Medical Art Therapy with Children

This is a chapter excerpt from Guilford Publications.
Handbook of Art Therapy, Edited by Cathy A. Malchiodi
Copyright © 2003
C H A P T E R
1 6
Medical Art Therapy
with Children
Tracy Councill
Medical applications of art therapy are a natural extension of the use of art therapy
with psychiatric populations. The fundamental qualities that make the creative pro-
cess empowering to children in general can be profoundly normalizing agents for
those undergoing medical treatment. When the ill child engages in art making, he or
she is in charge of the work—the materials to be used; the scope, intent, and imagery;
when the piece is finished; and whether it will be retained or discarded. All these fac-
tors are under the child artist’s control. Participating in creative work within the
medical setting can help rebuild the young patient’s sense of hope, self-esteem, auton-
omy, and competence while offering opportunities for safe and contained expression
of feelings.
Art therapy has been used with a variety of pediatric medical populations, in-
cluding cancer, kidney disease, juvenile rheumatoid arthritis, chronic pain, and severe
burns (Malchiodi, 1999). When medical art therapy is included as part of team treat-
ment, art expression is used by young patients to communicate perceptions, needs,
and wishes to art therapists, mental health professionals, child life specialists, and
medical personnel. It is extremely useful in assessing each young patient’s strengths,
coping styles, and cognitive development. Information gathered through artworks
can be invaluable to the medical team as it seeks to treat the whole person, not just
the disease or diagnosis.
WHAT A MEDICAL DIAGNOSIS MEANS
The diagnosis of a serious illness or injury is a catastrophic blow to the young patient
and the family’s fundamental sense of trust and well-being. The onset of a serious ill-
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CLINICAL APPLICATIONS WITH CHILDREN AND ADOLESCENTS
ness is often experienced as a bolt out of the blue, robbing the child and family of the
normal routines and functional illusion that bad things happen to other people.
Though adults may become ill as a result of destructive lifestyle choices or the aging
process, children are expected to grow and flourish. Although some serious disorders
result from a hereditary cause, and the family may be somewhat prepared when they
manifest in a child, many other diseases occur without explanation. For example,
most childhood cancers are diagnosed unexpectedly and without a known cause: A
cell in the body is manufactured incorrectly and the replication of that error becomes
the process of disease.
In his famous book, When Bad Things Happen to Good People, Kushner (1989)
explores the universal human wish for an explanation for misfortune. Painful as they
are, guilt and self-blame offer the comfort of an explanation. During my early years
as an art therapist with pediatric cancer patients, I worked with an 8-year-old boy
whose play and artwork evolved around the theme of punishment. The characters in
his art and play were always being punished, though what they had done wrong was
never clear. After working with him for some time without movement from this con-
stant theme, I decided to interpret his play and art expressions to him in words. “You
know,” I said, “doctors and nurses don’t know exactly why kids get cancer, but they
do know it isn’t their fault. Cancer isn’t a punishment, it’s when a person’s cells don’t
work right.” He stopped what he was working on, looked me straight in the eye and
said, “So you mean I got sick for nothing?” “Well, kind of,” I said, “but we do know
it isn’t your fault.” In my effort to replace what I felt was a mistaken assumption
with a compassionate truth, I had challenged his explanation. Though he had heard
these words before from his doctors and nurses, our work together in art and play al-
lowed him to consider for the first time an alternative explanation for his guilt.
The hospital setting itself can be a source of both hope and distress to the ill
child and his or her family. Though naming a condition and beginning treatment of-
fer hope for cure and relief from suffering, the medical environment itself can feel
like a foreign land. Medical terminology is a new language that must suddenly be
mastered. The hospitalized patient, surrounded by the sights, smells, sounds, and
rhythms of the medical environment, may feel transplanted into an alien culture
(Spinetta & Spinetta, 1981). A visit from the art therapist, a grown-up who brings
art materials and an invitation to draw or paint, instead of needles or pills to swal-
low, can be instantly comforting to a frightened child. Whether that first encounter
leads to an expressive piece of artwork or just a few simple marks, it can establish a
meaningful link to life outside the hospital and provide a concrete way to respond to
the hospital experience.
ART-BASED ASSESSMENT WITHIN THE MEDICAL SETTING
There are some general considerations in assessing medically ill children. Theories of
personality and cognitive development are fundamental and a therapist with a good
command of these concepts can be invaluable to the parents and the medical team in
helping them anticipate and meet the ill child’s needs along the way. For example,

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Medical Art Therapy with Children
209
knowing that a toddler, who is beginning to assert some independence and identity,
may react to treatment with fits of anger and regression can help parents decide how
best to respond to their little one’s behavior. The school-age youngster, who may be-
come demanding, irritable, and emotionally labile in the face of his or her loss of rel-
ative independence, can make use of creative strategies to use words and symbols to
express feelings and assert mastery. Generally, the older the child, the greater the
emotional impact of the losses associated with serious illness. Older children have
more independence to lose, and yet they have likely developed a broader range of in-
terests and strategies for meeting life’s challenges than have their younger counter-
parts. The capable therapist adapts art materials and processes to many levels of
sophistication so that any young participant can find a creative voice through art.
In the medical environment, it is also important to understand how children of
various ages think about their bodies and about the concept of death. For example,
young children may regard the body as a bag of blood and fear that venipuncture for
a blood test will cause all their blood to flow out. They can be reassured by a simple
explanation of how blood flows through the body and by drawing a picture of what
the body looks like inside. I sometimes use a body tracing as a starting point for a
life-size collage, asking children to place red ribbons inside the outline where the
blood goes, plastic bubble wrap for lungs, popsicle sticks for bones, and so on. This
exercise helps the therapist to understand the child’s perceptions and provides the op-
portunity to offer information that may correct misunderstandings and allay fears.
Most young children believe that death is reversible. They tend to be more con-
cerned about being abandoned by their caregivers than about dying. Young children
are often preoccupied with fears of bodily harm and physical integrity. They may un-
derstand that death is permanent, but they often interpret illness or death as a pun-
ishment. Older children generally have a more sophisticated understanding of death,
but it is normal for adolescents to believe themselves to be invincible. Coping with
the demands of illness and treatment may push young people to emotional maturity
beyond their years, resulting in a sense of being “different” from their peers.
Susan Bach (1990), a Jungian analyst who for many years collected pictures
drawn by hospitalized children, has developed a system of analyzing children’s art-
work to aid in understanding disease processes and predicting eventual outcomes and
children’s experiences of death and dying. She feels that certain graphic messages
point to processes of physical healing or degeneration, stemming from the child’s “in-
ner knowingness” of the state of his body and his fate (p. 185). Her work presents a
fascinating interpretation of symbols, colors, and pictorial composition, challenging
the therapist to remain open to the expression of children’s unconscious wisdom
through art expression.
One of the great values of art therapy is its capacity to call attention to the pa-
tient’s strengths. Elinor Ulman, in her work with the chronically mentally ill, stressed
an appreciation of the patient’s strengths as part of the personality assessment
(Ulman & Levy, 1975). Understood as a way of discovering strengths, art therapy
can be a bridge from the sad and lonely places of illness to the joy of human connec-
tion and understanding.
For example, a 7-year-old leukemia patient experienced an idiosyncratic reaction

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CLINICAL APPLICATIONS WITH CHILDREN AND ADOLESCENTS
to medication that caused her to exhibit strange seizure-like episodes with repetitive
motions and verbalizations, arising spontaneously and resolving without interven-
tion. Her symptoms did not easily fit the expected pattern of organic etiology, so I
was asked to contribute to the assessment, specifically to determine whether she was
pretending to have these “fits” to get attention. In one of the art evaluation sessions,
she created a dramatic marker drawing of an opera singer in Verdian costume,
mouth open wide, occupying center stage. The story she told about the picture was
that the singer had been kidnapped and held captive deep in the woods. She was sing-
ing as loudly as she could so her lover would come and rescue her (Figure 16.1). The
picture was reassuring in its sustained attention, integrated composition and sure
execution, suggesting that her cognitive functions remained intact.
The main character’s placement on center stage might well suggest attention-
seeking behavior, but the most compelling aspect of the picture was its unmistakable
cry for help: A frightened and lonely figure stood alone in the woods, waiting to be
rescued. Whether or not her seizures bought her secondary gains, she was able to use
graphic media to send a message to the health care team that she needed and wanted
their help. Through consultation with other institutions, her condition was soon di-
FIGURE 16.1. Drawing by 7-year-old leukemia patient.

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211
agnosed as a rare side effect of a particular medication. Her medications were
changed, and the strange episodes no longer occurred.
Art therapists have developed many methods of evaluating personality through
art, but the limitations of the medical environment, especially the difficulty of secur-
ing a private space for a long period, can make some art-based assessments difficult
to administer. Based on my experience with pediatric cancer patients, I suggest the
following art-based assessments as a prelude to treatment:
• Clinical assessments such as those developed by Rubin (1984), Kramer
(Kramer & Schehr, 1983), and Ulman (Ulman & Levy, 1975) can yield a
wealth of information, especially if there is concern that the child may have
underlying psychopathology beyond adjustment to illness. Rubin (1984) em-
phasizes spontaneous artwork and careful observation in her Diagnostic Art
Interview. Kramer recommends encouraging the child to try a variety of art
media in an open-ended art interview, evaluating the child’s approach to the
media as well as his or her reflections on the artworks produced. Ulman’s per-
sonality assessment tool may be used with older teenagers and young adults. It
combines “free pictures” and directed tasks to elicit information about the cli-
ent’s ability to organize his or her thoughts into visual expression, as well as
eliciting pictures with meaningful content.
• The Child Diagnostic Drawing Series (CDDS), developed by Sobol and Cox
(1992), is another procedure that combines free drawings and directed tasks.
The authors are collecting data in an effort to statistically validate the inter-
pretation of their instrument. This measure may have the added benefit of sci-
entific measurement in addition to interpretation in the context of the art ther-
apy literature—an important consideration when art therapy is part of medical
research. These assessments are perhaps the best known and most used in the
field of art therapy, but they all require an extended period of uninterrupted
time.
There are two one-drawing measures that may yield important information
about medical patients:
• A drawing of Person Picking an Apple from a Tree (PPAT) (Gantt, 1990;
Lowenfeld & Lambert-Brittain, 1975) is useful in evaluating coping ability
and resourcefulness. This drawing asks the child to depict someone solving a
problem—picking an apple from a tree—and expresses strategies children may
employ when encountering obstacles in real life.
• A drawing of a bridge going from one place to another and including oneself
on the bridge (Hays & Lyons, 1981) can yield information about the patient’s
perception of the present and expectations of the future. This can be an impor-
tant question for patients facing life-threatening illnesses or making the transi-
tion to home following a long hospital stay.
Both of these drawing tasks are ways to encourage metaphoric expressions about life
experiences, as opposed to full personality assessments. They must be reserved for

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CLINICAL APPLICATIONS WITH CHILDREN AND ADOLESCENTS
patients who can accomplish recognizable representations and generally are no youn-
ger than 5 years of age.
Assessment of patients’ adjustment to illness and/or injury is an important aspect
of medical art therapy. Valerie Appleton (2001) has developed an Art Therapy
Trauma and Assessment Paradigm for use with young people who have experienced
traumatic burn injuries. She proposes four stages, each characterized by specific
psychosocial issues, art themes, and graphic features. Her model is based on stages of
emotional reactions to trauma identified by Lee (1970), but Appleton has expanded
them to include the following art therapy goals: Stage I. Impact: Creating Continuity,
Stage II. Retreat: Building a Therapeutic Alliance, Stage III. Acknowledgment: Over-
coming Social Stigma and Isolation through Mastery, and Stage IV. Reconstruction:
Fostering Meaning. With such a model as a framework, art therapists can better un-
derstand the significance of clients’ graphic messages and assess their progress in
adapting to life circumstances that have been changed by traumatic injury.
Evaluating artistic development is essential to any therapist working with chil-
dren. It is important for the therapist to recognize the developmental stages in
children’s artwork and possible indications of pathology, from emotional distress to
organic brain damage. Although there is no formal assessment to evaluate children’s
artistic development, therapists should be familiar with The Child’s Creation of a
Pictorial World (Golomb, 1992). This volume is an excellent reference on develop-
ment and art, as are Lowenfeld & Lambert-Brittain’s (1975) Creative and Mental
Growth and Gardner’s (1980) Artful Scribbles: The Significance of Children’s Draw-
ings. Spontaneous pictures, too, can help the art therapist understand the patient’s
strengths, skills, and understanding, especially when children discuss the meaning of
their artwork with the therapist.
There is no one correct way to assess medical patients through art. It is impor-
tant that therapists receive training in how to administer and interpret specific assess-
ments and that they remain open to the multidimensional meanings and interpreta-
tions supplied by the client.
ART THERAPY WITH PEDIATRIC PATIENTS
Art therapy is beneficial to children for many reasons, but there are several reasons
that are particularly compelling with pediatric patients.
Rebuilding a Sense of Well-Being
Making art, the uniquely human act of creating meaning out of formless materials,
can be a powerful vehicle for rebuilding the medical patient’s sense of well-being. Of-
fering familiar materials with the skilled therapist’s support can reassure the ill child
that he or she is still a person with a great deal to offer. Edith Kramer (1979) recog-
nized the intrinsic power of the artistic process to bring order to the chaos within.
When a child is ill, words often fail, either because the child’s vocabulary does not
match the experience or because the ill child feels he must protect the adults around
him from his feelings (Bluebond-Langner, 1978).

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Engendering Hope
Snyder et al. (1997) theorize that “children who think hopefully can imagine and em-
brace goals related to the successful treatment of their physical problems . . . children
with health problems need to focus upon new goals, find alternative ways to do
things, and muster the mental energy to begin and continue treatment regimens” (pp.
400–401). Creating art is a safe vehicle for self-expression: It can start from just a
squiggle or a line, and it is the artist who decides what to include, when the work is
finished, and what it means. In particular, art therapy with physically ill children
helps them practice the hope-engendering process of creating art. The child and the
therapist work together to choose materials, set goals, and plan the means to achieve
them. The finished product is tangible evidence that the ill child can accomplish a
great deal. This kind of achievement helps transform the ill child from the passive
victim of a disease into an active partner in the work of getting well.
Gaining a Sense of Mastery
Art therapy can be used to help young patients gain a sense of mastery over troubling
events. As treatments become more effective, the medical community is learning
more about the impact of illness and treatment on those who are cured of their dis-
ease. In the study of childhood cancers, there is a growing body of literature about
“late effects,” the long-term effects of cancer treatment on young survivors.
Posttraumatic stress disorder is increasingly being appreciated in cancer survivors
and their parents, especially at times of developmental transition (Rourke, Stuber,
Hobbie, & Kazak, 1999). The disorder is characterized by a cluster of
reexperiencing, avoidance, and arousal symptoms associated with experiencing or
witnessing an event that is perceived as a threat to the bodily integrity of the self or a
loved one (American Psychiatric Association, 1994). According to Rourke, “a model
of posttraumatic stress, in which cancer and treatment are seen as life-threatening
events with the potential for precipitating trauma reactions, appears to explain the
ways in which child and adolescent survivors of cancer and their parents react to di-
agnosis and treatment” (Rourke et al., 1999, p. 130). Stuber, Cristakis, Houskaamp,
and Kazak (1996) suggest that supportive intervention, both during and after
treatment, can diminish the traumatic effects of treatment and help patients better
integrate their experiences.
In a long-term research project aimed at promoting integration of traumatic ex-
periences, Chapman, Morabito, Ladakakos, Schrier, and Knudson (2001) describe a
study of an art therapy intervention targeted specifically to reduce symptoms of
PTSD in children treated at a large, urban hospital trauma center. Chapman’s proce-
dure, the Chapman Art Therapy Treatment Intervention or CAATI, is designed for
“incident-specific, medical trauma to provide an opportunity for the child to sequen-
tially relate and cognitively comprehend the traumatic event, transport to the hospi-
tal, emergency care, hospitalization and treatment regimen, and posthospital care
and adjustment” (p. 101).
When art therapy can be offered during treatment, difficult experiences can be
described in art, encouraging steps toward mastery of troubling feelings. One 7-year-

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old being treated for cancer developed a highly contagious infection that required her
to be isolated from other patients for a period of several months. The infection was
not dangerous to those with normal immune function, but it posed a significant
threat to other clinic and hospital patients. She was not well enough to attend school,
go to movies, play sports, and take part in many other activities during her medical
treatment, so the added isolation from others at the outpatient center was a powerful
loss for her.
Though her therapists were able to develop ways to work with her safely
without spreading the infection, she attempted less and less in art as the period of
isolation wore on. When she was finally free of the infection and could rejoin the
waiting-room art sessions, her first creation was an elaborate clay sculpture of an
igloo, complete with an Eskimo to inhabit it, a dog, a supply of food, and a fire to
keep him warm. (Figure 16.2) As she explained it, “he has everything he needs,
but no people.” Her work seemed a detailed and matter-of-fact reflection of her
experience of prolonged isolation. Other patients in my experience have depicted
procedures they found anxiety-provoking, especially diagnostic scans and radiation
therapy. These procedures may be especially troubling to children because they
must be alone during treatment and the forces acting on their bodies are both in-
visible and intangible. Drawing the treatment setting, the machinery used, and
sometimes themselves receiving the treatment gives them the opportunity to revisit
the experience and assert mastery over it by bringing it into the shared reality of
therapist and client (Figure 16.3).
FIGURE 16.2. Clay sculpture of an igloo by young patient.

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215
FIGURE 16.3. Drawing of the radiation therapy machine.
MIND–BODY CONSIDERATIONS
For the past decade or so there has been a great deal of emphasis on the relationship
between physical well-being and emotional states. Healing and the Mind (Moyers,
1993) helped these concepts reach a larger audience. Practitioners in many disci-
plines, from doctors of conventional medicine to specialists in acupuncture and bio-
feedback, have explored the complex interrelationships between illness, healing, and
the unconscious messages that inform our perceptions of the self and the world. For
example, minimizing the perception of pain through self-hypnosis and dissociation
has been at the core of natural childbirth education for many years and is routinely
employed to help patients who experience chronic pain. Mobilizing the immune sys-
tem by expressing emotions and avoiding illness by positive thinking are the subjects
of both serious scientific inquiry and supermarket tabloids. The new emphasis on
preventive medicine and education to encourage healthy lifestyle choices has helped
normalize ideas that once seemed far-fetched.
The power of art therapy to support affective expression, assist clients in experi-
encing feelings of mastery and relaxation, and help individuals develop and practice
their own healing meditations has integrated the principles of mind–body and the
discipline of art therapy. For example, art therapist Carol DeLue (1999) studied the
physiological response of school-age children to the task of creating mandala draw-
ings. Using biofeedback techniques, she concluded that simply drawing within a cir-
cular outline produces a physiologically measurable relaxation response. Relaxation
has long been linked to reducing the subjective experience of pain and increasing
cooperation with medical procedures.

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Dr. Bernie Siegel (1990) and many others write of the significance of self-discovery
in the resolution or improvement of cancers in adults. Adults with cancer often re-
flect on their life histories, priorities, and relationships, usually in anticipation of
death. Sometimes it is reported that these individuals discover and reintegrate long-
denied aspects of themselves, and in some instances spontaneous remission of their
cancer follows. Carmen Zammit (2001) reports on such a case study using art ther-
apy as a medium to facilitate the patient’s journey of self-reclamation and the corre-
sponding spontaneous and durable remission of the patient’s cancer. She describes a
process whereby adults may use the creative process to gain insight into life choices
that contribute to illness and make changes that facilitate health.
Children’s illnesses are likely not related to lifestyle choices and problems in
intrapsychic development, yet the artwork of ill children most often speaks from an
intuitive place of wisdom. Susan Bach (1990) advances a system of interpretation of
graphic messages in the artwork of ill children that she feels can predict treatment
outcomes based on visual cues in their drawings. In a stunning example from my
own work, a young boy drew a one-legged “Anger Monster” during a period of re-
mission from his leukemia. I was so impressed by the drawing that I asked our medi-
cal team to evaluate his leg. No problem could be detected at that time, but two years
later the boy’s cancer returned in the form of a lesion in his right leg—matching the
spot where the drawn Anger Monster’s leg had been cut off. Spontaneous artwork
may add useful information to medical evaluations, both as an indicator of emo-
tional adjustment and a graphic representation of physical symptoms.
A boy of 9 who would eventually die from a brain tumor created a painting of a
bright blue and orange butterfly and inscribed it “I’m Healthy!” The butterfly was
his contribution to the annual Pediatric Oncology Art Exhibit that year, but it re-
flected a medical status contradictory to objective measures. His tumor was not re-
sponding well to treatment, but it would grow slowly, allowing him several years of
life marked by a gradual loss of functioning. When he painted his butterfly, he was
aware that his tumor was still growing despite aggressive treatment, but his artwork
spoke with authority about his experience of himself. There was a marked contrast
between his perception of himself as a whole person and the scientific measure of his
condition. His resilient personality, his family’s support, and his work in art therapy
enabled him to experience and affirm his healthy self in the midst of years of struggle
with cancer. This perception helped him maintain a core sense of self-esteem and
well-being even as he lost many cognitive and physical functions.
Medical illness can place profound stress on patients and their family systems.
Treatment for a chronic illness may go on for many years, requiring adaptation by
every member of the family. The health within the family system prior to diagnosis is
a well-documented predictor of the child’s adaptation to illness and treatment. A
1998 study of families of patients with sickle cell disease links behavioral problems
in child patients with caregivers’ self-ratings of hostility, anxiety, and depression
(Ievers, Brown, Lambert, Hsu, & Eckman, 1998).
Access to medical care itself can be a significant family stressor. It is not uncom-
mon for patients to temporarily relocate to a medical center far from home where
some specialized treatment is available. A 7-year-old boy in just such a situation ex-

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