Clinical art therapy

1. Introduction

Version followed: Helen B. Landgarten's "clinical art therapy" / "art psychotherapy" as set out in Clinical Art Therapy: A Comprehensive Guide (1981), Family Art Psychotherapy: A Clinical Guide and Casebook (1987), Adult Art Psychotherapy (ed. with Lubbers, 1991) and Magazine Photo Collage (1993; Routledge reissue 2017), plus the Landgarten Family Art Assessment as run today by the Helen B. Landgarten Art Therapy Clinic at Loyola Marymount University (LMU), Los Angeles. Source limit: the books' full texts are not drawn on (only publisher descriptions and tables of contents, a published book review, LMU clinic pages and thesis abstracts). Procedures below are therefore given only as far as those sources describe them; everything else is marked [synthesis] or [uncertain]. [source: Wikipedia, Helen Landgarten; Routledge pages; Leonard 1997]

What it is. Not a branded single protocol but a clinical approach: art therapy practised as psychotherapy ("art psychotherapy") across all ages and settings, including schools, outpatient clinics, psychiatric hospitals, day treatment, private practice, rehabilitation and chronic pain, and work with older adults. Landgarten (1921–2011) trained in fine arts (UCLA) and marital and family therapy (Goddard College), worked as an art psychotherapist in the psychiatry department at Cedars-Sinai Medical Center, and directed the clinical art therapy programme at LMU. She was a pioneer of family art psychotherapy. [source: Wikipedia; Routledge, Clinical Art Therapy page]
Core idea of change (as far as sources state it). Making art inside a therapeutic relationship brings conflicts and "unconscious messages" into a visible product that client and therapist can look at together. In family work, the joint process of making art shows how the family actually functions, and analysing it is presented as necessary for understanding and change. Parents, children and even grandparents are treated as partners in a collaborative process. Her 1991 edited volume argues that clinical art therapy can be adapted to different therapeutic theories and to the varied problems and life changes of adults, i.e. it is theory-flexible rather than tied to one school. [source: Wikipedia; Routledge, Adult Art Psychotherapy page]
Magazine Photo Collage (MPC) is her best-documented specific technique: a projective assessment-and-treatment method using pre-collected magazine pictures, designed for clients uncomfortable with drawing and adaptable to the client's culture. [source: Leonard 1997; Taylor & Francis MPC page]

2. Framework

Landgarten's books are organised by population and setting, not by a fixed phase sequence; no source gives a manualised stage model or session count. The structure below combines what the sources show with a clearly marked [synthesis] scaffold. [source: Routledge tables of contents]

Settings and formats covered in the primary texts [source: Routledge, Clinical Art Therapy and Family Art Psychotherapy pages]

Family art psychotherapy (evaluation; crisis intervention, e.g. for a child who had been molested; families in the midst of divorce; long-term treatment of a family with an encopretic child; single-parent household with abandonment issues and masked depression; intact family with an acting-out adolescent; three-generation treatment around a terminally ill grandparent).
Latency-age children; aged adults.
Psychiatric hospitals and day treatment: group art psychotherapy in the hospital, group art psychotherapy in day treatment, individual art psychotherapy.
Rehabilitation and chronic pain.
Adults (1991 volume): suicide as an "abortive life stage", women with eating disorders, borderline adults, group art therapy for mothers of incestuously abused children, people with AIDS, and termination theory and practice.
Group art therapy format with children of Holocaust survivors (1981 paper, title only seen). [uncertain: content]

Working phase scaffold [synthesis, organised around the documented elements]

Referral and assessment (1–2 sessions). Goals: engage the client or family, gather an art-based picture of conflicts and relationships alongside interview and standardised measures. Tools: MPC assessment tasks (individuals, any age); the Landgarten Family Art Assessment (families). Landgarten herself advises that MPC tasks are not sufficient alone and should be combined with interviews and standardised measures. [source: Leonard 1997] Move on when you have a shared formulation and the client/family has agreed goals. [synthesis]
Treatment phase. Goals: work on the presenting conflict through therapist-chosen or client-chosen art tasks, discussed in session; in families, joint art-making to change interaction patterns. Length depends on setting: the casebook includes both crisis intervention and long-term treatment, and the LMU clinic runs open and closed groups and weeklong workshops. [source: Routledge family TOC; LMU clinic page] Specific session counts: [uncertain: not given in the sources].
Termination. Landgarten's 1991 volume contains a dedicated chapter on termination theory and practice; its content is not drawn on. [uncertain] Practical scaffold: review the body of artwork, mark change, plan for ending in advance. [synthesis]

Format notes

Family assessment as consultation: at LMU, a licensed art therapist conducts the assessment for an outside primary family therapist, then debriefs and writes a report. Thesis work at LMU recommends that the family already has a stable relationship with its primary clinician and that the primary clinician is present in the room. [source: LMU Family Art Assessment fact sheet; Keynan 2013 abstract]
MPC can take more than one session: clients often want to look at every picture and may not finish all four tasks in one sitting. [source: Leonard 1997]

3. Guiding principles

Principles stated in or directly implied by the sources are cited; others are [synthesis].

Art therapy is psychotherapy. Practical meaning: you hold a clinical frame (assessment, goals, formulation, termination), not just an art activity. [source: book titles and Routledge descriptions; Wikipedia]
Fit the method to the setting and age group. Practical meaning: the same approach is reshaped for schools, inpatient groups, day treatment, private practice, older adults, rehabilitation. [source: Routledge, Clinical Art Therapy page]
Theory-flexible. Practical meaning: art tasks can sit inside your existing orientation (psychodynamic, family-systems, crisis work). [source: Routledge, Adult Art Psychotherapy page]
The family as collaborating partners. Practical meaning: include parents, children and, where relevant, grandparents as co-workers, not as observers of the "identified patient". [source: Wikipedia]
Process as well as product. Practical meaning: watch how people make the art (who leads, who withdraws, how materials are shared), not only what the image shows. Leonard reports that observing clients at work added information about their behaviour. [source: Leonard 1997; Gavron & Mayseless 2018 on joint painting]
Lower the skill barrier. Practical meaning: offer media (pre-cut photos) that need no drawing ability for clients who feel exposed by drawing, painting or sculpture. [source: Taylor & Francis MPC page]
Images must reflect the client's world. Practical meaning: stock your picture collections with "real people" in varied conditions and with ethnically relevant magazines matched to your clients. [source: Leonard 1997]
Projective material is not stand-alone evidence. Practical meaning: combine art-based impressions with interview and standardised measures; MPC has not been empirically validated. [source: Leonard 1997]
Training is required. Practical meaning: the MPC book does not train readers as art therapists; Landgarten's assessments at LMU are run by licensed art therapists (LMFT plus ATR or ATR-BC). [source: Leonard 1997; LMU clinic page]
Collaborate with the primary clinician. Practical meaning: when acting as art therapy consultant, debrief and report back, and work from an established therapeutic relationship. [source: LMU fact sheet; Haber 2012; Keynan 2013]
Never treat artwork as proof of abuse or diagnosis. Practical meaning: imagery prompts questions; safeguarding decisions rest on disclosure and standard procedures. [synthesis, per Domain VIII rules]

4. Intervention inventory

Scope note. The only Landgarten technique whose steps can be checked in the sources is the Magazine Photo Collage (MPC), through a published review of the book. The Landgarten Family Art Assessment is confirmed as an existing protocol and its consultation procedure is documented, but its actual art tasks are not drawn on [uncertain]. The remaining entries are treatment formats Landgarten names in her tables of contents. Their steps here are [synthesis] general art psychotherapy practice and are not attributed to her. To use her own procedures, read Family Art Psychotherapy ch. 2 (Family Evaluation) and Magazine Photo Collage directly, and train with a credentialed art therapy programme. [source: Leonard 1997; LMU fact sheet; Routledge TOCs]

Professional frame. At LMU, Landgarten's assessments and clinical art therapy are delivered by licensed art therapists whose listed credentials are LMFT plus ATR or ATR-BC (US art therapy registration and board certification, issued by the Art Therapy Credentials Board; professional body AATA). [source: LMU clinic page; ATCB/AATA details uncertain] In the UK, art therapists and art psychotherapists must be registered with the HCPC (professional body BAAT). [uncertain: per brief] A psychotherapist without art therapy training may use simple collage or drawing tasks within their own competence. They should not present projective interpretation of artwork as an art therapy assessment, and should not run the Landgarten Family Art Assessment without art therapy training. [synthesis; Leonard 1997 notes the MPC book does not train readers as art therapists]

Materials and physical safety [synthesis]: MPC uses pre-cut pictures, so scissors are needed only during preparation. If clients cut, use round-ended scissors with children and with clients at risk of self-harm, and count sharps in and out on inpatient units. Use non-toxic glue sticks and water-based markers, ventilate when using solvent-based materials, and supervise clay and paint with young children. Check pictures for graphic violence, sexual content, self-harm or weapons before adding them to a collection used with vulnerable clients.

4.1 Building the MPC picture collections

Purpose: Create the stimulus material that makes the MPC usable without drawing skill and relevant to your client population. [source: Leonard 1997; Taylor & Francis MPC page]
Steps: (1) Collect magazines that show real people in varied life conditions rather than idealised fashion models; the review names Life and National Geographic as examples. (2) Add magazines aimed at the ethnic and cultural communities you serve; the book lists such magazines and where to get them. (3) Trim the pictures and sort them into two collections: one of people, one of miscellaneous items that could connect to therapeutic issues. (4) Accept that collections are not standardised; they will differ between therapists and over time. [source: Leonard 1997] (5) Keep both boxes large enough that the client has real choice, and refresh worn or dated images. [synthesis]
Example language: none needed (preparation step).
Watch for: under-representation of the client's age, ethnicity, body type, disability or family form, which blunts identification; images that could be retraumatising for your caseload. [synthesis]

4.2 MPC Task 1: pictures that catch your attention

Purpose: Open-ended warm-up and free association; surfaces current preoccupations with minimal structure. [source: Leonard 1997]
Steps: (1) Offer the collections, a sheet of paper and glue. (2) Ask the client to choose pictures that catch their attention, glue them down, and say whatever comes to mind about them. [source: Leonard 1997] (3) Note which collection they use, how long they take, what they reject. (4) Ask open follow-up questions about each image. Landgarten supplies suggested questions and analysis guides; these were not seen [uncertain].
Example language (illustrative): 'Look through these and pick out any pictures that catch your eye. You don't need a reason. Then glue them on and tell me whatever comes to mind.'
Watch for: a client who wants to look at every picture (common; allow time and spread tasks across sessions); themes that recur across later tasks. Working: the client starts linking images to their own life without prompting; in the review, a widow linked images to her husband's terminal illness and her mother's death. [source: Leonard 1997]

4.3 MPC Task 2: what people are thinking and saying

Purpose: Projective access to inner dialogue, relationships and conflicts through identification with pictured people. [source: Leonard 1997]
Steps: (1) Ask the client to choose four to six pictures from the people collection. (2) For each, the client says or writes what the person is thinking and what they are saying. [source: Leonard 1997] (3) Write down the client's words beside each image, or let the client write them. (4) Afterwards, explore gaps between 'thinking' and 'saying', and ask which figure feels most familiar. [synthesis]
Example language (illustrative): 'Choose four to six people. For each one, tell me what they're thinking, and then what they're actually saying out loud.'
Watch for: a consistent split between unspoken and spoken content (suppressed anger, hidden fear); a client who can only give 'saying' lines may need more safety first. Working: the client starts using 'I' about a figure's thoughts. [synthesis]

4.4 MPC Task 3: something good and something bad

Purpose: Elicits values, fears and what the client experiences as helpful or threatening. [source: Leonard 1997]
Steps: (1) Ask the client to select pictures that stand for something good and something bad. [source: Leonard 1997] (2) Let them arrange both on one sheet or two, and ask them to explain each choice. (3) Explore the relation between the two (distance, size, which came first). [synthesis]
Example language (illustrative): 'Find a picture or two that mean something good to you, and some that mean something bad. Then we'll look at what you've picked.'
Watch for: 'bad' images linked to self-harm, violence or abuse; follow with a calm risk or safeguarding enquiry rather than interpretation (see section 5). [synthesis]

4.5 MPC Task 4: what is happening and what would change it

Purpose: Projects the client's story of their situation and their beliefs about change and agency. [source: Leonard 1997]
Steps: (1) Ask the client to pick a picture of a person and describe what is happening to them. (2) Ask whether the situation will change and, if so, what will bring the change about. [source: Leonard 1997] (3) Link the answer to treatment goals: who or what the client sees as the agent of change. [synthesis]
Example language (illustrative): 'Pick one person and tell me what's happening to them. Will it change for them? What would make it change?'
Watch for: hopelessness ('nothing will change') as a cue for depression and suicide-risk screening; change attributed only to others or to luck, which can become a therapy focus. Working: the client names realistic, self-initiated steps. [synthesis]

4.6 MPC as an ongoing treatment technique

Purpose: Landgarten's book shows how the MPC tasks can be adapted and built into ongoing therapy, with 26 case studies across ages, ethnic groups and presentations (including OCD, eating disorders, PTSD, suicidal ideation, acting-out, ADHD, drug use, schizophrenia and sexual problems). [source: Leonard 1997; Taylor & Francis MPC page] The specific adaptations were not seen [uncertain].
Steps [synthesis]: (1) Choose a theme-focused collage task tied to the current treatment goal (for example, a collage of a relationship, a feared situation, or a hoped-for future). (2) Let the client select, arrange and glue. (3) Discuss the collage: first the client's description, then your observations as questions. (4) Keep the collages and review them over time.
Example language (illustrative): 'Today, could you make a collage about how things are at home right now?'
Watch for: in the review, one wife who had dominated conjoint sessions produced three collages, a reminder that the medium can redistribute 'voice' in couples work. [source: Leonard 1997] Use in hospice, adolescent groups and by music therapists is reported. [source: Leonard 1997]

4.7 Landgarten Family Art Assessment (consultation format)

Purpose: Observe a family making art together to help a referring family therapist understand difficult dynamics and plan treatment. LMU describes it as observing families making art together using Landgarten's protocol, and calls it evidence-based [uncertain: no supporting study is cited; the LMU theses are small programme evaluations]. [source: LMU clinic page; LMU fact sheet; Haber 2012]
Steps (consultation procedure, as LMU runs it): (1) Information session for the referring agency's staff. (2) Agency appoints a liaison. (3) Primary clinician completes a referral form. (4) A trained, licensed art therapist is assigned. (5) The art therapist meets the family at the time and place the primary clinician sets, explains the process, obtains signed informed consent and clarifies expectations. (6) The assessment is conducted. (7) The art therapist debriefs the primary clinician. (8) A written report follows. [source: LMU fact sheet] Thesis work recommends that the family's relationship with its primary clinician is established first and that the primary clinician sits in the room. [source: Keynan 2013 abstract]
The art tasks themselves: the sequence, instructions and materials of Landgarten's protocol are set out in Family Art Psychotherapy ch. 2 and are not drawn on. Do not improvise them and call the result 'the Landgarten assessment'. [uncertain]
Example language (illustrative, for step 5): 'I'm going to ask your family to make some art together. There's no right or wrong and nobody needs to be good at art. Your therapist and I are interested in how you work together, and afterwards I'll share what I noticed with them and with you.'
Watch for: families who feel tested or judged; explain the purpose and who receives the report. Treat impressions as hypotheses for the primary therapist, not findings. No published reliability or validity data for the assessment were found, so it cannot diagnose a disorder or show that abuse occurred. [synthesis]

4.8 Joint family art-making in ongoing family art psychotherapy

Purpose: Landgarten's family work treats parents, children and grandparents as partners in a collaborative art process and analyses it to understand and change family patterns. Gavron and Mayseless cite Landgarten (2013 edition) among clinical writers who use joint painting to understand family relationships. [source: Wikipedia; Gavron & Mayseless 2018]
Steps [synthesis, not Landgarten's protocol]: (1) Agree the session's focus with the family. (2) Provide one shared surface and a set of materials; giving each member a distinct colour makes contributions traceable. (3) Give a brief, open task (for example, a picture made together). (4) Observe without steering: who starts, who decides, whether space is shared or defended, who is left out. (5) Invite each member to describe the product and the process, then reflect patterns back as questions. (6) Use later joint tasks to practise changes (for example, the quieter member chooses the theme).
Example language (illustrative): 'I noticed Dad's colour went all the way round the edge. What was that like for the rest of you?'
Watch for: scapegoating of the referred child through the art; parents competing for the therapist. Working: members comment on their own process and try new roles in the next task. [synthesis]

4.9 Family crisis intervention through art (named format)

Purpose: Landgarten's casebook includes family crisis intervention for a child who had been molested, and work with families in divorce. [source: Routledge family TOC] Procedure not drawn on [uncertain].
Steps [synthesis]: (1) Safeguarding first: confirm that statutory services are involved and follow mandatory-reporting rules. (2) Use art to support coping, safety and family communication, not to gather evidence. (3) Keep tasks structured and short; contain material before the session ends.
Example language (illustrative): 'Let's each draw something that helps you feel a bit safer at home right now.'
Watch for: never interview a child about abuse through drawings or treat imagery as proof; leave forensic questioning to trained investigators. [synthesis]

4.10 Group art psychotherapy in psychiatric hospitals and day treatment (named format)

Purpose: Named chapters in Clinical Art Therapy (group work on inpatient and day-treatment units; individual art psychotherapy). [source: Routledge, Clinical Art Therapy page] Content not drawn on [uncertain].
Steps [synthesis]: (1) Open with a brief check-in. (2) Give a theme or a free choice suited to the group's level of organisation (simpler, more structured tasks for acutely unwell members). (3) Art-making time. (4) Sharing: each member may show and say a little, with the right to pass. (5) Close with a grounding round; account for sharps and materials.
Example language (illustrative): 'You can show your picture and say one thing about it, or just pass today.'
Watch for: psychotic or disorganised imagery escalating distress; keep to the here-and-now and liaise with the ward team. [synthesis]

4.11 Individual art psychotherapy across the lifespan (named format)

Purpose: Landgarten applies art psychotherapy to latency-age children, adolescents, adults (eating disorders, borderline presentations, suicidality, AIDS) and older adults, plus rehabilitation and chronic pain. [source: Routledge TOCs] Specific tasks not drawn on [uncertain].
Steps [synthesis]: (1) Set the frame (time, materials, confidentiality and its limits, where artwork is kept). (2) Use directive tasks to address the formulation or non-directive time when exploration is the aim. (3) Talk about the work with the client's meaning first. (4) Keep a dated portfolio.
Example language (illustrative): 'What would you like to tell me about it?'
Watch for: adapt materials for physical limitations in rehabilitation, pain and older-adult work (thicker grips, collage instead of fine drawing, seated work). [synthesis]

4.12 Termination review

Purpose: Landgarten's 1991 volume includes a chapter on termination theory and practice. [source: Routledge, Adult Art Psychotherapy page] Content not drawn on [uncertain].
Steps [synthesis]: (1) Announce the ending several sessions ahead. (2) Lay out the client's artwork in sequence and review it together. (3) Invite a final piece about leaving or the future. (4) Agree what happens to the artwork.
Example language (illustrative): 'Looking at these from the beginning to now, what stands out to you?'
Watch for: abandonment themes resurfacing in the art near the end (relevant in Landgarten's single-parent and borderline case material); name them openly. [synthesis]

5. Handling problems

Only the first two items come from the sources; the rest is [synthesis].

Client can't finish the MPC tasks in one session (wants to look at every picture). Spread the four tasks over two or more sessions; the review reports this as common. [source: Leonard 1997]
Over-reliance on the collage as an assessment. Landgarten states the tasks are not enough for assessment on their own and recommends interviews and standardised measures alongside. MPC has no empirical validation. [source: Leonard 1997]
'I can't draw' / art anxiety. Switch to collage; offer the choice of materials; normalise that skill is irrelevant. MPC was designed for clients uncomfortable with drawing. [source: Taylor & Francis MPC page; response is synthesis]
Stuck or flat responses ('I just liked the colour'). Accept it, then move to a more structured task (Task 2 or 4) that gives a frame for projection; ask about the pictures they rejected. [synthesis]
Resistance in families (a teenager refuses, a parent dismisses art as childish). Give a role (choosing colours, deciding when the picture is finished), allow observation before joining, and name the refusal as information about the family rather than a failure. [synthesis]
One member dominates the shared page. Introduce turn-taking, separate sections of the page, or individual pieces later combined; reflect the pattern back gently. [synthesis]
Overwhelm or flooding during art-making. Stop the task, shift to grounding (describe the materials, feet on floor, breathing), turn the image over or put it away, and close with a containing task. Do not push interpretation of distressing images. [synthesis]
Images or statements suggesting suicide or self-harm (for example in 'something bad' or 'what will change' tasks). Ask directly about suicidal thoughts and intent, complete your service's standard risk assessment, make a safety plan with lethal-means counselling (secure storage or removal), and involve the wider team as policy requires. Do not treat the image itself as a risk rating. [synthesis]
Imagery or play that seems to suggest abuse. Do not interpret it as evidence or question the child leadingly. Record exactly what the child said and did, follow local safeguarding and mandatory-reporting procedures, and consult your safeguarding lead. Artwork is not diagnostic evidence of abuse. [synthesis]
Non-adherence (missed sessions, art 'homework' not done). Keep art-making inside sessions; review the fit of materials and goals; in families, check who resists attending and why. [synthesis]
Ruptures (client feels exposed or misread by an interpretation). Apologise for getting it wrong, return authority over meaning to the client ('you're the expert on your picture'), and agree how you will discuss future work. [synthesis]
Cultural mismatch. If the picture collection lacks images the client can relate to, say so, ask what is missing, and add culturally relevant material; this follows Landgarten's rationale for culture-matched magazines. [source: Leonard 1997; response is synthesis]
Consent, confidentiality and artwork ownership. Explain where artwork is stored, who sees it (including consultants' reports to referring clinicians), and how long it is kept; get written consent before any photograph or publication. With children, obtain parental consent and the child's own assent, and adapt tasks to developmental level. [synthesis; LMU fact sheet confirms signed informed consent for family assessments]
Working beyond competence. If you lack art therapy training, use these tasks as conversation aids only and refer for formal art therapy assessment or treatment to a credentialed art therapist. [synthesis; Leonard 1997]

Sources

Sources:

Books cited (not drawn on in full):

Landgarten, H. B. (1981). Clinical Art Therapy: A Comprehensive Guide. Brunner/Mazel (Routledge reissue 2013).
Landgarten, H. B. (1987). Family Art Psychotherapy: A Clinical Guide and Casebook. Brunner/Mazel (Routledge reissue).
Landgarten, H. B. & Lubbers, D. (Eds.) (1991). Adult Art Psychotherapy: Issues and Applications. Brunner/Mazel (Routledge reissue).
Landgarten, H. B. (1993). Magazine Photo Collage: A Multicultural Assessment and Treatment Technique. Brunner/Mazel (Routledge 2017).

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