Psychodynamic art therapy

1. Introduction

Version followed: Margaret Naumburg's "dynamically oriented art therapy" as set out in her 1958 chapter and Dynamically Oriented Art Therapy: Its Principles and Practice, Illustrated with Three Case Studies (New York: Grune & Stratton, 1966; xxiv + 168 pp., illustrated partly in colour; reissued by Magnolia Street Publishers, ISBN 9780961330910), with her earlier 1947 inpatient monograph on children and adolescents. Checked again in October 2026 and confirmed: the bibliographic details of the 1966 book (Penn Libraries catalogue; Bookshare, whose synopsis says the book uses three emotionally disturbed women to show how art therapy works in treatment); the 1947 monograph's title and series (Allen 1983; the Online Books Page lists it as Coolidge Foundation, 1947); the existence of Esman's 1968 review of the 1966 book (citation only); the US credentials and state licences (ATCB); and Florence Cane's scribble procedure (Wikipedia: Florence Cane, citing Cane 1951). Not drawn on: the text of any Naumburg book, and Junge's The Modern History of Art Therapy in the United States (2010). Naumburg's positions here therefore come from secondary accounts that quote her with page numbers (Bonfield/IAHIP; Allen 1983; the 1948 review of the 1947 monograph). The "transference to the image" material also draws on Joy Schaverien's later British analytic art psychotherapy. That is a separate development and is labelled as such. [source: IAHIP; Allen 1983; Penn Libraries catalogue; Bookshare; Wikipedia: Margaret Naumburg] [uncertain: primary texts]

What it is. It is a psychoanalytically oriented individual psychotherapy. The patient makes spontaneous drawings, paintings or clay pieces, then free-associates to them, and the patient (not the therapist) works out what the images mean. Naumburg called the method "closely allied to psychoanalytic therapy" and said it "has its roots in the transference relation between patient and therapist" (1958, p. 516). In her approach art is the main agent of therapy, not an add-on. [source: IAHIP]

How change happens. The aim is to make unconscious material conscious. Naumburg held that thoughts and feelings from the unconscious often show up in images before they can be put into words. She treated images as "symbolic speech" (1958). In her account a spontaneous image works in four ways: (a) it releases feeling (catharsis); (b) it communicates directly and gets past verbal censorship, which can speed treatment; (c) it lasts and is hard to disown, so the patient cannot easily deny having made it; (d) it becomes a mirror in which the patient gradually recognises their own motives. As the patient takes over interpreting their own pictures, they depend less on the therapist, and the transference is easier to resolve. [source: IAHIP, citing Naumburg 1958, 1966 p. 3, p. 8; 1948 review of Naumburg 1947]

Theoretical mix. Naumburg underwent both Freudian and Jungian analysis. Allen (1983) calls her approach "quite eclectic" and says she was most attuned to universal, archetypal symbolism. The 1948 reviewer likewise notes that she drew on both Freudian and Jungian views of phantasy. Her own framing for the method was mainly Freudian (IAHIP). Treat the Jungian strand as a further lens; she did not define a separate procedure for it. [source: Allen 1983; 1948 review; IAHIP]

Professional frame. In the UK, "art therapist" and "art psychotherapist" are titles protected by law under the Health Professions Order 2001. Only people on the HCPC register may use them, and misuse is a criminal offence. The route to registration is an HCPC-approved master's degree (2 years full-time or 3 years part-time). A psychotherapist who is not registered may use art inside their own psychotherapy but must not call the work "art therapy" or themselves an art therapist or art psychotherapist. [source: BAAT How to become an art therapist; BAAT Insight 2024] In the US, AATA is the professional association and the Art Therapy Credentials Board (ATCB) issues the credentials. These are ATR-P (provisional), ATR (registered), ATR-BC (board certified, accredited by the NCCA and linked to passing the ATCB examination, ATCBE) and ATCS (supervisor). State regulation varies. Several states issue a separate art therapy licence: LPAT in Delaware, Kentucky, Mississippi, New Jersey, New Mexico, Ohio, Tennessee and Washington DC; CLAT in Connecticut; LPCAT in Maryland; and art therapist licences in Oregon and Virginia. New York licenses art therapists as Creative Arts Therapists (LCAT). Texas uses a counselling licence with an art therapy specialty designation (LPC-AT). Some states require the ATR-BC or the ATCBE for licensure. Check your own state board before you use the title. [source: ATCB Licensure Requirement by State] [uncertain: the ATCB page did not set out the education and supervised-hours requirements for each credential] In Germany training is offered by art universities, art-education institutes and private schools (about 40 options in 2008), and most practitioners mix methods. [source: Schuster 2009, Deutsches Ärzteblatt] [synthesis] Before using this method as more than an occasional adjunct, get supervised training in analytic or psychodynamic art therapy. Handling the transference to the image, and patients' unconscious material in visual form, needs both psychodynamic and art-therapy competence.

2. Framework

Naumburg's published account, as reported in the sources, does not set out numbered phases, a fixed number of sessions or formal criteria for moving between phases. The 1966 book is not drawn on. Its catalogue and Bookshare records show that it is organised around three case studies of adult women [source: Penn Libraries catalogue; Bookshare]. From that, it can be inferred that any phase or session structure would have to be read out of those case narratives, not from a stated protocol. The arc below is put together from what the secondary sources describe. The criteria for moving on are the guide's own [synthesis]. [uncertain: phases and session counts]

Format. Individual sessions, usually alongside other treatment. In the 1947 work there were six inpatients at the New York State Psychiatric Institute, seen "for varying periods". Their art sessions ran in parallel with play therapy given by another worker and with occasional psychiatric interviews. The 1966 book illustrates the method with three case studies of emotionally disturbed women [source: Bookshare], and IAHIP describes her use of painting and clay in psychoanalytically oriented psychotherapy with adults. Media were mainly painting and clay modelling, plus drawing. No source gives a session length or a total course. [source: 1948 review; IAHIP; Bookshare] [synthesis] A typical modern frame is weekly sessions of 50–60 minutes, open-ended or 20+ sessions, with time divided between making, looking and associating.

Phase A: engagement and freeing expression. Goal: get from guarded, conventional output to spontaneous imagery. The 1948 review notes that early sessions often meant helping children get past "stereotyped copy work", and that spontaneous expression is "not always spontaneously achieved". Where a patient could not relax enough to work spontaneously, Naumburg offered art lessons or specific directed projects, and she used the scribble technique as a directive. [source: 1948 review; Wikipedia] Criterion for moving on [synthesis]: the patient produces some images that are not copied or stereotyped and will say at least a little about them.

Phase B: spontaneous imagery with free association. Goal: let unconscious material surface in images and link it to the patient's history and current conflicts through the patient's own associations. The therapist keeps asking for the patient's interpretation and keeps their own interpretations back; interpretation is used "sparingly" but can be essential at particular moments. [source: IAHIP; 1948 review; Wikipedia] Criterion [synthesis]: recurring themes or symbols show up across a series of images, and the patient starts linking them to their own life.

Phase C: growing autonomy in interpretation. Goal: the patient contributes more and more of the meaning and depends less on the therapist, and the images come to act as a mirror of the patient's own motives. [source: IAHIP, citing Naumburg 1966 p. 3] Criterion [synthesis]: the patient brings interpretations unprompted and can stay with an unsettling image without needing the therapist to explain it.

Phase D: resolving the transference and ending. Naumburg said the transference is "considerably modified" in art therapy (1966, p. 8), and that the qualities of images make it easier to resolve. [source: IAHIP] [synthesis] Ending work: review the body of artwork together, agree what happens to the pieces, and look at how the patient relates to the therapist and to the images now. For an analytic art psychotherapy version of this phase, see the Schaverien material in section 4.

3. Guiding principles

Art is the primary agent of change, not illustration for talk. In practice: give real session time to making, and treat the image as clinical material in its own right. [source: IAHIP]
Spontaneity over skill. In practice: discourage copying and "good pictures". Value whatever comes, and give technical help only to unblock expression. [source: 1948 review; Wikipedia]
The image is symbolic speech. In practice: "listen" to form, colour, placement and sequence as you would to a dream or slip, but take meaning only from the patient's associations. [source: IAHIP]
The creator is the interpreter. In practice: ask rather than tell. Naumburg held that only the person who made the work could validly interpret it. [source: Wikipedia; IAHIP]
Interpret sparingly, but do not abdicate. In practice: a well-timed interpretation can be essential. Offer it tentatively, once the patient's associations have prepared the ground. [source: 1948 review]
Work within the transference. In practice: notice how the patient relates to you through the images (what they show or hide, who the picture is "for"), and the patient's investment in the artwork itself, which Naumburg called a "narcissistic cathexis" and saw as useful. [source: IAHIP, citing Naumburg 1966 pp. 3, 8]
Images are durable records. In practice: keep the work safe and in sequence. Its permanence lets you both go back to it, see change over time, and makes it harder for the patient to deny what they expressed. [source: IAHIP]
The therapist's attitude shapes the material. In practice: the reviewer of the 1947 work observed that a constrained, merely observing role gave thinner material than a free, engaged one. Be present, interested and non-judgemental. [source: 1948 review]
Therapist self-knowledge through one's own art. In practice: Naumburg taught trainees to keep their own art-and-association notebook (see section 4). Do your own image work and get supervision on your countertransference. [source: Allen 1983]
Sound interviewing. In practice: Naumburg argued that art therapists need training in sound interviewing principles. Combine the image work with competent history-taking and clinical assessment. [source: Allen 1983]
Art is not a diagnostic test. [synthesis, informed by sources] Naumburg's 1947 title presents free art as a means of diagnosis, but the 1948 reviewer noted that psychiatrists disagreed about one case's diagnosis and judged the work scientifically weak. Never treat a picture as evidence of abuse, trauma or a disorder. Images are material for exploration, not findings. [source: 1948 review]

4. Intervention inventory

The sources describe the interventions below. Step-by-step detail is mostly my own operationalisation and is marked [synthesis]; all example language is illustrative. Naumburg also worked with patients' dream and fantasy images, but her procedure for this is [uncertain], so it is left out. [uncertain]

Setting and materials (applies to all interventions). [synthesis] Have available: paper of several sizes, including large sheets for scribble work; chalk or oil pastels; poster or tempera paint and brushes; and clay with water and a wipe-clean surface. Use non-toxic materials labelled for school or child use, and avoid solvent-based paints and fixative sprays in small rooms. To limit clay dust, wet-clean rather than sweep, and do not sand dry clay indoors. Check for allergies (latex, some clays) and supervise scissors or tools with at-risk patients. Keep a lockable folder or shelf so the artwork is stored safely between sessions.

4.1 Spontaneous art expression (free drawing, painting, clay)

Purpose / when: This is the core of the method. Use it in every session once the patient can work without strong inhibition. It releases unconscious imagery, gives catharsis and opens communication. [source: IAHIP; Wikipedia; 1948 review]
Steps: [synthesis] (1) Lay out materials and say the patient may make anything, in any way, and that skill does not matter. (2) Give no topic. (3) Sit nearby, attentive but not hovering, and do not comment on quality while the patient works. (4) Note your own observations silently: the sequence of making, hesitations, erasures, colour changes, things scribbled over. (5) When the patient stops, move to looking and associating (4.2). (6) Date the work and store it in sequence.
Example language (illustrative): "Use whatever you like and make whatever comes. It doesn't need to be a 'good' picture or even a picture of anything." / "You don't have to know what it is before you start."
Watch for: stereotyped, copied or clichéd images (go back to Phase A supports, 4.6); work that gets more personal and less controlled over time, which is a sign it is working; the patient becoming flooded or agitated while making (section 5). [synthesis]

4.2 Free association to the image

Purpose / when: To link the image to the patient's inner life. Use it after every spontaneous piece. In Naumburg's method, free association is how unconscious content becomes conscious. [source: IAHIP; Wikipedia]
Steps: [synthesis] (1) Set the work where you can both see it, propped up or on the wall, at a little distance. (2) Invite the patient to say whatever comes to mind while looking, including thoughts that seem irrelevant. (3) Follow their associations with open prompts about particular parts: colours, figures, empty areas, things left out. (4) Reflect back their words rather than adding yours. (5) Ask what the image reminds them of from past or present, and what they feel looking at it now. (6) Note recurring symbols across sessions.
Example language (illustrative): "Just tell me whatever comes as you look at it." / "What comes to mind about this dark corner?" / "If this figure could speak, what might it say?"
Watch for: associations that jump to personal memories or current conflicts (working); intellectualised art-critic talk (gently bring it back to feeling); long silences (allow them, then invite one detail). [synthesis]

4.3 Eliciting the patient's own interpretation (therapist withholds)

Purpose / when: To build the patient's autonomy and to make sure the meaning really is theirs. Use it throughout, and lean on it more as treatment progresses. Naumburg's therapist works continually to get the patient's own interpretation of their symbolic designs. [source: IAHIP, citing Naumburg 1958; Wikipedia]
Steps: [synthesis] (1) When you notice a possible meaning, turn it into a question about the image rather than a statement. (2) If the patient asks "What does it mean?", hand the question back warmly and explore what they fear or hope it means. (3) Write down your own hypotheses privately and wait for the patient's material to confirm or disconfirm them. (4) Over a series of images, ask the patient what links they see.
Example language (illustrative): "What do you make of it?" / "You're the one who knows what this is about. What's your sense?" / "Looking at last week's and today's together, what do you notice?"
Watch for: the patient increasingly offering meanings unprompted (the autonomy Naumburg describes, 1966 p. 3); dependence on the therapist as "decoder" (keep returning the question); a patient who experiences withholding as cold or rejecting (explain the rationale; see ruptures in section 5). [source: IAHIP; synthesis]

4.4 Sparing, well-timed therapist interpretation

Purpose / when: The 1948 review reports that interpretation was used sparingly but was essential at certain points. Use it when the patient's own associations have come close to a link they cannot quite make, or when a defence is blocking progress. [source: 1948 review]
Steps: [synthesis] (1) Base the interpretation on the patient's own words and on concrete features of the image. (2) Offer it as a tentative hypothesis. (3) Keep it short. (4) Invite the patient to correct it. (5) Watch their response and their next images; confirmation often shows in later artwork rather than in words.
Example language (illustrative): "I wonder whether the wall you've drawn between the two figures is a bit like what you described with your father. Does that fit, or not?"
Watch for: compliance ("yes, that's right" without any new material), which suggests the interpretation was imposed; new associations or a shift in subsequent images, which suggest it landed. [synthesis]

4.5 Scribble drawing (Florence Cane's technique, used by Naumburg as a directive)

Purpose / when: To loosen inhibition and release unconscious imagery when a patient is blocked, self-critical or stuck in stereotyped images. Florence Cane, Naumburg's sister, developed it. She described it as play with a freely flowing continuous line and meant it to foster imagination and unconscious imagery, much as free association does in psychoanalysis. She used it with fearful children because a scribble is the child's own design and cannot be compared with anyone else's. [source: Wikipedia: Florence Cane, citing Cane 1951, The Artist in Each of Us] The Naumburg Wikipedia article and Satou say that Naumburg used it as a directed technique. The Cane article does not mention this. [source: Wikipedia: Margaret Naumburg; Satou]
Steps (individual version, after Cane): (1) Start with brief stretching or rhythmic warm-up movements. (2) Give a large sheet and chalk pastel or paint. (3) The patient draws one free, continuous line with the whole arm, eyes open or closed. Closed eyes help the hand move without being steered. (4) The patient looks at the line, turning the page, to find a form or association in it. (5) They develop and colour the image. (6) Go on to free association (4.2). [source: Wikipedia: Florence Cane, citing Cane 1951] Non-dominant-hand variant: [uncertain]. Later, Elinor Ulman built the scribble and the warm-up movements into her Ulman Personality Assessment Procedure (Ulman 1975, cited in Wikipedia: Florence Cane). That is a separate assessment procedure, not part of Naumburg's therapy.
Two-person alternating version: A Japanese account describes therapist and patient taking turns, one scribbling and the other building on it, until an image emerges and is coloured. [source: Satou] [uncertain: not confirmed. The Cane source describes only an individual scribble, and the Japanese repository papers did not describe a turn-taking form. Treat it as a later variant reported in Japan, not as Naumburg's method.]
Example language (illustrative): "Let your arm move freely across the whole page, without trying to draw anything." / "Now turn it around and look from each side. Is there anything you can see in the lines?"
Watch for: relief, laughter or absorption (inhibition loosening); a patient who "can't see anything" (accept that, try another orientation, or let the scribble itself be the image); eyes-closed work raising anxiety in trauma survivors (offer eyes open, see section 5). [synthesis]

4.6 Art lessons and directed projects for inhibited patients

Purpose / when: Where a patient could not relax into spontaneous work, Naumburg offered art lessons or specific directed projects. With children she worked to move them on from stereotyped copy work. Use this in Phase A, or whenever spontaneity collapses. [source: Wikipedia; 1948 review]
Steps: [synthesis] (1) Name the difficulty without judgement. (2) Offer a small structure: teach a simple technique, such as mixing colours, a wash or pinch-pot clay, or set a contained task, such as a scribble (4.5), a single colour "how I feel today", or a shape. (3) Gradually reduce the structure as the patient gains confidence. (4) Go back to open-choice work once the patient begins making personal images.
Example language (illustrative): "Let's just play with how these paints mix. No picture needed." / "Last time felt hard to start. Would a starting point help today?"
Watch for: structure turning into a permanent crutch, or the sessions becoming an art class. Keep the purpose psychological, and note what the patient's dependence on instruction may say about them. [synthesis]

4.7 Clay modelling

Purpose / when: Naumburg recommended clay alongside painting in psychoanalytically oriented psychotherapy. [source: IAHIP] [synthesis] Clay is useful when feelings are bodily or aggressive, or when the patient needs a three-dimensional or tactile medium; it suits patients for whom drawing feels exposing.
Steps: [synthesis] (1) Give a fist-sized lump on a board, with water and simple tools. (2) Invite free handling first: squeeze, pound, pull. (3) Let a form emerge, or let the patient decide to leave it unformed. (4) Associate to the form, and to the act of making it, for instance pounding or smoothing. (5) Agree how to store it: let it dry on a labelled board, or photograph it and keep it damp.
Example language (illustrative): "You can just handle it for a while and see what your hands want to do." / "What was it like squashing it down just then?"
Watch for: regressive, messy play that is either freeing or disorganising (contain it with time limits and clean-up rituals); destroying the piece (explore it, see 4.11); dust and allergies (see the materials note). [synthesis]

4.8 Reviewing the series of images over time

Purpose / when: Images are durable and hard to disown, which is one of the advantages Naumburg claimed for art. Use the permanence of the work to track themes and change, and to counter denial of material the patient has expressed. [source: IAHIP] [synthesis] Do this every few weeks, at impasses, and at ending.
Steps: [synthesis] (1) Lay out several dated pieces in order. (2) Ask the patient what they notice: repetitions, changes, gaps. (3) Link recurring symbols to the associations they gave at the time. (4) Note what the patient avoids looking at.
Example language (illustrative): "Let's put the last six side by side. What stands out to you?" / "This shape keeps coming back. What do you make of that?"
Watch for: the patient recognising their own motives in the images, which is the "mirror" function Naumburg describes [source: IAHIP]; shame or self-criticism about earlier work (frame the work as process, not product). [synthesis]

4.9 Working with transference via the image (Naumburg's version)

Purpose / when: Naumburg kept transference central but held that in art therapy it is "considerably modified" (1966, p. 8). The image carries part of what would otherwise be directed at the therapist, and the patient's investment in their own artwork (a "narcissistic cathexis") is therapeutically useful. She also held that these qualities make the transference easier to resolve. [source: IAHIP]
Steps: [synthesis] (1) Notice who the image is "for": made to please, to shock, to test or to hide from you. (2) Notice images that seem to show you or the therapy, such as figures, doors, eyes or barriers. (3) Explore these through the image first ("this figure watching"), and only later, if it is useful, make the direct link to the relationship. (4) Respect the patient's attachment to the work: handle it carefully and do not judge it.
Example language (illustrative): "I notice you checked my face when you finished. I wonder what you thought I'd see in it." / "There's a figure at the edge, watching. Who might that be?"
Watch for: idealising or devaluing reactions to the therapist's response to the art; making work only to please; the patient feeling exposed when you look. Slow down and explore it. [synthesis]

4.10 Transference to the artwork itself (Schaverien's analytic art psychotherapy; a later development, not Naumburg)

Purpose / when: The abstract "Art within analysis: scapegoat, transference and transformation" proposes a transference to the art work itself, which it calls a "scapegoat transference". This transference is mediated within the transference–countertransference relationship and supports psychological differentiation: shadow or unbearable material is carried by the picture and can then be separated off. Schaverien's book presents analytic art psychotherapy as a way to work analytically with patients who are not ready for, or suited to, purely verbal psychotherapy, including psychotic and borderline patients, children and psychiatric inpatients. [source: Art within analysis abstract; JKP The Revealing Image] Authorship: the abstract page names no author. I attribute it to Joy Schaverien only because its concepts match her analytic art psychotherapy. The earlier attribution to her 2005 Journal of Analytical Psychology paper was wrong. That paper (vol. 50, pp. 127–153) has a different title: "Art, dreams and active imagination: a post-Jungian approach to transference and the image". [source: PEP-Web JOAP.050.0127A] [uncertain: author, journal and year of "Art within analysis" not confirmed]
Key distinction: "Diagrammatic" images illustrate or signal something that can then be talked about. "Embodied" images hold feeling in their very form and aesthetic qualities, and these evoke an "aesthetic countertransference" in the analyst. [source: Art within analysis abstract] [uncertain: these definitions are reduced from an abstract. Read Schaverien's The Revealing Image (1991/1999) before applying them.]
Steps: [synthesis, following the abstract's concepts] (1) Notice your own aesthetic and emotional response to a piece: does it move or disturb you, or leave you flat? (2) Use that response as information about whether the image is embodied or diagrammatic. (3) With embodied images, let the picture carry the feeling for a while and do not rush to put it into words. (4) Where appropriate, keep the work safe yourself. The abstract reports that the analyst's temporary safe-keeping of the artwork furthers the integration of shadow material.
Example language (illustrative): "We don't need to put words to this one yet. It can stay here with me, safely, until you're ready to look at it again."
Watch for: the image becoming a container that makes the material bearable (working); the patient dumping material into images without ever coming back to it (bring the review back gently); your own countertransference (take it to supervision). [synthesis]

4.11 Storage, keeping and disposal of artwork

Purpose / when: [synthesis] The durability of the image (4.8) and the analyst's safe-keeping (4.10) depend on clear, consistent handling of the work. Agree arrangements at the start, and revisit them at ending.
Steps: [synthesis] (1) Explain at the start that work is kept securely, in date order, for the duration of therapy. Treat it as part of the clinical record, with the same confidentiality as notes, and follow local records policy. (2) Ask consent before photographing work or showing it to anyone, including a supervisor or a multidisciplinary team. (3) If the patient wants to take a piece home, destroy it or change it, explore the impulse first, then respect their decision about their own work. (4) At ending, review the work together and agree what the patient takes and what is disposed of, and how.
Example language (illustrative): "Your pictures stay here, safely, and nobody else sees them without your agreement." / "Before you tear it up, can we look at what makes you want to?"
Watch for: a patient anxious about where the work goes or who sees it, which may be transference material; work left behind after a drop-out (follow records policy and do not display it). [synthesis]

4.12 Image-and-association notebook (therapist self-practice; adaptable for patients)

Purpose / when: Naumburg taught Allen a self-exploration practice. You make a free painting or scribble drawing, then write your thoughts, feelings and associations to it in a looseleaf notebook. The page is folded lengthwise to leave a wide margin for associations and insights added later. Allen describes this as "a commitment to using one's own art for self-understanding". The associations draw on both personal and universal symbolism. [source: Allen 1983]
Steps (therapist self-practice): (1) Make a free image or scribble. (2) Write down your immediate associations. (3) Leave the wide margin. (4) Come back later and add new associations and insights in the margin. [source: Allen 1983]
Patient adaptation: [synthesis] With stable outpatients, suggest an optional between-session image journal of the same kind, brought to sessions. Do not set it for patients who become flooded when working alone.
Example language (illustrative): "If it helps, you could keep a sketchbook and jot down whatever the picture brings to mind, leaving space for thoughts you have later."
Watch for: self-practice uncovering your own material (take it to personal therapy or supervision); patients turning the journal into a performance for you. [synthesis]

4.13 Working alongside the treatment team

Purpose / when: In the 1947 work, art sessions ran alongside play therapy and psychiatric interviews. The reviewer felt the art material was richer where Naumburg had a free hand than where she could only observe. [source: 1948 review] [synthesis] Use this in inpatient, child and multidisciplinary settings.
Steps: [synthesis] (1) Agree your role and how much freedom you have with the team. (2) Share themes rather than raw interpretations of pictures, and get the patient's consent before sharing images. (3) Coordinate so the different therapies do not duplicate or contradict each other. (4) Report risk and safeguarding concerns through the normal channels.
Watch for: colleagues reading pictures as diagnostic evidence (correct this, see section 5). [synthesis]

4.14 Adaptations for children and young people

Purpose / when: Naumburg's first formal study was with behaviour-problem children and adolescents, who were inpatients. [source: 1948 review; Wikipedia] [synthesis] The following adaptations are my own guidance, not taken from Naumburg.
Steps: [synthesis] (1) Get parental or carer consent and the child's own assent, in age-appropriate words, including about where the artwork goes. (2) Explain the limits of confidentiality before you start. (3) Use more structure early on (4.6) and keep verbal association brief; children often associate through stories about the picture or through play. (4) Keep sessions shorter for younger children. (5) Involve carers through regular review meetings that discuss themes rather than reading the child's pictures to them.
Example language (illustrative): "Can you tell me a story about what's happening in your picture?" / "What you make here is private, except if I'm worried someone isn't safe. Then I'd need to tell someone who can help."
Watch for: disclosures in words or images. Act on what the child says and on your duty of care, following local safeguarding procedures. Do not treat image content alone as proof of abuse, do not ask leading questions about a picture, and record exactly what was said and drawn. [synthesis]

5. Handling problems

The sources address only two of these problems: inhibition (art lessons, directed projects, scribble) and the therapist's role. Everything else in this section is my own synthesis. [synthesis unless tagged]

"I can't draw" / performance anxiety. Naumburg's own response was to offer art lessons or directed projects, or the scribble, to patients who could not relax. [source: Wikipedia; 1948 review] [synthesis] Also: use non-representational media (colour fields, clay), keep the session short, and do some parallel making yourself only if it helps the patient start, never to show how it is done.
Stereotyped or copied images (hearts, suns, cartoon characters). The 1948 review describes early work as helping children move past "stereotyped copy work". [source: 1948 review] [synthesis] Accept the image, then ask about it in a personal way ("Whose sun is it? What's the weather like there?"), and offer scribble or eyes-open free movement next.
Stuck: images repeat and associations dry up. [synthesis] Review the series together (4.8). Change the medium, the scale or the dominant hand (4.5). Notice your own boredom as possible countertransference. Offer a carefully timed interpretation of what the repetition may be holding (4.4).
Demanding the therapist's interpretation / dependence. [synthesis] Explain why you return the question: the patient is the authority on their own images, a position Naumburg held [source: Wikipedia; IAHIP]. Then explore what being told would give them. If you do offer something, keep it tentative and brief.
Withholding experienced as coldness, or rupture after an interpretation. [synthesis] Name the rupture and own your part ("I think what I said felt like I was reading you without permission"). Return the authority to the patient and invite them to show the feeling in an image. Do not take the interpretation back defensively, and do not insist on it.
Resistance in the image: blank pages, crossing out, tearing up. [synthesis] Treat this as communication, not refusal. Associate to the blank or destroyed piece. Ask before you rescue or flatten torn work, and keep pieces if the patient agrees (4.11). Do not force the patient to make an image.
Overwhelm or flooding (emotional dysregulation while making, primitive or disorganised imagery, dissociation). [synthesis] Stop making and turn towards grounding: here-and-now orientation, a structured task, or a calming medium such as smooth clay or a pencil drawing in a contained frame. Shorten the session, and move from free association to concrete description. Change course if eyes-closed or scribble work triggers trauma memories. Uncovering methods are not appropriate during acute psychosis, acute crisis or active trauma reliving without stabilisation; containment and supportive structure come first. Schaverien places analytic art psychotherapy within reach of psychotic and borderline patients, but within specialised analytic training and settings. [source on Schaverien: JKP The Revealing Image]
Suicidal or self-harm themes in images. [synthesis] Ask directly and calmly about current thoughts, plans, intent and access to means, as in standard risk assessment. Do not infer risk from the image alone, and do not dismiss it either. Follow your service's risk procedure, and document both what was said and what was shown.
Non-adherence: missed sessions, refusing to use materials, leaving work behind. [synthesis] Explore the missed sessions and the abandoned work as transference to you and to the images. Keep stored work secure and offer it back. Agree a boundary-setting contract early on: attendance, what happens to the work, and the ending process.
Image read as diagnostic evidence by others (e.g. family courts, school staff, team members). [synthesis] Point out that no source validates spontaneous art as diagnostic proof of abuse or disorder, and that the 1948 reviewer found the diagnostic claims of the 1947 work contested [source: 1948 review]. Share clinical themes and the patient's own words, not "readings" of pictures. For forensic questions, use validated procedures and refer appropriately.
Therapist over-identification or aesthetic over-involvement. [synthesis] Keep your own image notebook (4.12) and use supervision to sort your aesthetic countertransference (4.10) from your personal reactions.
Working without art-therapy registration. [synthesis] Present this as a psychotherapist using art within psychotherapy, not as "art therapy", which is a protected title in the UK [source: BAAT Insight 2024]. Refer to an HCPC-registered art psychotherapist when sustained uncovering image work, transference to the image, or a client population such as psychotic or severely dissociative patients is beyond your training.
Cultural and religious considerations. [synthesis] Some patients have religious or cultural restrictions on making figurative images, or strong associations with particular colours and symbols. Let the patient's meanings lead; never impose universal-symbol readings. Naumburg's interest in archetypal symbolism [source: Allen 1983] is a lens to hold lightly, not a code.

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