she “dives-in[to]” the
process. At some point there would be a “conflict,” and she would work through it, layering her
paints and magazine images, possibly even writing all over her canvas. Whatever it took to bring
order to the emotive chaos, and complete the process. While Adrian did not identify her
particular process as a relationship per say, she would have a “self-talk” between the piece and
herself while in the moments of making. The usual thematic content of the “talk” showed a
struggle or confrontation with the piece in development. This was especially true when
resistance to emerging content was higher. Once the impetus for creation was fully expressed,
the drive to create decreases and the process comes to a conclusion; of course, the larger the
piece or with a more intense content, the more formidable the relationship or dialogue. This
observation was different for those using magazine collage as their media of expression. The
next section will discuss the use of collage as a media and process, bringing pieces together in
one composition with attention to the process of gathering and planning for a creative
engagement.
Using collage as a media and restorative process. The interviewees’ background and
historical relationship with the visual arts had a noticeable influence in their creative practices.
Having a traditional visual arts background, although beneficial in the workplace due to the
repertoire of skills, at times proved challenging when personal work was the goal. Several
interviewees identified collage, as their go-to media and process. In the context of the interviews
the term collage, was only used in reference to the selection and layering of magazine images to
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visually communicate a concept. Leisy pointed out that the process of cutting out magazine
images in preparation for a creative session, whether for herself, or for clients, was “calming.”
Similarly, Devon identified collage as her “go-to” process to relax, offering a work around to her
traditional visual arts training. She indicated that when she created there was always an internal
pressure to “create good art.” In finding, trimming, re-assembling and embellishing she
expressed herself faster and without adding anxiety to an already emotively charged process.
Collage served as a versatile media and process; it could be used on its own (see Figure 5, 6, 7, 9,
& 15), or in conjunction with other media such as in mixed media pieces (see Figure 17, 18, &
19), or in journal entries with writing components (see Figure 11 & 13).
One interviewee used collage as her main process of visual expression using the
SoulCollage (“SoulCollage,” n.d.) method (see Figure 5, 6, & 7), it is a trademarked process.
SoulCollage was the creation of a personal deck of cards not too dissimilar from a tarot deck.
The cards were made using pieces of matt board measuring 5”x7,” and magazine images, they
were stored in clear sleeves and notes were kept about each of them in a journal that could be
referred to and added to as the cards were viewed and used. Keeping it simple, the small work
space needed meticulous care in the selection of images, cutting, assembling, layering, and
securing of the composition. She indicated that due to the small space the final processes
required her to work slowly to decrease tearing her painstakingly selected and trimmed images.
The process of cutting and re-arranging of the pre-existing images allowed her increased
distancing from the themes being processed. Organizing the 8 plus images needed for each card
orders her thoughts, and engages the original distressing cues over, and over; the process
becoming a contemplative practice. When time is short, or when she was too tired to invest in
the whole creative process, Blair separated images for later engagements.
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The process of art-making provided her with a contemplative practice, that extended into
her local community, and into SNPs. Although the cards were usually made on her own, from
time to time she would join a group of women from various professions for several consecutive
hours of creative expression; everyone coming together to create SoulCollage cards. Blair
indicated that it was the art process as well as the group who provided much needed support
during times of distress. She took consolation in knowing that the images themselves helped in
concealing her emotive expression from most. She further indicated that although the SNPs
provided support between local meetings she was careful in being selective of the images she
posted. Community and SNP challenges and support will be expanded upon in their respective
sections later in this chapter.
Accessibility. Blair, like some of the other interviewees engaged in several types of
visual expression at the time of the interview. While she did not submit her mandalas for review,
she did indicate that when in a pinch she turned to faster methods of visual expression.
Logically, less intense creative engagements took less time and considerably less emotional
commitment, but the pieces were still described as serving to clear the mind. Small cup-sized
hand drawn or colored mandalas were part of Blair’s creative repertoire for ‘fast-art’. She felt
more comfortable sharing these images through SNPs, because to her they contained less
emotive content than her meticulously composed SoulCollage cards. The small mandalas had
the added benefit of using simple accessible materials, and of being portable.
Accessibility and portability was also important for Adrian and Devon, who often found
themselves creating on the ‘go’. At the time of the interview, Devon’s primary means of
creating was her journal, with a limited supply of media. She indicated that in response to her
current constraints and needs, she found herself not making as much art as was customary, but
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when she did, writing was a big part of it. She also volunteered that in using a journal she had
access to the prior entries; much like Blair, both indicated looking through it often, even if no
new entries were made. There was some comfort in picking up the journal and leafing through
entries, visual or text. All three indicated that mobility, and accessibility of the visual
expression, whether one piece or a series, provided the maker with access for continued
reflection. The three art pieces selected by Adrian were of compositions within an artist journal,
exploring themes of self-care, she also spoke about accessibility to the visual artifacts.
Portable creative expression was discussed as being accessible. Ease of creative
engagement by means of media, or format size, was indicative of accessibility and portability.
These issues were especially important for those who worked in areas where the services they
provided necessitated portability, or dealt with a limitation in resources due to funds, or due to
setting. Adrian chose to engage in pieces that were accessible to make, as well as share with
others. She voiced having had various experiences over the years in portable or accessible art,
which she could return to as needed. While some of her creations were for personal use such as
her ‘signature strengths’ (which was not part of the uploaded artifacts), which she voiced
carrying around with her for a while as a reminder of her strengths, others were shared with her
‘community’. She explained that her daily art practices begun with daily digital photos, shared
on SNPs, after a while sharing her art became part of the creative process.
Responsive to the process. The creative process is an individual experience that is
nevertheless, responsive and adaptive. Most of the individuals interviewed indicated a themed
but otherwise unplanned and intuitive creative experience. “I kind of just create when I sit
down…I don’t have a plan in mind,” indicated Adrian who habitually creates, often on a daily
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basis. She advocated that from her experience, the creative process itself was responsive to
constraints.
The creative process is an extension of the individual, and the process is influenced by
their life’s events. Overtime the process changes slowly, in reflection and adaptation of changes
taking place in the individual. Some interviewees indicated noticing changes in their creative
process and by doing so they increased self-awareness. Such awareness came from knowing that
both the process and the final visual response could serve to reflect the makers’ mood, and issues
taking place at the time the creative process was engaged. Observable changes could include
methods employed, type of media used, practicality or mobility of process. Those who created
art most frequently indicated that the art process was their therapy. Both Blair and Leisy
advocated that in visual expression the process called for self-reflection, throughout the process
of making. In spite of organic or intuitive engagement there could be an increase sense of
awareness of what was taking place while it was actively happening.
The creative process is responsive to novelty. As indicated earlier when discussing the
workplace, interviewees indicated that novel experiences could bring challenges, as well as
rewards. In this case as indicated by Blair, with the occurrence of a novel experience in any area
of life, the chances increase that the subject will show-up in the creative process. The greater the
magnitude of the event, the more noticeable its influence on the process and final outcome; and
vise versa. Such novel events could emanate from life, work, career, and family, health, or
relationship changes. Just as novel experiences could provide a sense of excitement, increased
opportunities for learning, and self-reflection, they could also prove overwhelming.
How the creative process responded to the novel event was a reflection of how the
individual processed the events. While for some this was a conscious and intuitive process, for
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others it was described as something more subconscious and primal. With continued change, the
style and methods continued to respond to the environment and the individual. One respondent
indicated an increased verbal response in her art entries, using more words and poems versus
imagery.
At times it was the process itself that encouraged a novel experience to be processed in
rich detail. In several instances interviewees talked about intense situations that lead to an art
product. These visual responses were then viewed by their makers as providing insight, or at the
least, increased awareness of the particular situation. Blair talked about 2 of her images in which
she visually expressed her point of view. One of her chosen images expressed how she felt
during a particularly unsettling interaction at her place of employment with a supervisor (see
Figure 6). A second image visually communicated Blairs’ new resolve in regards to that
particular situation (see Figure 7).
As an art therapist, visually processing an event in order to gain new perspective or
understanding is not new. This aspect of the creative process was especially important to a
couple of the interviewees, who described using the process in order to better understand their
peers and their patients (see Figure 7, 9, & 18). Taking the time to process an event visually was
time consuming, and not easily accommodated into everyone’s work schedule. However, at
times the transpired event causes such an impression that the art therapist instinctively turns to
the art.
In choosing to process a distressing or novel event by means of the creative process, the
art therapist places into practice what they have been “preaching.” In one such instance, Camie
became upset with her fellow peers for the treatment of a patient; in order to gain a new
perspective on the situation she engaged the creative process (see Figure 9). Similarly, Leisy
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uses visual responses to work through challenging situations with her patients (see Figure 17).
Leisy further indicated that such process was especially helpful for processing lingering session
content that may not be readily noticeable, but that begins to affect her wellbeing (see Figure 18).
She asserted in using the creative process to better understand and connect to her patients who
are oftentimes very dissimilar from her. The process allowed for a connection between what was
known, and what was just beyond reach; it allowed the individual to take risks and make
mistakes they would not have otherwise had the opportunity to.
Communities as Part of the Process
All interviewees mentioned having some form of external support. These supports
ranged from family members, to employer, professional, to local or international; groups of such
systems of support will be referred to as communities. Some of the systems of support
contributed to the individuals’ creative expression by means of encouragement or actual handson engagement; they were often seen as part of the creative process. These means of support
provided witnessing and validation.
Local, familial and social support system. Throughout each interview the participants’
support systems surfaced for discussion. Those who were married or who identified living with
a significant other, readily voiced appreciation for their support. Most readily identifying the
role of the significant other as a counter balance, “bringing [them] down to earth,” as needed
while being supportive. Some voiced venting to their significant other, especially after
particularly demanding days, as a means to de-compress. However, while these individuals
presented as available, and at times willing to assist with the art therapists’ burden, using them
for this purpose was not always in their best interest. Leisy shared that her spouse had “felt
dumped-on,” and had communicated he lacked the proper training to deal with the information
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effectively. After which, Leisy reassessed her needs, and identified individuals with whom she
could vent while at the workplace. Interviewees implemented a variety of solutions to similar
issues of ‘how much to share with their support systems,’ in order not to overburden the ‘other’.
Maintaining with the observance of HIPPA, from time to time, these therapists still had instances
of needing to talk to someone, in such events they advocated keeping details to a minimum.
Better still, is finding work peers or other professionals, who do have the training, lacked by
family and significant others; they are better equipped for the recursive task.
Some individuals identified their workplace as having sustaining practices, and
supportive professionals. Others still indicated that participating in workshops or similar
activities with peers allowed them to feel a sense of “I’m not alone.” Knowing what it was like
for others was at times humbling. Camie voiced that she felt her place of employment, as well as
her supervisors, were looking out for her wellbeing. Her workplace had several supportive
practices in action such as, expressive lunches, regular meetings, workshops, retreats, and
supportive mental health practices amongst other things. The workplace was described as a
village with different professionals interacting and responding according to their own ethos, and
while the art therapist may fit within the workplace culture, they may also be in need of
supplemental social support.
Communal art-making for accountability and social support. Finding and partaking
in various forms of community support was endorsed by at least 4 of the interviewees.
Supportive communities were seen as providing accountability through continual contact and
endorsement of creative practices. Blair indicated she “wasn’t in a good space emotionally”
when a colleague directed her to the local SoulCollage group. She described a group of women
from varying careers and with diverse art skills, getting together about once per month for a span
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of 3 to 4 hours with the purpose of creating together. The group would then share and discuss
pieces made outside the group as well as those made together.
Creating and sharing with a group of creative individuals on a continuous basis has been,
and continues to be, an invaluable experience, says Blair. The group “forced me to start
creating;” they provided increased social support, and were the main ones who knew the
meaning of the art. Although she advocated that it was through the group that she once again
began to make art of substance regularly, she now is engaged in several sustained creative
practices of her own.
The traditional gallery art show within the local community. One of the interviewees
indicated using her local community as a means to become motivated to create. Leisy voiced
having been in an art “slump,” in order to get out of it she set a goal of putting-on a local gallery
show. Throughout the year prior to the show, she held herself accountable, and used the looming
deadline to motivate herself to work on her art on a more regular schedule. She explained that
while she worked she did not paint “for the show;” instead the deadline served as ‘valid’ reason
to paint.
Peers in the local community were supportive, and sought to connect through the show.
Leisy recalls the show opening as “nerve racking,” not only was there was a greater turnout than
she expected, but friends and colleagues were interested in knowing more about the content of
her art. She recalled feeling scared and vulnerable, she had not created the art for the show, and
it was all still personal. She had put herself “out there,” and now she found it hard to fully
explain the content. Overall she recalls the evening as positive, receiving positive feedback and
support from those in attendance. She also indicated that being on the other side of the
conversation brought up vulnerabilities similar to those of her patients, allowing her to better
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understand where they were coming from. In the end, she achieved both her goals of, hosting a
gallery show of her own, and now having an established habit of regular ‘art-making’.
Bridging local with online communities. While local communities have traditionally
been a source of information and support, in recent years SNPs have made online communities
more accessible to more people. Of those interviewed, 3 utilize SNPs frequently, considering
them a part of their social engagement, professional connectivity, leisure, and in some cases an
extension of the creative process. Those who expressed reservations in regards to the use of
SNPs did so in contemplation of ethics, and a personal discomfort of use and miss-use of the
system. Leisy indicated she would need to have “increased comfort with the art piece(s) before
posting on social media.” She further indicated she would be more apt to use SNPs for self
promotion versus personal visual responses.
In some instances, the SNPs and other online platforms such as blogs were the most
accessible means of communicating and establishing a community. Camie shared that several
years ago, she found herself practicing in a small rural landlocked town, where she felt
disconnected from her peers, and physically distant from friends, and family. After some
encouragement, she took-on the challenge of creating mandalas on a regular basis, and posting
them onto a private blog. The images were posted without descriptions. She animatedly
indicated how each week or so, observers projected their perspective onto the art, with individual
comments reflecting the authors’ relationship with the artist and the art. That was an unexpected
outcome, much like the outpouring of support encouraging her to create week after week.
During the interview she voiced that “it’s easy to get away from making art…but when I did it, it
was so helpful.”
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Social networking platforms as components in the process. Facebook, Instagram, and
Youtube were the only social media platforms (SNPs) used by the interviewees. Four out of the
6, were routinely using Facebook at least once a month, to keep connected to both personal and
professional peers at the time of the interview; at least 2 used Facebook on a daily basis. Two
were using Instagram regularly, ranging from weekly to daily posts. Both Facebook and
Instagram are considered SNPs due to the ability to connect profiles, follow, and post messages
for individuals or groups. Instagram however, is primarily an image (square format) and video
(up to 15 seconds) sharing community which can connect to some of the other social networking
platforms such as Facebook, Twitter, Tumbler, or Flicker, if the account holder chooses to.
Those interviewees who did use Facebook all had varying degrees of ethical
considerations about the complexity of personal, versus professional, cost and benefits.
Connectivity to other SNP users and groups as well as ease of access were the major selling
points. In cases where the art therapist was practicing away from their family or social support
group, SNPs were indicated as the main way to remain reliably connected. An interviewee
indicated that Facebook provided her an increased professional presence, being able to keep
track of peers and happenings in the profession and vise versa. Overall, those interviewees who
routinely used SNPs indicated they provided opportunities for continued action, support,
accountability, and community building. They were aware of the public nature of these
platforms, and conscious of what they were choosing to post.
What was shared, where and how mattered. Interviewees who frequently, used SNPs (4
of 6) indicated having an increased awareness of their intent for sharing either image, story, link,
or message. Some (2 of 6) indicated being members of groups with local connections, while
others (1 of 6) drew membership from across the globe. SNPs were used by local groups to
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establish and maintain connectivity with the membership, regardless of availability for in-person
gatherings. The SNPs provided group members access to images created outside of group
gatherings with the added possibility of providing supportive feedback. Another trait of an SNP
is its accessibility, making it possible for connected individuals to view past images on demand.
At local gatherings for instance, members would only be able to view images created or brought,
past images would generally be inaccessible unless prior arrangements were made.
Exercising caution, one participant voiced that she was conscious of sharing one type of
art over another or even where it was shared and with whom. By manipulating the settings on
SNPs posts could be shared publicly or access could be restricted to a selected few. For the most
part, sharing an image of a newly completed art piece was seen as normal with the adage that the
image format concealed the images’ ‘true’ content for most viewers. Not having full knowledge
of the image content did not detract connected SNP users from positive reviews, ‘likes’, and
overall encouraging remarks.
Several of the interviewees (3 of 6) did not regularly post their personal art onto an SNP.
Despite a lack of regular posts, one interviewee enthusiastically offered that she did follow
several peers. She indicated that those peers were neither art therapists nor self-identified artists,
but they regularly posted images or photographs and she found their commitment inspirational.
Individuals such as these, were also changing her perspective on what could be considered art or
visual expression.
SNPs were seen as having possibility for personal connection, as well as promotional,
and inspirational value. Using the platforms as a means to freely advertise personal work that is
for sale, or promote a cause of interest. With some exception, SNP connections could be made
with someone unknown, but who otherwise holds a similar interest or commonality. One
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individual voiced using SNPs and other online resources such as blogs, to routinely connect with
others from across the globe. Some activities mentioned were weekly inspirational or themed
posts by an artist community, creative challenges, gratitude practices, workshops, and even
swaps of art media or of completed pieces.
Those who frequently posted art (2 of 6) indicated that sharing the art had become part of
the creative process. The ease of incorporating the making aspect, with the SNP post within the
day to day schedule, had a huge impact on the continuation of the practice. Even when the
practice was several days a week versus daily there was an accountability piece because of the
SNP. Some provided stories to illustrate how in the past peers had connected and followed
routine creative endeavors. When regular posts were missed unsolicited encouragement was
given, holding the individual accountable.
Some challenges to SNP use emerging from the interviews were the concern for sociocultural constraints, ethical ramifications, public use or abuse, technology, and connectivity
issues. In some cultures and communities SNP use could still not be a widely accepted form of
professional networking. In these settings sole reliance on the technology could prove
counterproductive. Ethical issues arising from what was posted in a personal or professional
profile could also have a huge impact. Oftentimes once something has been posted be it text or
image it cannot be removed; in those instances where it is removable there would still be a trace
left, making it almost impossible to eradicate completely. Once it has been posted it is part of
the public scope and unless privacy settings were used, it can be re-shared, copied, linked-back
to, etc. One interviewee voiced that while the technology was necessary to keep in touch with
her social network, it could also become burdensome if it isn’t functioning properly, or if there’s
limited accessibility.
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Summary
In closing, this chapter presented the collected data from the research in three sections.
Phase I discussed the results of the online survey, including basic demographics, as well as some
perceptions on the use of visual expression and response art. All survey respondents were
female between the ages of 25 and 65 who had at least a master’s degree in art therapy. The
majority had their ATR, ATR-BC, or other licensure. When survey respondents were asked
about their perceived weekly stress level, most indicated a moderate level between 5 to 7, on a
likert scale, where 10 was the maximum. Most survey respondents also self identified as being
an active member in a creative group and understanding the benefits of creative engagement as
response art. Those who indicated engaging in their own response art were invited to take part in
Phase II of the study.
Ultimately, only 6 participants completed the image upload and interview, they were
introduced in the second section of this chapter. The Phase II interview section consolidated the
data into thematic groupings. This section presented participant beliefs indicating personal
connections to the creative experience before becoming part of the field of art therapy. Also
believing there is something particular about the creative process that makes it accessible,
appropriate, and effective as a means of mitigating distress in self and others.
Interviewees identified that workplaces could be generators of distress as well as places
of support depending on the culture present, structure, and boundaries. The loss of a client was
described as one of the most difficult challenges needing to process as a therapist. Also
discussing the importance of boundary elasticity, reflecting the abilities and needs of the art
therapist, their clients, and the facility or institution they work for. Interviewees noted personal
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physiological signs of accumulating distress as well as visual and process based red flags; such
as changes in symbolic content or in the method of working.
Although there was variation in the amount of response art, time devoted to each piece,
and methods of working the overall response was that creative engagement was found to be
restorative. An effective means of processing or distracting from stressful events; the creative
act itself serving as a means of slowing down, becoming aware, and processing the cause of
distress. Interviewees were also responsive to instances of novelty which were then reflected in
their creative process and artifacts.
Lastly, expanding individual creative practices beyond the personal, with surfacing
themes of local and SNP based communities as means of validation and support. All
interviewed, whether a consumer of SNPs or not, voiced awareness of ethical and privacy
concerns that were especially burdensome for therapists. However, for those who used SNPs the
benefits outweighed the risks; providing access to family, peers, and colleagues as well as
organizations and groups which may otherwise not have been possible.
In chapter 5, the research questions will be answered with support from the data collected
and presented in this chapter. Implications, limitations, and opportunities for future research will
also be discussed.
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CHAPTER 5
DISCUSSION
The organization of this chapter reflects how the main question was informed by the
supporting questions, and structured to first present a brief reminder of the connection between
expression and experience. The first supporting question sought to find if art was being used by
art therapists, and how. Methods of working and therapist connection to the art process are
discussed. Next, the second sub-question addressed the role of visual expression in mitigating
perceived burnout. In this section, therapists’ perspective on indicators of stress and methods of
addressing their needs is discussed. The last supporting question asked if and how responsive
art-making influenced therapists’ professional identities. In discussing the findings it is
important to discuss boundaries, expression as a positive investment of time, the role of novel
experiences, and the role of various communities which connected to the therapist through
creative expression. In answering these supportive questions, the primary question of how this
sample of art therapists employed personal visual expression to sustain their practice was
answered.
The overall findings positively endorsed the practice of self-care toward art therapist
resilience. In order to effectively manage daily stress, a variety of practices needed to be in place
in conjunction with creative expression. For practices to have a favorable outcome they needed
to be accessed often and tailored to the clinicians’ particular needs. A finding of note was the
observation of the importance of the element of novelty, which was presented with both stress
and excitement, expectation, or even a welcome break from an otherwise stagnant practice.
Novelty was shown in response to new experiences, new methods of working, new concepts
being expressed. It was possibly in line with the experiences noted by those therapists who made
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use of social networking platforms (SNP) to further expand their creative practices. SNP use
was seen as having a favorable outcome by those who used them frequently as a personal and
professional resource.
Expression as Experience
The creative act is an innate and intimate process (Dissanayake, 2000); it is also an
experience (Langer, 1953; May, 1975). As such, the creative act could be said to be a
dynamically interacting series of tensions and resolutions, that are responsive to the sensory
emotive self for the purposes of integrating knowledge. Creative expression is a means of
processing, storing, and retrieving experiences; it is a way of knowing (Dewey, 1980;
Dissanayake, 2000; Langer, 1953; Lusebrink 1990; May, 1975). Creative and visual expression
is endorsed by art therapists as a means of connecting to, and facilitating change in their clients.
However, the personal visual expression of art therapists continues to be a precarious topic in the
field, as few literature covers its use. This study’s focus was on the art therapist’s use of
personal visual expression. Survey participants identifying as not engaging in response art or
any other form of visual expression, were not given questions on those topics, they were also
excluded from Phase II. Of the 28 survey participants, only 6 indicated no interest in visual
expression.
Field Demographics
As indicated in chapter 4, all survey respondents were female between the ages of 25 and
65 at the time the survey was completed. The majority identified as Caucasian. All had a
master’s degree, 5 had attained their doctorate. About a quarter of respondents had attained
either their ATR or their ATR-BC, none had the newer ATCS credential. Years of experience
ranged between 5 and 24; the majority was employed at least part-time. Outpatient mental health
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and nonprofit associations or foundations were the most endorsed primary work settings, these
were closely followed by counseling centers, college or university education, and adult
psychiatric hospitals.
The majority of the survey respondents felt prepared by their graduate school
experiences. For the most part these art therapists felt gratified and satisfied by the work they
were currently doing and found the work to be proportional to what they could handle. About
half of respondents felt their concerns were being heard by their immediate supervisor. While
most felt their work was valued by either the supervisor or the agency.
Over half of respondents also identified feeling moderate levels of stress on a weekly
basis. A moderate level was defined as a range between 5-7, on a 0-10 scale. The majority of
those taking the survey also indicated using art directives on a bi-weekly or weekly basis.
Nearly all respondent indicated being an active member of a creative group. Furthermore, the
concept of response art was somewhat or very familiar to 21 survey respondents. Response art
was defined earlier as pertaining to the art process and outcome that sought to process a
workplace or distressful experience (Fish, 2006, 2008, 2012). Amazingly, 22 respondents
endorsed using response art, or visual expression for self-care. These art therapists primarily
created while either at home or while at work during idle time. Of those, 10 said they might
share their personal expression with others while 8 would definitely share. The response art was
primarily shared with art therapy colleagues and friends. Sharing often within particular network
communities such as during conferences, local peer networks, or through SNP groups amongst
others. All in all, respondents who positively endorsed creating response art and sharing it also
indicated that in doing so they felt validated and connected to others.
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Due to the limited scope of this research study, these results are not generalizable to the
field as a whole, but offer a glimpse into how the 6 interviewees, and the 22 survey participants,
viewed and used personal visual expression up to the time of participation in the research study.
Interviewees voiced that regardless of its intended purpose, there was a relationship with the
process of creating a visual expression. The visual expression process and product, served to
mirror current events, and was used a means of documenting, often also serving to bring
pertinent issues into awareness. While culminating the visual artifact held meaning, the
materials and individual acts involved in the process of creating were important to the overall
outcome. Media used reflected the identified need as well as accessibility. Those who engaged
in habitual art-making, talked about increased awareness of self, which extended beyond the
moment of active engagement. Process and artifact were also described as having various roles
in traditional and contemporary forms of community engagement.
Research Question 1: Is Art Used as Self-Care by Art Therapists and If So, How?
For the 6 art therapists involved in the interviews, self-care represented a variety of
activities and challenges. Although art was used as a means of self-care at some point in their
careers, it was not the current primary means of self-care for all of them. Self-care was defined
by the interviewees as engaging in activities that effectively processed or distracted the
individual from their current distress. Such activities were deemed effective if, after
engagement, the individual had sufficient energy and desire to tend to their work and personal
lives. Most of the activities mentioned were scheduled practices, such as attending weekly
religious services, engaging in a spiritual practice, having a balanced diet, and getting regular
physical exercise. Continuing education, workshops, and other creative group activities with
peers were also seen as restorative due to their novelty and community-building aspects.
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Being Responsive
Visual expression has been described as an innate means of making sense of the world
(Dissanayake, 2000), the creative act in itself being an experience (May, 1975) that could be
used to increase awareness between internal and external systems of knowing. The term,
response art was used to describe art made in reaction to a particular circumstance or event (Fish,
2006, 2008). Most often used as a means to come to terms with a change or to process intense
emotions, under the right circumstances it is also used to communicate and document events. As
indicated by at least two study participants, not all response art began with that purpose at times,
in the process of creative engagement, other content rose in primacy, surpassing the original
intended theme. A goal of creating response art did not have to be clear at the onset (Fish, 2006,
2012). As other content rose in primacy, if the person engaging the creative process was
receptive and responsive to the changes, that particular engagement became response art. At
other times, the person could purposefully choose to use visual expression to increase their
understanding of a particular set of events or clients this too was responsive art.
Over half the interviewees indicated that with increased emotional distress, or when faced
with challenging novel situations, there was an increased urgency present in the creative
processes. For some, increased emotional distress meant an increased desire to engage in
responsive art-making (Jones, 1983; Pakula, 1997). When creating, the emerging themes had the
potential of counter-balancing current life events. For example, when stressed, the emerging
themes could counter a fast-paced mental state with a process and imagery that aided in slowing
down the individual. The importance was in being receptive to the creative urgency, being
willing to engage in the creative process towards increasing awareness of whatever the issues
were.
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Exposure
In anticipation of particularly distressing events, some individuals chose to preemptively
become exposed through the creative process (Fish, 2008). Devon purposefully engaged the art
as a means of self-exposure in anticipation of an upcoming event that was causing her anxiety
(see Figure 11), illustrating the upcoming event and processing some of the accompanying
emotive distress. Adrian indicated that with increased exposure through creative engagement,
there was a noted decrease in the emergence of work-related content, possibly due to exhausting
such content. However, with decreased art engagement, there was an increased probability of
work-themed content surfacing. Another interviewee voiced the opposite, noting that in years
past when she created art on a regular schedule, it contained unsolicited material often related to
her work. It was unclear whether it was the frequency of making, differences in the acts of
creating, or the individual practices themselves which allowed the content to emerge in one
interviewee’s art and become extinguished, and not in the others. What is known is that,
regardless of intended purpose, in delving into a creative experience, the individual will have the
opportunity to connect with, and elaborate on whatever is of most importance at the time. In
doing so, they willingly expose themselves to potentially raw and intense material, but by doing
so on their own terms, they are able to gain a sense of control and mastery over the content.
Flexible Approach
What became evident was that with an expanded frequency of creative engagement,
interviewees voiced an increased flexibility in how the creative act tended to unfold. These
individuals tended not to have set schedules for working on the art, but found frequent times to
do so regardless of the total length of time devoted to the act. Spending whatever time they
could spare throughout their day for an impromptu and informal creative engagement. They also
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tended to describe their process as “organic,” and voiced being comfortable in beginning the
creative process with minimal or no specific topic. Beginning with a loose theme, often vague or
amorphous, these individuals would allow the process to “take them where they needed to go.”
All interviewees had a sense of attunement with the thematic content and chronology of
their artwork months and years after being made. Without fail, when viewing or discussing their
visual artifacts, interviewees were able to provide detailed stories of contributing events. Often,
each segment of an image elicited dialogue, and corresponded with noted changes in the
interviewees’ voice intonation and rate of speech. It was evident that all interviewees identified
with their visual responses and, regardless of elapsed time, each piece cued a particular set of
events and emotional responses.
Developing Intimacy
In the process of creating, each piece became intimately known; Blair explained that, “the
pieces become extensions of yourself.” Through engagement in expressive acts, the individual
developed increasing self-awareness (Dissanayake, 2000; Malchiodi, 2012; May, 1975). Beyond
each piece, the process of creative engagement was transactive. It was by means of creative
engagement that the individual processed the events to be expressed, coded, and stored the
experience. Developing over time, the process of creative engagement, much like a relationship,
changed with the individual’s skills, needs, and preferences. Providing each with time to “be
still,” “slow down,” and according to Blair, possibly come “face to face with [the current]
stressor…gaining some reflection.” Engagement in the creative process was intimate
(Dissanayake, 2000) it involved the whole individual, body and mind, as well as elements within
their environment.
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Importance of the Creative Process
The creative process required full attention and intention from the individual (Arnheim,
1986; Dewey, 1980; May, 1965). While it was not often identified as fun, the process was
described by interviewees as having some contemplative qualities. In the process of creating a
visual response, individuals seemed to retreat into a mindful state of personal focus. Leisy
described it as getting “in the zone,” even when creating within a group. With repetition,
components of the creative act gained or lost preference. Favorable acts serving the needs of the
individual were maintained, and over time became ritualized (Dissanayake, 2000; Hinz, 2013).
The more regular the art practice, the more ritual-like the creative process, with unexpected
changes within the process itself serving as red flags. For example, Adrian indicated that
working faster or slower than usual tended to alert her to underlying issues she might not have
been fully aware of prior to having engaged in the activity. Furthermore, the process of creative
engagement was described as consuming and rewarding, mirroring interviewees’ descriptions of
their practice of art therapy itself.
Those interviewed voiced having a flexible relationship with the creative process, with
their choices in media types invariably influencing their processes (McNiff, 2004) of expression.
One that was responsive to their career and overall needs, with the ultimate goal being the health
of the therapist. With that in mind there were three types of processes that were identified as
effective for interviewees when attending to their stress: traditional art engagement, the collage
process, and an intuitive approach, which could apply to the first two styles as well.
Traditional art process. Traditional art engagement in its media set-up and preparation
for working, tended to be more contemplative than repetitive. As described by one of the
interviewees, in the set-up of the work space, no matter how small, there was a narrowing down
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of attention from a multitude of thoughts down to the one of import. In more traditional methods
of working, there could also be a requisite amount of time needed for the process of expression
due to set up, working time, and clean up. Tools and processes could also be media specific. In
traditionally trained therapists, there tended to be an inner struggle between outcome and
process. Some of the interviewees voiced struggling with self-judgment, over the outcome of a
piece, which could keep them from fully expressing the urge. In a worst-case scenario, selfjudgment could compile, adding to the distressing material already needing to be processed. One
way of bypassing such self-critique in favor of a more fluid creative expression was a change in
media type or means of application such as with collage, and mixed media, just to name a few.
Collage as a contemplative practice. As a contemplative practice, collage is a series of
focused intentional and repetitive steps, requiring higher-order cognitive processes (Hinz, 2013).
Even though it is often used in the art therapy field for its versatility and accessibility, there
seems to be more to the practice. Interviewees who used this method voiced that it was
especially helpful when they were limited on time, but still had the urge to create. Under
limiting circumstances, creative work could consist of finding, compiling, trimming, and setting
aside the selections for a later session when it could all be assembled. In spite of the piece not
being completed in one session, interviewees indicated feeling relief after manipulating the
scissors or X-acto-knife to trim the images found. There seemed to be an intensity of focus in
the coordination of moments needed to carefully trim an image. In time, pausing and relaxing in
order to find another image, another focal point, and then repeating the process several times
before exhausting resources. The process imbued the selected and carefully trimmed images
with importance; these were special, they left the anonymity of a magazine pile and joined other
pieces with purpose. Interviewees described the process of searching, trimming, and assembling
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of pieces as “calming.” Some indicated that whether the pieces being trimmed were for personal
use or for clients, the outcome was nevertheless beneficial. The particulars of preparing for a
collage assembly required the individual to slow down, to focus on the objects being handled,
and to then compose and re-compose the piece before finalizing it. The contemplative elements
in the practice of preparing for and creating a collage overall were seen by this group of art
therapists as beneficial. Going a step further, the same collage process could also be used
adjunctively with more traditional practices or intuitive approaches for a variation in the overall
creative process and outcome.
Intuitive approach to the creative process. As used in this study, the intuitive approach
refers to an art process that is responsive to individual needs, and preferences, as well as
environmental constraints. Working with whatever is readily available without definitive
timeframes or schedules, the individual using this approach has not necessarily set aside a time
and place for creating a visual expression. Rather, they respond to the urge intuitively. The time
needed to complete a piece could be minutes or days. Those who were able to work in this
manner were not incapable of working in other styles, but they were more responsive to the
immediacy of engaging the creative process, an on-the-spot approach. This seemed to work well
for those who did not have scheduled time for creating art, and instead engaged in the process
between client sessions or other duties, utilizing whatever tools and media were at hand. At
times, the purpose of such an approach was to gain control over an experience or to gain distance
from one in a shortened amount of time. Such an opportunity would be needed between back to
back sessions with challenging clients in order to access a more stable emotional state before
returning to other planned activities. Blair’s response to time constraints was a combination of
traditional methods: a mandala drawing, scaled down to a few inches in order to be a quick
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response to clear her mind. Devon, voiced challenges in not having access to the media and
tools she had been accustomed to using, and thus had to be flexible and use whatever was
available, whenever it was available. In being responsive to her environment and needs, she
noted changes in her creative practices, especially during times of transition and perceived stress.
At the other end of the spectrum, in the vibrancy of workshops and conferences, Mari indicated
feeling overwhelmed and needing to retreat to an art space. Once there, she voiced getting “into
the zone” and creating with minimal awareness of peers moving around her. Creating a piece
that expressed the duality of excessive energy and providing a means for containment, before
returning to her scheduled activities.
At the workplace, the tasks completed by these therapists, was for the benefit of their
clients, but in engaging the creative process there resulted in gains for the therapists as well. Art
was used by the interviewed art therapists at some point in their careers as a means of self-care.
Becoming aware early-on of the innate intimacy of the creative process and its usefulness in
mirroring events of importance. Those with habitual creative engagements noticed changes in
the process serving as red flags, alerting them to accumulating stress. The creative process could
then be used to express the emotive content.
Therapist flexibility and awareness were more important than which type of media and
process to use. Therapists needed to remain aware of the personal cues alerting them to
accumulating stress and the rising urgency to turn to creative engagement. Flexibility, then,
meant the willingness to take the time for self-reflection that was afforded through the act of
creative engagement. It also implied a readiness to work with whichever materials were
available, and for an unscripted amount of time, 5 minutes, an hour, or another time period. The
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purpose for engagement was noted to be release, processing, or documentation, but that was not
to say it did not serve other purposes at different times, depending on the needs of the therapist.
Research Question 2: Does Personal Visual Expression Mitigate Perceived Burnout?
Burnout was understood to be a natural response allowing for detachment (Maslach,
1982; Maslach, Schaufeli, & Leiter, 2001) from an otherwise chronic state of mental and
physical exhaustion (Chernizz & Krantz, 1983; Farber, 1983a; Maslach, Schaufeli, & Leiter,
2001; Pines, 1983). For the most part, interviewees expected a certain level of stress as a hazard
of being an art therapist; describing the job at various times as being both stressful and
rewarding. Recounting residual stressful material generated from their daily interactions with
clients. Several of the interviewees further spoke about turning to creative expression after
particularly difficult events, such as a difference of opinion within the group (see Figure 9), the
loss of a client (see Figure 10), or an argument (see Figure 5). Their stories were indicative of
mirroring session outcomes, both when being successful and when incurring losses. All
interviewees advocated for the importance of self-care as a general practice, emphasizing the
need to find an effective means of disconnecting from workplace roles and clients for selfpreservation (Figley, 2002b). One interviewee indicated that the cyclical nature of stress as a
pattern, required continual action on the part of the therapist to ensure hope was not lost.
Identification of Increased Stress
Several interviewees indicated becoming alerted to rising stress levels by a combination
of behavioral or emotional changes, as well as by emerging red flags within their visual artifacts
and processes. Typical physical complaints that also served as cues of increasing stress were
chronic tiredness, headaches, muscular aches, illness, and similar ailments. Difficulty sleeping
or work-related nightmares were also discussed as being indicative of accumulating stress.
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Camie described it as being “spread thin,” and Mari voiced being familiar with walking in a
mental “fog.” Under such circumstances, the interviewees indicated noticing an overall
emotional reactivity, including decreased patience with clients and peers, and a generalized loss
of ability to manage emotions. Although far from being classified as burnout, interviewees were
aware of the adverse effect on their personal and professional relationships of continuing to work
without effectively addressing the accumulating distress. Those interviewees who routinely
engaged in the creative process indicated that they noticed changes in their art-making behaviors.
Changes in process as red flag. Most interview participants had sufficient experience
with their personal creative processes, to be familiar with their nuances, as well as any
deviations. These deviations from the usual processes were considered red flags. Even those
who did not have a habit of engaging in the creative process would notice fluctuations in their
desire to create: the higher the distress, the more pronounced the urge to create. Those who did
practice routinely voiced noticing changes in their usual manner of working. Speeding up or
slowing down, could be seen as responsive and balancing actions. As indicated earlier, in so far
as these visual artifacts served as mirrors of current events, they were also bound to contain
elements indicative of stress. Regardless of the action when the red flag was noticed, it brought
the event into awareness, allowing for further corrective action to take place. For some that
meant additional visual engagement in order to clarify the issues presented. For others it was
counseling, increased physical activity, changes in work routines, or meditative practices.
Residual Material
While informed on the effects of burnout, interviewees also noted struggling with
allocating time for self-care practices. Ambiguous or intangible, losses incurred while on the job
could be additive, and leave the therapist feeling drained (Skovholt & Trotter-Mathison, 2011).
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However, it was actual losses, personal or otherwise, that the interviewees struggled with the
most. Employers played a large role in how client losses were communicated and processed.
Several of the interviewees voiced the importance of peer support, during distressing events,
noting the importance of knowing you are not alone, and of finding a means of processing the
loss.
After losses, or build-up of daily stress, these therapists advocated finding a means of
purposeful processing. Some of the work-places that were discussed provided access to various
means of processing as part of the work routine, as a means of keeping their professional staff
healthy. These supportive practices included meetings, workshops, creative gatherings, open
discussions, or retreats. This was not the norm, however, and was not a readily available outlet
for most of the therapists. Interviewees voiced being inspired by workshops, peers, or even
clients themselves, to engage in practical daily acts that were restorative. Interviewees indicated
that despite best efforts, there would be residual material from working with clients, which could
buildup and needed to be regularly addressed. Restorative acts in serving this purpose needed to
have a component of being in the moment, and whenever possible of also extending beyond the
individual and connecting with a supportive community. Diversity in the social support system
was essential for the therapist’s well being (Figley, 2002b; Westwood, 2009). For some of those
interviewed, this meant seeking traditional community support, while for others it was intimately
linked with various social networking platforms (SNP).
Traditional community support. Traditional means of supportive practices referred to
family, professional, and other community interactions, which were not conducted through SNP.
Interviewees identified significant others, and family members, as providers of communal
support. Significant others were described as providing a counterbalancing, and supportive role.
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However, as many did not have the training necessary to process the information being given,
significant others could at times be over-burdened, possibly straining relationships.
Some interviewees were replenished by taking part in creative group activities within
their communities. Leisy spoke about a past experience where she coordinated her own gallery
showing, as a means to motivate herself to create a routine for visual expression. Her gamble
paid off, and she developed her art practice and was able to experience having her art observed
and discussed. Pieces she described as being intimate were on display and she was asked about
them by the supportive community members and peers in attendance. Years after the gallery
show, she continues her creative practices.
Blair’s creative practices included group art-making, and sharing within her local
community. She took part in a creative group gathering for several hours every few weeks to
create visual artifacts. Creating within the group gave her a sense of camaraderie, of sharing the
experience and knowledge among the gathered participants. Looking back, she expressed having
found the group in times of personal distress, and gave credit to the group as well as the creative
process for getting her though the situation. In both of these cases, local communities provided
witnessing and validation of the visual artifact and as an extension of the makers, they validated
the time and efforts of the makers as well.
Social networking platform communities. In processing excessive stress through
creative engagement, some of the interviewees turned to SNP as an addition to, or even an
extension of their practices. SNP provided accessibility to individuals and communities or
groups of people whether known or strangers. Depending on the platform, SNP use allowed
individuals to communicate and share through text, image, and video. They allowed contact to
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be made and maintained beyond that of the traditional local communities of peers and
professionals.
Such was the case with Blair and Camie, who both used SNP to extend their contact with
peers that would otherwise not have been possible. Blair indicated that she stayed connected to
her community group by using a closed group account on an SNP. This platform exchange was
crucial during the times between physical group gatherings, or for those members who could not
otherwise attend the meetings. SNP use allowed members to communicate in spite of inclement
weather, illnesses, scheduling, distance, or other limitations.
Years prior to the study, Camie indicated feeling physically and mentally disconnected
from friends and family. After some coaxing, she created and managed a closed blog where she
would post images of mandalas she created with minimal or no description. Invited members
could see her posts and provide feedback and encouragement. She indicated that she was
surprised by the support she received, and while engaged in the process of creating and posting,
she found it helpful. A survey respondent indicated that sharing response art provided her with
“a sense of feeling valued, understood, connected.”
SNP have both inspirational and promotional values as well. Several of the interviewees
indicated that it was through such platforms that peers shared their creativity or inspirational
messages, which in turn affected the viewer. “It is validating when others can visually
appreciate your feelings toward an event. It often encourages others to take the risk themselves,”
indicated a survey respondent. In one discussion, Camie voiced being moved by such creative
professionals, most of whom were not classically trained artists nor art therapists. This seemed
to be an especially important routine on those weeks and months when she found herself unable
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to create art herself. The ease of incorporating the technology into daily routines made it
accessible.
Overall, those who routinely used SNP indicated that they did so due to the reliability of
connection and accessibility despite the risks: they had personal and professional value. As
primarily public platforms, the content of what was shared could easily become distributed
among more than those intended. Any posts would also be seen as linked or endorsed by the
individual doing the posting. Those working in rural settings would need to be particularly
mindful of the content of their public profiles and posts in case they were found by current, past,
or prospective clients. In spite of this, SNP were identified as a means to maintain a professional
presence and remain updated about peers across the globe. This was especially important for
those art therapists practicing away from their local communities. Also of note was that while
only half of the interviewees routinely posted on SNP, at least some of the others indicated using
SNP as a means to stay connected. However, they expressed that they did not trust the platforms
enough to use them routinely in the posting of images such as personal art. In general, SNP use
provided the majority of these art therapists with opportunities for continued action, support,
accountability, and community building.
Personal visual expression aided in the identification, processing, and documentation of
distressing life, and workplace events. While the art therapists interviewed did not identify as
having been burned out, they knew that as therapists and empathetic individuals the possibility
was present. Throughout the interviews they described instances, most documented through
their visual artifacts, which caused significant distress (see Figure 9, 10, 11, & 19). In those
cases, visually documenting their experiences as art therapists helped them to come to terms with
those challenges, such as the difficulties of losing a client, not being immediately accepted at a
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new job, feeling displaced or alienated, being at odds with a client or supervisor, or being
belittled, on top of having personal hardships. Creative engagement was responsive to the needs
of the therapist, and even with small amounts of time, aided in bringing stressors into awareness,
processing them, and diffusing them.
The art therapists interviewed spoke about their past and present creative engagements as
well as how these were used in the processing of overall distress. The last supporting question
builds on the prior questions in order to better understand how art therapists use responsive artmaking.
Research Question 3: Does Responsive Art-Making Influence Art Therapists’ Professional
Identity, and If So How?
Interviewees indicated there was a duality or struggle, between being an open empathetic
clinician, and the need to keep themselves at a safe distance. Camie voiced that:
It’s a really fine balance for counselors…I think especially for art therapists that on the
one hand we need to be these really open empathetic people, but on the other hand we
can’t let it penetrate us, because if we let all of that muck into ourselves we would just be
distraught.
Interviewees expressed having a connection to their profession; to them it was more than just a
job. Camie explained that, “if you really love what you do…you’re also going to want to bring
your work home…to share it…and you can’t just, like, cut it off.” There seemed to be a personal
connection to the relationship between the interviewees and their choices to become art
therapists, which was reflected in their core beliefs about the art as important, and the overall
process as beneficial. Through their understanding of the art therapy profession and their
personal relationship with the creative process, these 6 women adamantly expressed a desire to
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stay in the field, in spite of the challenges. The pursuit of practices that mitigate the inherent
stress of working with individuals in need is not a static one. In past years other art therapists
have advocated for developing a personal art practice as a means of clinician role development
and maintenance (Fish, 2012; Kramer, 2000; McNiff, 2004; C. Moon, 2002; Robbins, 2000).
A Case for Flexible Boundaries
Boundaries were one of the key elements needing to be in place early in the career of the
art therapist, but which needed to remain responsive, like the creative process, to changing needs.
As such, boundaries were seen as needing to have an inherent flexibility to function in response
to both the work culture and personal needs. There simply was no clear separation between
work roles and personal life. Several interviewees described their work boundaries as being
blurry, at times bringing work home and not finding it depleting. However, the opposite was
also true: lingering workplace stressors could detrimentally affect home life. While in school,
some voiced having more definitive boundaries and self-care practices due to the predictability
and nurturance of the environment as well as continual reminders from peers and professors.
Over time and with varying experiences, boundaries as well as self-care practices changed. The
degree of responsive flexibility varied depending on the employing facility, personal comfort,
and geographical location and culture. Camie voiced that it was complicated, “there’s times
where I pulled from my clinical work and it gives me tools to help cope…but there’s also times
when things going on [in my personal life]…makes me really adverse to dealing with things at
work.” It was definitely “not the black and white that we were taught in school,” she explained.
Visual Expression as a Positive Investment of Time
In encouraging continued clinician resilience, being able to recognize, accept, and adapt
to changing circumstances was seen as a crucial and recursive practice. Restorative activities
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were those with the ability to contain and process the distress. Working through the tough
moments when they felt “out of the water,” was crucial. Of outmost importance was the need to
remain focused within over-stimulating and demanding work environments. This functionality
came at great personal cost to the therapist. Those interviewed indicated physical ailments,
headaches, excessive tiredness, muscular aches, changes in sleep habits, and a generalized
inability to turn the mind off from work-related topics. When under stress, these art therapists
also noticed decreased patience, feeling spread thin, becoming snappy at others, and being down
or in a fog. In general, when dealing with excess stress, these art therapists voiced having an
overall decreased ability to manage their emotions. However, in those stressful events there was
also opportunity.
The interviewees voiced turning to the creative process at some point in their careers as a
means of expressing frustrations about particular events, or as a means of gaining a new
perspective on challenging situations. In doing so they took part in the reciprocal creative
process, facilitating the exchange between the artifact being developed and the content needing
to be expressed (Dissanayake, 2000). In devoting time to the creative expression, the acts and
resulting content were imbued with distinction from other similarly-occurring events (Anderson,
2004). Through the creative act, individuals were able to sublimate overwhelming emotive
experiences (Levine, 1995; Lusebrink, 1990; McNiff, 2004). By means of expanding and
contracting the concepts needing to be processed, there was transformation and new connections
made. Serving as a means to make sense of the world, to stimulate action, and contain any
dissonant content, the dynamic aspects of the creative process became increasingly personal and
particular with practice (Dissanayake, 2000). In her artifacts, Blair visually expressed her
feelings and beliefs in reference to a distressing workplace confrontation (see Figure 5 & 6). In a
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subsequent piece, she collaged symbols she deemed pertinent to her professional identity (see
Figure 10) following the workplace incident. In using the art as a means of elaboration, the
individual developed a sense of competence over the experience (Dissanayake, 2000; Hinz
2013). Several of the other interviewees also used the creative process as a means to visually
conceptualize issues of client treatment (see Figure 9), losses (see Figure 10), stagnation (see
Figure 17), and documentation (see Figure 18). The interviewees advocated for the importance
of therapist creative engagement, even if the practice was inconsistent. Adrian voiced that in
spite of society’s views, that condemn self-care as a selfish practice, it was necessary to take the
time for personal well-being (see Figure 2, 3, & 4); without such practices art therapists would
not be able to do the work they do reliably.
Novel Experiences
A theme which emerged out of the interviews was that of a novel experience serving to
break a pattern of behavior. The concept of a novel experience surfaced in the areas of role
identification, work environment, stress, and visual response. Novel experiences brought on an
increased sense of excitement as well as accompanying stress. These opportunities were
concurrent with new employments, new roles, clients, or duties. For instance, graduate programs
having semesters with cycles of new courses, internships, and a variety of client populations. To
balance the external demands there tends to be an inherent structure and in the best of cases, a
system focused on instilling self-restorative practices in the developing professional.
Interviewees explained how their lingering work-related distress was not due to their clients, but
to the workplace, environment, peers, and leadership. Novel experiences in general provided
unexpected challenges and rewards; they provided a respite from the monotony of stagnant work
practices.
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As Blair reflected, whenever present, novel experiences seemed to take precedence in the
art, “lately, because the position is so new that most of my artwork tends to do with work in one
way or another” (see Figure 5, 6, & 7). The stress and anxiety accompanying the novel
experience were expressed through creative engagement. Such expressions seemed able to take
place either unconsciously or purposefully, depending on the individual and their relationship
with the creative experience. Such was the case when Mari attended a national conference for
the first time and had excess energy to process (see Figure 14). She did so through “losing”
herself in the creative process, and only after her piece was completed did she return to the day’s
events.
In exercising control over the creative process, the individual also took on limited
exposure in order to come to a new understanding of the event. As such, creative engagement
for the processing of a stressful experience could be a willful action in attempts to mitigate the
outcome. In creative expression, as the experience is elaborated, the individual gains a sense of
competence (Dissanayake, 2000). When Devon had a stressful event ahead of her, she
preemptively created a visual response illustrating her fears and encouraging herself at the same
time (see Figure 11). In illustrating her hopes and fears, she processed some of her anxiety and
the piece served as documentation for review after the experience had passed.
Creative expression also served as an outlet for processing an emotionally overwhelming
workplace experience. In deconstructing stressful experiences, the therapist is confronted with
and must work through their vulnerabilities (Saakvitne, 2002). When faced with ethically
challenging circumstances in the treatment of a client, Camie turned to a visual response as a
means of developing the dialectic. Collaging images and words together within a mandala (see
Figure 9), she later voiced that creating the piece helped her resolve her feelings about the case in
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a “constructive way.” Leisy also turned to visual expression as a means of elaborating and
processing challenging clients in order to better understand them and herself (see Figure 17 &
18). Adrian observed that in her own work, the more prolific her art, the less work content it
contained (see Figure 2, 3, & 4), because then the work is not being created solely to process
workplace distress.
The creative process, while able to be used as a means to work through distressing
events, could also serve to break from a stagnant pattern of behavior. Engagement in response
art or other creative expression could be a means of instigating a novel experience. Creative
expression allows for the physical and cognitive engagement of a past experience, itself serving
as an experience. Instigating a novel experience through the creative process would provide
access to the one engaged in the art for an on-call respite. The experience provides a distraction
to be used as needed. Such purposeful means of distraction could also provide the art therapist
with amplified creative experiences, which could then be applied to their therapeutic practice.
An increased frequency of making would also serve to develop the relationship between the
therapist and the creative experience, which interviewees spoke about. Rollo May (1975) would
also agree that creativity, like other skill sets, would need to be ‘honed’ throughout the life span,
in order for it to prove useful when needed. It is in regular creative expression that there lies the
possibility for continued personal and professional development.
Community Role
Considering that not every art therapist involved in this research created response art
regularly it was interesting to see the contributions of communities in their creative and
professional practices. There was a small subset of participants who indicated that after creating
art, they proceeded to share it with others. Those who created response art and choose to share
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it, did so primarily with art therapy colleagues (77.8%, n=14) or friends (72%, n=13). This was
done through local networks and SNP use. Whenever available, workshops and conferences also
become venues for sharing response art. Few respondents (17%, n=3) reported sharing their
visual artifacts with the general public.
Those who shared their art using SNP indicated that sharing had become part of the
creative process. According to a Phase I survey respondent, sharing response art with others
“validates, normalizes, [and] provides a sense of witnessing & belonging.” This follows the
literature presented previously, which indicated that there was a natural progression of
communication between the individual and their community that was established, maintained, or
otherwise enriched by means of the art (Becker, 1982; Dewey, 1980; Dissanayake, 1988, 2000;
Rosen, 2009). Sharing art through an SNP expanded the art therapist’s access by connecting the
otherwise isolated clinician to an online collective, broadening their sense of identity through the
art contributions to the group (Anderson, 2004). Another respondent indicated that “sharing my
artwork with peers and colleagues allows for increased self-reflection and additional feedback
related to subject matter of art work and ultimately better understanding of professional self.”
All in all, those who did engage in responsive art-making said it positively impacted their
work and personal life. Those interviewed expressed having a connection to the art early on in
their lives or careers, before developing their art therapist identities. Having been present early
on, the relationship with the creative process expanded as new roles and professional identities
were explored. Visual expression was seen as a rewarding investment of time that left behind
concrete artifacts to illustrate points of personal transition. In their creative expression, the
participating art therapists processed and expanded on their experiences.
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Main Question: How Do Selected Art Therapists Employ Personal Visual Expression To
Sustain Their Practice?
In answering the main question, it was necessary to first address all the supporting
questions, because as will be demonstrated, it was through these supporting questions that the
main question could be answered. Keeping in mind that because the focus of this research was
on how visual expression was used by art therapists to sustain their practice, all those who were
interviewed were art therapists who had some interest in the topic. All those interviewed had
made art at some point that they considered to be responsive in nature. While only some
continued the practice, it became evident that through the process and the visual artifacts, these
art therapists made lasting connections to particular events.
The participating art therapists used art as part of their self-care routines and activities.
Visual expression was not their only means of processing stress, but it was one of the ways they
could become aware of its accumulation. Creative expression was deemed effective if, after
engagement, the therapist’s stress was alleviated enough that she was able to resume work and
personal life. However, this required a certain degree of responsiveness on the part of the art
therapist, which in this context pertained to the ability to notice increasing urges to create and
following through in a timely manner. Responsiveness also referred to the therapist’s ability to
allow surfacing content to be expressed in place of the original intended theme.
In being responsive to the rise in urgency to create and in then using the creative process
to do so, these art therapists increased their awareness of their particular set of events. While
exposure to emotionally triggering events could be planned, it did not have to be. Intentional
participation in a creative act in order to process specific themes did not decrease its percevied
effectiveness. Similar to Leisy’s use of her creative practice for the exploration of workplace
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themes, other clinicians had used visual expression to inform the course of treatment (Fish, 2006,
2008, 2012; Kramer, 2000; Levine, 1995; Malchiodi, 2012; B. Moon, 2003; C. Moon, 2002).
For those therapists who created on a consistent basis, a soft approach gave them the flexibility
to respond to the rise in urgency as soon as feasible, whether that meant creating at work, during
commutes, or in the minutes between activities. For these individuals, being flexible also meant
using any art media that was available and most feasible. These quickly-made pieces, while not
seen as masterpieces, at times not even complete, served their intended purpose of diffusing
anxiety. Some brief creative engagements only permitted time for acts of preparation versus
complete creation. In their repetitive and focused processes, these acts were also seen as
effective at dissipating stress.
Engagement in the creative process, like any other relationship, had the potential to
develop over time. All those who took part in the interviews voiced a pre-existing connection
with creative expression, which adapted over time to the needs and preferences of the therapist.
Experiencing through the creative process was an instinctual way of exploring dissonant
concepts. Creative engagement provided these art therapists with a contemplative practice, a
state of distraction from the world, and intense focus on the actions and themes immediately
before them. It was described as a consuming and rewarding experience, requiring practice and
dedication for increased understanding.
Self-care was seen as a necessary part of being an art therapist. Residual material
emanating from workplace stress or personal life events, were frequent possibilities. Being
aware of the warning signs of accumulating stress, was therefore fundamental to being able to
take reparatory steps early on, before performance was affected. While all those interviewed
were aware of physiological cues alerting them to accumulating stress, those who frequently
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responded to the creative process were also able to notice other cues. Cues resulting from
creative engagement emerged as early as the process began and at any point thereafter. Although
the changes could be subtle, they were noticed as not fitting-in with the ritual or rhythm of
creation. These unsolicited changes in process or thematic content were observed as red flags,
and served as an alert system. Red flags brought the accumulating stress or other particular
events into awareness, but it was up to the therapist to do something about it.
It was within the creative process that stressful and often dissonant concepts could be
explored and given order (Dewey, 1980). Providing for the expansion and adaptation of
experiences, the creative process facilitated critical thinking (Dissanayake, 2000) in the
individual involved. Visual expression as a tool for exploration of an experience could also
serve as a means to change it. In sequencing repetitive movements, control can be exerted over
the experience and over the concepts being expressed (Dissayanake, 2000). The resulting
artifact connects the maker to the experience and the collection of moments and acts that led to
it, a personal symbol of the transpired events serving to cue specific content when needed (Fish,
2008, 2012; Levine, 1995; Robbins, 2000).
Being aware of the presence of stress and having engaged in response art was at times not
enough. The element of connection with the other was sought through peers, professional
colleagues, and family. Supportive communities extended from traditional face-to-face access,
to more expansive SNP collectives. While both offered validation, encouragement, and
feedback, the latter had greater accessibility. SNP exchanges proved their most useful in
connecting users across time zones and geographic locations, through inclement weather and
illnesses. Both methods of building community were seen as helpful and necessary, as well as
adjunctive, working together to inspire and expand the therapists’ accessibility to others while
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providing them with access as well. However, because their online presence formed part of their
professional identity, art therapists were rightly cautious of SNP use.
The professional identity of these art therapists benefited from their engagement in acts
of personal visual expression. While creative practices were for the most part begun prior to
graduate studies, in the course of their education art therapists developed their relationship with
the creative act. When they entered the field and whenever their circumstances changed, creative
engagement was once again sought, the flexibility informing developing boundaries. It was
understood that for continued resilience as an art therapist, a means of processing and dispelling
excess stress was necessary. In spite of all odds, these art therapists routinely engaged in
restorative practices that in turn influenced how they identified and performed. Serving as a tool
for honing their skills, engagement in the creative process required sustained practice (Kramer,
2000; McNiff, 2004; B. Moon, 2003; Robbins, 2000). Engaging in the creative process was seen
as a positive investment of time and effort, providing a means to express frustrations, manage
emotions, or document an experience.
Participation and documentation of creative expressions could also serve as novel
experiences. Novel experiences emerged in the interviews as sources of stimulation and stress
but when seen as positive, could elicit enthusiasm in the anticipation of a good thing. Because of
their primacy, novel experiences flooded awareness and creative acts until effectively processed.
Knowing this, art therapists could purposefully create response art towards the amelioration of
distressing content. Novel experiences could also be sought in the creative process as a means of
spurring-on and breaking out of a stagnant pattern of behavior.
In the pursuit of effective recurring restorative practices that work in tandem with
established schedules and practices but which served to enhance said practices, the creative
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experience was key. In answering the question of how selected art therapists employ personal
visual expression to sustain their practice, I will build on the themes already presented by using
one of Bandura’s (1999, 2001, 2012) theories of knowledge acquisition. Triadic reciprocity can
be used to explain the exchange between an individual, the environment, and behavioral
variables towards the attainment of knowledge. In processing an event, the individual therapist
brings their prior knowledge and current emotive content to the experience. Environmental
constraints come together with the art media and time allocation, and further contribute to the
event. The third element, the individual’s behavioral output is influenced by both the emotional
component and the environmental elements. All 3 elements, when working in unison, create a
feedback loop through media manipulation and the creative process. Personal visual expression
is thus a sustaining practice for art therapists because of the dynamic interaction present within
and between the elements in the creative acts, serving to sublimate emotive impulses into
ordered experiences by means of the processes. Overall, the creative process served as a
recursive process best when used frequently and with awareness of contributing elements. It
provided the therapist with the means by which to process and document experiences. In doing
so, the therapist also gained experience in the processes involved, and these in turn affected how
they performed their duties.
Conclusions
This study sought to investigate how selected art therapists employ personal visual
expression to sustain their practices. Supporting questions addressed whether and how art is
used as a self-care practice by art therapists, whether personal visual expression mitigates
perceived burnout, and whether responsive art-making influences art therapists’ professional
identity development.
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This study was conducted in order to contribute to the existing body of knowledge in
regards to art therapist practice. In answering the main question it was first necessary to
establish whether art therapists used art for self-care. The majority of those who took part in the
preliminary stage of the study endorsed use of creative expression, some in the form of response
art, and others not. In the interest of increasing understanding of how art therapists were using
personal visual expression, responses were limited to those who did use it.
Those art therapists who use art for self-expression do so as often as possible following a
distressing event in order to process and contain the emotive content. Creative engagement does
not automatically mean response art, nor does one have to enter into the expression with that
purpose. What is important is being responsive to the urge to create as a means to process
distress. It is also important to be flexible in means and methods of creative engagement to
allow for increased creative acts. With frequent engagements, there was repetition and
concretization of movements, which led to ritualized processes. This meant that when
responding to an urge to create, the individual settled into a habitual and comfortable pattern of
behaviors. This pattern provided relief from stress by instilling a contemplative creative
transaction. Months or years later, when the visual artifact was reviewed, it served to cue
emotive and factual information about the initiating events.
Interviewed art therapists were clear on the negative attributes they experienced when
under stress, as they were familiar with them. Regardless of boundaries and protective practices,
residual material was to be expected. Those who had a practice of frequent creative engagement
were able to notice and label such changes as red flags, which served to alert them of
accumulating stress. Responsive therapists were then able to enact restorative practices.
Restorative acts such as regular creative engagement, provided the therapist with a meditative-
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like practice, which for some had the potential to become a shared experience. Using traditional
means of sharing their artifacts or SNP, therapists gained access to diverse community support in
terms of feedback and validation. Such groups also provided direct and indirect motivation for
continued creative practices. Furthermore, SNP were identified as a means of maintaining
professional contact with colleagues and peers, which was especially important for those
practicing away from their local communities or in professional isolation.
Those interviewed expressed that their roles as art therapists were more than a job; they
had a pre-existing connection to the art. Cultivating boundaries through education and
experience, they developed flexibility over time with increased self-awareness. Providing a
means of sublimating overwhelming emotive experiences, visual expression was seen as a
positive investment of time, and one which could serve to break stagnant or otherwise
monotonous practices by distracting and processing felt distress. The expressive process was at
times extended beyond the experience by being shared with a community of peers. While
unexpected, it made sense that taking part in the process of creating and sharing, the therapists’
social networks would diversify, and through this, contribute to their identity.
Those who participated in the interview portion of the study used art as part of their selfcare routines. The process served as a means of alerting them to increasing levels of stress
through red flags, as well as serving to dissipate stress through the mechanisms of expression.
Such mechanisms were reciprocal, indicating an interconnected process that was responsive to
the elements involved and through which all components underwent change. While the acts
themselves varied in style, length, and material use, these individuals felt an innate connection to
the process. It was something that was present before they joined the profession and which
persisted in spite of their daily hardships and workplace losses. This connection, when nurtured
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through practice, became more responsive to the changing needs of the therapist. With repetition
and practice, contemplative elements within the creative acts became more pronounced and were
retained. These behaviors which formed a part of the therapists’ creative processes were found
to ameliorate felt distress, even in the absence of completed visual artifacts. Through the
repetition of these intentional behaviors, the therapist was able to attain contemplative states
which were described as restorative. Over time those behaviors which were found effective were
retained, expanded upon, and integrated into the therapists’ clinical practice.
Limitations of the Study
This study’s design was limited in some aspects by its design and then by unforeseen
problems during data collection and analysis phases. As noted in chapter 1, this study was the
result of a personal interest in the use of creative expression for processing wok place distress by
art therapists. Researcher subjectivity was sought to be addressed through the design of the
research, data collection, and extensive analysis. Being an art therapist and having familiarity
with the topics and themes discussed was seen as a benefit to establishing a sense of competence
and trust with those interviewed. Such familiarity was also helpful during data analysis, at which
time key themes pertaining to the nuances of how participants create, versus what they create,
began to be noticed.
The design of the study distribution protocol limited participation before any data were
collected. Initially, the American Art Therapy Association (AATA) was contacted for
distribution of the study invitation to their membership. The AATA suggested instead that the
link be posted on their Facebook page. The survey link was also distributed through email to
chapters of the AATA in order to reach additional members. Both SNP and email outreach were
not as fruitful as expected. It is possible that emails were unattended or otherwise unused, and
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there was no means of knowing whether the messages were read unless the emails were returned
as undeliverable. Among the issues with SNP posts, such as those on Facebook, were that with
increased popularity of the service, there was increased movement of posts limiting their
visibility to users. While this was not as problematic with the chapter Facebook pages, it was
with the AATA’s. Chapter pages were designated as groups and required the researcher to join
in order to post. Another hurdle in using SNP for link distribution was the limitation of the post
due to character length restrictions and overall design, requiring the study-related posts to
compete with advertisers and flashy news feeds. Those who did not have access to SNP had no
access to the survey link, unless it was forwarded to them by someone who had received it.
The design of the study itself limited participation, in that only a subset of art therapists
participated in the research. Art therapists had to meet specified criteria in order to begin the
survey: namely they had to have graduated from a Master’s degree program and have had at least
6 months of practice experience. The research was divided into 2 phases and participation in the
first phase was the only means of proceeding to the second phase. An interview participant first
had to complete the Phase I survey, then upload images through the emailed link, before being
contacted for an interview. Furthermore, only those who indicated in the survey that they saw
value in response art or had engaged in responsive art at some point were given the option of
receiving more information about Phase II. As part of Phase II, participants were emailed an
individual and time-limited link that provided access to a brief questionnaire through which
images could be uploaded. Without timely response to this segment of Phase II, the participant
would not be considered for an interview. These requirements may have limited the final number
of participants.
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During Phase II there where scheduling, software, connectivity, and preference
adjustments. Due to the recording software being installed on a laptop computer, all calls had to
also be completed through it, with no live interviews unless a different means of recording was
used. All calls were therefore made through Skype; fluctuations in bandwidth and in the
software caused glitches and dropped calls on either end. Lastly, the timing of the research
approval by the IRB finalized after the annual conference and no recruiting was able to be
completed during the most attended event of the organization; the results of these limitations
were a small and homogeneous group of participants.
During the conceptualization of the research, certain elements were included as a means
of providing objectivity and further data for analyses. However, some of these elements turned
out to be impractical and irrelevant for the current study and ultimately were not used. For
example, originally a form was created to be used in the observation and objective
documentation of the art pieces provided by the participants. The form’s intended use was to aid
in the methodical observation and annotation of specific attributes present within each piece
using the elements and principles of design. The process was time-consuming and was found to
be irrelevant to the guiding research questions. While close observation of the pieces was
necessary prior to the interviews, it was the discussion with the art therapists which elicited the
most useful and rich data regarding the artifacts and their associated memories. The art pieces
themselves served as vehicles for expanding on the scripted questions. All in all, the small
sample size and exploratory nature of this study provided discipline specific insights particular to
these individuals and is not generalizable to the field of art therapy.
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Implications of Findings
The primary implication of this study will be for the field of art therapy, its students and
clinicians at large. This study’s findings were primarily qualitative in nature and may not be
generalizable to the field as a whole. However, the findings do contribute to the literature on the
practice of art therapists particularly in regard to the use of art for self-care. The data obtained
from the surveys suggested that a proportion of practicing art therapist’s use art as a means of
self-care and they also choose to share it with others. The qualitative information obtained from
participant interviews provided a glimpse into the creative practices, challenges, and beliefs of 6
art therapists with varying amounts of experience, and how they were utilizing visual expression
to sustain their practices. The study assessed particular elements of the creative process that
were found to be effective, especially during brief creative encounters, such as repetition and
ritual. Responses noted the importance of flexible boundaries that are responsive to the
therapists’ needs and are informed by their creative expressions. Providing a break from
stagnation and eliciting excitement, the novel experience surfaced as a contributing component
to a resilient practice.
Some of the practices discussed could be of significance for those clinicians who have
apprehension about initiating a creative practice. While some of the practices discussed were
elaborative and took hours before completion, some were succinctly and still effective. Most
often clinicians voiced tailoring their creative encounters in response to their time or expressive
needs. Regardless of method or time consumed the practice was most often referred to as
eliciting a state of contemplation, providing the therapist with increased self-awareness. Such
firsthand creative practices, when maintained, become part of the mechanism of how the
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therapist processes experiences. Emotionally charged and distressing experiences in particular
were often represented in the respondents’ artworks.
Art therapists provide specialized services by means of being familiar with and using
creative expression. In turn, they face challenges unique to the profession which could benefit
from further research, especially in the area of how maintaining a creative practice benefits them
both professionally and personally. This study increases awareness of the lack of research in the
field of art therapy about the continual practice of creative expression. It is hoped that it will
lead to future research conducted on those art therapists who, in spite of their demanding
schedules, find time to nurture their own creative practices. It is likely that much can be learned
from this subset of clinicians with regard to how art may be used as therapy for clients and for
the clinicians.
The study also contributed to the discussion of the creative process, moving beyond an
individual endeavor to an experience that was often shared with a larger community. In sharing
visual expressions with a collective, the feedback provided was validating and enhanced
clinicians’ motivation for continued creative practices. Having the advantage of continuous
visibility and potential feedback, SNP provided greater accessibility to users than a traditional
local group or community. Both traditional and SNP could further expand therapists’
professional presences and supportive practices, connecting those clinicians who practice in
isolation with art therapy colleagues, regardless of geographical location. This sense of
interconnectedness may be useful in preventing or reducing the effects of burnout. Future
research may attempt to investigate whether sharing art with colleagues or otherwise forging
connections with one another through social media has any effect on perceived stress or career
satisfaction.
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These findings may also be of importance to anyone in the helping professions who is
creatively inclined, such as counselors, art educators, social workers, music, and creative arts
therapists. They would understand that acquiring and maintaining effective means of processing
stress throughout their careers would be beneficial to their personal and professional
development.
Additional studies using larger sample sizes are needed to replicate and offer further
support for the findings obtained in the research. In order to increase participation, coordinating
recruitment with the national conference may prove helpful. Another modification that might
improve upon the current design would be a brief preliminary questionnaire which could be
completed as an interview, with a follow-up portion conducted online in the following weeks. A
study with a focus on art therapist use of SNP may provide a wealth of information for the art
therapy profession, which continues to reluctantly move toward interconnectivity, as its
membership becomes younger, more tech savvy, and regionally diverse.
What is clear from these results is that the use of creative expression as a form of selfcare is described as beneficial by a subset of practicing art therapists. The respondents also noted
the presence of varying types of stress, both in their personal lives and in their professional work.
Participants’ responses also supported the idea that art therapists are at particular risk of the
effects of burnout, due to their unique exposure to clients’ traumatic experiences through visual
media. The current study provides evidence that art may be effectively used as a therapeutic
process, both for clients and for the art therapists themselves. As the field advances, it must
remain open to the possibility of expanding notions of what self-care is, and even what
constitutes art and expression, for these concepts seem to be re-shaped by the increasing use and
rapid pace of technology.
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APPENDIX A
PHASE I DEMOGRAPHIC & INFORMATIONAL SURVEY
In order to continue please certify that you meet the following 2 criteria.
 I graduated from an approved masters level academic program that adheres to the
guidelines set forth by the American Art Therapy Association (AATA) or from a
nonapproved masters level academic program that adheres to the guidelines set forth by
the AATA.
 I have had at least 6 consecutive months working as an art therapist (post graduation).
 I do not meet 1 or more of the above criteria. Please take me to the end of the survey.
Demographic Information
What year were you born? -- [Year selection drop down]
What is your gender? -- [Gender selection drop down]
What is your race? (select 1)
 White/Caucasian
 African American
 Hispanic/Latino
 Asian




Native American
Pacific Islander
Multiracial
Other [Text field]
Which state, country, or continent do you live in? (select 1) -- [State selection drop down]
Main Body of Questions
Level of Education (select 1)
 Current Masters Student
 Masters Degree
 Postgraduate Degree
 Current Doctorate Student
 Doctorate Degree
 Other [Text field]
Credentialed Professional Status (select 1)
 ATR
 ATR-BC
 ATCS
 Other
 Other licensure held
 Not a credential holder
Employment Status
Please select the answer(s) that best represent your current employment status. (multiple
selections permitted)
 Working Part-Time
 Student Full-Time
 Unemployed
 Student Part-Time
 Retired
 Working Full-Time
Years employed in the field of art therapy. (select 1) -- [Year selection drop down]
Primary Work Setting (multiple selections permitted)
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 Art Center/Studio Hospital
(Psychiatric/Adolescents)
 Association/Foundation Hospital
(Psychiatric/Adults)
 Business/Industry Hospital
(Veterans)
 Correctional Facility Private Practice
 Counseling Center Inpatient Mental
Health
 Day Treatment Center Outpatient
Mental health
 Drug/Alcohol Program Non-Profit
Association/Foundation
 Education (K-12) Rehabilitation
Facility
 Education (College, University, etc)
Residential Treatment Facility
 Geriatric Facility Shelter (Domestic
Violence)
 Group Home Shelter (Homeless)
 Hospice/Bereavement Social Service
Agency
 Hospital
(Medical/Adolescents/Pediatrics)
Wellness Center/Program
 Hospital (Medical/Adults) Other
 Hospital
 Hospital
 Hospital
 Private Practice
 Inpatient Mental Health
 Outpatient Mental Health
 Non-Profit Association/Foundation
 Rehabilitation Facility
 Residential Treatment Facility
 Shelter (Domestic Violence)
 Shelter (Homeless)
 Social Service Agency
 Wellness Center/Program
 Other [Text field]
How has your work/employment status changed in the last 5 years? (check all that apply)
 Graduated from an art therapy
 Lost my job/ was fired/ quit
program
 Retired
 Returned to school
 No change
 Applied for a job
 Other [Text field]
 Hired (for art
therapy/counseling/rehab/or related
areas)
Indicate the degree to which you agree or disagree with the following statements on the scale
provided. Where 1 is completely disagree and 5 is completely agree.
Likert scale
1
Completely
Disagree
2
Somewhat
Disagree
3
4
Somewhat
Agree
5
Completely
Agree
Decline
To
Answer
Does
Not
Apply
I feel my preparation in graduate school adequately prepared me for real-world application.
I feel qualified to do the job I was hired for.
I am gratified by the work I am currently doing.
I feel that when I have concerns they are being heard by my supervisor or department head.
My work load is proportional to what I can handle.
I feel that what I do is valued by my peers.
I feel that what I do is valued by my supervisor(s).
I feel that what I do is valued by my agency/facility administrator(s).
I use art directives in my practice on a weekly basis.
I use art directives in my practice on a daily basis.
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I use art directives in my practice on a biweekly basis.
I have considered leaving the field of art therapy recently (within the last 12 months).
Please use the slider to the right to rate your level of work related/induced stress on a weekly
basis. Where 0 represents 'no stress' and 10 represents the 'highest level' of perceived stress
possible. [Slider selection dial]
What is your level of familiarity with the concept of response art? (select 1)
 Very Familiar
 Have heard the term before but I am
 Somewhat Familiar
not very familiar with it.
 Not familiar.
Briefly define response art in the space provided. -- [Comment box]
Are you a member of any groups/associations that encourage creative expression?
 Yes
 No
Do you consider yourself an active participant or contributor to said creative expression group?
 Yes
 No
Do you use response art/visual expression for self-care?
 Yes
 No
Do you see a value in the use of response art/visual expression for self-care?
 Yes
 No
Please read the following definition of response art. Then, keeping that definition in mind answer
the following questions.
Response art is a term used to indicate the art process and outcome that seeks to process an
experience, usually to do with the work environment and client interactions (Fish, 2006, 2008,
2012). For the purposes of this research I am referring to response art that primarily relates
to processing work/job distress.
How often do you engage in response art? (select 1)
 Never
 Less than Once a Month
 Once a Month
 2-3 Times a Month
 Once a Week
 2-3 Times a Week
 Daily
Which of the following most accurately describes your time-frame for creating response art.
(select 1)
176
 On the spot. I am often at work when
I begin planning for, or engage a
piece of response art.
 As soon as feasible. I try to get to it
as soon as possible (ie. within 72hrs
post distressing event).
 Within that work week (ie. if
distressing event was Tuesday, I
would begin something by the
following Tuesday).
 I make art, but it is not response art
(i.e. it does not relate to what is
taking place at work).
 I only seldom engage in response art.
 I do not engage in response art.
Where have you engaged in response art? (check all that apply)
 At Work
 I have time/place set-aside for it (ie.
 At Home
scheduled studio time)
 In transit
 Other [Text field]
 Idle-time (ie. between tasks)
When did you begin using creative expression as a means to self-care? Please select an
approximate year. (select 1) -- [Year selection drop down]
Do you share your response art with others outside of your immediate family?
 Yes
 No
 Maybe
Please indicate who you are likely to share your response art responses with. (multiple selections
permitted)
Local network of individuals/peers (ie. individuals in my local community/vicinity).
Through social networking sites (ie. Facebook, Google+, Pinterest, Twitter, LinkedIn, blog, etc).
 Friends
 Family
 Art therapy colleagues
 At workshops
 At Conferences
 With non-art therapy
professionals/peers
 General public (ie. through a gallery
or other similar means)
 Other [Text field]
177
How do you feel sharing your work with others contributes to your self-care practice?
-- [Comment box]
If there is anything else you would like to share with the researcher please leave a comment here.
-- [Comment box]
Thank you for taking the time to complete the Phase I web-based survey. This section serves to
provide some information about Phase II of the study.
I am interested in analyzing relationships between visual expression and art therapist resilience.
To do this I would like to obtain your current perspective on the contribution of visual expression
within the art therapy profession. I would like to do this by obtaining visual artifacts which you
identify as ‘response art’. The study is scheduled to take place in 2 phases, the first of which was
the online survey. The second Phase Involves submission of visual artifacts and the possibility of
an interview. You may also choose to submit visual artifacts and opt-out of the possibility of an
interview.
Phase II involves the submission of at least 1 and up to 3 images of visual artifacts that you
created as a means of processing work stress. Along with the images the participant will
complete a brief questionnaire about each of their images. Images submitted as part of this
research will be kept for possible future research unless you request to only use the image file(s)
for the present research.
Some participants will be contacted for a Skype interview. You will have the option of opting
out of the selection process for the interview. There is no guarantee that submitting images will
result in being interviewed.
Any and all participation is voluntary and refusal will involve no penalty. Participation may be
discontinued at any time. Results from the study will be used for academic purposes (ie.
professional presentations, conferences, publications).
 If you are interested in reading more about & possibly participating in Phase II of the
research please provide an email address. -- [Text field]
 No thanks. I'm done.
178
APPENDIX B
PHASE II ARTIFACT REVIEW & UPLOAD FORM
The following is a snap-shot of the Qualtrics survey used in the uploading of the image files.
Basic questions about each file will help populate the artifact image review document.
Consent & Introduction:
Thank you for participating in the qualitative research study being conducted by Sheila Lorenzo
de la Peña, M.S., ATR-BC, a student at Florida State University with the Art Education
Department. The researcher is interested in the relationships between visual expression and art
therapist resilience. As a participant in the study you will be contributing to the understanding of
how art therapists are perceiving stress, burnout, and responsive art-making. There will be no
monetary form of compensation for participation in this study.
Use of Images:
As the participant, you are agreeing to upload at least 1 image (and up to 3). Basic information
about the image(s) will be requested to accompany each image file that is uploaded. With this
consent you are granting the researcher permission to print and otherwise use the images for
academic and scholarly purposes. All records generated will be kept private and confidential.
The images will not be presented in a for-profit manner. As the participant, you understand that
the images submitted may be identifiable by others who are familiar with your work. All images
submitted will be kept for possible future research unless a request is made that they only be
used for the current research.
Optional Skype Interview:
As part of Phase II, some participants will be selected to participate in an optional Skype
interview. At the end of the image submission process there will be an option to opt “out” of the
interview selection. Submission of images and accompanying information does not guarantee
selection for interview. All interviews will be audio recorded and transcribed. The interview may
take from 45minutes up to 90 minutes to complete. Throughout the interview you will be
identified by your preferred name. Thereafter, the researcher will assign a participant ID in order
to maintain confidentiality. The results of the interview and image review will be compiled and
the results will be used for scholarly presentation and publications. The records of this study will
be kept private and confidential to the extent permitted by law.
Risk and Confidentiality:
There may be a possibility of a minimal level of risk involved by participating in this study. If at
any time you feel uncomfortable answering questions, you reserve the right to decline to answer
and/or stop participation.
Research records will be stored securely and only the researcher and university professors will
have access to the records.
As the participant, you understand that there are limits to confidentiality: In case of a court
subpoena and in case of observed abuse (ie. to a minor, an elderly, or an individual with a
179
disability). You have the right to withdraw consent at any time with a written request to the
researcher.
I, the participant, have read the consent form and agree to be part of the study. My identity will
be kept confidential.
Contacts and Questions:
The researcher conducting this study is Sheila Lorenzo de la Peña. If you have questions, you are
encouraged to contact the PI through email at [information has been redacted]. You may also
contact the supervising professor, Dr. David Gussak, at [information has been redacted].
If you have any questions or concerns regarding this study and would like to talk to someone
other than the PI, you are encouraged to contact the FSU IRB at 2010 Levy Street, Research
Building B, Suite 276, Tallahassee, FL 32306-2742, or 850-644-8633, or by email at
[email protected].
If you would like a copy of this information to keep for your records feel free to click on the
print icon at the bottom of the form. You may also email the researcher listed above.
This consent form will be kept by the researcher for at least three years beyond the end of the
study.
฀ By continuing you consent to the above.
Thank You for consenting to participate in Phase II of this research project.
Please indicate whether you would like to be considered for the pool of participants for the
optional Skype interview. Your selection will not impact participation in the Phase II image
submission and questionnaire.
฀ Yes, I understand that the Skype interview is optional. I would like to be part of the
selection pool.
฀ No, I am not interested in the optional Skype interview.
Email addresses will be used for archival purposes & in the case of those who are selected for the
Skype interview. This information will be kept separately from the data. If you are not
comfortable providing your email address you may decline by typing N/A in the fields provided
and proceeding.
First Name:
Email Address:
[Text field]
[Text field]
The next step is to select and upload at least 1 image and no more than 3 images. For each image
selected there will be several questions to answer. Depending on your connection speed and the
time you take to answer the corresponding questions the estimated time to complete the form
would be 5 to 10 minutes per image section. As indicated earlier the images will be used as part
of the data and if selected for an interview the images will be used as part of the interview.
180
Instructions
In this section there will be a series of inquiries each followed by an upload button. Each section
corresponds with the image file to be uploaded. By clicking on the Continue button you will
advance to the next section. Because the minimum requirement for participation is 1 image, the
first series of questions are all required before being able to advance. The subsequent 2 pages
will be optional. The last page will have an area for Comments.
Please select a minimum of 1 and up to 3 images that are representative of work related response
art. Response art has been generally defined as visual expression that is a result of engagement
in the creative process as a means to work through work related distress.
You may include up to 1 image of the work space were you generally work on response art,
count as part of the 3 allotment.
•
•
•
All images must have at least a minimum print resolution allowing for a clear image
print of 4"x5" or larger.
Only image files will be accepted (i.e. JPEG, TIFF, BMP, etc).
Each image file may be up to 3MB in size.
Submission of images and accompanying information does not guarantee or enhance selection
for interview.
If there are any problems with the browser during submission reload and return to the form
within 1 day. If you are ultimately unable to submit your images contact the primary researcher.
Please include a description of the issue along with your request for another link.
Artifact Index Questions: Set 1
1st Artifact: Title (if there is no title insert the file name instead) -- [Comment box]
1st Artifact: Date of completion (you may include a date range if the item was worked on for
longer than 1 day) -- [Comment box]
1st Artifact: Context in which the artifact was made (context; where was it made; who were you
with; etc) -- [Comment box]
1st Artifact: Media used (list any & all media used) -- [Comment box]
1st Artifact: Dimensions -- [Comment box]
1st Artifact: Type (ie. painting, sculpture, etc) -- [Comment box]
1st Artifact: Any further comments or information about the image & why it was chosen to
represent response art? -- [Comment box]
Upload your 1st Artifact here. -- [File upload]
Artifact Index Questions: Set 2
2nd Artifact Title (if there is no title insert the file name instead) -- [Comment box]
2nd Artifact: Date of completion (you may include a date range if the item was worked on for
longer than 1 day) -- [Comment box]
2nd Artifact: Context in which the artifact was made (context; where was it made; who were you
with; etc) -- [Comment box]
2nd Artifact: Media used (list any & all media used) -- [Comment box]
181
2nd Artifact: Dimensions -- [Comment box]
2nd Artifact: Type (ie. painting, sculpture, etc) -- [Comment box]
2nd Artifact: Any further comments or information about the image & why it was chosen to
represent response art? [Comment box]
Upload your 2nd Artifact here. -- [File upload]
Artifact Index Questions: Set 3
3rd Artifact Title (if there is no title insert the file name instead) -- [Comment box]
3rd Artifact: Date of completion (you may include a date range if the item was worked on for
longer than 1 day) -- [Comment box]
3rd Artifact: Context in which the artifact was made (context; where was it made; who were you
with; etc) -- [Comment box]
3rd Artifact: Media used (list any & all media used) -- [Comment box]
3rd Artifact: Dimensions -- [Comment box]
3rd Artifact: Type (ie. painting, sculpture, etc) -- [Comment box]
3rd Artifact: Any further comments or information about the image & why it was chosen to
represent response art? -- [Comment box]
Upload your 3rd Artifact here. -- [File upload]
Final Section
Please use the space below to leave any further comments. -- [Comment box]
Congratulations! You have reached the end of Phase II. In the coming days I will be reaching out
to a few participants to gain a better understanding of how they process work stress through
visual expression. Those who opted to be considered for the interview, please monitor the inbox
of the email you provided, as the researcher will be contacting selected participants through
email in about 7 to 14 days. As indicated earlier image submission does not guarantee an
interview.
Thank You for your participation!
182
APPENDIX C
SOCIAL MEDIA POST
Art therapy research participants needed!
Participants needed for a dissertation research study seeking
to explore the relationships between visual expression and art
therapist resilience. The study is broken-up into 2 phases, the
first of which is an online survey.
Participants must be graduates of an approved or nonapproved masters level academic program that adheres to the
guidelines set forth by the American Art Therapy Association.
Participants must have at least 6 consecutive months working
as an art therapist (post graduation).
Phase I Survey Link:
___________________________________________
If you encounter any issues or if you have any questions or concerns regarding this
study please contact the researcher, Sheila Lorenzo de la Peña, at [information has
been redacted], the supervising professor, Dr. David Gussak at [information has
been redacted], or FSU IRB at 2010 Levy Street, Research Building B, Suite 276,
Tallahassee, FL 32306-2742, or 850-644-8633, or by email at
[email protected].
183
APPENDIX D
PHASE I SURVEY INVITATION
Hello,
My name is Sheila Lorenzo de la Peña, and I am a doctoral candidate in the Art Therapy
program at the Florida State University. I am interested in analyzing relationships between
visual expression and art therapist resilience. To do this I would like to obtain your perspective
on the contribution visual expression has on your profession as an art therapist. The study is
scheduled to take place in 2 phases, the first of which is an online survey. The second Phase
Involves submission of visual artifacts and the possibility of an interview. Participants may
choose to participate in the Phase I survey without participating in Phase II.
Phase I - Study participants will be able to complete a web-based survey estimated to take
approximately 15 minutes to complete. Questions include demographic information such as age,
gender, professional status, and work history. The information collected will be anonymous.
At the end of the online survey, participants will have the option of volunteering to take part in
Phase II of the study which involves the submission of up to 3 images of visual artifacts the
option to self identify as a prospect for possible interview.
Any and all participation is voluntary and refusal to participate in either Phase I or Phase II will
involve no penalty. Participation may be discontinued at any time. However, you will need to
complete the entire Phase I survey in order for the results to be used. Results from the study will
be used for academic purposes (ie. professional presentations, conferences, publications).
If you have any questions or concerns regarding this study please contact the researcher, Sheila
Lorenzo de la Peña, at [information has been redacted], the supervising professor, Dr. David
Gussak at [information has been redacted], or FSU IRB at 2010 Levy Street, Research Building
B, Suite 276, Tallahassee, FL 32306-2742, or 850-644-8633, or by email at
[email protected].
Thank You for your Consideration,
Sheila Lorenzo de la Peña
Doctoral Candidate
Florida State University
The Phase I survey can be reached via this link: ________________________________
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APPENDIX E
PHASE I CONSENT FORM
You are invited to participate in a qualitative research study being conducted by Sheila Lorenzo
de la Peña, M.S., ATR-BC, a student at Florida State University with the Art Education
Department. The purpose of the study is to explore the relationships between visual expression
and art therapist resilience. To do this I would like to obtain your perspective on the
contribution visual expression has on your profession as an art therapist. The study is scheduled
to take place in 2 phases, the first of which is an online survey. The second Phase Involves
submission of visual artifacts and the possibility of an interview. Participants may choose to
participate in the Phase I survey without participating in Phase II.
Eligible participants will be those who meet the following criteria:
1. Participant identifies as having graduated from an approved masters level academic
program that adheres to the guidelines set forth by the American Art Therapy Association
(AATA).
2. In addition, participants need to have attained at least 6 months post graduation from said
approved program of consecutive experience providing art therapy services. *Art
therapists who are not currently practicing art therapy will still qualify to participate if
they meet the conditions above.
Background Information:
The purpose of this study is to learn about the contributing factors of responsive art-making by
art therapists and its perceived contribution to their professional practice.
Procedures:
Participation in this study is voluntary. Participants have a right to withdraw consent at any time
with a written request to the researcher. By clicking the button to begin the online survey the
participant agrees to having read the consent form. Furthermore, by clicking to begin the survey
the participant agrees to participate in this study. The participants’ identity will be kept
confidential. The results of the survey will be compiled and the results may be used for scholarly
presentation and publications.
Phase I - study participants will be able to complete a web-based survey estimated to take
approximately 30 minutes to complete. Questions include demographic information such as age,
gender, professional status, and work history. The information collected will be anonymous.
At the end of the online survey, participants will have the option of volunteering to take part in
phase 2 of the study which involves the submission of up to 3 images of visual artifacts and the
option to self identify as a prospect for possible interview.
185
Risks and benefits of being in the Study:
There is a risk that you may find some of the questions to be personal in nature. If at any time
the participant feels uncomfortable answering questions, the participant may decline
participation by closing the survey window.
Benefit(s):
As a participant in the study you will be contributing to the understanding of how art therapists
are perceiving stress, burnout, and responsive art-making.
Compensation:
The participant understands that there will be no monetary form of compensation as a result of
completion of the online survey for this study.
Confidentiality:
The records of this study will be kept private and confidential to the extent permitted by law. In
any sort of report that is published anonymity will be maintained. Research records will be
stored securely and only the researcher and university professors will have access to the records.
The participant, understands that there are limits to confidentiality: In case of a court subpoena
and in case of observed abuse (ie. to a minor, an elderly, or an individual with a disability).
Voluntary Nature of the Study:
Participation in this study is voluntary. Your decision whether or not to participate will not
affect your current or future relations with the University. If you decide to participate you are
free to not answer any question or withdraw at any time without affecting those relationships.
Contacts and Questions:
The researcher conducting this study is Sheila Lorenzo de la Peña. If you have a questions, you
are encouraged to contact the PI through email at: [information has been redacted]. You may
also contact my supervising professor, Dr. David Gussak, at [information has been redacted].
If you have any questions or concerns regarding this study and would like to talk to someone
other than the researcher, you are encouraged to contact the FSU IRB at 2010 Levy Street,
Research Building B, Suite 276, Tallahassee, FL 32306-2742, or 850-644-8633, or by email at
[email protected].
If you would like a copy of this information to keep for your records please email the researcher
listed above.
This consent form will be kept by the researcher for at least three years beyond the end of the
study.
186
APPENDIX F
PHASE II CONSENT FORM
You are invited to participate in a qualitative research study being conducted by Sheila Lorenzo
de la Peña, M.S., ATR-BC, a student at Florida State University with the Art Education
Department. The researcher is interested in the relationships between visual expression and art
therapist resilience.
As a participant in the study you will be contributing to the understanding of how art therapists
are perceiving stress, burnout, and responsive art-making. You understand there will be no
monetary form of compensation for participation in this study.
As the participant, you will upload images (1-3) and answer basic questions in regard to each
image file being uploaded prior to the interview. With this consent you are granting the
researcher permission to print and otherwise use the images for academic and scholarly purposes.
The images will not be presented in a for-profit manner.
As the participant, you agree to have the interview recorded. You understand that there may be
questions about your life and work environment. You understand there may be a possibility of a
minimal level of risk involved if you agree to participate in this study. You might experience
anxiety or emotional distress during the interview. If at any time you feel uncomfortable
answering questions, you reserve the right to decline any questions that you are uncomfortable
with. You may decline participation by informing the researcher at any time.
You are aware that the interview may take from 30minutes up to 90 minutes to complete. You
are aware that the results of the interview will be compiled with other interviews and the
transcribed script may be used for scholarly presentation and publications.
Throughout the interview you will be identified by your preferred name. Thereafter, the
researcher will assign a code and a pseudo name in order to maintain confidentiality. The results
of the interview and image review will be compiled and the results will be used for scholarly
presentation and publications. The records of this study will be kept private and confidential to
the extent permitted by law. In any sort of report that is published anonymity will be maintained.
Research records will be stored securely and only the researcher and university professors will
have access to the records. Photographs may be included in academic and educational reports.
All audio recordings will be transcribed; both the electronic audio file and the transcription will
be confidential.
As the participant, you understand that there are limits to confidentiality: In case of a court
subpoena and in case of observed abuse (ie. to a minor, an elderly, or an individual with a
disability). You have the right to withdraw consent at any time with a written request to the
researcher.
187
I, the participant, have read the consent form and agree to be part of the study. My identity will
be kept confidential.
Contacts and Questions:
The researcher conducting this study is Sheila Lorenzo de la Peña. If you have questions, you
are encouraged to contact the PI through email at: [information has been redacted]. You may
also contact the supervising professor, Dr. David Gussak, at [information has been redacted].
If you have any questions or concerns regarding this study and would like to talk to someone
other than the PI, you are encouraged to contact the FSU IRB at 2010 Levy Street, Research
Building B, Suite 276, Tallahassee, FL 32306-2742, or 850-644-8633, or by email at
[email protected].
If you would like a copy of this information to keep for your records feel free to click on the
print icon at the bottom of the form. You may also email the researcher listed above.
This consent form will be kept by the researcher for at least three years beyond the end of the
study.
188
APPENDIX G
PHASE II ARTIFACT REVIEW DOCUMENT
Artifact Index
189
Artifact Index Questionnaire
190
Artifact Observation of Characteristics
191
Artifact Notes
192
APPENDIX H
PHASE II INTERVIEW QUESTIONS & NOTES DOCUMENT
The following list shows the questions and notes document that was used for the interview.
Some questions were sourced from: Baker (2003)
Date of interview:
Begin:
End:
[duration
]
Name*:
Skype ID*:
*To be used for interview purposes and will be omitted from transcripts
**The current document reflects my hand-written notes during interview.
**It only reflects the scripted questions. For more details and for the non-scripted questions see
the actual interview transcripts.
[Work] How would you describe the kind of work you do? (ie. type, duties, population, etc)
Notes:
[Work] What is the impact of your clinical work on the other areas of your life?
Notes:
[Work] What kind of emotional demands/stresses do you experience outside of work that
directly or indirectly affect your work performance? (ie. family, school, etc)
Notes:
[Stress] How does your stress tend to manifest? (ie. emotionally, behaviorally, physically)
Notes:
[Self-Care] How do you define self-care?
Notes:
[Self-Care] How have your attitudes/beliefs/behaviors changed over time in regards to self-care?
Notes:
[Self-Care] What challenges do you encounter when attending to self-care?
Notes:
[Artifact] Tell me about the images you selected… What made you select these images?
Notes:
[other]
Notes:
[other] Is there anything else you would like to mention that I may have left-out?
Notes:
193
APPENDIX I
PHASE II INTRODUCTION & OVERVIEW
Hello,
Thank you for taking the time to complete the Phase I web-based survey and for volunteering to
take part in Phase II.
I am interested in analyzing relationships between visual expression and art therapist resilience.
To do this I would like to obtain your current perspective on the contribution of visual expression
within the art therapy profession. I would like to do this by obtaining visual artifacts which you
identify as ‘response art’. The study is scheduled to take place in 2 phases, the first of which was
the online survey. The second Phase Involves submission of visual artifacts and the possibility
of an interview. You may also choose to submit visual artifacts and opt-out of the possibility of
an interview.
Phase II involves the submission of at least 1 and up to 3 images of visual artifacts that you
created as a means of processing work stress. Along with the images the participant will
complete a brief questionnaire about each of their images. Images submitted as part of this
research will be kept for possible future research unless you request to only use the image file(s)
for the present research.
It is recommended that participants access the following questionnaire via their main computer.
That is, a computer that will grant access to the selected image files that will be uploaded.
Some participants will be contacted for a Skype interview. You will have the option of opting
out of the selection process for the interview. There is no guarantee that submitting images will
result in being interviewed.
Any and all participation is voluntary and refusal will involve no penalty. Participation may be
discontinued at any time. Results from the study will be used for academic purposes (ie.
professional presentations, conferences, publications).
If you have any questions or concerns regarding this study please contact the researcher, Sheila
Lorenzo de la Peña, at [information has been redacted], the supervising professor, Dr. David
Gussak at [information has been redacted], or FSU IRB at 2010 Levy Street, Research Building
B, Suite 276, Tallahassee, FL 32306-2742, or 850-644-8633, or by email at
[email protected].
The Phase II questions can be reached via this link: ________________________
Please note:
-It may be helpful to select the images you wish to share with the researcher before clicking on
the above link.
194
-This link is paired with the email provided at the end of the Phase I survey. Please do not share
it anyone else.
-The link is set to auto expire in 30 days from _________.
-If there are any issues with the link contact me.
If you know of other art therapists who may be interested in this research study please direct
them to the Phase I Survey via this link: _____________________________________________
Thank You for your Consideration,
Sheila Lorenzo de la Peña
Doctoral Candidate
Florida State University
195
APPENDIX J
IRB APPROVAL LETTER
196
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203
BIOGRAPHICAL SKETCH
Sheila Lorenzo de la Peña is a practicing art therapist from Miami, Florida. Born in
Cuba, she emigrated to the United States as a child. She cultivated an interest in the visual arts
from a young age. Receiving a Bachelor of Science in Art Education from Florida International
University, and a Master of Science in Art Therapy from the Florida State University. She holds
an ATR-BC credential from the Art Therapy Credentials Board.
Serving as the art therapy internship coordinator at a forensic psychiatric hospital, she
provided onsite supervision to master’s level art therapy students. She has provided art therapy
and Dialectical Behavior Therapy to clients with severe mental illness. Her research interests
include clinician burnout and self-care, the therapeutic use of mandalas, and adaptive media use.
She has presented at national and regional conferences of the American Art Therapy Association
and the American Music Therapy Association. As an adjunct she has taught several art therapy
courses at the Florida State University.
She promotes routine use of creative expression in both clients and clinicians as a means
of building resiliency and she maintains several creative outlets of her own. Documenting on her
artistic pursuits and adaptive media uses through blogs and social media platforms.
204