Hacking

The psychopathology of everyday art:
a quantitative study
by
Suzanne Hacking
November 1999
A dissertation submitted
in fulfilment for the degree of
Doctor of Philosophy
Department of Psychiatry
School of Postgraduate Medicine
University of Keele
i
ii
Abstract
Analysis of psychiatric artwork has been largely based on its content or verbal reports of its meaning. This
thesis presents an alternative approach to psychopathology of paintings, in the development of a new
instrument, the Descriptive Assessment for Psychiatric Artwork (DAPA). This thesis reports the
steps taken to validate the DAPA: through examination of the literature, initial study, reliability study and
the main comparison of 86 patients with disabling psychiatric disorder and controls.
The surface distribution of 12 operationally defined characteristics of paintings was recorded: 10
formal (red, yellow, green, brown, blue, black, intensity, painted and drawn line, and space covered by
media) and 2 content characteristics (subjective emotional tone and dominant form) using a grid of twenty
rectangles placed over the picture. These scores were collapsed to produce average scores for each painting.
All paintings within subject were also collapsed to produce a subject profile of 12 continuous scales.
Reliability assessment between six independent raters and the author were excellent. Intraclass
correlations were 0.86-0.99 and Cronbach's alpha 0.91-0.99.
Design: Subjects were classified using ICD-10 diagnostic classifications for research (depression,
schizophrenia, personality disorder, substance abuse). 1-way ANOVAs were performed with post-hoc
comparisons using the Duncan procedure. Discriminant analysis predicted patient/control classification
and controlled interactions between variables.
Results: ANOVA showed highly significant differences (p<0.01) between controls and all patient groups
on 5 scales: green, drawn line, space, emotional tone and dominant form.
There were significant differences between two or more groups on ten scales out of twelve. 3
variables isolated diagnoses between patients: black, emotional tone and dominant form, and there were
indications that combinations of variables could further isolate groups.
Discriminant analysis consistently differentiated patients from controls 80-90% accurately. Effect
size comparison against a compilation of reliable formal and content variables from the literature analysis
placed the DAPA far ahead of the field.
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Table of Contents
Page Number
Chapter One: Introduction
1. Organisation of thesis
1
2. The argument for another art assessment 2
Chapter Two: Literature Review

1. Is there a way through the jungle? What kind of literature is
relevant to this study?
Literature search methods and exclusion criteria 30
Impressionistic and theoretical studies 35
Artists: Are they special cases? 42
2. Research Studies
Case and series studies 47
Expression of feelings 49
Changes or signs in content or form of artwork 54
Therapeutic Relationship 63
Summary of case studies 65
Controlled studies 69
Analysis 71
Summary 87
Validity analysis of the literature 88
Summary and conclusion 93
Reliability analysis of the literature 95
Summary of reliability study 136
3. Conclusion and Summary 141
Chapter Three: Positive Thinking: What are the common

psychiatric characteristics of paintings?
Meta Analysis of reliable studies identified by the literature 143
Conclusion for meta analysis 158
Summary of findings from the common results 158
Chapter Four: The Descriptive Assessment for Psychiatric Art

The ideal characteristics for a new test: Development of the DAPA 162
The DAPA test
Illustration of scoring procedure and rating guide 171-2
Methods Section 173
1. The Main Study 173
Sample 174
Instruments 178
iv
Analyses 182
Procedures 189
2. Reliability Study 193

3. Study 1 206
Chapter Five: Results Section

1. Results of the statistical tests
Preparation of the data 217
Comparison of groups
221
2. Interpretation of the figures
Specific differences from the ANOVA 223
Discriminant analysis 236
3. Subordinate analyses 241
Chapter Six: Discussion 245

1. Expectations and anomalies
Colour 250
Structure 262
Conclusion and summary from discussion of the results 273
2. Relation of results from Study 1 to Study 2 278
3. Discriminatory power between controls and patients 284
(i) Is the DAPA a better assessment than the other tests
reviewed in Chapter 2? 284
(ii) Which variables discriminate between patients and
controls? 286
Strengths and weaknesses of the study 288
Effectiveness of the DAPA 291
Chapter Seven: Conclusion 293

Is the DAPA better than other art assessments? 299
Where do we go from here? 300
The future for measures of Psychopathology 302
Appendices
Descriptions of terms from analyses of the literature Appendix
1
Tables of data relating to the Chapters 2 and 5 Appendix 2
Table of authorities Appendix 3
Development of the instrument (the DAPA) Appendix 4
Permission and informed consent for experiments with patients Appendix 5
Bibliography
v
List of Illustrations, Figures and Tables
Chapter 2.
Impressionistic studies
Table 1: Analysis of 253 impressionistic and theoretical papers by diagnoses
according to the theory of art value to therapy. 37
Table 2a: Environmental description for 253 impressionistic and theoretical papers
according to explanation of art therapeutic value. 39
Table 2b: Commonly claimed benefits for 253 impressionistic and theoretical papers
according to explanation of art therapeutic value. 40
Table 3: Summaries of impressionistic studies of or about artists. Appendix 2
Case studies
Table 1: Diagnostic groups for case studies by levels of benefit where the primary
purpose of artmaking was the expression of feelings.
51
Table 2: Descriptions of 67 case studies showing consistency of the research by
levels of benefit from expression of feelings. 52
Table 3: Chi square results for association between method of study, form of
expression and benefits for 67 studies which claimed 'expression of
feelings' as the main benefit for the use of art with psychiatric patients.
53
Table 4: Summaries of papers reporting changes or signs in the theme/content of
the artwork. Appendix 2
Table 5: Summaries of papers reporting general signs of psychiatric disturbance.
Appendix 2
Table 6: Summaries of papers reporting changes or signs in the form of the
artwork. Appendix 2
Table 7: Summaries of papers reporting the most important feature of art therapy
was the therapeutic relationship. Appendix 2
Table 8: Summaries of papers reporting behaviour changes for case studies.
Appendix 2
Contingency tables for Chi square calculation to indicate association between method of
study, form of expression and benefits for categorised commonalities of the 67
'expression of feelings as main benefit for art therapy' studies:
crosstabulation 1: Orientation by method of study. Appendix 2
crosstabulation 2: Orientation by form of expression. Appendix 2
crosstabulation 3: Orientation by benefit. Appendix 2
crosstabulation 4: Method of study by benefit. Appendix 2
crosstabulation 5: Form of expression by method of study. Appendix 2
crosstabulation 6: Form of expression by benefit. Appendix 2
Controlled Studies
vi
Table 1: Descriptive statistics for 51 controlled studies. 73
Table 2: Frequency and percentage of demographic variables for 51
controlled studies by levels of result. 73
Table 3a: Diagnostic groups 1-4. Frequency and percentage for

whole study. 75
Table 3b: Diagnostic group 1. Frequency and percentage by levels of result. 75
Table 4: t-tests performed to compare the means of ordinal demographic
variables by year of study. 76
Table 5: Non-parametric tests performed to compare the ranks of categorical study
variables by year of study. 76
Table 6: Significant variables identified from the Mann-Whitney non-parametric
association test. Frequency and percentage for Group 1, early studies
1973-1977; Group 2, late studies 1992-1996. Changes in methods and
measurements. 78
Table 7: Frequency and percentage of test variables for whole sample of
controlled studies by results. 79
Table 8a: Analysis of variance compared 5 demographic variables
by 7 study factors. 83
Table 8b: Analysis of variance performed to compare the means of 5
ordinal demographic variables by 7 study factors. 84
Table 9: Frequency and percentage for measurement form by no. of
criterion measures. 85
Table 10: Frequency and percentage for test derivation and results by
no. of judges. 86
Validity Analysis
Table 1: Frequency and percentage of criterion variables for 70 studies
by result. 91
Table 2: Diagnostic groups for 70 studies with criterion measures. Frequency
and percentage by levels of result. 92
Table 3: Non parametric test to show differences between study factors for
findings of association and non-association of art-test with criterion
measure. Mann-Whitney U-Wilcoxian Rank Sum Test.
92
Reliability Analysis
Table 1: Reliability statistics and discriminating variables for category of
theme. 105
content. 107
Table 3: Reliability statistics and discriminating variables for category of body
detail in picture. 110
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quality. 113
line quality. 115
shape. 118
colour. 120

reality 123
space. 126
Table 10: Reliability statistics and discriminating variables for category of energy.
128
Table 11: Reliability statistics and discriminating variables for category of pictorial
detail. 130
complexity. 132
control.
133
composition. 134
Chapter 3
Meta Analysis
Table 1: Results of the aggregated combination of all variables from tabulated areas
for patients and any type of control 155
Table 2: All variables for 11 studies from the tabulated 15 different areas of
drawing measurement. 155
Table 3: Aggregated results for patients/all controls by form or content
variables. 157
Chapter 4
Development of the DAPA
Table 1: The simplified positive findings from case and control studies reviewed
relating to content of picture. 164
Table 2: Table of expected characteristics from the literature. 169
Methods
Table 1: Demographics for all experimental groups. 175
Table 2: Category definition of case assignment to 4 types: Affective disorder,
Schizophrenia, Personality Disorder, Substance Abuse. 190
Table 3: 21 patients who were excluded from the study. 190
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Reliability Study
Tables showing scores given by 6 raters and author for 7 pictures, no. of exact
agreements, mean rating for 6 raters and difference to score 7.
Figures showing plot of differences in interrater score with author score for Mean
Raters+Author plotted against average, Rater score+author score/2
Table/figure 1: Red Appendix 2
Table/figure 2: Yellow Appendix 2
Table/figure 3: Orange Appendix 2
Table/figure 4: Purple Appendix 2
Table/figure 5: Green Appendix 2
Table/figure 6: Blue Appendix 2
Table/figure 7: Brown Appendix 2
Table/figure 8: White Appendix 2
Table/figure 9: Black Appendix 2
Table/figure 10: Intensity Appendix 2
Table/figure 11: Painted Line Appendix 2
Table/figure 12: Drawn Line Appendix 2
Table/figure 13: Space Appendix 2
Table/figure 14: Emotional Tone Appendix 2
Table/figure 15: Form Appendix 2
Table 16: Standard deviation of the differences between the mean of the 6 trainee
raters and the author ratings over 7 paintings. 198
Table 17: Means and standard deviations of rater scores for each variable over the
sample of 7 pictures. 202
Table 18: Ordering of DAPA variables for reliability. 201
Table 19: Inter-rater reliability showing Cronbach Alpha score for internal
consistency of scores between raters; and correlation coefficient for linear
association between scores of raters. 202
Study 1
Table 1: Demographics for experimental groups. 207
Table 2: Diagnosis: Assignment to type. 211
Table 3: Multiple ranges: group means significantly different at the 5% level.
Duncan procedure. 214
Chapter 5
Results
Boxplots, spreadplots and tables showing distribution for each diagnostic group against
whole population for variables from the DAPA test with heterogeneous distribution
before transformation.
Table, boxplot and spreadplot 1a (red). Appendix 2
Table, boxplot and spreadplot 1b (yellow). Appendix 2
Table, boxplot and spreadplot 1c (orange). Appendix 2
Table, boxplot and spreadplot 1d (purple). Appendix 2
ix
Table, boxplot and spreadplot 1e (brown). Appendix 2
Table, boxplot and spreadplot 1f (white). Appendix 2
Table, boxplot and spreadplot 1g (painted line). Appendix 2
Table, boxplot and spreadplot 1h (drawn line). Appendix 2
Table, boxplot and spreadplot 1i (form). Appendix 2
Boxplots, spreadplots and tables for variables which were kept in their original state
because they showed homogeneity in their distribution from the Levene test, or the
transformation did not improve their distribution pattern.
Table, boxplot and spreadplot 2a (green). Appendix 2
Table, boxplot and spreadplot 2b (blue). Appendix 2
Table, boxplot and spreadplot 2c (black). Appendix 2
Table, boxplot and spreadplot 2d (intensity).
Appendix 2
Table, boxplot and spreadplot 2e (space). Appendix 2
Table, boxplot and spreadplot 2f (emotional tone). Appendix 2
Mean scores for variables from the DAPA test showing distribution norms of over 109
subjects after transformation.
Table, boxplot and spreadplot 3a (red). Appendix 2
Table, boxplot and spreadplot 3b (yellow). Appendix 2
Table, boxplot and spreadplot 3c (brown). Appendix 2
Table, boxplot and spreadplot 3d (painted line). Appendix 2
Table, boxplot and spreadplot 3e (drawn line). Appendix 2
Table, boxplot and spreadplot 3f (form). Appendix 2
Table 4: Projected transformations for data based on computations designed to

verify the assumptions of the ANOVA test. 218
Table 5: Transformed data based on computations designed to verify the ANOVA
test. 218
Figures 6, standard differences from mean of each diagnostic group.

6a, plot of red Appendix 2
6b, plot of yellow Appendix 2
6c, green Appendix 2
6d, blue Appendix 2
6e, brown Appendix 2
6f, black Appendix 2
6g, intensity Appendix 2
6h, painted line Appendix 2
6i, drawn line Appendix 2
6j, space Appendix 2
6k, emotional tone Appendix 2
6l, dominant form Appendix 2
Figures 7, standard differences from mean of diagnostic groups: abnormal distribution.
x
7a, orange Appendix 2
7b, purple Appendix 2
7c, white Appendix 2
Table 8: Results of analysis of variance for the purpose of identifying diagnostic

grouping variables between 4 groups of psychiatric patients and one
control group on 13 formal measures of their paintings. 222
Table 9: Main Analysis: multiple comparisons, Duncan procedure. 222
Specific Differences for each variable

Figures showing confidence intervals and means by diagnostic type for DAPA variables:
Figure 10a, red 224
Figure 10b, yellow 225
Figure 10c, green 226
Figure 10d, blue 226
Figure 10e, brown 227
Figure 10f, black 228
Figure 10g, intensity 229
Figure 10h, painted line 230
Figure 10i, drawn line 231
Figure 10j, space 232
Figure 10k, subjective emotional tone 234
Figure 10l, dominant form 235
Table 11: Discriminant analysis to classify controls or patients. Classification

functions from the first sample are used to classify the second sample.
Repeated 5 times with different partitions of the data set. 238
Table 12: t-test results for significant differences between means of variables
measured from paintings by patients against non-patients as though they
were independent. 239
Table 13a: Separate effect size for each variable from the DAPA test. 240
Table 13b: Separate effect size for each variable from the DAPA test. 240
Table 14: Results of 2-way ANOVA: diagnostic groups by number of paintings
from each patient.
242
Table 15: Correlations between number of pictures within each group with each
variable. 243
Table 16: Correlation for DAPA variables measured from the paintings of
schizophrenics - a) Colours b) structure. Appendix 2
Table 17: Correlation for DAPA variables measured from the paintings of substance
abusers - a) Colours b) structure. Appendix 2
depressives - a) Colours b) structure. Appendix 2
xi
Table 19: Correlation for DAPA variables measured from the paintings of controls
- a) Colours b) structure. Appendix 2
personality disorder - a) Colours b) structure.
Appendix 2
Chapter 6
Discussion
Table 1: Summary table of results. 249
Table 2: Interpretations of the use of colour in artistic production, taken from
S.P.Amos. 251
Figures 3a-e: Map of associations between colour variables measured between

diagnostic groups from the results of the DAPA test.
252
Figures 4a-e: Map of association of structural variables measured between diagnostic
groups using the DAPA test. 262
Illustration: example of use of grid system with marked score for 'red'. 171
xii
List of Abbreviations
Am. Assn. Art Therapists American Association of Art Therapists (AAAT)

Am. American
Am. Educational Research J. American Educational Research Journal
Am. J. Art Therapy
Am. J. Psychotherapy American Journal of Psychotherapy
Art Psychotherapy The Arts in Psychotherapy
B. J. Psychiatry British Journal of Psychiatry
Bull. Art Therapy Bulletin of Art Therapy
British Assn. Art Therapists (BAAT) British Association of Art Therapists
Canadian Psychol. Canadian Psychologist
CDAT Comparitive Description of Artwork Test
DAPA Descriptive Assessment for Psychiatric Artwork
DAP Draw-A-Person (used in drawing tests)
DDS Diagnostic Drawing Series
HFD Human Figure Drawing
HTP House-Tree-Person (used in drawing tests)
Int. International
J. Journal
J. of the Am. Academy of Psychoanalysis Journal of the American Academy of
Psychoanalysis
J. Am. Psychoanalytic Assessment Journal of American Psychoanalytic Assessment
J. Clin. Psychol. Journal of Clinical Psychology.
J. Exp.l Psychol. Journal of Experimental Psychology
J. Gen. Psychol. Journal of General Psychology.
J. Nervous Mental Dis. Journal of Nervous and Mental Disease
J. Pers. Assess. Journal of Personality Assessment
J. Sch. Psychol. Journal of School Psychology
Percep. Motor Skills Perceptual and Motor Skills
Psycholog. Bull. Psyhological Bulletin
Psychol. Mon. Psychological Monographs.
WHO World Health Organisation
xiii
Acknowledgements, thanks and foreword
This thesis comes as a culmination of questions that have arisen, mostly unformulated,
over many years of involvement in art, which started casually through community
projects, continued during a degree in Fine Art, and subsequent professional involvement
with mental health groups. During the last decade, I touched on the same sort of question
under the auspices of academic psychology during my MA., but finally the opportunity
to research through psychiatry has led me to approach the subject from a far different
angle than I had originally envisiaged. I have not become a multidisciplinary expert, I
have tried to understand what I have applied, but no doubt shortcomings can be found
in it. The course of this research, however, has changed me. It has given me new and
useful skills, and thought structures, but it has also taken away some aspects I was not
fully aware of; I am still synthesising the widely different contexts it covered.
I am aware this thesis may read as an attack on the profession of art therapists,
although this is far from the intention. It is a sad picture of art therapy research that
emerges, and I have related its failings rather than the clinical achievements of this
dedicated profession for which I have the greatest respect and whose research work is
often constrained by lack of funding and low status.
This research was made possible by the interest and generous help and
encouragement I have received from some who gave their valuable time and went out of
their way to assist this novice. I should like to record outstanding debts of gratitude to
Dr. David Martin Foreman, Senior Lecturer, Psychiatry Dept. School of Postgraduate
Medicine at the University of Keele, who supervised this research through the depths of
depression to its highlights and whose unfailing encouragement, useful comments,
criticism and suggestions most motivated me over the six years it took. I would like to
specially thank also Mike Fletcher, Head of Dept., School of Computing, Staffordshire
University, who provided specialist knowledge and supervised the application of the
discriminant analysis technique and who kindly checked over the first draft of the results
section.
I thank these Consultant psychiatrists from N. Staffs. Hospitals, who allowed me
access to their patients: Dr. K. Bloore, Dr. K. Barrett, Dr. F. MacMillan, Dr. J. Crisp,
Dr. Ward, D. Gee, Dr. Slade, Dr. J. Boardman, Dr. Myers and special thanks to Dr. K.
Barrett, Clinical Director, Bucknall Hospital and Senior Lecturer in Psychiatry, Post
Graduate School of Medicine, Keele University whose interest, encouragement and
supervision of the initial stages for the first DAPA study was instrumental in
development of the test theory.
John Belcher of the Dept. of Mathematics, Keele University did his best to
instruct me in basic statistics in the early stages of this research; Professor Terry Shave,
of the Dept. of Fine Art at Staffordshire University allowed me to recruit his students
as test-raters; Dr. Linda Gantt, of Alexandria sent me her Ph.D thesis from the USA and
provided some useful contacts.
Finally, without the unceasing support and encouragement of my partner David,
I should never have been able to finish what has seemed at times an impossible task,
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especially since the birth of our daughter Ellie 3 years ago. His support, love and
understanding is my greatest resource.
Chapter One: Introduction
Organisation of thesis: The first three chapters introduce the background to the study,
the need for systematic assessment of painted artwork and the development of a novel
approach to the assessment of drawing categories. Chapter one provides an overview,
points out that conventional interpretive evaluative methods do not identify what is
specifically psychiatric about artwork produced by patients and reveals the neglect of
formal measures. Chapter two reviews the development of assessment of psychiatric
artwork over the past 20 years in two sections. Section 1 introduces a number of popular
views about how art therapy works and Section 2 concentrates on the information from
case studies and controlled studies; common findings, conclusions and changes in
assessment methods. These results are then critically discussed with particular reference
to methodology. In chapter three a meta-analysis is performed on studies from the
review to identify which groups of variables are central to reliable and systematic
assessments of psychiatric paintings. The summary gathers the knowledge from the
literature review to show the kinds of measurement which have the best repeatability and
validity for new instruments.
Chapter 4 describes the development of a novel instrument, the Descriptive
Assessment for Psychiatric Art (the DAPA) and introduces the steps taken to validate
it: the main experiment, inter-rater reliability and the initial study. Chapters 5 presents
the results of the main study. Chapter 6 considers the support for and discrepancies
from the DAPA results with previous work. Finally, Chapter seven summarises and
15
concludes on the effectiveness of the instrument with some thoughts on how the
approach exemplified by the DAPA extends previous practice in this field.
The Argument for Another Art Assessment
Introduction
It has long been remarked upon that people with mental illness can sometimes produce
quite surprisingly communicative and highly organised art, the explanation of which has
had a number of theoretical approaches1. The general task has been to describe and
explain the phenomena of psychotic art in relation to the behaviour and experience of
mental illness. This issue has been discussed within many disciplines, without producing
final solutions, but the psychological aspects have been, to some extent detached and
investigated on an empirical level. The subject is too complex to be handled as a whole
and it has been divided into many different problems for research. MacGregor (1989) and
Waller (1991) have made recent extensive reviews of the history of ideas in the field of
psychiatric art2. These two sources alone provide a comprehensive historical
background, but Winner3 adds a useful analytical framework and the diversity of
1
For summaries see Tessa Dalley and Caroline Case (1992), Handbook of Art Therapy, London:
Routledge, probably gives the most readable account of the diversity of theoretical approaches; T. Dalley
and A. Gilroy, eds. (1989), Pictures at an Exhibition, London: Routledge, explores the range of
psychoanalytic explanations thought to be related to psychopathology in art; Marion Liebmann (1990),
Art in Practice, London: Tavistock, describes the variety of art therapy practised with different client
groups in one area; and V. Lusebrink (1990), Imagery and Visual Expression in Therapy, New York:
Plenum, identifies most of the different practical approaches to art therapy.
2
Diane Waller's (1991) Ph.D. based Becoming a Profession: the history of art therapy 1940-1982, London:
Routledge, gives a useful and informative in-depth study of the roots of current theoretical practice. John
Monroe MacGregor (1989), The Discovery of the Art of the Insane, New Jersey and Oxford: Princetown
University Press, also developed from his Ph.D. research, provides a detailed interdisciplinary history of
the earlier empirical and case studies, personalities and work of insane artists.
3
Ellen Winner (1982) Invented Worlds: the psychology of the arts, Cambridge, Mass: Harvard U.P.
16
contributors to the exploration of emotion through art have been comprehensively
discussed elsewhere4. The foci of investigation fall between two domains, closely
interrelated: those describing the process of creation and therapeutic benefit and those
describing the product.
This chapter introduces a number of popular views about the explanation and
investigation of pictures produced by psychiatric patients. When we talk about art
therapy, we refer to a belief that art is somehow expressive in itself or even healing5. Art
therapists are not united in their subscription to any explanatory theory but most agree
on these principles: disturbed people, particularly schizophrenics, produce artwork
which is communicative in a way that their language is not; the thoughts or feelings of the
patient are literally re-presented in concrete form; connections are made cognitively or
visually which approximate insight experiences; the paintings are described as powerful
and disturbing, often filled with bizarre imagery. These features have been related to the
artist's mental or emotional state. The commonly understood advantage in using art with
people who may not be able to fully express themselves in language is that as the painting
4
see, for example: Tessa Dalley (1984), Art as Therapy, London: Tavistock; T. Dalley et al. (1987), eds.,
Images of Art Therapy, London: Tavistock, giving a range of perspectives on the therapeutic aspects of
art; Joy Schaverien (1992) gives a very readable psychoanalytic breakdown of the relationship of affect and
transference and the development of the therapeutic relationship, The Revealing Image: analytical art
psychotherapy in theory and practice, London: Routledge.
5
Joan Woddis (1992) comments on the belief of many art therapists in a "mythology concerning the
intrinsic healing properties of the art-making process" (Art Therapy: new problems, new solutions in Diane
Waller and Andrea Gilroy, eds., Art Therapy: A Handbook, Bristol: O.U.P. p.39). For example, to use
a standard text on art therapy, Dalley and Case (1992, Handbook, op.cit. p.54) acknowledge the split
between art therapists on this issue and also on the relevance of psychoanalytic theory. Whilst Dalley
generally emphasises the vital importance of the therapist in access to the image, elements of the healing
function of art do enter pervade into her writing: She explains her personal view of the function of the art
therapist as "providing a setting in which healing can occur". Another 'setting' argument: "The activity
of painting sets up a relationship between client and the paper, which can be exclusive of the therapist, but
the therapist... holds the safety of the scene, like the mother ever attentive to her infant" (p.59). Recent
papers which offer this view as an explanation for the therapeutic process are reviewed in Chapter 2.
17
or drawing progresses, relationships and reinforcement develop between the parts of the
composition, which can be monitored by the therapist, or manipulated to produce
specific reactions, as with a conversation.
This overview does not provide a historical survey, which would both step
outside the conceptual boundary of this thesis and require more space. The background
is only discussed as far as it affects this thesis. It introduces two kinds of assessment
which informed the study of psychiatric art: case studies, which are split into four areas;
and projective testing. Although limited, this background is important here because many
of the assumptions underlying the theoretical base used to analyse content, especially in
impressionistic studies, hark back to speculations that were published at the turn of the
century but have been subject to serious criticism ever since6; for example, the confusion
of relations between insanity and artistic creativity. This section also introduces a few
of the terms and jargon commonly used in studies of art but not all of them since many
are based on theoretical assumptions which do not concern this study7.
6
But not from writers on psychopathological art. D. Waller (1991) op.cit. gives an account of the
development of current theory but there is little personal comment. Most writers on art therapy rather than
tackle arguments try to embrace a range of apparent contradictions by modifying or integrating theory;
Waller explains "art therapy is a term which has been used to describe a collection of diverse practices, held
together fundamentally by their practitioners' belief in the healing value of image-making", Waller and
Gilroy (1992) introduction, op.cit. Dalley and Case (1992), Handbook, op.cit. write that art activity is
both a conscious process (p.51, 98) and an unconscious process (p.64), point out that images are complex
and take time to understand both for the therapist and the artist and need discussion (p.52, 64) and Dalley
goes on to interpret a series of paintings left by a client who never spoke to her (p.118). Notable
exceptions are David Maclagan (1989) who includes acerbic comments in his articles concerned with the
relation of verbal psychotherapy to the image produced, see for example, The Aesthetic Dimension of Art
Therapy: luxury or necessity, Inscape, Spring: 10-13; John Birchtnell (1981) Is Art Therapeutic?, Inscape,
V(I).p.10 and J. Champernowe (1971), Art and Therapy: an uneasy partnership? Am. J. Art Therapy,
April, X(3):131-143 which gives the bones of the arguments.
7
Dalley and Case (1992) op.cit., p.60-3 gives a useful glossary and explanation of the main analytic terms
and interpretations, but there is no generally agreed standardisation.
18
Another reason that little time is spent here is because before the 1950s concept
change in psychiatry, there was a totally different approach to diagnosis so we can't
really be sure that previous descriptions are comparable with today's psychiatric
categorisations. Institutionalisation may have accounted for much of the previous
findings of global differences between patients and controls. During the late 1960s,
psychiatric diagnostic criteria was standardised between the U.S. and the U.K., especially
in operational definitions of specific categories.
The need for more research in art assessment
The two most commonly recognised uses of art with psychiatric patients other than as
a diversionary activity, are in therapy for expression of emotional issues and for
psychological assessment, as an aid to diagnosis or treatment. There is pressure on art-
therapy to control and assess its therapeutic input for the latter two categories if art
activity is not to be relegated to the first. The descriptive literature points to obvious and
felt benefits from clients' experience of art therapy, but there is a marked paucity of
criticism of the theoretical bases of the practices and a lack of investigative research into
the contribution of the artwork to psychopathology8.
Investigation into the psychopathology of art: the background
8
Recognised by the majority of contemporary writers in this field, for example: David Edwards (1987),
Evaluation in Art Therapy, in Derek Milne, ed., Evaluation in Mental Health Practice, Beckingham:
Croom Helm, pp.53-69; Andrea Gilroy (1992) Research in Art Therapy, in Waller and Gilroy, Handbook,
op.cit. pp.229-247; Shaun McNiff (1986), Freedom of Research and Artistic Inquiry, Arts in
Psychotherapy, V.13: 279-84; comments from Linda Gantt and Gladys Agell (1994) in, R. Goodman,
G. Agell, L. Gantt and K. Williams, 'Are there Doctors in the House? Does Art Therapy Need a Cure?'
Am. J. Art Therapy, V.33, p.3-13.
19
The link between genius as a product of madness and creativity, which was first
proposed by Lombroso, Italian psychiatrist and criminologist, in 18919, has survived in
popular culture and to some extent in learned circles, as have two articles written by Paul-
Max Simon (1876 and 1888)10. Lombroso and Simon separately describe the use of
characteristic features as a means of psychiatric diagnosis. Simon's conclusions, from
clinical observation, were based on only 14 creative individuals and Lombroso's offer only
his own speculations. Nevertheless they were a great influence on the psychiatric
approach to art of the late 19th century. MacGregor describes the refinement of Simon's
work in the more systematic experimental approach of Fritz Mohr (1874-1966), derived
from the school of Kraepelin (1856-1926)11. Mohr's methods were adopted by students
of the subject12 and led to the development of standardised tests on the one hand, and on
the other hand, the descriptive case study. Both methods subsequently developed
separately, each strand evolving its own literature, techniques and theory. Prinzhorn
(1886-1933), a psychiatrist as well as an art historian, studied the Heidelberg collection
of psychiatric art. His book, Artistry of the Mentally Ill (1922)13 presents and does not
interpret the work of particularly talented but selected individuals, commenting on the
9
Cesare Lombroso (1891), Man of Genius, London: Scott.
10
see MacGregor (1989) op.cit., Chapter 7, pp.103-115 for a description.
11
Emil Kraepelin discussed the drawings of dementia praecox patients (his own category for schizophrenia)
in his Lehrbuch der Psychiatrie (1883) distinguishing several subtypes, although his involvement with
patient art was rather superficial (MacGregor (1989, op.cit.):188-9).
12
Although he never got further than descriptive studies himself. Most of his followers contributed little
to his original findings with a few notable exceptions (e.g. Herman Rorschach, 1884-1922 and Karl
Jaspers, 1883-1969).
13
Hans Prinzhorn (1922), Artistry of the Mentally Ill, Berlin: Springer Verlag.
20
style and communication value. Prinzhorn ridiculed the diagnostic use of drawings:
"Anyone unable to make a diagnosis without the drawings will certainly not have an
easier time with them" (p.3). This work is still held as the most complete treatment of
the field at the time, but there is no doubt that some of his 'schizophrenics' would not be
so diagnosed today. By the turn of the century, psychiatry14 acknowledged the
systematic drawing test as a useful aid to diagnosis. Illustrated case studies with
attempts to link characteristics from drawing and painting to psychiatric symptoms were
published, although with few exceptions these were poor quality: their material was
selective, they confused observation and interpretation, were unreliable in their
reporting15. By mid-century, there were hundreds of descriptive case studies, some book
length16. Speculative attempts to relate psychiatric symptoms to images were mostly
discredited when the confounding influences of intelligence, art experience, skill in
patients were demonstrated to influence raters' judgement of normality in the 1970s17,
14
Macgregor (1989, op.cit., pp.243-244) describes the interest of Karl Jaspers in the comparison of
aesthetics in paintings by artists with a mental illness with those of psychiatric patients from the Prinzhorn
collection, (K. Jaspers, Strindberg und Van Gogh); Henri F. Ellenberger (1970), The Discovery of the
Unconscious - The History and Evolution of Dynamic Psychiatry, Harmondsworth: Penguin Press, gives
a good account of the gradual medical recognition that drawings by the mentally ill functioned as
externalisation of their delusional preoccupations and that specifically disturbance of speech was related
to disturbance of pictorial rendering.
15
A. Anastasi & J. Foley (1941), A Survey of the literature on artistic behavior in the abnormal: 1.
Historical & Theoretical Background, J. of Gen. Psychol., V.25:111-142; for later criticism of the
substandard quality of much of the research material of the past, see: S. Russell-Lacy, V. Robinson, J.
Benson, J. Cranage (1979), An Experimental Study of Pictures Produced by Acute Schizophrenic
Subjects, British Journal of Psychiatry, V.134:195-200; Harriet Wadeson (1980), Art Psychotherapy, New
York: Wiley; Cathy Malchiodi (1993), Introduction to special issue on Art Therapy and Professionalism,
Is there a crisis in Art Therapy Education? Art Therapy, V.10(3):122.
16
Artist, A. Hill (1945), Art Versus Illness, and (1951) Painting out Illness, London: Allen Unwin.
Books now considered minor classics by psychiatrists: R. Pickford (1967), Studies in Psychiatric Art
London, Tavistock; F. Reitman (1950) Psychotic Art, London: R and KP, and J. H. Plokker (1964),
Artistic Self-Expression in Mental Disease, London; Littlebrown, while E. Cunningham-Dax(1953), made
a more objective and controlled study, Experimental Studies in Psychiatric Art, London: Faber Faber.
17
R. Langevin, M. Raine, D. Day and K. Waxer (1975), Art experience, intelligence and formal features
21
again by a multidisciplinary team who tested different diagnostic groups against non-
patients in 197918 and more recent studies have confirmed these findings19.
Art Therapy and Psychoanalytic Interpretation
It is not really possible to discuss this section generally, so it is necessarily limited in
scope because of the enormous complexity of the understanding of psychoanalytic
theory and also because of the limited application to this thesis. Nevertheless, some
aspects of the contribution of psychoanalysis to art therapy research must be
summarised, since the bulk of the literature reviewed in this thesis, and hence the
direction and questions come from therapists, whose formal training includes some
breakdown of psychoanalytic theory20, trying to share the sense of the imagery they face
in their clinical practice.
in psychotics' paintings, Arts in Psychotherapy, Fall V.2(2):149-158; Frank A. Johnson and Roger P.
Greenberg (1978), Quality of Drawing as a factor in the interpretation of figure drawings, Journal of
Personality Assessment, V.42(5):489-495; R. Cressen (1975), Artistic quality of drawing and judges
evaluations of the DAP, Journal of Personality Assessent, V.39:132-137.
18
S. Russell-Lacy et al (1979, op.cit.).
19
M. Miljkovitch and G.M. Irvine (1982), Comparison of drawing performances of schizophrenics, other
psychiatric patients, and normal schoolchildren on a draw-a-village task, Arts in Psychotherapy, V.9:203-
16; G.C. Cupchik and R.J. Gebotys (1988), The search for meaning in art: interpretive styles and
judgement of quality, Visual Arts Research, V.14:138-50; J. Sims, R.H. Dona and B. Bolton (1983), The
validity of the DAP as an anxiety measure, J. Pers. Assessment, V.47:250-7; see review by F.F. Kaplan
(1991), Drawing assessment and artistic skill, Art Psychotherapy, V.18:347-52.
20
The qualification for art therapists in Britain is an art degree and a postgraduate one year training course,
which may not even include experience of personal therapy, in art therapy run by specialist centres, so
much of their information is simplistic and self-taught; recent application of psychoanalytic theory to art
therapy is covered in a special issue devoted to transference and countertransference in the creative arts
therapies, Arts in Psychotherapy (1992) V.19(15).
22
Others have given summaries of the immense influence of Freud and Jung on art
evaluation21, both need no introduction here. Freud never used drawings in his work, but
his model of the artist as a borderline psychiatric case became the public view of the
'unconscious made visible' of the artist's work. Freud's deconstruction of the work of
Leonardo and Michelangelo22 was probably his influential contribution to the technique
of interpretation23. Jung painted and sculpted and encouraged his patients to do the same
"in order to escape the censure of the unconscious mind"24. He rejected Freud's negative
view of phantasy as a source of unconscious or as sublimations of infantile conflicts. He
made a distinction between personal and collective unconscious, and based his
interpretations and assumptions concerning archetypes25 and universal symbols26 on a
21
MacGregor (1989) op.cit., pp.245-270 gives a perspective of Freud and Jung's limited involvement in
true psychotic art and the development of method and theory from Kris; Joy Schaverien (1992) op.cit.,
takes particular aspects from psychoanalysis to develop her own methods for art therapy and evaluation,
but gives a very clear explanation of transference and counter transference; Ellenberger (1970) op.cit.,
shows the development from the theories of Freud to today's 'dynamic psychiatry'; Waller (1991) op.cit.,
presents a perspective of the synthesis of methods in psychoanalysis for
interpretation of art in therapy in Britain from 1940, and Maxine Borrowsky Junge and Paige Pateracki
Asawa (1994), A History of Art Therapy in the United States, Mundelein: Am. Art Therapy Assn., review
the art therapy literature which summarises the contributions of first and second generation art therapists
in America but is generally less theoretically orientated. For a more in-depth analysis of psychoanalytic
methods in art, E. Kris (1964), Psychoanalytic Explorations in Art, New York: Intl. U. P., and R.
Wollheim (1964), Art and its Objects Cambridge (reprint 1980): Writers Readers, probably give the most
understandable explanations. Books on art therapy generally are too simplistic and use a synthesis of
different methods with no overall context.
22
Laurie Schneider Adams (1993) Art and Psychoanalysis, New York: Harper Collins gives a perspective
on Sigmund Freud (1910), Leonardo Da Vinci - a memory of his childhood, Art and Literature, Pelican
Freud Library, V.XIV, Harmondsworth: Penguin, mostly derived from his childhood memories and
speculations on the infancy of Leonardo. It was in The Moses of Michelangelo, ibid., (1914) that he
explored expression in the artwork.
23
But he made a number of assumptions based on faulty translation of Italian histories.
24
C.G. Jung and R. Wilhelm (1931), The Secret of the Golden Flower, London: Macmillan, p.94;
Schaverien (1992), op.cit., gives a good description of the concept of the 'unconscious' and its application
to modern day art therapy pp.22-25.
25
Archetypes in art; inherited unconscious images that are component parts of the 'collective unconscious'
shared by all.
26
Universal symbol: a symbol that is assumed to represent the same referent universally. Such symbols
23
theoretical foundation relating art products to innate and inherited personal and universal
potentialities.
Psychoanalytic interpretation of content has thrown the only major light on
access to art and artists through their paintings. There have been accusations of obscurity
due to the metaphoric language. However, there has been limited involvement with true
psychotic art, and more concentration on the psychoanalysis of the artist. Followers
who did involve themselves have largely abandoned Freud's categorisation of primary
(primitive) and secondary (rational) processes and derived their methods from dream
analysis techniques with theoretical excerpts from Jung.
The psychiatrist, Schilder, working with the artist, Levine, in 1942, describes the
development of this thesis for art therapy:
Drawings which are offered during the analysis can be handled in the
same way as dream material irrespective of whether they have contents in
the common sense or whether they are to be classified as abstract art. The
drawing corresponds to the manifest content of a dream and also abstract
forms are basically the expression of human problems and conflicts. The
material at hand allows the conclusion that in abstract forms particularly,
primitive and important drives make their appearance. Their study is
therefore revealing, not only from the point of view of art but also from the
27
point of view of therapy .
reflect basic components of the human psyche.

27
Paul Schilder (1942) Mind: perception and thought in their constructive aspects, Oxford U.P reprint
1981, p.10.
24
Simplistically, art is understood to access the unconscious processes between two
people, and the theory is based around the process of projective identification,sometimes
with the image and sometimes with the therapist. The purpose of the analysis is to
mediate. Bringing the unconscious in a controlled way to consciousness is deemed to
release the emotions (catharsis): universal images may be interpreted as archetypal
symbols, i.e. they often mean the same things to different people.
A number of prominent analysts were seriously involved with art besides
Winnicott28; Ernst Kris, the Freudian psychoanalyst and art historian, contributed a
study of a psychotic sculptor29 and developed the crucial explanation of the creative
process as "regression in the service of the ego"30. No analyst has succeeded in
penetrating the world of the psychotic artist and the image as far as Marion Milner,
whose book In The Hands of The Living God (1969) detailed her work (1943-1959) with
Susan, a schizophrenic girl, which has had a great influence on the theoretical
development of art therapy31. Milner wrote this book as an inditement on insensitive
treatment of patients in hospital, of the isolation of the schizoid and the need to make
contact. She described the tendency for some patients to produce spontaneous drawings,
28
for others see: H. F. Ellenberger (1968), The Concept of Creative Illness, Psychoanalytic Review, 55,
pp.442-56; MacGregor 1989, op.cit. gives a very detailed analysis; D.W. Winnicott (1971), Playing and
Reality London: Tavistock.
29
Ernst Kris (1952), study of Messerschmidt, a psychotic artist (trans. chap 4), in Psychoanalytic
explorations, op.cit. p.128-50.
30
R. Shafer (1958) Regression in the service of the ego: the relevance of a psychoanalytic concept for
personality assessment in G. Lindzey (ed.), Assessment of Human Motives, London: Grove Press, pp.119-
148, explores in more detail the idea presented by Kris (1952, op.cit) that creation or enjoyment of the arts
involves a controlled use of the capacity to shift quickly from mature cognitive activity to less mature
forms.
31
for example, authors who acknowledge her influence: Dalley and Case (1992) op.cit.; Schaverien (1992)
op.cit.; Waller and Gilroy (1992) op.cit.
25
the content of which was seemingly dependent on the pathological depths of the patient,
and the more contact the patient had, the more the need to draw diminished32. Among
other influential case studies was that of a woman who could draw but not speak about
her painful emotional experiences, by the Australian psychiatrist, Meares33, and another
by Jungian psychiatrist, Baynes34, paralleling the clinical techniques of therapeutic art
practice in the 1940-50s. Recent traditional psychoanalytic works have not departed
from this type of careful in-depth study35 and there is further promise of development
from new theoretical structures, such as from the writings of Lacan36.
The overriding agreement in all serious psychoanalytic writing is that it is time-
consuming, particularly in the development of a relationship, and there can be few
immediate results, but this important qualification is disregarded by many art therapy
perspectives of these techniques37, another qualification from psychoanalytic literature,
32
An observation which has generally been ignored by her later followers.
33
Ainslie Meares (1958), The Door of Serenity.
34
H. G. Baynes (1940), Mythology of the Soul London: Tindall Cox.
35
A recent example is the 20 year analysis of a female patient "recovering a hidden artistic talent" and the
discussion of theories arising from the paintings; Margaret I. Little (1997), Miss Alice M. and her Dragon,
New York: Binghampton.
36
Lacan's esoteric ideas have made a massive impact on most aspects of psychoanalysis, especially his
reinterpretations of Freud. When it is possible to assess how Lacan's later view of the image, as a separate
category, fits in with his theory of signifiers, it may offer much to the study of psychopathology through
systems other than language, J. Lacan (1988) The Topic of the Imaginary, in J.A. Miller (ed.), The
Seminar of Jacques Lacan, Book 1 (trans. Forrester), Cambridge U.P.; Bruce Fink (1995), The Lacanian
Subject, Oxford: Princeton U.P.
37
see these examples from collected essays edited by well-respected art-therapy authors and lecturers (who
do not expound these views themselves): Sheila McClelland (1992), Brief Art Therapy in Acute States:
a process oriented approach, in Waller and Gilroy op.cit., pp.189-207, The author claims to draw on the
work of Dr. Mindell on process science and psychological interventions in psychiatry and the personal
construct work of G.A. Kelly (1955). She interprets many of the typical features of work presented by
psychotic and neurotic referrals and recommends 1. rapid establishment of rapport, 2. maintaining a focus,
3. Active assertive therapist style and 4. anticipating the ending, but qualifies that considerable training
is needed. This method is described as "a minimal intervention as it aims to draw forth what is already
26
neglected as a matter of course now for art-therapy 'referrals', is that the art must elicit
spontaneously from the patient38. MacGregor makes the point that he discusses little
of the contribution of art therapists to the history of investigation of the image making
of psychotic individuals, "The interference of individuals with minimal training in either
psychiatry or psychotherapy cannot be seen as an advantage"39, although he goes on to
point out that a full psychoanalytic training with art skills makes a valuable contribution
to the therapeutic milieu, giving the example of Margaret Naumberg, psychoanalyst and
generally acknowledged as the inventor of American psychodynamic art therapy40.
Demonstrations of the therapeutic ineffectiveness of psychoanalytic treatment
have led to a loss of confidence in the theory, but it at least offers a framework of
happening"; Paola Luzzatto (1989), Drinking problems and short-term art therapy: working with images
of withdrawal and clinging, in Andrea Gilroy and Tessa Dalley, eds., op.cit., pp.207-219 discusses
treatment of 2 patients who were also attending group therapy, through interpretation "linking behaviour
and feelings - past and present" and confrontation "allowing, or even encouraging, the exploration of
alternative ways of defence" in only 11 hours of art therapy by "stimulating free associations to the image".
She assumes transference to the imagery and supports her views with a variety of noncontextual references,
assumes a therapeutic relationship, and none of the interpretations of imagery or counselling relates to the
patient's drinking, but to "underlying problems". She discusses the anger of her second patient who "had
art therapy chosen for him". The images were recognised by the patients as symbolic of their own attitude.
38
Margaret Naumberg (1947) Studies of the free art expression of behaviour disturbed children as a means
of diagnosis and therapy, New York: J.Nervous Mental Dis. Monographs, Cooleridge Foundn.; (1950)
Schizophrenic Art, Its meaning in Psychotherapy New York: Grune Stratton; Art Therapy: its scope and
function in E.F. Hammer, ed. (1958), Clinical Applications of Projective Drawing, Springfield: Thomas;
(1966) Dynamically Orientated Art Therapy: Its Principles and Practices New
York: Grune Stratton; and Marion Milner 1969, op.cit., were both very specific that the patient should
come spontaneously to art and not be given standard exercises.
39
MacGregor (1989), op.cit. p.311.
40
Margaret Naumburg, (1947, 1950, 1958, 1966, op.cit.); Kris was particularly conscious of the
psychoanalytically orientated form of art therapy developed by Naumburg and refers to it as providing
detailed case material "I believe that future students of this question will be strongly impelled to draw on
the material so carefully presented by Naumburg. In no other similar publication of which I know is there
for instance, an equal opportunity to compare graphic and verbal productions of one patient", Kris (1953),
Review of Schizophrenic Art, by Margaret Naumberg Psychoanalytic Quarterly V.22: 98-101. Kris also
makes reference to H.G. Baynes (1940) op.cit. as providing an example of the Jungian approach to the
same problem.
27
approach. Some of the major criticisms of psychoanalytic theory41 would more than
equally apply to their art derivatives: the metaphorical language, vague theoretical
concepts and the assumed correspondence between concept and behaviour. Farrell42
notes that belief and attitude towards psychoanalytic interpretation of art depend on
previous disposition and training and the weight attached to Freudian theories. Freud
himself admitted much about the weakness of psychoanalytic methods and serious
criticisms have been made at all levels43. Art therapy is not psychoanalysis, but some
techniques have been absorbed, albeit sometimes in a non-contextual and piecemeal way.
Dalley recognises that art therapists are not agreed as to what actually constitutes art
therapy44. Most art therapy explanations of how psychoanalytic interpretation and
theory applies to art therapy are necessarily abbreviated to fit in with the general context
of a book or a paper for clinical practice. They give the impression of confusion,
subjectivity, lack of context and provide a synthesis of sometimes incompatible theory45.
41
Ernst Nagel (1959), Methodological issues in psychoanalytic theory, in S. Hook, ed., Psychoanalysis:
Scientific Method and Philosophy: A symposium, London: Grove Press, pp.38-56; Brian Anthony Farrell
(1981), The Standing of Psychoanalysis, Oxford (originally 1955): OUP
42
Farrell (1955/1981) op.cit. p.82-84 and Freudian theory p.71.
43
For a review see H. J. Eysenck (1961), The Effects of Psychotherapy, in H. J. Eysenck, ed., Handbook
of Abnormal Psychology, London: Basic Books, pp.697-725.
44
Diane Waller and Tessa Dalley (1992), Art Therapy: a theoretical perspective, in Waller and Gilroy
op.cit. p.1.
45
For example, Dalley and Case (1992) op.cit. Chapter 4 provides simplistic combinations of theories
from different analysts working at different times. Quotes from art historian, Peter Fuller (Art and
Psychoanalysis, 1980), relating to artists, support their deconstruction of Freud and others; The published
papers are discussed in more detail in Chapter 2; There are numerous examples of confusing language but
even the more respected practitioners are culpable Schaverien (1992), op.cit. in attempting to explain her
methods of analytical art psychotherapy uses psychoanalytic terms, mixed with her own derivatives, states
that "mythical thought processes are evident within the pictures" (p.41) and speaks of "sympathetic magic"
as a technique and explanation. Further explanation by association to psychoanalysis: "In analytical art
psychotherapy as in psychoanalysis, the scientific and the mythical modes of thought are both of
28
Many art therapists are deeply uncomfortable about the use made of psychoanalytic
techniques46. Criticism of the application does not necessarily imply the theoretical
assumptions are invalid, but that these hypotheses require proof of their relevance.
Neither Freud, Jung, nor others have ever produced sufficient evidence.
concern."; By Jung (1946, op.cit. p.12) "The patient, by bringing an activated unconscious to bear on the
doctor constellates the corrupting unconscious material in him, owing to the inductive effect which always
emanates from projection in greater or lesser degree. Doctor and patient thus find themselves in a
relationship founded on mutual unconsciousness." This image from Dalley and Case (1992, usually clear)
on how the client takes an active part in the therapy "The healthy part of the client aids the sick part,
feeding it and, in doing so, feeds itself".
46
Dalley and Case (1992) op.cit., p.53-54; J. Champernowne (1971), Art and Therapy: an uneasy
partnership. op.cit.; Shaverien (1992) op.cit., develops her own theories about the role of the image as
reflective of the art therapy process. R.W. Moore (1983), Art Therapy with Substance Abusers: a review
of the literature, The Arts in Psychotherapy, V.10:251-60 identified 20 papers with a range of orientations,
all using structured sessions dominated by art techniques rather than psychotherapeutic. Many art
therapists have adopted systemised protocols of assessment such as the DDS (B.M. Cohen, J. Hammer,
S. Singer (1988) The Diagnostic Drawing Series (DDS): a systematic approach to art therapy evaluation
and research, Arts in Psychotherapy V.15(1):11-21) in direct opposition to recommended principles from
Naumberg and lending support to her unease about the relationship between Freudian analysis and art
therapy (Naumberg 1966, op.cit.); David Maclagan aired concerns that some therapeutic methods were
incompatible with pictorial imagery, that therapy is assumed to be inherent in the process of creating the
pictorial image and that the verbal discourse takes place in a different and more explicit frame of mind
(1989) op.cit. this argument, p.10. Maclagan is not arguing against psychoanalysis but is suspicious of
attempts to decode the picture. He goes on to state that "If there is an 'art' in this analytic work, then it
is all to often a devious, detective art, concerned with un-doing what the pictorial image is composed of
and weaving into it a web of its own devising"; Janet Lee Bachant and Elliot Adler (1997) Transference:
Co-constructed or brought to the interaction? J. Am. Psychoanalytic Assessment, V.45(4):1097-1120
detail the evolution of the transference controversy.
29
Gestalt Analysis
Rudolph Arnheim has been a seminal influence on the development of art therapy47. His
was also the monumental figure who presented the most comprehensive and unifying
framework for perceptual, emotional, expressive and cognitive-development for the
interpretation of the visual arts, Gestalt theory. The principles of Gestalt, therefore,
pervade much present day thinking about the assessment of artworks by art therapy
clients48 and must therefore be mentioned.
The meaning of visual data was seen at three distinctive and individual levels: the
representational and recognisable; in symbol systems; and the abstract understructure,
the form of everything we see49. Any visual event is a form with content but the content
is highly influenced by the significance of the constituent parts, such as colour, tone,
texture, dimension, proportion and their compositional relationships to meaning.
47
see The Arts in Psychotherapy 1994, V.21(4) passim. Shaun McNiff and Bruce Moon, two prolific and
influential recent authors of art therapy texts and discussions, acknowledge their debt to Arnheim as do
others (McNiff, Celebrating the Life and Work of Rudolf Arnheim, p.247-8, and Rudolf Arnheim: A
Clinician of Images, p.249-260; Moon, What Kind of Art Therapy, p.295-298). Arnheim himself gives
an interesting brief perspective on his interest in expression, The Thoughts That Made Me Move, p.245-6.
Arnheim has been on the editorial board of the journal, The Arts in Psychotherapy since the 1970s.
48
see Dalley and Case, 1992, op.cit. Chapter 6, traces the development of psychoanalytic understanding
(from the point of view of art therapy) to the theories of A. Ehrenzweig (1967, The Hidden Order of Art),
dealing with the unconscious structure of the work, actually at odds with the surface constructions of
Gestalt theory but are here integrated and seen as the predecessors of writers such as Adrian Stokes, painter
and aesthetician, with such statements as: "Stokes saw the work of art itself as an individual separate
object, differentiated, yet made of undifferentiatedmaterial" (p.133). The influence of Arnheim can be seen
in much of the description of assessment of art therapy, for example, in the reasons for rejection of
molecular analysis for the global assessment of the whole picture (for example in Wadeson, 1980 op.cit.)
and in descriptions of how the client experiences art in therapy. A recent example of the new 'empathetic'
research approach appears in the description of a client's experience of art therapy: Judith Quail and R.W.
Peavy (1994) A phenomenological research study of a client's experience in art therapy, Arts in
Psychotherapy, V.21(1): 45-57.
49
Donis A. Dondis (1973), A Primer of Visual Literacy Cambridge: MIT Press, p.13.
30
This is not all, however, there is also an emotional reaction, especially to art, of
the kind described by Ralph Ross50, which,
Yields an experience of the kind we call aesthetic, an experience most of us

have in the presence of beauty, which gives deep satisfactions. Exactly
why we have these satisfactions has puzzled philosophers for centuries,
but it seems clear that they depend somehow on the qualities and
organization of a work of art including its meanings, not on meanings in
isolation.
Sensing and interpreting were seen to be only a part of the total process of
perception, varying with expectations, desires and emotional attitudes. Gestalt was
always a theoretical model and many of its wider precepts have since been challenged51.
Very few of Arnheim's hypotheses were ever subjected to experimental proof, partly
because most of the theory is untestable52.
Criticism of Gestalt theory began early in its development and continued53. The
main focus has been that the definition of a criterion for a true Gestalt is the
unpredictability of its effect from a knowledge of its parts and their relations. This idea
is important to this thesis, because it offers the explanation that a picture is more than
the sum of its constituents and so to the belief that pictures can only be assessed on a
50
Ralph Ross (1963) Symbol Systems and Civilisation, New York: Harcourt Brace.
51
For a quick summary of the criticism and experiments on the Gestalt position see James Hogg (1969),
Some Psychological Theories and the Visual Arts, in Hogg, ed., Psychology and the Visual Arts,
Harmondsworth: Penguin, p.78-81.
52
J. Hogg (1969), op.cit. makes the point that to appeal for direct evidence in order to evaluate Arnheim's
work would be to miss the point that he has set out to establish a way of looking at the psychological
experience of art not a body of experimental detail.
53
But most attacks were on the theory of perception: E. Nagel (1952), Wholes, Sums and Organic Unities,
in D. Lerner, ed., Parts and Wholes: The Hayden Colloquium on Scientific Method and Concept, reprint
1963, London: Macmillan; B. Petermann (1932), The Gestalt Theory and the Problem of Configuration,
London: Kegan Paul. Arnheim writes from an analytic perspective on art and adopts the Gestalt
assumption of inherent constructs which may be modified by training and experience.
31
molar level and not by individual elements. Thus we can also look to this literature for
an answer. It is this very independence of the whole from its parts that Gestalt is
initially attempting to explain54. But, because the effects of a complex system cannot be
predicted from its parts, it does not mean that the appropriate relations cannot be
found55.
Projective testing
The projective drawing test has evolved from the search for emotional and
psychiatric 'indicators', inferred from the acknowledged unreliability in scoring on
intelligence measures in psychiatric populations. Psychoanalytic writings describe how
traits and emotions from the disturbed person are ascribed to another (projection).
Projection accompanies a refusal to acknowledge the projected feelings (denial). It
functions as a defence mechanism56 to protect the individual from repressed anxiety and
conflicts. A projective test is NOT designed to probe the unconscious, but to provide
a forum where desires, needs, beliefs and attitudes are revealed which may not be
consciously known. It systematically assigns emotional, symbolic or expressive value
to particular ways of marking a painting, or to particular images. The advantage of
projective tests over the unstructured single case method is in their systematic
54
The Gestalt concept "has become the explanatory principle from which as a primary given fact, the
phenomena may be deduced", Petermann (1932) op.cit., p.49.
55
Nagel (1952), op.cit. p.140 comments on criterion from Kohler, 1924, who proposes the same argument,
paraphrased by Hogg (1969), loc.cit.
56
Mary Levens (1989), Working with defence mechanisms in art therapy, in Gilroy and Dalley, op.cit.
p.143-6 gives a good description of defence mechanisms.
32
application to large numbers. Projective tests are claimed to detect hurt, anxiety,
depression and psychiatric disturbance57, however, individual interpretation of the
elements by the therapist is essential, since operational definitions are often ambiguous
or non-existent.
The projective art test assumes that a given drawing represents the self and that
dysfunction in perception of the self will reflect in dysfunction of that representation.
This externalising function of drawing is very important clinically as it presents a way
of communicating outside language. Most projective art tests use the human figure. The
draw-a-person test58 is a popular intelligence test for IQ or ability measures in normal
children. It uses a friendly medium which is well understood by a child, is not dependent
on language skill and the drawing is rated by a total sum of the recognisable parts of a
figure. Although developed for children, it is regularly used for adult psychiatric patients,
for which population it is yet to prove reliable, since although it correlates highly with
other developmental tests, it consistently over or under estimates individual scores in
normal populations59.
57
see Abell et al, (1994) op.cit. for a review; K.G. Aikman, R.W. Belter and A.J. Finch (1992) Human
Figure Drawings: Validity in assessing intellectual level and academic achievement, J.Clin Psychol.,
V.48(1):114-120) tested 216 child and adolescent psychiatric patients and found more than half
misclassified. Goodenough herself provides an appendix chapter speculating on the distortions expected
in psychiatric populations (1926, op.cit.).
58
see D. Harris (1963), Children's drawings as measures of intellectual maturity, New York: Harcourt
Brace, p.12-36 for a review of the early descriptive and developmental studies; the best known is the
Goodenough-Harris Draw-a-manscale, (F.L. Goodenough and D.B. Harris (1963), The Goodenough-Harris
Drawing Test, New York: Harcourt, Brace, which revised and extended studies by Florence Goodenough
(1926) Measurement of Intelligence by Drawings, New York: Harcourt Brace.
59
S.C. Abell, A.M. Heiberg and J.E. Johnson (1994), Cognitive Evaluation of Young Adults by Means
of Human Figure Drawings: an empirical validation of 2 methods, J. Clin. Psychol., V.50(6):900-5; for
a review see L. Slansky, M. Short-Degraff (1989), Validity and Reliability issues with Human Figure
Drawing Assessments, Physical and Occupational Therapy in Paediatrics, V.9(3):127-142; and G.H.
Fabry, and J.E. Bertinetti (1990), A Construct Validation Study of the Human Figure Drawing Test,
33
Attempts to lists characteristics of clinical significance have produced no
consensus of agreement between studies60. When attributes of the picture which are
supposed to accompany symptoms are examined, the question of what kind of
accompaniment is still at issue. Projective tests do not have answers, they collect
information. For example, the interpretation of a subject's projection onto the highly
ambiguous stimuli of inkblots (the Rorschach Test) is said to reveal deep unconscious
needs and personality factors. The prototype of the projective approach is the landmark
work of Machover (1949)61, which stresses the significance of isolated signs and details
in human figure drawings. The usefulness of this method has been challenged by the
failure of validation, reliability and validity in objective studies, and that it is by no means
certain what they measure, how they work, or if indeed they do work62. Later authors
have adopted a more clinical intuitive stance63. Wadeson64 had doubts, as a few other
Perceptual and Motor Skills, V.70:465-466, give modest support for validation but do not recommend
its use in isolation.
60
Harriet Wadeson and William T. Carpenter (1976), A Comparative Study of Art Expression of
Schizophrenic, Unipolar Depressive, and Bipolar Manic-Depressive Patients, J. Nervous Mental Dis., May
V.162(5):334-344. Found characteristics of different diagnostic groups of patients unrelatable to table
expectations derived from the literature. Wadeson later commented that there was as much evidence for
as against these characteristics (1980 op.cit.) For recent studies, refer to Chapter 2.
61
K. Machover (1949), Personality Projection in the Drawing of the Human Figure, Springfield IL: 1978
10th ed., Charles C. Thomas.
62
Sophia Kahill (1984) Human Figure Drawing in Adults: an update of the empirical evidence 1967-1982,
Canadian Psychol. V.25(4):269-292 noted some improvements in research methods but had nothing to
add to previous reviews "While it is obvious that figure drawings are not meaningless, establishing what
it is they mean with any precision or predictability is difficult" (p.288).
63
G.D. Oster and P. Gould (1987), Using Drawings in Assessment and Therapy: a guide for mental health
professionals, New York: Brunner Mazel, describes a drawing protocol; E. Koppitz (1983), Projective
Drawings in Children and Adults, Sch. Psychol. Review, V.12:421-427. provides informal projective
scoring scores which depend on experience/insight of administrator; recent example of Silver: Rawley
Silver and Joanne Ellison (1992), Identifying and Assessing Self-Images in Drawings by Delinquent
Adolescents, Arts in Psychotherapy, V.22(4):339-352.
64
Harriet Wadeson (1987), The Dynamics of Art Psychotherapy, New York: Wiley.
34
writers who have published detailed discussion of formal research and its problems65,
over the relevance of quantitative methodology for assessing the qualitative idiographic
insights provided by interpretation of the productions from projective testing. After a
career of scientific investigation into the psychopathology of art, Wadeson challenged the
received wisdom about what constituted 'schizophrenic' or 'depressed' drawings. She
contended that,
Although the graphic and sculptural characteristics can provide

information about the art therapy client's state, patients of the same
diagnosis may exhibit different graphic or sculptural characteristics" ...
"There is no such thing as a 'schizophrenic picture'. There are confused
looking pictures, fragmented organization, bizarre representations66.
Wadeson offered a set of twelve drawings for readers to test their skills to decide if the
artist was psychotic. She implies difficulties.
Few researchers have taken note of criticisms in reviews of projective tests67.
Despite the lack of experimental validation68, the standardised procedures from projective
65
H. Wadeson (1978), Some uses of art therapy data in research, Am. J. Art Therapy, V.18(1):11-18; Bruce
Males (1979), Is it right to carry out scientific research into art therapy? Therapy V.3:5; Males (1980) Art
Therapy: Investigations and implications, Inscape, 4(2):13-15; T. Dalley (1980), Assessing the therapeutic
effects of art: an illustrated case study, Arts in Psychotherapy, V.7:11-17; David Edwards (1987)
Evaluation op.cit.; Sean McNiff (1986), Freedom of research op.cit.; McNiff (1987) Research and
Scholarship in the creative arts therapies, Arts in Psychotherapy, V.14:285-92 arguing against
inappropriate methods for the subject; Andrea Gilroy (1992), Research in Art Therapy, in Waller and
Gilroy, op.cit., pp.229-247; Michael Franklin and Rosalie Plitsky (1992), The problem of interpretation:
implications and strategies for the field of art therapy, Arts in Psychotherapy, V.19(3):163-175.
66
Wadeson (1987), op.cit. p.93.
67
Generally, A. Anastasi and B. Foley's (1941) 4 article survey of the literature, condemned the poor
quality of research: empirical tests were badly reported, lacking in basic information; associations of
characteristics were idiosyncratic, unreplicated, used extreme groups and results were often contradictory
or uninterpretable (A survey of the literature on artistic behaviour in the abnormal IV, experimental
investigations, J. Gen. Psychol. V.23:187-237). Qualitative variation not differences were noted across
groups especially in writing in (p.193). Research on spontaneous work (Section III, Psychological
Monographs, V.52(6):1-71) revealed "ambiguous ill defined mentalistic concepts which add much
confusion to the problem. It is difficult in certain studies to draw the line between observation and
interpretation" (p.64); In 1968, C.H. Swenson, Empirical Evaluations of Human Figure Drawings,
35
tests are still popular in assessment, diagnosis and treatment decisions, probably because
of what Swenson (1968)69 described as "a random partial reward schedule" due to the
occasional case where projective drawings gave an indication of a client's problem,
although clinical caution in their interpretation seems rare70. There have been very few
empirical studies, reflected in the lack of confidence in statistical approaches, and these
mostly still lack methodological validity71. The focus has been to isolate the diagnostic
content through association of symbols or identify 'markers'72. However, some studies
show naive raters can globally categorise pictures of patients and non-patients through
'intuitive' feelings of abnormality73 and can be reliable. Thus it seems that there is
Psychological Bulletin, V.70:20-44, advised researchers attend to characteristics of the work rather than
unrelated hypotheses and criticised interpretive assumptions. Hammer (1968, op.cit.) and others after
made similar recommendations, but Cathy Malchiodi (1994) op.cit. was able to make virtually the same
criticisms describing the term 'assessment' as a misnomer, most tests as directives, and that few interrater
studies, reliable and valid scoring systems were available.
68
E.F. Hammer (1968) op.cit., Clinical Application of projective drawings; Swenson's eight year reviews
of research (C.H. Swenson, Empirical Evaluations of Human Figure Drawings, Psychological Bulletin
1957, V.54:431-466, and 1968 op.cit.) concluded that "Machover's hypotheses concerning the DAP have
seldom been supported by the research" and more recent publications have nothing to add: Scott (1981)
Measuring Intelligence with the Goodenough-Harris Drawing test, Psychol. Bull. V.89:483-505; Kahill
(1984), op.cit.; Abell (1994), op.cit.
69
Swenson (1968) op.cit. p.370.
70
Most writers acknowledge the appropriate uses for the DAP are with body image disorders, such as this
example: Sandy K. Reuven (1998), Reversal of a body image disorder (Macrosomatognosia) in Parkinson's
disease by treatment with AC pulsed electromagnetic fields, Intl. J. of Neuroscience 1998, V.93:1-2.
Abuses of the process continue, for example, the use of the Goodenough-Harris Draw-a-Man test, as
developmental indicator for adult psychiatric populations, despite the lack of research evidence for it,
general admonition (inc. the authors) and numerous studies condemning the practise as unreliable.
71
The claim by the authors of the Diagnostic Drawing Series, a standardised evaluation from 3 pictures,
to have demonstrated replicable differences between patients (B. Cohen et al., 1988, op.cit.) is discredited
at length in the reliability analysis, Chapter 2 of this thesis.
72
Recent studies (over the last 22 years), both empirical and other are discussed in the literature review,
Chapter 2.
73
Bernard I. Levy and Elinor Ulman (1967), Judging Psychopathology from Paintings, J. Abnormal
Psychol., V.72(2):182-7; Ulman and Levy (1968), An Experimental Approach to the Judgement of
Psychopathology from Paintings, Bull. Art Therapy, V.8(1):3-12; Ulman and Levy (1973), Art Therapists
as Diagnosticians, Am. J. Art Therapy, V.13:35-8. These articles reprinted three times (1975, 1984 and
36
something recognisable about the artwork which has not been isolated. Projective testing
approaches continue to be developed74, and recently there have been encouraging
developments based on more rigidly defined formal criteria with children75.
The research contribution of Art Therapy to assessment issues
Wadeson's (1976) table of psychiatric characteristics of art from the previous literature
had little empirical basis76. Gantt and Schmal's (1974) annotated bibliography of art
therapy literature over 33 years77 listed 1175 items from English and foreign language
sources: only 39 were classified as 'research' and not all dealt with art therapy. There was
little attempt at replication, reliability, and definition of terms. Linda Gantt and J.
Howie's (1979, unpublished) chart of correspondences between characteristics of the
artwork of patients and the DSM111 seemed to offer an alternative framework for
1992) show that from 55 judges of varying backgrounds, some art or psychiatry related, all predicted
patient status better than chance; Linda Gantt (1990) tested 6 art therapy graduates on 30 pictures between
6 DSMIIIR groups and attained the same results: A Validity Study of the Formal Elements Art Therapy
Scale (FEATS) for diagnostic information in patients' drawings, Unpublished Doctoral Dissertation, U.
Pittsburgh, Pensylvania, U.S.A.
74
For the main projective tests in use today, see D. Arrington (1992), Art-based assessment procedures and
instruments used in research, in H. Wadeson, A Guide to Conducting Art Therapy Research, Mundelein,
IL: Am. Art Therapy Assn., pp.157-178.
75
Micheal S. Trevisan (1996), Review of the Draw A Person: Screening Procedure for Emotional
Disturbance, Measurement and Evaluation Counselling and Development V.28(4):225-8. Reviews the
DAP:SPED by J. Naglieri and S.I. Pfeiffer (1992) Performance of disruptive behaviour disordered and
normal samples of the DAP:SPED, Psychological Assessment, V.4(2):156-159 with a complex and
comprehensive projective approach to assess 55 items of emotional disturbance in children.
76
Wadeson and Carpenter (1976), Comparative Study op.cit. were unable to relate characteristics of
different diagnostic groups of patients to a table derived from general analysis of expectations from the
literature.
77
L. Gantt and M. Schmal (1974), Art Therapy, A Bibliography (1940-73) (George Washington University
and National Institute of Mental Health (NIMH), U.S.A (unpublished).
37
investigation of artwork, but few have taken up this challenge78. Moore's review of 392
papers from 1974-198079 found only 69 claimed to deal with research, although some
were speculations and suggestions for research possibilities. The bulk of the literature,
even in the 1990s has been concerned with techniques of therapy. There have been no
recent comprehensive reviews (to my knowledge) to bring us up to date80. The spate of
books in the 1970-80s were illustrated, focused on case material and theoretical positions
and had little to say about research or diagnostic questions and the '90s 'cookbooks' of
techniques and theories81 advocate feminist82, phenomenological, empathetic and
qualitative approaches using case studies83. The phenomenological type of investigation
78
Chart of pictorial characteristics equating to diagnostic symptomatology related to DSMIII categories
(1979), NIMH unpublished. Linda Gantt advises that the chart is now out of date and the work must be
redone (personal correspondence, 1994).
79
R. Moore (1981), Art Therapy in Mental Health, Rockville MD: NIMH.
80
Diane Waller's review takes us only to 1982.
81
Such as Bruce Moon's (1992) rather evangelical Essentials of art therapy training and practice,
Springfield, IL: Thomas; Leah Bartal and Nira Ne'eman (1993), The Metaphoric Body: Guide to
Expressive Therapy Through Images and Archetypes, London: J. Kingsley; Waller and Gilroy (1992),
Handbook, op.cit.
82
Shirley Riley (1997), Conflicts in Treatment Issues of Liberation, Connection and Culture: Art Therapy
for Women and their Families, Art Therapy, V.14(2):102-8 on women's need to be heard and access to
communication in male dominated treatment systems; Franklin and Plitsky (1992) problems of
interpretation, op.cit.
83
see for example discussion of propriety of empirical research, advocating separate systems of empathetic,
understanding research and diagnosis on the basis that problems of art therapy clients are 'essentially
creative': Borrowsky Junge and Linesch (1993), Our Own Voices op.cit.; Linda Gantt (1986), 'Systematic
investigation of art works: some research models drawn from neighbouring fields, Am. J. Art Therapy,
V.24(4):111-18 arguing inadequate training of art therapists for empirical research therefore more rigour
in appropriate methods; Andrea Gilroy (1992), Research in Art Therapy, in Waller and Gilroy, Handbook,
op.cit. pp.229-247 cites many more advocates for phenomenological research; Helen Payne, ed. (1993),
Handbook of Inquiry in the Art Therapies: One River, Many Currents, London: Kingsley, passim; David
Aldridge (1994), Single-Case Research Designs for
the Creative Art Therapist, Arts in Psychotherapy, V.21(5):333-342; Herman Smitskamp (1995), The
Problem of Professional Diagnosis in the Arts Therapies, Arts in Psychotherapy, V.22(3):181-187; Rosalie
H. Politsky (1995), Towards a Typology of Research in the Creative Arts Therapies, Arts in
Psychotherapy, V.22(4):307-314; Cathy Malchiode (1993), crisis, op.cit.
2 recent examples of these processes: Quail and Peavy (1994), phenomenological study, op.cit. use 'the
verbal descriptions of the client as the main source of data'. These retrospective impressions of a group
38
is thought to generate more appropriate information than empirical techniques for
psychotherapy, and fits in with a general trend of more integrated approaches suggested
by the new breed of recent books84. However, studies based on these precepts present
a deluge of unanalysed information in which it is difficult to distinguish a purpose or
research value.
The problems of the approach to psychiatric pictures
Single case descriptive methods, projective tests and indeed most descriptions or
interpretations of psychiatric paintings have in common an approach typical of art
criticism to the paintings, which has been applied without consideration of the
assumptions the language implies. One of the most obvious assumptions is the conscious
and serious intention of the artist85. This approach cannot cope with involuntary
experience were stimulated by interviews about selected drawings and relate change in the client to the art
process. Quail feels that this validates and confirms the value of art-therapy; Debra Linesch (1994),
Interpretation in Art Therapy Research and Practice: The Hermeneutic Circle, The Arts in Psychotherapy,
V.21(3):185-195 applies a model of interaction to a case study of an abused girl.
84
for example: Frederick J. Leger (1998), Beyond the therapeutic relationship: behavioral, biological and
cognitive foundations of psychotherapy, New York: Haworth, attempts to integrates and unite multifarious
psychotherapies and discusses scientific difficulties; Arthur Robbins et al.(1998), Therapeutic Presence:
Bridging Expression and Form, London: Kingsley, explores nontraditional interactions; and articles:
Herman M. Adler (1997), Towards a Multimodal Communication Theory of Art Therapy: the vicarious
coprocession, Am J. of Psychotherapy, V.51(1):54-66, supports common therapeutic processes of music,
art and other events; Sarah G. Banker, The Power of Art and Story: women therapists create their own fairy
tales, in A. Robbins, Therapeutic Presence op.cit., explains how symbolic presences open up multiple
solutions for expression; G.L. Engels (1977), The Need for a New Medical Model: a challenge for
Biomedicine, Science, April 8, V.196(4286):129-37, discusses the out-of-date medical model of disease
and the new personal rather than illness focus; Ruth Cohn Balletino (1998), The Need for a New Ethical
Model in Medicine: a challenge for conventional, alternative and complementary practitioners, Advances,
V.14(1):6-16 joins the debate and introduces suggestions for a new ethics code for new boundaries.
85
Gilroy and Dalley (1989) Pictures at an Exhibition, op.cit. is a synthesis of essays dealing with art
therapy of mental patients, and psychoanalytic examination of the work of artists, using the same kind of
language and treatment of the subjects, and assuming an active creative process. Recent example of use
of language and aesthetic analysis to artwork of mental illness in Dalley and Case (1992), op.cit. Ch. 6,
Development of psychoanalytic understanding p.119-145; Art and Psychoanalysis p.71-96.
39
expressions of a disordered psyche. Therefore conventional methods of art criticism are
not sufficient to identify the psychiatric components of artwork produced by patients.
The madman is not an artist and neither is art a cure for madness86.
86
John Birchtnell (1981) op.cit. recognises (but does not subscribe to) the belief by art therapists that
making of art is in itself therapeutic; Refer back to introduction to ch.1 for examples of this theory; Shaun
McNiff, a prolific author on art therapy, has described the art therapist as "One who works with the
supernatural, a technician of the sacred, a master of ecstacy, mystic healer, priest and artist" (1979 - From
shamanism to art therapy, Art Psychotherapy V.6(3):155-61).
40
The problems of secondary sources as data
Most research still relies on clinical observation of case studies and they comprise the
major part of the published literature. These reports suggest that the art produced by the
patient changes with improvement in the patient, and more contraversially that the act
of making the art promotes change in the patient. The generally accepted solution to the
recognised influence of the interpreter on the interpretation has been to have the patient
provide a verbal explanation of the picture87. So far, serious methodological difficulties
have not been recognised or addressed and reliable evidence for interpretive accounts is
not available88.
Presently, the measures which are used to assess art in therapy assess the
therapist's or the client's opinions of the psychotherapeutic process, or attempt to
correlate verbal interpretations with the visual products. The transformation to a verbal
explanation is useful, because the language of psychiatric diagnosis helps place the
elements of the picture in a clinical framework. However this transformation loses its
visual integrity of form as it places the emphasis on what the patient tells us, or even
what the therapist tells us, with a focus on interpretation of a covert message. In this
respect it loses the integrity of psychiatric diagnosis, in which form is implicit89. This
way of thinking about art has not been shown to be wrong, but it is difficult to test the
truth of it because of the problem that we have to rely on what people tell us about their
87
But that interpretation may not be a translation has been recognised, David Maclagan (1989), op.cit.;
H. Wadeson (1975) Is interpretation of sexual symbolism necessary? Arts in Psychotherapy, V.2(3-4):233-
9.
88
Franklin and Plitsky (1992) Problems of interpretation, op.cit.
89
K. Jaspers (1963) General Psychopathology (Manchester U.P., 7th ed. Eng. Trans.).
41
own paintings, or on interpretations from others, or even on speculative models. These
alternatives are certainly subjective, probably incomplete and/or distorted, but they are
virtually all we have to work with. Science has nothing to offer when it comes to
symbols or unravelling of metaphor. There are no generally accepted methods for
translation nor is there any sign of such a thing in the near future. Any picture can be
interpreted in quite different ways by any two 'experts' each following their own theories
and I know of no empirical evidence which supports one approach at the expense of
another. There is evidence that there are loose associations between psychiatric
disturbance and psychiatric indicators in pictures, but we cannot assume there will be a
simple point for point mapping between verbally explained and non-verbal
symptomatology, or even a direct relationship.
How will research benefit from a psychopathology of art?
As a general topic, there are a surprisingly high number of unknowns about art activity.
We know very little about visuospatial cognitions except that understanding is not coded
verbally. Advances in behaviourial science, the clearer definition of diagnostic
classifications for mental illness and the greater accuracy of statistical procedures give
hope for advancement in fields which have been traditionally problematical because of the
interaction of confounding variables.
Specifically, for art therapy to be seen to be effective: that is, to change the
condition of the patient, psychotherapy needs to be closely related to topics in which the
symptomatology is present. This has not yet been demonstrated in the effects of art
42
therapy. It would markedly improve the psychiatric impression of art therapy to
identify the conditions where art therapy is most relevant and also to identify the
direction in which it would be most effective to go90.
More speculatively, a technique which sets us on the road to map visuospatial
functions may allow a clearer neurobiological understanding of disorder. The ability to
describe symptomatology relating to widely differing cerebral locations would be of help
to neurobiological research. There may be groups of disturbed patients whose condition
may only be described effectively with visuospatial psychopathology and these may
currently be misdiagnosed and treated.
The need for another art assessment
Research based on reported interpretive techniques and clinical observation of patient's
paintings has proved difficult, partly because of ambiguities in the description.
Confusion has also arisen in the description of diagnosis, outcome of treatments and
research methodology. It is unlikely that single case studies will provide more
information and there are no systematic assessment measures which explore the
visual/verbal split.
There seems no reason why there cannot be formal characteristics which
correspond with particular diagnoses or symptomatology. Projective testing has not seen
the formal elements of the artwork as the focus of systematic study, and evidence
90
Some of this is covered by Joan Woddis (1986) Judging by Appearances, Arts in Psychotherapy,
V.13(2): 147-9; also Maralynn Hagood (1990) Art Therapy Research in England: Impressions of an
American art therapist, Arts in Psychotherapy, V.17(1): 75-9.
43
pointing to integrative or global judgments rather than specific indicators seems to
indicate diagnosis of holistic disturbance. No evidence, however, supports the benefits
of such separate diagnosis for psychotherapeutic treatment. Most studies of art have
chosen not to study the artwork itself, but the message conveyed. This approach neglects
possible non-verbal elements and also unconscious disclosures.
The way forward
If diagnosis matters, psychopathology matters. There are strong hints of systematic
differences between two dimensional artwork from different groups of patients. We
cannot understand completely how we use communication by studying only the meaning
of what is communicated. In order to study meaningful pathology of visuospatial
relations, it is necessary, not only to investigate what is communicated, but also how it
is communicated. We must look at communication from the point of communication - the
object of study.
The first stage in establishing a measure must be to show the association of
variables with already existing classifications of symptomatology. Previous literature has
failed to do this.
First Steps: Review of the literature
So where do we go from here? How can past experience inform and develop a
new approach unless the literature can be compared and classified? Recent suggestions
include comparison of case study approaches to produce an overall view of qualitative
44
work91. This suggestion has merit and this thesis uses impressionistic reports and case
studies to generate comparative information as a complement to that of statistical studies,
in order to provide a balanced view of the overall approach to the investigation of the art
product in mental illness.
Chapter 2 details the last 20 years of published research studies into two
dimensional art by psychiatric patients. There are four reasons why this 20 year period
is considered:
1. Reviews and tables of pathological characteristics in the art of mental disorder from
the more recent literature are neither systematic nor complete.
2. The literature on diagnosis in art contains similar clinical observations about diagnostic
groups. These generalisations are not supported by statistical or scientific research. The
relatively recent refinement of more reliable diagnostic categories, clinical terminology and
standards of reporting now permits a re-examination of some basic questions about
psychiatric symptoms in art.
3. Earlier research was based on clinical observation from many disciplines, later research
aimed to develop theory and used a variety of illustrative background.
4. The earlier literature has been adequately summarised before.
91
A. Gilroy (1992) Research in Art Therapy, op.cit. p.238, "The experimentally based case study ... leads
to data which is easily comparable with other case-studies and types of therapeutic intervention".
45
Chapter Two: Review of the recent literature over 20 years.
1. Is there a way through the jungle? relevant literature to this study
Anyone who tries to review the literature on art and mental health encounters a huge
body of literature, most of which is of poor quality. It is difficult to ascertain what is
known about how the characteristics of mental disorder may manifest pathologically in
the artwork of those affected since a published comprehensive and systematic review of
the more recent literature over the last 20 years is not available. Chapter Two aims to
collect all the available interpretable evidence of pathological characteristics in the artwork
of psychiatric patients from published papers over the last 20 years. It was more
appropriate to categorise the literature under methodology rather than concepts as the
literature is constrained by the methodological difficulties which encumber it.
The literature search method
Studies met the following inclusion criteria:
(a) Subjects for case and controlled studies were adults or adolescent: the evidence
suggests that children's drawings show considerably more inter-individual
variation than those of adults92, and there are also developmental complications,
so it seemed sensible to narrow the subject categories in the comparable studies,
to those whose motivations, psychopathology and clinical picture there is access.
The impressionistic papers showed more range of illustration for general
92
Maureen Cox (1992), Children's Drawings, Harmondsworth: Penguin.
46
principles, so some were included where their comments/experiences were
relevant to the range;
(b) Studies involved psychiatric patients93;
(c) Studies examined patients' drawings or paintings94.
(d) Reports and papers in English.
Articles for review were selected from a computerised search of 3 databases and from a
manual search. The Psychlit, Medline and BIDS databases were searched using the
following search criteria:
(i) ART or DRAWING or PAINTING or PICTURE and THERAPY or
PSYCHOPATHOLOGY or PSYCHIAT* or SCHIZOPHRENI* or
PATIENT.
(ii) Not STATE-OF-THE; not SYMPTOM-PICTURE; not CLINICAL-PICTURE;
not CHILD* in DE; or PRESCHOOL in DE; or SCHOOL-AGE in DE; not
PICTURE-SORT*.
This strategy of searching anywhere in the abstract for significant words was not efficient
as much had to be eliminated by eye due to the context, but assigned descriptors often
did not mention artwork and studies of interest were classified under disparate categories.
There were considerable overlaps from the BIDS database and Medline with studies
93
There were many studies which used undiagnosed groups (including artists), sometimes described as
'screened' for psychiatric disturbance - the procedure remained ambiguous as did the disturbance. The
authors typically extrapolated their conclusions to psychiatric patients but as research this is meaningless,
and such studies were excluded.
94
But not drawing tests as part of a battery for a purpose which did not depend on the art score, for
example IQ, ability. Pain drawings and maps and some drawings, e.g. cubes, were excluded as the task
47
retrieved from the Psychlit, which produced many more hits. The first two sources were
clearly inferior for this type of material which was well within the Psychlit domain and
not a borderline subject.
Because research in the field of art is not fully represented on databases,
additional unsystematic searches of art therapy journals, books, citations contributed to
it over the six year progress of this research. Through personal correspondence over four
years of the writing, I undertook to discover any major omissions and a small amount of
unpublished work was added. This review concentrates on published studies, but they
have the advantage of accessibility and of peer review as that of uncataloguedjournals and
unpublished work is of uneven quality. Although, no doubt, not every paper is
represented here, especially unpublished work, there is sufficient coverage of the area to
make informed judgements and there is no reason to believe that overlooked papers would
provide different information95.
All art therapy journals referenced here were international, mostly American,
There is only one British journal dedicated to art therapy, Inscape96, which is neither
catalogued nor indexed. An unsystematic search of an incomplete collection at the local
nursing library found articles which were mostly of speculative clinical interest and
did not call for expression or personal input.

95
Studies in other languages, especially eastern Europe seem to have a greater emphasis on interdisciplinary
therapy (impressions from abstracts).
96
Produced by the British Association of Art Therapists.
48
current professional and administrative issues. Articles generally lacked sufficient detail
to contribute to this review97.
Search Results
This search resulted in 751 studies of which 428 met the inclusion criteria from the
databases98 and 24 were added from other sources99. To limit the data to that of direct
relevance to research, these were classified into:
• impressionistic papers 253
• case studies 148
• controlled studies 51
Complete references for all papers appear as tables of Authorities in Appendix 3.
The literature was organised broadly and qualitatively as follows:
1. Individualistic theories or philosophy of art and healing presented as impressions,
which were examined for their perspective on the purpose of art in therapy (the
impressionistic studies introduced a number of popular views about the nature
of art and healing. It would be unwise, in an exploratory study, to exclude such
97
A search by Bloch (1988) of 20 years of Inscape articles found only 13 research-based papers (reported
by Gilroy 1992, Research in Art Therapy op.cit.) reflecting the prelevant view that "research has little
impact on psychotherapy practise".
98
Database abstracts were first screened for inclusion criteria for foreign papers difficult to obtain. Suitable
papers were obtained from British Library resources. Only a few papers were of very limited circulation
and were omitted but generally papers from the large databases were accessible.
99
Only one was a controlled study.
49
a major proportion of the study material without at least investigating what it had
to say)100;
2. Studies of artists were separated from the case studies because, although many
the same assumptions and speculative impressions appeared, they were reported
differently than those of other patients;
3. Case studies (including series studies) were examined for their common underlying
concepts and for generalisable information on imagery or interpretation;
4. Controlled studies were examined for the common underlying concepts and for
the generalisability of their findings.
What we need to know from the literature:
Two kinds of information were required from this review of the literature:
1. What kind of techniques, orientation and concepts are involved in art therapy so
that we may allow for it.
2. What kind of characteristic is attributed to which set of painted marks.
Problems of extracting this information
The traditional anti-scientific bias of art literature, results in a heavy emphasis on the case
study and otherwise poor methodology. The problem of how to classify the techniques
and concepts sympathetically is complicated because there is confusion in reports of
100
The type of classification was broadly qualitative and thematic: originally impressionistic studies and
opinions were separate from speculation and theories including psychoanalytic theory, but they were
ultimately combined because distinctions were blurred and their communications indistinguishable.
50
therapy between what is generally accepted as established theory and the opinions and
beliefs of the author. Moreover, access to the data is impeded because it is difficult to
separate what actually happens from how it is interpreted. This is important because it
affects the types of questions investigated. For example, the question 'where on the
surface of the paper does the patient express?' is not generally addressed. The main
assumption, that it is not on the surface of the paper, but from the interaction of the
client's associations with the work, shapes the presentation of the report and the main
direction of research towards content analysis. Of course, therapy encourages projection
of emotions onto transitional objects101, and this may include imagery in artwork, but as
research it is often difficult to form any conclusions about what is reported. Reports
often neglect much practical detail on what actually happened on the paper to generate
the interpretation because they are not concerned with point 2 of 'what we need to know'
- above, but represent the main concerns of the literature with point 1, so this section
concentrates on the first part of what we need to know, the concepts and orientation.
Why consider impressionistic reports?
If the search were limited to properly controlled scientific criteria, very few studies
would qualify. The subsequent picture would therefore be unrepresentative of the bulk
of literature. To neglect these voices is to neglect some serious, if not structured or
proven conclusions from this collected experience about the way art is thought to reflect
101
from psychoanalytic theory: an object or person viewed as a psychological bridge, allowing a person
to make a transition from primary narcissism to a mature emotional attachment to others (adapted from
A.S. Reber (1985), A Dictionary of Psychology, Harmondsorth: Penguin).
51
psychopathology, something which is not at all clear from the controlled studies. The
hypotheses and direction of the controlled studies are often takedn from this collected
experience and there are many assumptions derived from clinical experience which are not
at all obvious, especially in the interpretation of results.
Impressionistic and theoretical studies
Description of the range of studies included in this breakdown
There were 253 general impressionistic papers or papers which reported theories or
personal experiences to show the therapeutic effects or benefits of art. These papers
differed from research studies in that they focused on the explanatory, speculative and
theoretical not the particular. They discussed typical work of patients and tried to
explain their conclusions or argued different theoretical standpoints. The purpose of this
breakdown and analysis was twofold: primarily, to identify the way therapists
considered that art produced by a patient contributed to beneficial change in the patient;
secondarily, to identify the theoretical basis of explanations so that the underlying
concepts may be explored and to test the relationship of explanation or theory to
particular benefits gained.
Characteristics of each paper were summarised. There were 5 categories of
information common to most papers102 and the discussions centre around the explanation
of the value of art to therapy (complete descriptions of categories appendix 1):
102
A complete description of categories appears in appendix 1.
52
• Descriptive information about the study, whether it gave examples of
patient's work, techniques, advice or discussed experiences or theories;
• Diagnoses of the patient group;
• Theory of the study: psychotherapeutic, psychoanalytic, diagnostic or
assessment, environmental, social or psychosomatic;
• Author's personal explanation of how art promotes therapeutic
change: as an illustration or signpost for the therapist, as innately
curative, as a vehicle for insight for the patient, as a vehicle for transfer of
learning, as an environment, or for communication.
• Benefit to the patients: expression of feelings, communication,symptom
relief or healing, developmental or social, body awareness, through
relationship.
The purpose of this analysis was to explore how the collected observations of these
authors' experiences of the effect of art in therapy varied with the conditions of therapy
and the diagnosis; that is, how consistent the effect was.
Analysis of 253 impressionistic and theoretical papers according to their theories of the
value of art in therapy. Table 1
D103 all sign self group in- transfer communi no

I studies posts healing inter- sight of skill cation explan-
A act'n ation
G freq % freq % freq % freq % freq % freq % freq %
freq %
1 15 6 6 6.5 1 3 1 5 2 14 1 5.6 3 21 1 2
2 24 9.5 14 15 1 3 1 5 0 0 3 17 1 7 4 7
103
Diagnostic group:
1 Schizophrenic; 2 Traumatic stress/sex abuse; 3 Substance abuse; 4 Psychotic; 5
Alzheimer's/Dementia/BrainDamage; 6 Emotional disorder; 7 Depression; 8 Conduct Disorder; 9 Normal;
10 Retarded; 11 Undifferentiated psychiatric patients; 12 Sex Abnormalities/Abusers.
53
3 13 5 5 5 1 3 2 10 0 0 2 11 0 0 3 5
4 12 5 4 4 4 11 1 5 1 7 0 0 1 7 1 2
5 9 4 0 0 0 0 0 0 0 0 2 11 1 7 6 10
6 13 5 2 2 4 11 2 10 1 7 0 0 2 14 2 3
7 12 5 5 5 1 3 0 0 1 7 1 5.6 0 0 4 7
8 4 1.6 1 1 1 3 0 0 0 0 1 5.6 0 0 1 2
9 3 1 3 3 0 0 0 0 0 0 0 0 0 0 0 0
10 15 6 2 2 2 6 1 5 2 14 3 17 0 0 5 8.5
11 126 50 48 52 20 55.5 11 55 7 50 5 28 6 43 29 49
12 7 3 2 2 1 3 1 5 0 0 0 0 0 0 3 5
100% 253 92 36 20 14 18 14 59
Did the effect vary with diagnostic group?
Table 1 shows that there were far more papers related to undifferentiated psychiatric
patients (diagnostic group 11) than to any specific diagnosis. The most common
explanation of the function of art in psychotherapy for undifferentiated patients and for
most other diagnoses was that the patient's work was thought to show 'signs' which
illustrated and provided access to the trauma site for the therapist. No explanation was
specific to a particular diagnostic group but there were indications that: signpost
explanations were more common for patients with traumatic stress, schizophrenia,
depression and non psychiatric patients; healing explanations were more common in
emotional disorders; and few papers offered explanations of effect for brain disease, brain
damage or for retardation.
So, we can conclude, according to the collected experience of these authors, the
function of art in therapy was not determined by diagnosis.
54
Did the effect vary with conditions of the study?
Origin: The papers were divided between whose which offered arguments or presented
an opinion and those offering an experience or reporting a programme. Similar
percentages offered no explanation and insight explanations. More opinion studies
offered signpost and healing explanations and many more communication explanations,
but experience studies offered more group interaction and transfer of skill explanations.
Description of study: Only 14% of papers used case material, the majority presented
either illustrative examples or gave no coherent explanation. Nearly half the papers which
described techniques gave a signpost explanation consistent with their advice to generate
them. Advice was more evenly distributed, but just over half gave signpost or healing
explanations. More than half the general recommendation for art papers offered either
signpost or healing explanations, but most of the rest offered no explanation at all.
Table 2a: Environmental description for 253 impressionistic and theoretical papers
according to the explanation of therapeutic art value.
all sign self group Insight transfer communi no

studies posts healing inter- of skill cation explanation
n=253 action
freq % freq % freq % freq % Freq % freq % freq % freq %
Origin of study
material
opinion 94 37 40 43 15 42 4 20 5 36 6 33 8 57 16 27
discussion 44 17 14 15 7 19 4 20 3 21 1 6 3 21 12 20
experience 90 36 36 39 14 39 9 45 4 29 7 39 3 21 17 29
programme 25 10 2 2 0 0 3 15 2 14 4 22 0 0 14 24
description of study
case material 35 14 11 12 4 11 4 20 2 14 2 11 1 7 11 19
technique 96 38 42 46 6 17 9 45 8 57 9 50 2 14 20 34
advice 95 37 30 33 20 56 6 30 4 29 6 33 11 79 18 30
general recommend'n 27 11 9 10 6 17 1 5 0 0 1 6 0 0 10 17
theoretical base
psychotherapeutic 77 30 35 38 10 28 6 30 6 43 6 33 4 29 10 17
psychoanalysis 39 15 18 20 3 8 2 10 5 36 1 6 5 36 5 8
environmental 53 21 10 11 11 31 4 20 1 7 6 33 1 7 20 34
55
social/developmental 19 7 4 4 2 6 2 10 0 0 1 6 1 7 9 15
energy theories 31 12 9 10 8 22 4 20 0 0 2 11 2 14 6 10
assessment 34 13 16 17 2 6 2 10 2 14 2 11 1 7 9 15
explanation - how it
works
no's in each group 92 36 36 14 20 8 14 5 18 7 14 5 59 23
Complete descriptions of value to therapy categories appear in Appendix 1.
Theoretical base: The most popular theoretical base was psychotherapeutic. Half the
environmental and the developmental studies offered no explanation and most of the rest
used signpost or healing explanations. Despite the theoretical orientation of the
discussion or therapy, the signpost explanation was more prevalent than any other. The
assessment methods predictably concentratedon signposts, but a considerable percentage
of psychotherapeutically orientated papers explained the function of art as an energy or
power derived through the therapist or through the patient or through communication
with the unconscious. However, where the discussion centred on the mystical conduction
of healing power through the therapist to the patient or where the art environment and
the practice of art itself was thought to be therapeutic in some way, there was still an
equal focus on the signpost explanation.
Table 2b: Commonly claimed benefits for 253 impressionistic and theortetical papers
according to explanation of the therapeutic value of art
all sign self group Insight transfer communi no

studies posts healing inter- of skill cation explanation
action
freq % freq % freq % freq % Freq % freq % freq % freq %
104
Benefits to patient
express feelings 156 22 72 26 19 19 12 20 7 17 8 15 9 21 29 20
develop skill 107 15 30 11 12 12 12 20 7 17 8 15 4 9 34 24
communicate 159 22 64 23 21 21 13 21 8 19 10 19 14 33 29 20
self awareness 125 18 43 16 20 20 11 18 8 19 15 29 8 19 20 14
symptom relief 140 20 53 19 24 24 11 18 10 24 9 17 6 14 27 19
relationship 22 3 10 4 2 2 2 3 1 2 2 4 1 2 4 3
104
There were four measures of benefits to patients allowing 4 answers in any order. Frequency and
percentage here represent totalised positive answers to reduce non-answering bias: only 5% (13) of studies
did not describe one benefit for the patient, but many studies gave two or more benefits.
56
Benefits: The most common benefits of art were given as expression of feelings,
communication and symptom relief, with little emphasis on the relationship as a benefit
in itself. The majority of studies, no matter which benefits were listed, including
relationships, offered a signpost explanation; the next most common explanation was of
healing.
Summary
The main purpose of this analysis was to clarify the function of art in therapy and also
to find out if explanations changed with different diagnostic group, whether explanations
derived primarily from the opinion of the therapist or through experience changed with
the theoretical base of the therapy, and whether different benefits were apparent in each
explanation.
No explanation stood out within particular diagnoses. The explanations were
independent of the theoretical base of the therapy/discussion and did not vary with
different benefits claimed for the patients. Where the paper dealt with a general
recommendation for art or gave advice, there were more healing explanations, but on the
whole, signpost explanations were more common. Papers which relied on the opinion of
the therapist, rather than those which related specific experience or described a
programme, advanced many more communication explanations and slightly more signpost
and healing explanations, focusing on content in the picture. Signpost explanations were
57
advanced from all types of papers but mostly from those with a psychotherapeutically
based theory and least from those with social or developmental base.
The self healing explanation, which is obfuscated by the terminology in which it
is swaddled, seems to derive from Jungian theory of contacting the unconscious, but sees
the therapist as a conductor for a force or power of healing. This is not an explanation
but a speculative model. Authors who offered these explanations generally gave advice,
came from a psychotherapeutic or an environmental base and claimed all benefits equally.
Explanations other than signpost or healing were marginal and equally thinly
distributed. All explanations were independent of any variable examined here. The
papers which described an experience or a programme dealt mainly with group interaction
and transfer of skill, looking at formal measures.
Conclusion
This analysis has clarified the terms and general area of interest, but has not provided an
explanation of the function of art in psychotherapy, nor any clearer idea of the area of
operation expected for different theories. The primary benefits to patients were
expression of feelings, communication and symptom relief. It is assumed that therapists
have access to a means of decoding personal associative material, but consistent
explanations were not provided on how this would be accomplished and practically based
reports dealt with the communication value of art. This is not unexpected in such general
material, but is irrelevant to the main issue here of exactly what is decoded by the
58
therapist to aid the therapy or assessment. This issue is further explored in the next
section which deals with case and controlled studies.
We can say then that the direction of these papers indicates there is change in the
patient, which parallels a change in the artwork, and that generally the explanations do
not relate the change to the methods to direct the change. The therapist reports that
artwork produced by the patient is translated but the method of translation and how it
produces change in the patient is not discussed.
Artists: are they special cases?
Aesthetic interpretation of psychiatric art by art historians
There have been what looks like points of convergence between aesthetics and
psychology, but which are, in reality, similarities in superficial language. Some historians
have adopted psychoanalytical and psychological jargon, but most of this is
uninterpretable in a psychoanalytic sense. Various psychoanalytical perspectives on art
have been given, generally by medical people. Few historians have tackled this area,
probably with good reason, as the assumption that there must be an essentially normal
way of painting105, and that divergence would have pathological roots, seems
questionable. Griselda Pollock and others106 have tried to answer these kinds of
questions but most work is concentrated on trained artists.
105
Exemplified by a painting everyone understands - such as Constable's 'The Haywain'.
106
Some examples of recent readable texts which seriously attempt to unravel or question unconscious
symbolic material (but all use artistic illustrations): Griselda Pollock (1988) Ch.6, Women and sign:
psychoanalytic readings in Pollock, Vision and Difference, London: Routledge pp.120-154; G. Pollock
and J.M. Ross, (eds.), (1988) The Oedipus Papers, Conn: Madison; Jim Hopkins (1992), Psychoanalysis,
interpretation and science in J. Hopkins and Anthony Saville, (eds.), Psychoanalysis Mind and Art:
59
Art therapists begin their career from art training and this influences the ways in
which they try to make sense of a picture107: the search for iconography, the borrowed
language of art criticism in content appraisal108.
Very little art historical analysis looks at the broad discrete forms of the actual
work; the language is only relevant and meaningful in relation to other objects. Critical
descriptive language is used to describe a continuum of iconographical, contextual, social
and aesthetic perspectives.
The romanticism generally put forward about artists adds to false assumptions
and myths that grow up around them. For example, popular opinion sees Van Gogh as
a typical example of a mad artist, but none of his famous pictures were painted at the
height of his madness. It is highly unlikely that the crow picture by Van Gogh,
constantly pictured in movies as his last work before he shot himself, actually was his
last. Louis Wain's pictures of cats are often quoted as showing the process of degeneracy
- as the form dissolves, the madness progresses. But who is to say that he was not trying
to portray or simplify his ideas? In the case of Richard Dadd, there was no visual
perspectives on Richard Wollheim, Oxford: Blackwell; Peter Fuller (1980) Art and Psychoanalysis,
London: Writers Readers; Donald Kusbit, Signs of Psyche in Modern and Postmodern Art, Cambridge:
Cam.U.P.
Also perspectives on how we understand art: John M. Thorburn (1925) Is art symbolic? (pp.73-79) and
Art as the relation of outer and inner (pp.151-6) in Thorburn, Art and the Unconscious: a psychoanalytical
application to a problem of philosophy, London: Kegan Paul; Michael J. Parsons (1989) How we
understand art: a cognitive developmental area of aesthetic experience, Cambridge U.P. (2nd ed. original
1987) describes 5 stages of perception: favoritism, beauty, expression, style, form.
107
C.F. Nodine, P.J. Locher and E.A. Krupinski (1993) The role of formal art training on perception and
aesthetic judgement of art comparisons, Leonardo V.26:219-227 proved differences in perceptions/eye
movements of people with art training, and without. Main finding was concentration on thematic patterns
from art trained, and focus on representational issues/accuracy, without.
108
The requirement of an art degree as a primary qualification for would-be art therapists has provoked
concerns that too much emphasis is placed on the aesthetic and the mistaken but pervasive concept of the
creation of art was itself therapeutic, J. Birchtnell (1981), Is Art Therapeutic? Inscape I: 10-13.
60
counterpart of the thought disorder apparent in his written notebooks109. The well
known collections of psychiatric art work which were used to illustrate psychopathology
were by selected exceptionally talented painters studied for research. The knowledge
cannot be separated from the intention. Work by naive artists is personal, rarely involves
an audience and does not operate in a deliberate way to research and develop the work.
It does not contribute to art because it does not intentionallyrefer to it and thus it cannot
be placed on the continuum. Therefore, for work by non-talented patients, art critical
interpretations, which vary with the theoretical stance of the interpreter, are not
appropriate.
The assumption that a picture is a sort of print-out of how the world is seen and
that some unconscious force paints through the artist must be wrong. The best 'outsider'
artists, even though they might lack training and technical skill, show a search for
organisation, considerable awareness of balance and awareness of the world and that
knowledge is communicated through their pictures. Studies of art and perception show
that in order to construct an image of power and balance a great deal of awareness is
needed110. Making a picture is a constructive process and a complicated one, with
metaphors such as paint standing for light and 3d objects.
Studies of psychiatrically disturbed artists tended to focus on the discussion of
whether there was something about mental illness itself which contributed to artistic
109
from J.M. MacGregor (1989), The Discovery of the art of the insane, N.J.:Princetown U.P.
110
Ernst Gombrich (1977) Art and Illusion: a study in the psychology of pictorial representation, Princeton
NJ: Phaidon (5th ed. original 1960); J.J. Gibson (1980) foreward in M.A. Hagen, (ed.), The Perception
of Pictures V.1, New York: Ac. Press, and for an explanation that cognition must be involved in moving
between images to interpret spatial relations: Shona Rogers and Alan Costall (1983), Pictorial perception
and Gibson's concept of information, Leonardo, V.16(3):180-2.
61
talent and therefore do not fit in with other reports. The purpose of this analysis was
to examine the commonalities between 29 studies of artists and investigate possible
generalisation. The impressionistic interpretations of pictures or studies about artists
were summarised (case summaries table 3, appendix 2); 18 were case studies and 11
discussions. There were 2 types of discussion:
(1) Whether or how work was creative or aesthetic, and
(2) that it illustrated mental illness:
The main focus was on illustration of psychosis or depression (15 studies) and
of how psychosis affected or enhanced creativity of the mentally ill. 20 studies reported
that mental illness had a positive effect on the creativity or art of the subject and all
implied that the practice of art had a 'healing effect', by which they meant that the
practise of art was seen to relieve the artist of a mental burden. Descriptions were poor
but generally some expression of emotion and some form of catharsis was reported. 6
studies reported no effect and only one reported a negative effect. They differ from the
usual case study in that:
• no other type of medical writing used so little information; and
• what was used was selected, or adopted a subjective view of the product of
mental illness as a separate issue.
These works were assumed to deviate from a standard of normal, but, at the same time,
perfectly normal modern art was also shown to possess the same attributes that were
described as indications of psychopathology. All studies here concentrated on illustrated
diagnostic indications of dissolution, fragmentation or disorder of thought and
62
communication, but ignored the fact that these paintings apparently represented highly
successful communications of content. The act of illustrating coherently and effectively
in a familiar medium was not usually impaired.
Conclusion
Artists are hard to work with and the meagre evidence suggests art therapists do not feel
comfortable with their technical skill. It is difficult to assess how many actually
succeeded in using art for therapy (despite the reporting) as the analytic process rests on
an unconscious use of compositional relationships, where an artist is all too aware. The
evidence suggests artists too are uncomfortable with this use of their work111
(professionally, their own explanations are rarely accepted as the best interpretations).
The style and aim of these studies relates to speculations on a possible positive
aesthetic effect on creative output, thus is contradictory to that of studies of untrained
psychiatric patients which tries to identify visual elements of individual
psychopathology from the work. That art has therapeutic qualities is mentioned, but
although the benefits of expression as a way of externalising conflict and communicating
with the unconscious are described in both cases, there seems no supporting evidence
relating concrete visual elements to remission of symptoms or better communication in
other forms for the artist.
111
Leslie Gertler (1985) Therapy with an aging artist, Am. J. Art Therapy, V.23(3):93-9 (study 28),
recommends methods of removing the concerns of content, as does D.C. Muenchow, J. Aresenian (1974)
An artist in turmoil during art therapy, Am. J. Art Therapy, V.14(1):18-23 (study 29); The author of study
9, too, advises readers that the work often goes beyond the interpretation of the artist.
63
2. Research studies
There were two kinds of studies which offered evidence to support their authors'
conclusions:
1. 119 case or series studies presented examples of work and interpretations or
extrapolations of this evidence. This kind of study was oriented towards
exploring and developing the concepts, techniques and orientation of art therapy.
2. 51 studies of groups systematically compared artwork with that of another group.
This kind of study attempted to define characteristics common to specific
groups of patients.
Section 1. Comparison method for case studies
Much of the information presented in these studies could not be classified because of the
personal way it was presented: studies presented a section of a personal history,
individual to the client; the information given was necessarily selected by the author to
contribute to their interpretation and thus was not complete. Data was referred to that
was not presented (other pictures or feelings or comments) and the extent of material not
presented could not be estimated; thus the interpretation by the author was personal,
subjective and not generalisable. Statistical analysis of such description would be artifice.
Organisation of this section
64
The purpose of this analysis is to explain how art concepts and techniques benefitted the
individual and whether studies identified diagnostic characteristics from psychiatric
paintings. There were 4 purposes of making art defended in this literature:
1. 67 studies presented illustrations of the image drawn by the client and concluded
that the primary benefit in artmaking was the expression of feelings.
2. 31 studies presented illustrations of themes or signs in the artwork of the client
and identified typical diagnostic characteristics.
3. 17 studies presented illustrations of the image drawn by the client and concluded
that the primary benefit in art therapy was the therapeutic relationship, within
which 8 concluded that the primary benefit in artmaking was to occupy the
patient in engaging activity within a supportive environment.
4. 4 studies identified a change in the client's behaviour whilst undertaking art
therapy.
Descriptive information is presented and discussed through 5 categories of information
common to all studies112. The discussions centre around the primary purposes of art-
making: the therapy value to the patient, and which variables are independent:
• Descriptive information about the subjects: age (adolescent, adult, old),
sex, diagnosis (1-15 see table 1, note 2, for details);
• Orientation or intentions of the researcher: not known, cognitive,
projective, occupational, analytical;
112
A complete description of all information categories appears in Appendix 1 of this thesis.
65
• Method of study or description of technique: projective, psychoanalytic,
expressive, occupational, or comparative;
• Form of study - what is described or interpreted: content, formal or
stylistic elements, mix of content/form, behaviour or verbal;
• Benefit to the patients: cathartic/reflective, communication,
healing/symptom relief, developmental or social, relationship.
Accordingly information is presented by levels of benefit identified, which can be
considered as results for the purposes of this analysis.
Form and content
This division is made to differentiate analysis of form, used here to distinguish
descriptions of the local qualities of elements and regional qualities of complexes within
a visual design from descriptions of internal relations among the elements and among the
complexes within the object; i.e. what the painting represents to the individual, how that
representation is associated with other phenomena in the mind of the patient; in other
words, the meaning, here described as content analysis. This discrimination has not been
successfully made in the literature but it is crucial to determining the subjectivity of the
analysis.
Expression of feelings. Description of the range of explanations within this term.
67 studies concluded that the primary benefits of artmaking for the patient was in "the
expression of feelings". The term was ambiguous: it was used by the majority of papers
66
and indeed throughout the literature without further explanation to identify a goal for
therapy and also as a benefit in itself. Few papers questioned whether feelings were
expressed or what expression was or how they identified that it had occurred; the
identification was always global and subjective. Thus these studies were separate from
those which offered specific interpretations for expressive content, which appear later
in this thesis. The interpretation of expression of feeling was often not particularly
related to the drawing medium, but rather to the personal experience of the
therapist/researcher. These studies argued the importance of psychotherapeutic method;
they illustrated their papers with drawings by the patient, but were vague as to specific
exemplars; they confirmed personal theories with reference to the illustrations and
emphasis on the relationship with the therapist. They especially referred to the
idiosyncrasies of the individual unconscious mind of the patient. The purpose of this
analysis was to identify how patients are said to express feelings through art and in what
way their art output contributes to the benefits which are said to derive from that
expression.
Who benefits?
Demographics: The total number of subjects over the 67 studies was 180: 28 studies
dealt with males, 26 with females and 13 with mixed groups. One study used 42
subjects, but 67% of studies (n=45) were single cases, the other 21 had up to 10 subjects.
Age ranged from 8 to 90 years, but only 37% (n=21) studies dealt with under 16 year
67
olds and only 2 with over 60s. The typical subject was therefore a case study of an adult
with affective disorder.
Table 1 showing diagnostic groups for case studies by levels of benefits where the
primary purpose of artmaking was the expression of feelings
D113 All studies no benefit catharsis communi healing social/ relation

I -cation developm't ship
A n=67 n=8 n=16 n=20 n=10 n=8 n=5
G freq % freq % freq % freq % freq % freq % freq %
1 9 13.4 2 25 2 12.5 1 5 1 10 1 12.5 1 20

2 13 19.4 0 0 5 31.3 5 25 1 10 2 25 0 0
3 4 6 0 0 2 12.5 0 0 1 10 0 0 0 0
4 9 13.4 2 25 1 6.3 3 15 2 20 0 0 1 20
5 5 7.5 2 25 1 6.3 1 5 0 0 1 12.5 0 0
6 13 19.4 1 12.5 2 12.5 6 30 2 20 1 12.5 1 20
7 11 16.4 1 12.5 2 12.5 3 15 3 30 2 25 0 0
10 3 4.5 0 0 1 6.3 1 5 0 0 1 12.5 0 0
There was a broad range of disorders treated with no particular bias to any diagnostic
group. Cathartic benefits were particularly apparent in people with emotional trauma
and depression, who also showed higher communicative benefits but the other
beneficiaries showed more range of distribution.
Results: From Table 2, overleaf, the majority of the studies (54%, n=36) recorded the
primary benefits as communicative and cathartic-reflective. These were achieved by
researchers who were oriented towards projective techniques, who used these techniques
to facilitate the expression of emotion (for communication there was an equal use of
educational methods) and analysed the content of the finished work. Secondly came
113
1 Schizophrenia
2 Emotional trauma
3 Drug/Alcohol addiction
4 Psychotics or phobias
5 Brain disease/damage
6 Adjustment disorder/emotional reaction
7 Affective disorder/depression
10 Retarded
68
healing or symptom relief which was achieved through the same combination although
there was more emphasis on expression in behaviour in the analysis, but not as an
intended method. Thirdly, developmental-social benefits were also claimed for
educational methods and the therapeutic relationship for projective methodology, but
descriptions of expressive form were inconsistent with this aim, they were almost
exclusively behavioral for relationship and mostly for social.
Descriptive statistics for whole study, interactive variables. Table 2, showing

consistency of the research by levels of benefit from expression of feelings
LEVELS OF All No Cathartic comm'n healin develo relation

BENEFIT -> Studies benefit benefit benefit g pment/ ship
social
n=67 n=8 n=16 n=20 n=8 n=5
Study variables freq % freq % freq % freq % n=10 freq % freq %
freq %
Sex
male 28 41.8 2 25 10 62.5 9 45 3 30 0 0 3 60
female 26 38.8 4 50 4 25 8 40 5 50 5 62.5 1 20
mixed 13 19.4 2 25 2 12.5 3 15 2 20 3 37.5 1 20
Orientation
not known 3 4.5 1 12.5 1 6.3 1 5 0 0 0 0 0 0
cognitive 6 9 0 0 2 12.5 3 15 0 0 1 12.5 3 60
projective 38 56.7 2 25 12 75 12 60 6 60 3 37.5 0 0
social/occupational 9 13.4 2 25 0 0 1 5 3 30 3 37.5 0 0
analytical 11 16.4 3 37.5 1 6.3 3 15 1 10 1 12.5 2 40
Method of study
illustrative 4 6.0 1 12.5 1 6.3 2 10 0 0 0 0 0 0
proj./expressive 39 58.2 5 62.5 9 56.3 11 55 7 70 3 37.5 4 80
behaviour 4 6.0 1 12.5 3 18.8 0 0 0 0 0 0 0 0
psychoanalytic 7 10.4 1 12.5 2 12.5 1 5 2 20 1 12.5 1 20
educational/exp.ce 13 19.4 0 0 1 6.3 6 30 1 10 4 50 0 0
Form of study
formal/style 1 1.5 0 0 0 0 1 5 0 0 0 0 0 0
content analysis 33 49.3 1 12.5 9 56.3 8 40 4 40 2 25 1 20
mix content/style 5 7.5 0 0 1 6.3 3 15 1 10 0 0 0 0
behaviour 17 25.4 4 50 4 25 4 20 3 30 3 37.5 4 80
verbal analysis 9 13.4 0 0 2 12.5 3 15 2 20 2 25 0 0
other 2 3.0 0 0 0 0 1 5 0 0 1 12.5 0 0
Primary benefit 8 12 16 24 20 30 10 15 8 12 5 7.5
The main purpose of this analysis was (a) to determine the concepts and techniques of
studies which claim to produce expression of feelings, and (b) to describe the pictorial
69
form of this expression and how it was therapeutic. The form of expression was
predominantly through content of the picture and the primary benefits were cathartic
release of emotion and communication. The overriding orientation of the research was
towards content analysis through projective methodology. However, there were
indications that other methods seemed to produce similar benefits.
The table does not indicate whether the orientation of the research was consistent
in method and results. Accordingly contingency tables were produced114, from which
Chi-square results (summarised below in table 3) showed no correlations between the
description, the method of study used, the form of expression or the benefits claimed.
Table 3: Chi square results for association between method of study, form of expression
and benefits for 67 studies which claimed 'expression of feelings' as the main benefit for
the use of Art with psychiatric patients.
Method of study Benefit claimed by study Form of expression
Orientation of researchers _ 2 = 26.29640 _ 2 = 20.57888 _ 2 = 35.43668

df = 20: p<0.1562 df = 20: p<0.4223 df = 25: p<0.0806
Form of expression _2 = 14.50528 _2 = 12.29713

df = 20: p<0.8040 df = 20: p<0.9055
Primary benefit claimed _2 = 19.52039

by study df = 16: p<0.2426
Conclusion - expression of feelings.
Although expression of feelings was mostly claimed through content evaluation of a
projective test, other methods were as likely to give the same result, the benefits gained
were not particular to a single technique and there is little basis for discussion. The only
correlation was of the orientation of the researcher towards projective testing (if the less
114
Crosstabulation tables 1-6 can be found in appendix 2.
70
stringent cutoff point of p<0.10 is used), which was likely to result in content evaluation,
but this was independent of what the therapist did and what the patient did. So,
researchers tended to find what they were looking for.
The main benefit that the patient derived was from communication, which seemed
to be present whatever the theory and orientation of the study; secondly from catharsis,
which was particularly noted when projective methods were applied and content was
interpreted; thirdly from some form of symptom relief.
Comparison between studies with different goals is not available, and there is
some overlap as projective methods seem to be used for a variety of purposes and with
all kinds of diagnoses. It seems that expression of feelings through content of the picture
is not particularly related to particular therapeutic benefits claimed for it, and is not owed
to the context or the techniques of projective methodology, but more to the individual
orientation of the therapist.
Changes or signs evident in the artwork of patients helpful to diagnosis or
interpretation.
Changes or signs were reported in:
• content, which reported qualitative changes, this included themes, symbols and
interpretations by the therapist and the patient;
• observable characteristics, called form here, which reported quantitative changes.
Studies were not sharply divided and some reported both form and content changes
equally, these were assigned to whichever type was predominantly discussed.
71
Content: 16 studies reported changes or signs in the themes, the subject matter or what
was represented. 43 patients (22 males and 21 females) were described115. 11 were
single case studies and the diagnostic groups were fairly evenly distributed. The studies
interpreted common themes in drawings by the same patient. They focus on two types
of information:
(1) the therapeutic effect of the treatment, and
(2) description of the characteristics of the subject's pictures and associations with the
diagnosis.
Table 4 (Appendix 2) summarises demographic, diagnostic, pictorial and interpreted
information.
How Art Promotes Therapy: The art therapist decodes and sometimes co-author a
private language, the complexity of which may provide a way of avoiding direct
confrontation with an emotive issue or at least distance. The interpretation thus also
becomes a product of both the therapist and the patient. The art begins as a device for
indirect communication until therapy ceases to be a non-verbal event. The therapeutic
value may be similar to desensitisation therapy in that it becomes easier to face the
underlying issue which is producing the psychological damage by repeated exposure to
analogues of it.
Are there consistently meaningful systematic signs in content of the art work?
115
2 studies (15 and 16) described paintings over many years in a variety of settings.
72
There were no specific visual constructs to which a particular meaning could be
assigned and in fact observable representations were not generally discussed. These
studies mostly described common patterns 'read' by the therapist116: a struggle
progressing through the guidance of the therapist which generally related to inner
resolution of the immediate situation of the patient, especially to body image. Symbols
were interpreted in 11 out of 16 studies: for example, the metaphor of broken land was
said to correspond to body image from a male with brain injury117; the mouth as a symbol
for transition through childhood from an autistic adolescent118; and in psychotics, a
struggle for separation119 and egocentrism120; ambivalence by a foster child as a reaction
to his life changes121; metaphors of loss from an alzheimer's patient who died of
cancer122; symbols of realistic hopes in depression123 and less recognisable imagery from
aphasics124.
116
Shown graphically by B.M. Cohen and Carol, T. Cox (1989) (Breaking the code: Identification of
multiplicity through art productions, Dis. Progress in the Dissociative Disorders, V.2(3):132-7), (Table
4, study 16) who identify 10 categories described as thematic, structural and process (but all fit the
content/thematic category in this review) which relate directly to the language and techniques of
psychotherapy.
117
Table 4, study 8.
118
Table 4, study 4.
119
Table 4, study 10.
120
Table 4, study 9.
121
Table 4, study 1.
122
Table 4, study 11.
123
Table 4, study 15.
124
Table 4, study 14.
73
Pictures by bipolar depressives show gloomy colours and themes (minus
phenomena) in the depressive phase and (plus properties) bright colours in the manic
phase125, which tends to support the illustration-of-the-illness hypothesis assumed by
many of the authors, but it will be seen in the report from observable characteristics
(next) that pictures by unipolar depressives and schizophrenics often show these same
qualities126 or, equally, bright colours and happy themes127.
Where studies described the outcome of therapy, they tried to show that changes
in the theme of the artwork parallelled improvement in the patient128. Additionally, the
element of hostility, discussed in 8 studies (indicated on table 4 by *), probably
represents denial, the initial opposition to the therapeutic alliance, which provides a
supportive structure for confrontation. These conclusions suggests that thematic
interpretation of pictures relate to therapy rather than the illness.
Conclusion for content studies
There is no agreement as to how the meaning of what is represented is extracted, or
consistency of application to further examples, although Cohen and Cox (1989) have
made a promising start. Categorisation of signs can only be attempted when terms and
methods are systematic or consistent, but terminology, methods and theoretical base vary
in all studies considered here. Much background knowledge is also assumed on the part
125
Table 4, studies 6 and 12.
126
Table 4, study 5; Table 6 studies 20, 23, 24.
127
Table 4, study 15.
128
Table 4, studies 3, 5, 8, 9.
74
of the reader. The opinion of the interpreter is inextricably linked with what was actually
observed and what is known about the patient129. Largely, the therapist commented upon
the meaning of the picture and its internal relations based on what the patient said,
knowledge of the patient and observations on significant relationships between figures,
feelings, colours and details. Thus content is not divisible from style. The difficulty of
interpretation is illustrated by the description of pictures produced by a Native American
psychiatric patient, whose compositions were thought of as impoverished and
incongruent with instructions until her background was considered130. A fewstudies
mentioned but did not analyse equally diverse specific identifiable formal signs or changes
in the paintings attributed to therapy, which are included in the following discussion of
form where appropriate.
The most common uses or benefits suggested for art therapy were as a monitor
of progress and as a therapeutic communication. These suggestions are only specifically
valid for art if there is some meaningful way to access the images. The interpretation
varied with the relationship between therapist and patient, orientation of the therapist,
and the emotional involvement of both, which is not to say that it is not meaningful;
certainly it has meaning and effects as related to the verbal interaction with the patient,
just that no evidence justifies its relation to the art.
Observable characteristics in the artwork of patients (form)
129
Problems for the therapist in personal involvement are discussed later under relationships.
130
Table 4, study 2.
75
This section does not deal strictly with form as there were overlaps between what was
observed and what was recognised in depicted material, that were impossible to separate.
This group of studies, however, was qualitatively distinct from those categorised as
content analysis because the findings were primarily to do with observable changes in the
artwork of the patient. Art therapy reports commonly focused upon the content of the
artwork to describe individual variation in the artwork of the patients rather than
collective. Their style of reporting often neglected the objective findings to concentrate
on the analysis of meaning. The categorisation here thus may actually contradict the
theoretical orientation expressed by the authors of some of these papers. 3 papers using
mixed groups of 'psychiatric patients' accounted for 65% of the total cases and their
general findings are described first.
General signs of psychiatric disturbance
General signs were summarised seperately (Table 5, appendix 2). There were three
general indications of psychiatric status:
(1) distortion of figures;
(2) odd placing of drawing elements;
(3) circling behaviour.
Specific diagnostic signs
Table 6 (appendix 2) summarised studies which reported specific diagnostic signs in the
analysis of formal artwork.
76
Analysis
There were many overlaps and contradictions among studies that reported a majority of
formal signs in descriptions of patient art. Actual events were often obscured by the
reporting style of emotive description, techniques and the general imprecision of clinical
observation; only suggestions for further investigation can be made. As previously noted
in the content section, the characteristics of depression are particularly unclear131; the
most confusing reports are of parallel illustrative affect (e.g. random uncontrolled lines
and colours, lack of structure or organisation and focus, expressive of disorientation,
turbulence and lack of connectedness132) also noted in the depressive phase of bipolar
disorder133, characterised by disturbed content and missing detail as mutilated figures,
more primitive drawings, while two studies report monochromatic rigid well defined still
life134, sombre dull colours which parallel the depressive state135, also noted in bipolar
disorder136, changing to bright colours on recovery. However, 2 studies reported bright
colours and happy themes characterising art therapy in depression as a state of hope137.
This conflict of opinion perhaps explains the non-significant findings reported from a
131
Table 6, study 25.
132
Table 6, study 23.
133
Table 4, study 6.
134
Table 6, study 20.
135
136
Table 4, study 12, together with less creative activity, less or missing detail, less action.
137
Table 4, studies 7 and 15 mainly content scale.
77
correlation of art elements with depression or anxiety tests on 100 patients with
alexithymia who were asked to draw their illness138.
Organic disorders were characterised by distortion of form139 (which was also a
general sign), perseveration, simplification & proportion errors, disconnections, limited
colour & difficulty comprehending directions140. All of these were also apparent in
borderline personality disorder, depression, brain injury, aphasia, manic depression and
dementia141.
Degeneration of the image appeared as a product of declining intellectual
function142, but regression to childlike forms was present in dementia, manic depression,
schizophrenia and personality disorder143. Fragmentation in personality disorder144 may
easily be mistaken for the description of uncontrolled lines and lack of connectedness in
depression, aphasia or disconnections in organic disorders and schizophrenia145. Lack of
structure appears in reports of depression, schizophrenia, aphasia146 and is difficult to
differentiate from disorganisation, which was identified as a general sign (Table 5,
138
Table 6, study 25.
139
Table 5, general signs, studies 30 and 31.
140
Table 6, study 27.
141
Table 6: Borderline personality disorder, study 19; depression, study 20 and 23; brain injury, study 17;
dementia, study 18; Table 4: aphasia, study 14; manic depression, study 6.
142
Table 6, studies 17, 18 and 8.
143
Table 6, childlike forms, in: dementia, study 18; schizophrenia, study 26 personality disorder, study
19; Table 4: manic depression, study 6.
144
Table 6, study 19
145
Table 6, lack of connectedness in: depression, studies 20 and 23; organic disorder, study 27;
schizophrenia, study 26; Table 4: aphasia, study 14.
146
Table 6, lack of structure in: depression, studies 20 and 23; schizophrenia, studies 26 and 27; Table 4:
78
appendix 2), present in the above groups, in personality disorder and organic disorders147.
Rigidity was described as characteristic of both schizophrenia and depression148.
There is a suggestion that visual learning may occur unconsciously149 and that
anorexics may communicate more effectively nonverbally as they produce more and
better quality visual work150. Indeed, this result relates to that of 500 alcoholics, who
also produced more drawings of a person of better quality, that is, finer and improved
detail, under treatment but with the qualification that previous measures may have been
taken under the effects of drugs or starvation151. It is commonly thought such signs may
be affected by drugs152, or concealed and distorted when the patient is under
chemotherapy153.
Summary of form
It is clear that the methods used to analyse style or form of pictures between individuals
or diagnostic groups were dependent on the subjective associations of the therapist or
were inconsistent by type. For example, although manic depressives were judged
depressed from the content of their paintings, they were judged manic on characteristics
aphasia, study 14.

147
148
Table 6, rigidity as a characteristic of: schizophrenia, study 26; depression, study 20.
149
Table 6, study 22.
150
Table 6, study 21.
151
Table 6, study 28.
152
H. Wadeson (1980), Art Psychotherapy, New York: Wiley.
153
Manny Sternlicht, Pincus Rosenfeld, Louis Siegel (1973), Retesting with graphic production: resolution
of a diagnostic dilemma, Art Psychotherapy, V.1(3-4):299-300.
79
of form154. The formal elements were inseparable from the content issues where they
were described emotively; for example, sombre colour, and by negative characteristics,
which tended to favour content issues and overlap between groups. It could be argued
that in many cases the intentions of the formal analysis were not so rigid, but if evidence
which is said to be objective is presented to support the subjective conclusions of the
therapist or researcher, then it is necessary that it be differentiated from those opinions.
The formal analysis reflects the confusion of the content analysis, in that each study is
individualistic, presenting different information for each subject and there are few
associations within types of patient and little systematic description of the output of the
patient.
Conclusion for formal and content analysis
Three points arise from this discussion of case and series studies:
(1) Increased output may be associated with withdrawal of drugs and different mood
states as much as with therapy; and
(2) If the immediate situation of the patient is, as suggested by the content analysis, the
overriding element in the pictures, and these associations are too subjective and individual
to be consistent within patients, then holding the content constant should emphasise the
characteristics of artistic style. This would help to test whether the apparent diversity
of pictorial characterises in depression was due to environmental circumstances or some
other factor;
154
80
(3) Formal characteristics may be easier to standardise, systemise and rate than content
because they do not depend on subjective opinion.
I suggest that formal characteristics are rated on positive scales, without reference to
content and with firm discriminations between terms so that they do not overlap with
other terms.
The Therapeutic relationship
Table 7 (appendix 2) summarises papers which concluded that the therapeutic or
supportive relationship was the most important feature of art therapy. There were three
types of relationship presented by 18 studies:
1. Nurturing relationships;
2. Communicative relationship;
3. Relationships which were environmentally supportive.
Nurturing relationships
7 studies (4 males and 3 females with largely different diagnoses and aged 15-30) dealt
with personal and individual guidance of subjects towards a resolution of their situation.
The therapists claimed to recognise structural or developmental psychopathology in the
artwork of the patient and that psychodynamic exploration of these images gave them
access or understanding of their patients' world. They claimed to undertake role play
which allowed the client to transfer their undesirable emotions onto them and thus
through guidance resolve it, or by directed drawing or mirroring to help the client
81
recognise and work through the situation visually. The nurturing relationships showed
two different therapy styles:
(1) Drawing or 'painting together' was used for three cases by four therapists who saw
themselves as operating from within the patient, they saw aspects of the patient resisting
or using defenses and who must be made receptive. They did this through a special kind
of bond with the patient described as a symbiotic relatedness, merging with another
person, uniting, and giving empathetic response. The therapist acted as a kind of
'psychic plumber', tracing blockages in the system and replaced the damaged part with
a new corrective experience, or provided... (what was) denied, reorganised and
restructured leaving room for further growth. The 'inside' therapists used the art as a
holding environment for the patients and saw their products as records of progress, and
as maps of the system of the patient.
(2) the other three therapists saw themselves operating outside the patient, their job was
to encourage, to focus, to help nourish the inner self and emotional needs , to help
develop insight in the patient and promote growth, they described their relationship as
an alliance, as having good relations, serving as self-objects. This relationship allied the
therapist with the patient in a common goal to communicate and saw patient's products
as communications whose meanings were obscured.
Communicative relationships
Three communication relationships were all developed with young male non-verbal
schizophrenics by female art therapists who claimed to use art as an outlet for the
82
expression of unsocial feelings of the patient. The interaction itself seemed to be the main
benefit to the patient and the art was most useful as an environment for it.
Supportive relationships
From 14 patients (2 young females and 12 young adult males) 11 were retarded. Various
techniques were used with the aim of increasing self esteem through acquiring control over
the materials and skill which, it was claimed, would then generalise an understanding of
internal control in other areas of the patient's life and increase self awareness. It was
emphasised that art was most useful as an environment, especially with retarded people,
because it provided an atmosphere of equality and respect with natural interaction
Summary for case studies primarily benefitting from the therapeutic relationship
Mostly, drawings were said to illustrate the present situation of the patient and thus
change it in an analogy to psychotherapy. In the nurturing relationships, the therapist
implemented change through other procedures than art, but used art as a containment area
(or holding environment). Communicative relationships also used the art environment as
a base for interactive therapy, although the therapists pointed out elements which were
said to refer to feelings, it was from a personal knowledge of the patient rather than from
any characteristics inherent in the art. The naturally nonthreatening environment was
again the main benefit of art in supportive relationships, although some of what was
reported was not therapy orientated but occupational, in that there was no change in the
patient expected.
83
Conclusion
The use of art was not inherently related to the therapy for the patient but was felt by
the therapist to provide a special sort of receptive atmosphere. Artwork was an activity
in which patients felt able and liked to participate. When used therapeutically, it offers
a non direct form of confrontation with underlying issues of conflict and the obscurity
of the communication encourages verbal interactions and allows mutual involvement
towards the goal of interpretation of the meaning through this medium. Therefore the
stated purpose of the use of art in therapy relationships was communicative, but the
underlying purpose of the art component was distraction and distancing for the patient.
4. Change in behaviour
Table 8 (appendix 2), summarised information from 4 studies which used an art
environment but measured changes in behaviour. Their results reflect the conclusions of
the supportive relationships; the environment offers a non-threatening situation which
is enjoyed by the subjects. The skills learned increase self esteem, especially if
recognised by others and increased involvement in the work. The other studies reported
verbal/nonverbal comparisons of disturbance of thought in schizophrenia (1) that lower
levels of disorder occurred whilst engaging in artwork; and (2) Speech and language were
both affected, but planning and carrying out a plan were the most affected. These results
do not cover the area, but one suggests that nonverbal pathways may not be as affected
by thought disorder as verbal pathways. Speculatively, it is possible that the reason art
84
is less affected is that drawing is not rigidly sequential and that relationships and time are
expressed in different dimensions than the construct of language.
Summary of Case Studies
There were two elements recorded in art therapy research using case studies: (a) the effect
of the art process upon the patient of which reports the studies mostly consisted, and
(b) the process of decoding the picture, which was reported obscurely, individualistically
and inconsistently.
(a) Therapy: The use of art with patients seems to be therapeutic since observational
evidence of lower symptom levels and educational or social benefits such as skills learnt
by the patient are presented and there is a suggestion that art may provide an alternative
route to communication for the thought disordered patient. Art therapy is generally
useful for retarded people as an activity where people feel able, although there is no
agreement on what kind of techniques to apply. The relationship between the therapist
and the patient was very important in the view of the therapist and was said to provide
therapeutic benefits in itself, but the nature of the involvement by the therapist tended
to obscure the reporting. Thus the therapist was not the ideal researcher.
(b) Decoding: The largest section examined here was that categorised as general
expression of feelings, where projective methods and content interpretation were thought
to induce cathartic release and facilitate communication between the therapist and patient.
However, these benefits seemed to be independent of method or orientation of the study
and seem to indicate that the art provides a third interactive function for the patient.
85
Thematic interpretation varied with the patient and was dependent on the relationship
with the therapist. No common correspondence could be discerned when comparing
studies in this review. The interpretation of content was a shared communicative device,
depictions often bore emotional loads, were idiosyncratic and did not translate to
universal characteristics.
Observable characteristics in artwork do indicate psychiatric status, whatever the
orientation of the therapist or the psychiatric status of the patient, but there is no
agreement on differentiation, definition of terms or typical diagnostic characteristics.
Systematic research which differentiates between content and form would further this
investigation and test premises which are expressed as knowledge in the literature; no
study used formal characteristics alone in this review.
Case studies are the traditional and best known method of reporting therapy and
Chapter One describes how this type of research is still recommended by prominent
writers and the weaknesses of this approach. The authors are unable to even describe the
paintings, as the problem of standardising terminology, identifying and describing changes
in observable form or in content has not been successfully addressed. The usual method
has been to print sample paintings from which it is intuited which elements represent the
improvement of the patient. The lack of established psychopathologicallinks means that
the case study method does not fulfil the crucial point discussed, how psychopathology
is expressed in artwork. This is a very poor method of assessment.
86
Controlled Studies. Comparison and Analysis
Problems in categorising the data for analysis
Several factors limit the conclusions which can be drawn from this review of controlled
investigations into patient art. The tendency of the research was towards clinical tools,
and there was little replication or validation of the plethora of instruments proposed.
Speculative studies and unpublished, unvalidated measures were often cited by other
studies as though they were proven instruments; some studies did not even specify
which scale they were using and others did not explain or validate measures developed
for the study.
Inappropriate statistics were frequent, and test design and results often bore little
relation to the intentions, conclusions and interpretations of the author. This meant the
orientation of the researcher and the relation of the description or purpose of the
instrument to what was recorded had to be considered. In many studies the focus on the
interpretation of the work dominated the description of the objective phenomena, and the
opinions and involvement of the therapist were also treated as objective phenomena. The
use of subjective or interpretive criteria was often erroneously described as formal, or
objective. Behavioural and other changes occurring in the patient, were attributed to the
art therapy even though it may have been geared towards a totally different goal, and
other therapeutic influences were ignored.
There were two stages to this analysis:
(1) to find out what kind of techniques, orientation and concepts produce results or no
results of whatever kind in art therapy; and
87
(2) to find out how the art relates to the kind of characteristics attributed to it.
The problems were: in (1), that the study definitions of approaches were sometimes
inconsistent with their practice; and in (2), the information reported was often
incomplete. The solution I adopted was to descriptively examine as much of the
literature as possible for the first question and to narrow the focus gradually for the
second question, dropping out studies which could not supply the information.
The DAPA 1996 study
One of the studies picked up by the literature search was the DAPA pilot study
(1996)155, it has not been included because as part of the present thesis, this research was
itself developed from an informal version of the process of examination of the literature.
Hypotheses and development of the measure has occurred over a period of 6 years.
Inclusion of the DAPA test would hardly affect the qualitative analysis, because it carries
few content fields, but would probably bias the meta-analysis which tries to show the
direction and efficacy of the main body of literature.
Organisation of this section
The literature is discussed in 3 parts156:
155
Hacking, S., Foreman, D., Belcher, J. (1996) The DAPA: a new way of quantifying psychiatric
paintings, J. Nervous Mental Dis. 184 p.425-9.
156
There are three analyses which contain different variations from the same pool of 79 studies. For clarity,
studies retained the same identification number in all analyses. Numbers 1-79 alphabetically are used
throughout. A full list of studies appears in Appendix 3 (Table of Authorities).
88
1. All studies reported enough information about tests between patients and
controls, or patient groups to be evaluated methodologically for orientation,
concepts and results.
2. A small number of studies which investigated the correspondence of art tests
against criterion measures and were not included in group 1 were added for the
discussion of validity.
3. A small group of studies which investigated inter-rater reliability were added to
those studies from group 1 which used more than one rater for:
(a) an evaluation of psychopathological signs in patient artwork;
(b) a meta analysis to determine the effect size for art measures (Chapter 3).
Amongst the 51 controlled studies were 4 comparisons between therapy groups. They
measured behavioural details using non-art measures and one rater, although two used
another criterion measure. They are included in the analysis where appropriate, but their
aims, directions and information presented were different and they were omitted from
some of the tables for clarity. Group sizes therefore do not always add up to 51.
Methodology for analysis of controlled studies
Characteristics of each paper were tabulated according to the variables described below.
Descriptive statistics were used for a preliminary comparison of data from all 51 studies
to find out what results were claimed for art therapy. There were 3 categories of
information common to most papers: information about the test subjects, the study
purpose and procedure, the results and conclusions from the test.
89
There were 7 demographic variables:
•sex of subject;
•ages, whether adolescent (13-18), adult (18-60), older adult (60+);
•diagnosis of condition 1, 2, 3 and 4 (condition 1 was the main experimental
group and condition 2 the main comparison group, which were normal controls
if included);
•number of subjects in condition 1;
•total no. of subjects in study;
•whether subjects were matched on age and sex;
•no. of judges.
There were 5 study factors:
•orientation, type of therapy offered;
•measurement method, what the instrument was intended to measure;
•design of the test - pre and post intervention, post intervention only,
comparison of test pictures or retrospective;
•no. of measures used;
•derivation of the main study measure, whether own test, adapted or established.
Sensitivity of the test and results.
•measurement form, what type of elements in the picture the instrument was
actually sensitive to;
•the results of the study: differences between patients and normal or patient
controls; or no difference.
90
One alternative was marked for each category157. For ease of readability, integer
percentages are used here. Interactive effects were investigated and the results for the
ordinal variables are presented in tables 8a and 8b.
Demographic variables: descriptive statistics for demographic variables are shown in
Table 1 and Table 2.
Table 1. Descriptive Statistics: controlled studies n=51
Variable Mean Std. Dev. Min. Max.
Numbers of subjects 39 40 5 239

in experimental
groups
No. subjects each 115 190 11 1373

paper covered
No. of judges 2 8 1 60
No. of measures 2 2 1 15
Table 2. Frequency and percentage of demographic variables for 51 controlled studies by

levels of result.
Frequency Result 1 Result 2 Result 3

& Percent Difference in Difference No Difference
all studies patients/nonpatient or
patients subtypes Inconsistency
n=51 n=21 n=12 n=14

Variables freq % freq % freq % freq %
Sex male 5 10 0 0 3 25 2 14
female 4 8 2 14 0 0 1 7
mixed 42 82 18 86 9 75 11 79
Age 13-18 6 8 0 0 2 17 2 14
18-60 41 80 17 81 10 83 12 86
60+ 4 8 4 19 0 0 0 0
Controls
Matched 20 39 10 48 5 42 3 21
Unmatched 31 61 11 52 7 58 11 79
157
A full list of alternatives is presented in Appendix 1.
91
No. 1 35 69 13 62 8 67 10 71
judges 2 9 18 3 14 2 17 4 29
3 4 8 3 14 1 8 0 0
4 2 4 1 5 1 8 0 0
60 1 2 1 5 0 0 0 0
No. 2 32 63 13 62 6 50 10 71
Study 3 15 29 6 29 5 42 3 21
groups 4 4 8 2 10 1 8 1 7
Age and sex: Few studies gave much demographic information. Many studies simply
described the group as 'adult', but the majority described only the group ranges or the
mean age even when they were considerably wide. The sex distribution was often only
described as 'mixed' so could have been considerably uneven and sometimes group
numbers were missing, especially of diagnostic categories.
Controls: 72% of studies used non-psychiatric controls, and gave little information on
age, sex, origin, screening procedure and numbers. Where descriptions of controls were
given, they were always hospital staff. Mostly, there was no indication that control
pictures were done under the same conditions, or even the same number of pictures!
(One study used an average of up to 99 pictures from therapy sessions for patients,
against one picture painted in a non psychiatric outside art group158).
Matching: Chapter one makes the point that IQ is difficult to match for psychiatric
patients, since tests may not be sympathetic to psychiatric disturbance, but the majority
of studies failed to match for age, sex and mostly even group numbers.
158
C. Bergman and M. Gonzalez (1993), Art and Madness: can the interface be quantified? Am. J. Art
Therapy, V.31:81-90 on development of the SPAR scale.
92
Table 3a. Diagnostic groups 1-4. Frequency and percentage for 51 controlled studies.
All studies, All studies, All studies, All studies,

diagnosis 1 diagnosis 2 diagnosis 3 diagnosis 4
n=51 n=51 n=19 n=4

Diagnosis, freq % freq % freq % freq %
schizophrenia 15 29 5 10 2 4 0 0
emotional trauma 4 8 1 2 0 0 0 0
drug/alcohol 1 2 0 0 0 0 0 0
psychotic phobia 3 6 2 4 1 2 0 0
neurological damage 6 12 2 4 5 10 1 2
depression 6 12 1 0 1 2 1 2
conduct disorder 1 2 1 2 2 4 0 0
retarded 1 2 0 2 0 0 0 0
gender disorder 1 2 0 0 0 0 0 0
personality disorder 1 2 0 0 0 0 0 0
mixed patients 12 23.5 3 6 6 12 0 0
normal 0 0 36 71 2 4 2 4
Diagnoses: 1. Main experimental group; 2. Control group; 3. Experimental group 2; 4. Experimental

group 3.
Table 3b. Diagnostic group 1. Frequency and percentage by levels of result.
1. Difference 2. Difference 3. No
patients/nonpatient Difference or
patients subtypes inconsistency
Diagnosis, n=21 n=12 n=14

1 freq % freq % freq %
schizophrenia 7 33 4 33 4 29
emotional trauma 2 9.5 1 8 1 7
drug/alcohol 0 0 1 8 0 0
psychotic phobia 0 0 2 17 1 7
neurological damage 3 14 2 17 1 7
depression 4 19 0 0 1 7
conduct disorder 0 0 0 0 0 0
retarded 1 5 0 0 0 0
gender disorder 0 0 0 0 1 7
personality disorder 1 5 0 0 0 0
mixed patients 3 14 2 17 5 36
Diagnoses: Frequency tables for diagnoses are shown in Table 3a, and in 3b by
experimental group results. The main comparison group were classified under condition
2, and the experimental under condition 1. Those normal controls appearing in groups
3 and 4 were less important to the study than the main comparison group. The most
frequent diagnosis was Schizophrenia, mostly undifferentiated and which probably
included diagnoses which were differentiated by other studies. Schizophrenia is not a
93
satisfactory classification as it is not an exact diagnosis and there are forms that have
quite different phenomenology. Some studies simply tested ward groups (which can be
very variable) and in many cases there was no operational criteria typical of a common
symptom picture.
Other study effects: It was impossible to control for experience of art, as the vast
majority of studies did not describe the psychiatric history of their patients. Although
one or two tried to control for art experience, their reliance on formal or school education
tended to favour the controls and did not account for therapy sessions, which could be
part of a patient's life for many years.
Time: the studies were spread fairly evenly over the 22 year period; 50% of the studies
either side of 1986.
Table 4. T-tests were performed to compare the means of ordinal demographic variables
by Year of Study.
GROUP 1 = YEARS 1973-1977 (12 CASES); GROUP 2 = YEARS 1992-1996 (18 CASES)
df=28 for all variables
Variable mean Standard Standard T Pooled Variance

Group--! Deviation Error Value 2-tailed probability
No. Subjects 1 33.50 26.62 7.68 -0.45 0.66 NS

(Condition 1) 2 39.22 38.56 9.09
Age 1 4.83 0.58 0.17 0.00 1.00 NS

3=13-18; 2 4.83 0.92 0.22
5=18-60; 6=60+
Sex 1 2.83 0.58 0.17 0.91 0.37 NS

1=male; 2 2.61 0.70 0.16
2=female; 3=mixed
Matched 1 1.58 0.51 0.14 -0.15 0.88 NS

Controls(age/sex) 2 1.61 0.50 0.12
match 1=yes; 2=no
No. Judges 1 0.67 0.99 0.28 -0.24 0.81 NS

2 0.78 1.35 0.32
No. Measures 1 1.42 0.79 0.23 -1.05 0.30 NS

2 2.44 3.31 0.78
94
Table 5: Non-parametric tests were performed to compare the ranks of categorical study
variables by Year of Study.
GROUP 1 = YEARS 1973-1977 (12 CASES); GROUP 2 = YEARS 1992-1996 (18 CASES)
df=28 for all variables
Variable mean mean z score pooled variance

Group -! rank 1 rank 2 2 tailed prob.
Diagnosis 15.67 15.39 -0.0857 0.9317

Orientation 11.00 15.17 -0.3644 0.7156
Measurement method 11.92 17.89 -1.9695 0.0489
Measurement form 12.08 17.78 -1.8276 0.0676
design 14.92 15.89 -0.3664 0 7141
test derivation 11.58 18.11 -2.2196 0.0264
results 16.08 15.11 -0.3122 0.7549
Elements of change over 22 years: t-tests were performed to compare ordinal
demographic variables over the period of the study (22 years) (Table 4), in order to
assess change in research techniques and orientation. The categorical variables were
compared by rank, using the Man-Whitney non-parametric t-equivalent (Table 3b). No
differences were found in demographic variables, in orientation of therapy, measurement
form, the design of the test or the results, but there were differences in the measurement
method (the described purpose of the test). Derivation of the test and measurement form
just missed significancebut is considered a strong trend here (see Table 6). Both the early
tests and the later described their methods as formal comparisons or mixed content and
form comparisons, but the earlier studies used more direct formal comparisons and the
later more mixed and more non-art tests. The earlier emphasis on form probably reflects
the exploratory nature of the studies and their developmental basis. Their tests are
almost exclusively self-developed and more sensitive to style and formal elements; the
later studies were more split between self-developed and existing tests. They compared
and described more interpretatively and used behavioural terms, their tests were less
sensitive to form than content comparisons in the same test. They also used behavioural
95
or non-art tests which were not seen at all previously. The actual tests do not
significantly differ in their orientation, but the differences in the other variables tend to
support the trend.
Table 6: Significant variables identified from the Mann-Whitney non-parametric

association test. Frequency and percentage for Group 1, early studies 1973-1977; Group
2, late studies 1992-1996. Changes in methods and measurements.
Variables with scales Early studies Late studies

freq % freq %
Measurement method
Formal 7 58 5 28
Meaning content 1 8 1 6
Mixed form and content 4 33 9 50
Behaviour- non-art 3 17
Measurement form
Formal comparison 7 58 6 33
Meaning interpretive 3 25 4 22
Mixed form and content 2 17 2 11
Non-art or behaviour 4 22
Verbal 2 11
Derivation of test
This study self-developed 10 83 7 39
Adapted existing 1 8 3 17
Existing 7 39
Observational/clinical 1 8 1 6
The z values for all variables in Table 5 are negative which indicates linear relations. Over
22 years, similar elements are measured in art tests although there were differences in
orientation towards content and more interpretation of content from the later studies.
Most earlier tests were developed for the research and the later studies used a mix of self
developed and existing tests, but with no greater controls. Controlled comparisons exhibit
the same type of mixed sex and ill-differentiated groups. There is no better match of
controls to condition 1 subjects and results are still ambiguous and inconsistent. Thus,
research into art psychopathology has remained static.
96
Table 7: Frequency and percentage of test variables for whole sample by Results159.
All studies Result 1 Result 2 Result 3

Difference Difference No Difference or
patients/ patient inconsistency
nonpatients subtypes
Variables n=51 n=21 n=12 n=14

freq % freq % freq % freq %
Test design
pre & post int'n 6 12 2 10 1 8 1 7
post intervention 3 6 1 5 0 0 0 0
comparison only 36 71 16 76 9 75 11 79
retrospective 6 12 2 10 2 17 2 14
No. measures
1 31 61 14 67 8 67 7 50
2 9 18 3 14 3 25 2 14
3 8 16 3 14 0 0 4 29
4 2 4 0 0 1 8 1 7
15 1 2 1 5 0 0 0 0
Derivation of test
developed this study 23 45 8 38 5 42 9 64
adapted 8 16 5 24 1 8 2 14
observation/clinical 4 8 1 5 3 25 0 0
established 16 31 7 33 3 25 3 21
Orientation
comparison only 43 84 21 100 10 83 12 86
expressive 3 6 0 0 1 8 1 7
therapy - self esteem 5 10 0 0 1 8 1 7
Measurement method
formal comparison art 19 37 8 38 5 42 6 43
meaning/content 4 8 2 10 0 0 2 14
mixed comparison 21 41 11 52 6 50 4 29
nonart/behaviour 7 13 0 0 1 8 2 14
Measurement form
objective detail 18 35 9 43 4 33 5 36
content subject/theme 11 22 4 20 2 17 5 36
mix objective/content 13 26 7 33 4 33 2 14
other behaviour 7 14 1 5 2 17 0 0
verbal 2 2 0 0 0 0 2 14
Design: The majority of the studies (71%, n=36) compared a picture specially produced
for the test rather than pictures produced during therapy. Pre and post measures were
159
Results - all cases frequencies percentage
1. Difference patient/non patient 21 41.2
2. Difference subtypes of patient 12 23.5
3. No differences / inconsistencies 14 27.4
4. Difference for therapy groups 4 7.8
TOTAL 51
97
favoured (12% n=6) over post measures (6% n=3) for therapy state of patients. 12%
compared spontaneous pictures retrospectively.
No. of measures: 61% (n=31) of studies used only the test described and the diagnosis;
18% (n=9) used one other measure and 22% (n=11) used 3 or more.
Derivation of measure: 69% (n=35) of tests were either; designed for the study (23),
were adaptions of an existing test (8), or were observed or clinical ratings (4), and only
31% of studies used an established test.
The orientation variable shows 84% (n=43) of studies measured drawings produced for
the study and not as part of a therapy programme.
Measurement method: Scales have not been contrasted on this review as many studies
failed to provide coherent definitions of what they did measure, relying on common art
terms. Most studies included present or countable items, but this form of measurement
is not always objective as it often requires interpretation, if only in the sense that marks
must be recognised and judged against an internal model by the rater. For example, to
note that a head is or is not unusually large, a head must be reconstructed from the marks
on the paper and compared with what the rater thinks is normal.
This category brings together what is generally accepted as observable criteria: i.e.
those generally recorded in draw-a-person tests that there is little disagreement in
recognising. In applying the main test measure to the drawings, 41% (n=21) of tests
used a comparison requiring both subjective and objective judgments; 37% (n=19) used
a direct comparison of observable detail (e.g. draw a person tests); 12% used non art tests
(e.g. IQ, achievement, behavioural tests etc.).
98
Measurement form: The most frequent forms measured from the patient were observed
details (35%), the next was a mix of details and content (25%) closely followed by
content measures of subject/theme (22%) and behaviour (12%).
Results: (see notes, Table 7). According to this analysis of 51 studies, 72.5% (n=37) of
studies report differences between the experimental group and controls, either between
patient/non patient (41%, n=21), subgroups (23% n=12) or therapy groups (7.8%, n=4)
(these claims will be further investigated in Chapter Three, within the tightly controlled
comparison criteria of meta analysis).
Summary: The typical test compared a drawing done in standardised conditions by
about 30 adult schizophrenics of both sexes, and an unmatched control group of people
without psychiatric history. The test would be designed for the study, be rated by the
author, and would not be compared with any other measure except the diagnosis.
Patients' pictures would be expected to differ from non-patients by both content,
typically subject or theme decisions; and objective detail, such as particular colours and
positioning of figures.
Interactive effects for study variables by level of Result (shown in Tables 2 and 7).
Demographics: Most studies employed mixed sex experimental groups, adult subjects
and 2 conditions (normal controls). Sex and age were often only reported as a range or
categorically, i.e. adult. Differences between patients and controls were found in all of
the older groups (Table 2), but this may reflect differences in expectations, measurement
99
procedures, or publishing bias, since there were very few studies using old people.
Control groups for studies that found differences either in patient/control or between
subtypes, were equally balanced in matched controls and non-matched, and more often
schizophrenic, than a range of other psychiatric diagnoses. Where no differences were
found, control groups were not usually matched (Table 2), but there was a clear
predominance of either undifferentiated patients or schizophrenics. Unsurprisingly,
studies finding subtype differences used more experimental groups; 4 included normal
controls.
Design and sensitivity of test: The tests finding differences were most frequently
designed to measure a mix of observable qualities and interpretative elements and their
instruments were generally congruent with his aim, although 20% measured content
exclusively. Studies finding no difference emphasised the measurement of formal
elements in the design rather than content, but a third of their instruments were
exclusively sensitive to content. Tests which found patient/nonpatient differences used
a mix of self-developed, adapted and established tests; tests finding differences between
subtypes used a mix of self developed, observational and established tests; but tests
which found no differences used many more tests developed for the study (Table 7).
Reliability and Validity: The majority of studies which found no differences used
slightly more 1-rater tests (Table 2) but more criterion measures than studies finding
differences (Table 4), all results levels had few measures and raters.
100
Summary: Studies finding no differences were fewer and less controlled than those
which found differences; they used more unmatched controls, more undifferentiated
patients, and more tests developed for the study, coupled with less judges. Their
instruments were less suited to their stated purpose than tests that found differences.
Table 8a: Analysis of variance compared 5 demographic variables by 7 study factors.
Study Factors Diagnoses Design Valid Test
df=12 sig df=3 sig df=3 sig

Test variables F of F F of F F of F
No. of subjects 0.51 0.89 0.62 0.61 0.28 0.84

condition 1
age of subjects 1.68 0.12 0.67 0.58 1.79 0.16

3=13-18; 5=18-60;
6=60+
sex of subjects 2.41 0.02160 0.28 0.84 0.38 0.77

1-male; 2-female;
3-mixed
controls matched 1.78 0.09 2.10 0.11 4.40 0.01161

1-yes; 2-no
no. of judges 0.19 1.00 0.11 0.95 0.57 0.64

162
160
Too few cells are filled for meaningful analysis. 2 of the 12 diagnostic groups cover 53% of studies.
161
Studies using adapted tests were less likely to match for age and sex in controls.
Summaries of age and sex match in control by levels of validated test
VALIDTEST LEVELS Mean Std Dev Cases
For Entire Population 1.61 .49 51
1 test developed for study 1.83 .39 23
2 test adapted 1.25 .46 8
3 established test 1.44 .51 16
4 observation/clinical 1.75 .50 4
162
Nonart behaviourial measures tended to be used with younger subjects.
Summaries of age group for condition 1 by levels of measurement method
LEVELS OF METHOD Mean Std Dev Cases
1 direct comparison 4.89 .57 19
2 meaning 4.75 .50 4
3 some interpretation 4.95 .74 21
4 nonart - behaviourial 4.33 1.03 6
101
Table 8b. Analysis of variance performed to compare the means of 5 ordinal
demographic variables by 7 study factors.
Study Factors Orientation Measurement Measurement Results

(df=5) method (df=5) Form (df=5) (df=4)
F p F p F p F p
No. of subjects 1.03 0.36 0.72 0.58 2.05 0.10 0.81 0.53
condition 1
subjects age 1.92 0.16 2.63 0.057 5.29 0.00163 2.47 0.06164
3=13-18; 5=18-60; 6=60+
sex of subjects 0.35 0.71 0.44 0.78 2.88 0.03165 0.92 0.46
1-m; 2-f; 3-mixed
controls matched 0.49 0.62 1.58 0.20 1.39 0.25 0.92 0.45
1-yes; 2-no
no. of judges 0.16 0.85 0.34 0.85 0.39 0.82 0.41 0.80
6 personality 3.00 .00 1

163
Studies which used measures of behaviour or content used younger subjects.
Summaries of age group for condition 1 by levels of measurement form
MEASUREMENT FORM Mean Std Dev Cases
1 objective detail 5.17 .38 18
2 content - theme 4.36 .92 11
3 mixed 1 and 2 5.00 .41 13
4 behaviour 4.00 1.10 6
5 verbal 5.00 .00 2
6 expressive other 5.00 .00 1
164
Therapy groups were younger; groups in studies using criterion measures tended to be older; and studies
finding a patient/nonpatient difference used no adolescents and contained all the older groups.
Summaries of age group condition 1 by levels of result
LEVELS OF RESULT Mean Std Dev Cases
1 difference in experim'l group1 5.10 .54 21
2 diffs. in subgroups 4.67 .78 12
3 no difference 4.80 .63 10
4 therapy group 4.00 1.15 4
5 noncorrelation/inconsistent 4.50 1.00 4
165
Mixed objective/subjective elements were measured exclusively in mixed groups.
Summaries of sex by levels of measurement form
MEASUREMENT FORM Mean Std Dev Cases
1 objective detail 2.72 .67 18
2 content - theme 2.64 .68 11
3 mixed 1 and 2 3.00 .00 13
4 behaviour 2.67 .82 6
5 verbal 1.50 .71 2
6 expressive other 3.00 .00 1
102
Demographic interactive effects: The means of ordinal demographic variables were
compared between test factors and results are shown in Tables 8a and 8b. The study
population was mostly adult and mixed sex. Analysis of variance showed most
differences related to age of the study population: that studies using adapted tests were
least likely to match for age and sex in controls; nonart behaviourial or content measures
were used with younger subjects as were therapy groups, possibly reflecting recognised
difficulties in the interpretation of children's art166 as the lesser success rate for
patient/nonpatient differences indicates; groups in studies using more criterion measures
tended to be older probably reflecting the greater level of disability measures given as
standard in this population, medical opinion on these groups and also the longer term of
their confinement.
Table 9: Frequency and percentage for Measurement Form by No. of criterion measures
Diagnosis + Diagnosis, test + Diagnosis + 3 or

Test = 1 1 other = 2 more others = 3+
Measures n=31 n=9 n=11

Freq % Freq % Freq %
Measurement form
objective comparison 9 29.0 2 22.2 7 63.6
meaning/content 7 22.6 1 11.1 3 27.3
mixed formal/content 10 32.3 3 33.3 0 0.0
nonart/behaviour 3 9.7 2 22.2 1 9.1
verbal 2 6.5 1 11.1 0 0.0
Design of test levels by criterion: 31 studies used no other criterion measure than
diagnosis and the study test (Table 9) and these were mostly studies which found
differences (Table 2). The comparison of artwork for 1 criterion measure was broadly
166
Glynn V. Thomas and Angele, M. J. Silk (1990) An Introduction to the psychology of children's
drawings, Herts: Harvester Wheatsheaf.
103
spread between subjective and objective scales but with the addition of 1 other criterion
measure, the number of content measures dropped and behaviour measures increased.
For 3 or more measures (n=11) (which were equally split - difference/no differences),
tests favoured objective comparison of countable items (n=7), although there were some
content measures, there were no mixed comparisons. So, the observable and countable
measures tended to use more criterion measures, the mixed formal and content measures
used less criterion measures.
Table 10: Frequency and percentage for test derivation and results by No. of judges.
Judges 1 Judge 2 Judges 2+ Judges

n=35 n=9 n=7
Freq % Freq % Freq %
Test Derivation
developed this study 12 34 7 78 4 57
adapted 6 17 0 0 2 29
observation/clinical 4 11 0 0 0 0
established 13 37 2 22 1 14
Results
diff. pat/nonpat 13 37 3 33 5 71
diff. patient groups 8 23 2 22 2 29
no difference 10 29 4 44 0 0
therapy groups 4 11 0 0 0 0
Test derivation and result levels by judges: The vast majority of studies (35) used
only one rater and 13 used established tests (Table 10), most of which found differences.
Thus, reliability was not established for 22 tests, of which most found no differences.
There were fewer tests using more raters, but the majority of 2-rater tests (n=7; 78%)
were developed for the research; half reported differences. All 7 tests with more raters
104
reported differences between patients/controls or between subgroups. So, generally,
findings of difference increased with the number of judges167.
Summary: Whether or not studies found differences, they were poorly controlled, but
control was even poorer in studies finding no difference. Generally, all studies used test
items which measured more content than they intended to, but the studies finding
differences used mostly formal or mixed test measures which were consistent with the
aims of the study. The majority of 1 rater tests found differences, but of studies which
found differences, more multi-rater tests and more established tests were used, although
they used less criterion measures, more mixed measures than those finding no difference.
The studies finding no difference predominantly used instruments which measured
content qualities only, but were usually described as formal or mixed. They used less
raters, but slightly more criterion measures, more content tests, more behaviour tests and
many more self-developed tests (although all result levels had high percentages of self-
developed tests). A validity note is that as more criterion measures were added, the use
of form-only measures increased and mixed comparisons and content measures decreased.
This probably reflects the rigour of the studies.
Validity analysis of the literature
Tests designed for study: Very little evidence has yet been produced that characteristic
symptoms, which, when associated, lead to diagnostic categorisationof psychiatric status
167
If we assume that established tests have already been reliability tested.
105
are linked to those artistic characteristics which are interpreted by art therapists. Many
of the studies reviewed here developed their own tests for the study using artistic
characteristics which were said to be equivalent to the behaviourial symptomatic
characteristics used for diagnosis. The only criterion used in many cases was how the
experimenters thought the visual sequelae of thought disorder should look, supported by
previous examples of the same process. This is not enough. It is unsound to conclude
that paintings are or are not diagnostically valid if there is no evidence that the test items
are a) reliable themselves or b) measure any symptomatic behaviour and c) relate to visual
output. The DDS team168 have argued that they cannot produce a validity index since
there is yet no comparable instrument with the DDS, but there are many other
established tests measuring diagnostic and other qualities which could provide non-visual
indices for DDS correlations, and which so far have not been used. Indeed, the DDS itself
has not even produced good correlations with its only criterion, diagnosis itself169,
although it has produced a reliable format. Adapted tests too, must provide a criterion
measure, so that it is certain that aspects which have been deleted are not integral to the
validity of the test. The first validity question therefore must be: are these assessment
measures really measuring what they are designed to measure?
Even where obvious and relatively consistent phenomena are reported, what is
measured may be a confounding variable, something which accompanies the symptom,
168
Mills et. al. (1993) Reliability and validity tests of the Diagnostic Drawing Series, Arts in
Psychotherapy, V.20:83-88.
169
See my critique later in Chapter 2, reliability analysis. DDS produced by B. Cohen, J. Hammer and
S. Singer (1988) The Diagnostic Drawing Series: a systematic approach to art therapy evaluation and
research, Arts in Psychotherapy, V.15(1): 11-21. Although to be fair, the DDS is head and shoulders
above the competition, and further research on the statistics would produce a more suitable analysis.
106
rather than the symptom itself, thus unreliable, since it may appear in other
circumstances170. The validity of a test is proved when it correlates highly with another
proven method which measures similar elements.
Validity Analysis of Controlled Studies
70 studies were included in the analysis: all the controlled studies were included (51), 12
studies were added from the literature which dealt specifically with criterion validity and
7 studies from the literature on reliability171. 33 (47%) studies used an art test simply
against the diagnosis and 37 (53%) used the diagnosis and another criterion. The criterion
which was primary in the discussion was used for this review: 6 studies used a self
report; 1 study used a test with both content and formal evaluations; 27 (39%) used a
nonprojective measure of ability or IQ; and 3 used a verbal evaluation. The tables describe
5 validity characteristics from each of 70 studies172.
170
For example, R. Langevin, and L.M. Hutchins (1973) found that judgement of patient status correlated
higher with quality of the artwork than diagnosis, even when judges were prewarned what to expect (An
experimental investigation of judges ratings of schizophrenic and non-schizophrenic paintings, J.
Personality Assessment, V.37(6):537-543).
171
All studies are detailed in the Table of Authorities (Appendix 3). Study numbers for those which
appeared in the controlled analysis remain the same.
172
A full list of alternatives appears in Appendix 1.
107
3 Demographic variables were used from the controlled analysis:
•sex of subject;
•age, whether child/adolescent (under 18), adult (18-60), older adult (60+);
•diagnosis of the main experimental group;
There were 3 study factors:
•arttest form, what form of information did the art test collect;
•criterion form, what form of information did the criterion collect;
•no. of criterion measures used;
Sensitivity of the test and results.
•comparison, what type of qualities were the instruments being compared on;
•the results of the study: did the art test results correlate or significantly agree
with the other criterion test.
One alternative was marked for each category. Tables 1 and 2 show frequency and
percentages of study factors for all studies, and are divided between studies showing
association or none between the main art test and the criterion. The mean ranks for
study factors between the two result levels were subjected to a non-parametric test of
association, and the results are presented in Table 3.
108
Table 1. Frequency and percentage of criterion variables for 70 studies by result
all cases Result 1: Result 2:no

associatio association
n
n=70 n=42 n=28

Variables freq % freq % freq %
No. criterion
measures
0 33 47.1 26 61.9 7 25
1 13 18.6 6 14.3 7 25
2 12 17.1 4 9.5 8 28.6
3 9 12.9 3 7.1 6 21.4
4 2 2.9 2 4.8 0
15 1 1.4 1 2.4 0
Comparison
cognitive 11 15.7 5 11.9 6 21.4
emotion 12 17.1 8 19.1 5 17.9
development 9 12.9 2 4.8 4 25
diagnosis 37 52.9 27 64.3 5 35.7
Criterion form
diagnosis 33 47.1 26 61.9 7 25
self report/picture 6 8.6 2 4.8 4 14.3
mix of content/form 1 1.4 1 2.4 0
behaviourial/IQ 27 38.6 12 28.6 15 53.6
verbal 3 4.3 1 2.4 2 7.1
Art-test form
KFD 6 8.6 3 7.1 3 10.7
DAP 24 34.3 11 26.2 13 46.4
Formal other 3 4.3 1 2.4 2 7.1
copy 5 7.1 4 9.5 1 3.6
other theme 16 22.9 12 28.6 4 14.3
free 16 22.9 11 26.2 5 17.9
Result 1: significant association of measure with criterion test.

Result 2: no association of measure with criterion test
Most of the criterion tests used measured diagnosis or IQ. Diagnostic criteria were
compared with a mix of art tests (DAP 24%, free 30%, other theme 36%); thematic were
more popular and they were always compared on diagnosis. Achievement tests were
popularly compared with the Draw-a-person protocol (44%) but were compared equally
on cognition (30%) and development (30%), and a smaller percentage but equal
distribution of emotional (18.5%) and diagnostic functions (18.5%).
109
Table 2. Diagnostic groups for 70 studies with criterion measures. Frequency and
percentage by levels of result.
Result 1: sig. Result 2: no

association association
Diagnosis, condition 1 n=42 n=28

freq % freq %
schizophrenia 11 26.2 7 25.0

emotional trauma 5 11.9 2 7.1
drug/alcohol 1 2.4 0 0.0
psychotic phobia 2 4.8 1 3.6
neurological damage 5 11.9 2 7.1
depression 4 9.5 2 7.1
conduct disorder 1 2.4 1 3.6
retarded 3 7.1 2 7.1
gender disorder 0 0.0 1 3.6
personality disorder 1 2.4 0 0.0
mixed patients 8 19.0 10 35.7
Result 1: significant association of measure with criterion test.
Result 2: no association of measure with criterion test
Table 3. Non-Parametric test to show differences between study factors for findings of
association and non-association of art-test with criterion measure. Mann-Whitney U -
Wilcoxian Rank Sum Test.
Study variables Mean Rank for Mean rank for no Z scores Significance
association of association of level.
test- criterion test - criterion 2-tailed p
n=42 n=28 value.
Age group 36.58 33.88 -0.6545 0.5128

Diagnosis 33.13 39.05 -1.2151 0.2243
Criterion form 30.29 43.32 -2.8692 0.0041
No. of criterion
measures 30.67 42.75 -2.5916 0.0096
Art-test form 39.32 29.77 -1.9900 0.0466
Comparison 39.33 29.75 -2.1027 0.0355
There were no biases in demographic variables of age and diagnosis for studies which
showed association or not. The majority of studies which showed associations between
the art test and the criterion measure did not employ other criteria than the clinical
diagnosis and used a mixture of test methods, whereas the tests which found no
associations used predominantlycognitive criteria (IQ or achievement tests), were equally
divided between 0-3 other measures than diagnosis and used primarily formal test
110
measurements, favouring the Draw-a-person protocol. The comparison was
predominantly developmental, which category was absent from the tests which showed
associations; cognitive measures were also popular and least popular was emotion, which
was most popular in the test which showed associations.
Summary: There were many more tests which showed associations with the criterion
measure, but almost half the tests employed no other criteria than clinical diagnosis.
However, the relationship of the diagnostic criterion to the art test was consistent with
the comparison made by the study (on diagnosis), whereas the majority of the measures
which employed another measure were achievement tests and their comparison was often
not consistent with the orientation of the art test (37% compared achievement tests on
diagnostic or emotional criteria). If the tests using only the diagnostic criteria were set
aside, there are 2 points to note:
(1) Tests which compared developmentalqualities in drawings showed no association
with criterion measures; and
(2) Tests which compared emotional qualities tended to show association with
criterion measures.
There were equal numbers of studies on both sides for tests which compare cognitive
aspects. These results confirm the recognised doubts about the validity of painting or
drawing tests as developmental measures for psychiatric populations discussed in
Chapter 1, and so their predictions of cognitive function and use in place of IQ tests.
111
However, there were few tests which actually provided a suitable criterion for emotional
qualities.
Conclusion: For the controlled studies, the derivation of the measure had an influence
on the control of the study as did poor control on the result levels of no difference. Type
of treatment (orientation) and number of criterion measures varied with the age of
subjects. The interaction of demographic variables with levels of result together with the
failure to match or describe experimental samples in many studies and the confusion of
comparisons with criterion measures show the substantial quandary of treating this
literature as a whole. The advantage of examining a number of studies is that the general
direction of the majority overrides the diversity of confounding variables, but
developmental or cognitive criterion measures are inappropriate. This preliminary
overview has accomplished its purpose in that it has shown, generally, differences
predominate over no difference findings, and that diagnostic and emotional dimensions
rather than developmental and cognitive dimensions are valid directions for further
investigation. Further investigation, especially for characteristics which relate the art to
symptomatology must use studies which conform to common research criteria and which
minimise confounding variables. Comparable studies are those which use matched control
groups, at least on age and sex, a reliability index (if using a test which is not established,
if the rater is untrained or if there are mainly content variables).
112
Reliability Analysis
Judgement of characteristics differentiating patient groups
All rating scales have limitations, especially those involving human subjects. Given
enough different people performing a measurement, individual differences will contribute
to error, but a single rater may be inconsistent, or may be scoring on other criteria than
the published instrument. If a measure is unreliable, there is no possible way that any
sort of statistically significant relationship or difference with that measure can be
documented. It makes little sense therefore to list the characteristics for every study in
the controlled and case analyses unless they have established inter-rater reliability so that
it is certain their scoring is consistent and their definitions of terms unambiguous.
Terms used in this analysis of studies
Most studies have some counted or presence/absence scales, but there is a wide range of
opinion on what is described as objective or formal qualities. Here, formal qualities are
broadly differentiated from objective qualities as relating to the structure of the picture;
how it is made, rather than why it is made or what it represents173. Objective decisions
can be made about elements of form and content; although a characteristic can be both
formal and objective, it cannot be formal and subjective. For this review, objective
categories may be considered as observable dimensions; for example: the presence or
absence of some element, countable items, differentiation of structural aspects or
elements of the picture, such as lines, shapes and colours. Objective dimensions also
173
This form description is broader than the formal description for the DAPA, which appears in Chapter
3. It is clearly not reasonable to apply criteria to studies which are not aimed at that point.
113
include recognisable or identifiable objects/persons (but do not attribute meaning to the
image or compare it with an internal model). These objective categories can be
differentiated from subjective categories in that they do not require interpretation of the
image (fitting a meaning to the marks or images), do not require judgements of relations
between images or opinions on such personal judgements as aesthetic quality or
emotional associations. E.g. to note the presence of decoration, a subject must be
reconstructed from the marks on the paper and compared with what the rater thinks is
essential to structure: this is an opinion. On the other hand, phrasing can be misleading:
rating criteria demanding presence or absence of a symbol does not require an objective
but a subjective decision, because it requires the opinion of the rater on the intentions of
the artist. Many of the tests here had global elements for which operational definitions
cannot be considered reliable for a single rater.
Selection: To minimise confounding variables, the studies which were to be included in
the reliability assessment were those:
1. Which actually measured art variables from the pictures (4 studies of the benefits
of art therapy were excluded because the tests did not measure attributes of the
picture; they used self reports or behaviourial assessment. 3 other non-art
studies were excluded: Study 71, which used the TAT Make a Picture Story Test
protocol but assessed the verbal explanations of the patients; Study 62 and 15,
which used rigid copy accuracy measures.
2. Which used more than one rater if the rater was not trained for an established test
or if the test used mainly content variables.
114
3. Which assessed agreement between the raters: 2 studies were excluded, because
although they used multiple raters, they did not assess their agreement but
compared the judgements with diagnosis directly (including the most famous and
often quoted series of studies of judgements by Levy and Ulman174, who used
intra-rater measures, every judge being their own control), .
18 studies survived these strictures, 13 of which had 2 or more raters from the controlled
analysis, the majority using a test developed for the study. 5 studies used one rater and
claimed to use a previously established test; they will be discussed first.
Established tests with 1 rater - further exclusions
These studies claimed to use recognised tests, but examination reveals they used art
directives, adding their own scoring and therefore consistency was needed. Study 77
found differences using the protocol for a projective tree drawing test with elderly
schizophrenics, demented and control subjects on the basis of proven reliability, but did
not reference this statement and used their own interpretive system, which was not
subjected to reliability analysis. Study 29 found no significant differences in the size of
figures drawn by depressed patients and controls using a Draw-a-Person protocol, but
this is only one element in the DAP scale and the method should be tested independently
for reliability.
Two studies used tests of emotional indicators: Study 70 used the DAPQ (Karp
1990, unpublished) to find more incest markers in the drawings of abused than control
women and different treatment of sexes. Study 55 found no differences in development
174
B.I. Levy and E. Ulman (1974) The effect of training on judgement of psychopathology from paintings,
Am. J. Art Therapy, V.14:24-5 (study 43).
115
and emotional indicators in drawings from schizophrenic mothers than from control
mothers using a Draw-a-Man test (unspecified) but 5 significant differences between the
children.
The study of emotional indicators as symptoms of pathology have mostly been
done on drawings of children. Their clinical utility is low as indicators are rare but their
use as danger markers is recognised175. There is no evidence to show these studies may
generalise to adults.
Study 34 used the DDS176 to compare 81 eating disordered patients with an
undescribed control sample, collected and rated by Cohen 6 years earlier. It is most
undesirable for the two ratings being compared to be carried out by different observers177.
Any systematic variation between observers would have been inseparable from any
difference between groups. The original 1988 study is also not included since the DDS
team have not been able to supply basic information such as numbers of controls and of
patient groups used in the study178.
The reliability of the measures in these five studies is clearly more questionable
than in studies which used their own tests and two or more raters. Therefore, from the
175
Maralyn M. Trowbridge (1995) Graphic indicators of sexual abuse in children's drawings: a review of
the literature, Arts in Psychotherapy, V.22(5):405-93.
176
Cohen et al (1988) op.cit.
177
It is included in the analysis of controlled studies, but not here as it did not include a separate reliability
test.
178
Despite repeated personal communications over 4 years: 1994, 1996 and 1998. The original paper states
that further information is available, but from private letters and other communication the team cannot
comment on the statistical basis of the paper. Their reliability study, however, reported fully in 1993 was
included.
116
main analysis of 51 controlled studies, only those 13 studies whose characteristics were
rated by more than one rater were included in the reliability analysis.
The exclusion of the DDS
The Diagnostic Drawing Series, published and peer reviewed in the art-therapy press179
is currently the most well known contemporary art therapy assessment instrument in
America. It has repeatedly claimed to be the only art assessment method which has been
reliably tested, validated and has demonstrated reliable differences between diagnostic
groups. It uses 23 categories, most of which would be considered here as a more
objective form of content analysis but half of which are claimed by the authors to be
formal measures. The DDS is a useful therapeutic tool in that it offers a standardised and
structured format for assessment which is acceptable to a therapeutic milieu. Three
pictures are required, a person, a tree and a free picture. The reliability of the categories
has been demonstrated as good between 2 or 3 raters, although their methods of
calculating reliability are not clear and one study found that only 6 out of 23 categories
showed good reliability as calculated by the Kappa statistic between 2 raters, which gives
room for questions180. To ignore this major study could be seen as serious neglect, so I
will give my reasons for leaving out this study at length.
Are the claims for the DDS valid?
179
Cohen, Hammer and Singer (1988) op.cit.; also Art Therapy No. 15 1996, passim. The DDS appears
all through this issue as the premier assessment method for art therapy and research. It is repeatedly
claimed to have demonstrated clinically reliable differences between patient groups.
117
The DDS (1988) study was an exploratory study which described an evaluation
procedure applied to the pictures of 3 diagnostic groups of patients: Dysthymia,
Depression, Schizophrenia, and one non-patient group within a population size of 239.
In order to evaluate it properly, it would be necessary to know the sizes of the sample
groups, since the detection of 100% accuracy in one sample may refer to a different
number than another group. There were indications within the text that the control group
was in some way abnormal or small.
The instrument itself rated up to 23 categories for each of three pictures by each
patient. Some categories were reduced to 2 binary variables, and some with 3 or more
choices were reduced in some other way that was not explained. The text indicated that
there were then 36 variables in the end for each picture giving a patient profile of up to
108 variables between 3 pictures, treating the repeated measures as independent. This
procedure was not well explained and their illustration form did not employ either 23
categories or 36 variables. Furthermore, if the extra variables were included as was
indicated on the results tables, there would have been more than 108 variables. Despite
repeated enquiries, none of these concerns have been addressed by the authors.
4 multiple-regression analyses were calculated, one for each group against the
total population. That for an analysis to have 108 variables was unsatisfactory because
of the sample size required was recognised by Cohen in the paper. The variables were
rotated by some unspecified procedure but it is a mystery why they used the variables
that appear in the resultant tables, which were supposed to compare between diagnostic
180
E.L. Neale (1994) The Children's DDS, Art Therapy, V.11(2):119-126.
118
groups, rather than any other. Each table used a different set of variables so they were
difficult to compare. In addition, the variables were treated as though they were
completely unrelated, but there must have been a high degree of multicollinearity (most
of the variables must be related, especially those which are derived from the same
category and those which measure different pictures using the same variable) and most
would not contribute anything extra to that of the main differentiator, which means the
co-efficient presented cannot really be interpreted as an effect.
Cohen quotes the F-test as a measure that the combination of predictors does
better than chance, meaning that some element in the equation differentiates the
dependent variable (patient or control). However, this does not mean that it is effective.
All the ANOVA tells us is that at least one characteristic is good. There is evidence from
some of the t-tests that the co-efficient of the variable is not 0, but even ignoring the
method, looking at the coefficients as effect sizes181, the Dysthymia group shows an
almost negligible effect (-0.08 to 0.13); the Depressive results and Controls are similar
(depressed 0.13-0.17; controls 0.13-0.28), the strongest are water scenes for both
(depressed 0.37 and control 0.36182), which is not mentioned in the discussion of the
results; only Schizophrenia shows a high effect on one variable, minimal trunk (0.63, but
otherwise 0.16-0.29).
I therefore disagree with most of the statements in the discussion of significant
characteristics which are supposed to identify diagnostic groups, which include some
181
The coefficients could be interpreted as effect sizes if the variables were independent in the same way
as the t-statistics.
182
But the t-statistic has a significance of p=0.07 which does not indicate exclusivity.
119
which were not significant - and I would totally disagree with the assumption that
negative coefficients implied another characteristic was a strong indicator of
predictability, especially when the variable itself was tested, but not included: eg. "a
striking feature of dysthymia was light pressure" (indicated by a negative coefficient on
medium and heavy pressure). The t-values for heavy pressure were greater than one in
both picture A and B, which merited some discussion, but surely this indicated heavy
pressure was not applied, not that light pressure was applied! One of the study variables
was light pressure - why was it not included in the results? Similarly monochrome as a
significant characteristic is inferred from the negative correlations on multicoloured
pictures from schizophrenic patients. Monochrome was one of the study variables, why
was it not included in the schizophrenia results if it was a significant characteristic?183
It is obvious the technique of multiple regression is not appropriate for this
analysis, as reflected in the low levels of the multiple r-squared statistic184 and does not
do justice to the clinical merit of the DDS.
When the DAPA was being developed, the DDS was already rather famous.
Over 10 years, it has developed a 4 page resources list185. I contacted the DDS team and
183
The DDS team have declined to answer any of these serious criticisms. They have also ignored my
requests for clarification of their methods, since they are no longer in contact with their statistician. But
the DDS team are still encouraging art therapists to use this measure and bring in new work (DDS
Newsletter Dec. 1998).
184
Multiple r2 measures the fit of the model to the information provided - the closer to 1 the better. A
good fit would typically be 0.7-0.99. The DDS results were: Dysthymia 0.15; Depression 0.10:
Schizophrenia 0.22; Control 0.44. The control shows the best fit and the t-statistics are significant on
more variables, but very weak. However, if the numbers in the group are very different - as is hinted in
the paper, this might have a confounding effect.
185
DDS Resource List (1988) unpublished. 64 items mostly unpublished in cassette form. All published
material is discussed in this thesis.
120
invited them to provide substantiation for their claims since their original 1988 published
study was uninterpretable for this review. Despite this study being ten years old none
of these criticisms had been put to the DDS before186, which shows the statistical naivety
of their readership. Their whole output of papers and other resources are based on the
1988 study. The DDS team could not provide me with a better estimate of the
effectiveness of the DDS.
Tabulation of studies for reliability and discriminant characteristics
Firstly, each study had different combinations of reliable variables and different systems
of combining these variables for analysis. 28 studies were included in the analysis. 18
studies (which included 13 from the controlled analysis) were taken from the validity
analysis of 70 criterion measures, 3 were series uncontrolled studies (examined in the
analysis of 163 case studies, Chapter 2). The remaining 7 studies were not discussed
elsewhere: 3 were studies which examined judges predictions of patient status from their
own criteria, 2 were related studies which examined judge reliability on interpreting self-
images from paintings and 2 were specific reliability studies for the same test (the DDS).
There were three more controlled replications of studies by the same authors, all of
whose results cast doubt on their initial acceptable reliability. Study 9 was succeeded by
study 10; study 37 was succeeded by study 38; and study 58 was succeeded by study
59. Only the later studies are considered in the breakdown of elements. Those studies
which are not marked unreliable and do not show discriminant characteristics are either
186
Private communication, Anne Mills and S. Hacking 1998.
121
reliability studies or studies which use comparisons of total scores rather than isolated
elements. The total score comparisons are entered separately into the table as composite
variables.
In order to compare studies it was necessary to identify commonalities in
variables between studies and classify them into categories. These categories were
tabulated into 14 different areas of drawing analysis. The tables show the original terms
as far as possible. Terms are usually defined by the studies, and some produce booklets
of rating criteria, but they do not exactly compare with each other. These definitions are
not reproduced as each is individual; a list would be lengthy, require specific vocabulary
in some cases and serve little purpose. Different studies recorded similar elements,
globally and through combinations of details; I have tried to reflect this in the text. There
is little information on unreliable categories, as they tend to be barely mentioned and do
not appear on the variable lists, but those mentioned are presented in the tables, although
these are much fewer than in reality. Reliability is presented according to the author's
own evaluations, since this is a clinical decision, unless otherwise specified, as most
present only their final statistic. Some reliabilities are quoted by their authors only as
'better than chance' or 'acceptable', without figures. These were included here, but not in
the meta-analysis. Reliability tests are given by type, a key to which appears under
every table. A discussion of the limitations of the reliability statistics appears separately
at the end of the section. Discrimination analyses were simpler and test details are not
presented. Studies here present a more objective approach than is usual in this literature.
122
Studies which included reliability tests from controlled and uncontrolled analyses
of literature on art tests 1974-1996
• Studies showing reliability only do not test discriminant properties.
• Divisions are for subcategories of like variables by heading or by 1st variable in
bold; (o) objective (s) subjective (c) content (f) form. No.s are study No.s from
Table of Authorities (Appendix 3), No.s below headings denote same term
different study.
• Variables tested individually for reliability scores in bold, others are reliabilities
for whole test.
123
Thematic variables
Table 1: reliability statistics and discriminating variables for category of theme.
Thematic variables (Study No.) % other discriminates patient discriminates subgroups of

(o) objective (s) subjective (c) content (f) ag't test /nonpatient control patients
form (1-6) rel'y1 (nf=no figures)
presence of main image (48) (c) (o) 99

(49) 77
absence of focal configuration (56) 4 high NS NS
unintelligible essential (36) 90 5 .915 (nf) Alzheimer's
omission of essential (36) 90 5 .915 nf
presence of named elements (c) (o)

house (56) 4 high NS NS
1 dwelling or building, 2, 2+, estate (46) 96 NS
people present (48) 100
(46) 96 NS
(21) 3 .90 Organic** Depression/ Organic**
(49) 77
(3) 3 .96 depressed p.d. **
animals present (48) 99
(46) 96 NS
(49) 77
tree present (48) 96
(49) 77
water landscape (48) 93
(49) 77
inanimate object (48) (s) 97

(49) 77
(33) 94 4 .96 severe mental retd'n **;
acute/chronic psychosis*
1- reliability tests: 1 = % agreement; 2 = product moment correlation; 3 = correlation coefficient; 4 = association test Chi
sq. or T; 5 = Kappa; 6 = Anova.
** p<0.01; * p<0.05.
Reliability: There were no unreliable variables among the 6 experimental and 2 reliability
studies which generated 26 thematic variables, so there were no disputed subcategories.
There were 10 variables measured individually, although 6 came from 1 reliability study
(48). 3 simple subcategories of content evaluation are shown in Table 1: the objective
presence, absence or confusion of a main image (48, 49, 36, 56); the objective
identification of the subjects of the picture (46, 56, 48, 21, 3, 49) and the subjective
evaluation of animate status (48, 49, 33).
124
Discrimination: From 26 reliable variables, 8 were tested for discrimination properties
by 5 studies; there were 4 differences. There were no significant differences between
schizophrenics and controls on absence of focal configuration (56). A similar variable,
omission of essentials, was identified as a strongly significant and frequent predictor of
Alzheimer's disease against normal controls (36) and was distinct from unintelligibility,
in which there was no difference in the same patient group. Between presence of named
elements, people present were drawn more frequently by normal controls than patients
with both depression and organic brain damage (21; this study probably lacks power as
the numbers are very small) and this result is partly supported by similar findings from
a study of depressed patients with a main diagnosis of personality disorder (3, but no
subgroup numbers were given). The findings of study 46, that schizophrenics and other
patients scored equally on countable named elements in pictures also support this
differential score for depression. There were differences between different partitions of
schizophrenic patient groups from study 33, which distinguished duration of psychosis
as long or short and severe from other grades of mental retardation (33), in the use of
inanimate objects, but neither compensation, nor power calculations were made for the
process of multiple testing and unequal numbers.
Summary: Objective thematic evaluation of content is reliable. Normal controls may
draw more people than patients and Alzheimer's patients may omit more essential
elements than both controls and patients. Use of inanimate objects may distinguish
125
between grades of the same diagnosis, particularly in retardation, but the evidence is very
weak for all suggestions.
Content
Table 2: reliability statistics and discriminating variables for category of content.
content variables (study No.) % other discriminates patient/ discriminates subgroups of patients
(o) objective (s) subjective (c) content ag't test1 nonpatient control
(f) form (1-6) rel'y (nf = no figures)
paucity content (36) (s) 90 5 .915 Alzheimer's freq.

general poor content (36, composite v) (nf)
Alzh'rs **
bizarre content (38) (s) 2 NS 90

(36) 5 .915 Alzheimer's freq
(33) 70 4 .566 (nf) paranoid from non-p schizophrenia*;
mild from other retarded
schizophrenics**; retarded from non-
r schizophrenics*
incongruity (36) 90 5 .915
fused/hybrid image (36) 90 5 .915 nf
nf
morbid content (36) (s) 90 5 .915 nf

hopelessness (75) 2 .94 depressed **
suspicion (36) 90 5 .915 nf
masklike drawing (33) NS 4 NS
personal content (s)

expressive (44) 3 .63 schiz. coping techniques*
(36) 90 5 .915 nf
symbols (38) 2 NS
original (38) 2 > .60 NS
problem solving (21) 3 .92 patients ** depressed **
identification of themes (50) (s) own criteria NS

continuity of themes (50) own criteria
several ideas (38) NS 2
related ideas (38) NS 2 NS
>.60
interest self (75) (s) 2 .94 depressed **

interest family (75) 2 .94 depressed **
** p<0.01; * p<0.05.
shaded area - unreliable category.
Reliability: 7 experimental studies generated 22 content variables, which were grouped
by six subjective subcategories of content evaluation. Only 4 variables showed individual
element scores and there were 6 unreliable variables distributed over 4 categories, which
126
implied contradictions between studies measuring similar variables. The studies using
overall scores showed high agreement (mostly over 90%), although they were results of
5 different types of measurement and so, difficult to compare. Reliable subcategories
were: paucity of content (36) and interest in self and family (75). Personal content and
morbid content were similar variable types which seemed reliable if rated globally
(subjective decisions such as masklike drawing [33] or symbols [38] were unreliable), but
there may have been large variations in terms. Bizarre content was rated by 3 studies, 2
indicating high agreement between 3 raters (36, 33), but study 38 found the same term
unreliable between 2 raters. Since study 33 used a similar patient group, the most likely
difference would be in definition. There was poor agreement for the theme subcategory,
in identification and continuity and in 2 variables from study 38, where related ideas were
reliable, which is of questionable value if it is difficult to determine if there is more than
one idea (several ideas, 38 unreliable). It is more likely that this variable measures some
other quality of the picture such as internal relations between elements but it was not
clear and therefore was rejected as ambiguous. 5 subcategories were therefore reliable.
Discrimination: From 10 reliable variables tested for discrimination properties, 8
showed results. Schizophrenia groups were distinguished in paranoia and retardation
from non paranoic and non retarded, and particularly, mild retardation from other grades
in the presence of bizarre content in their paintings (33). This point was supported by
qualitative reports from study 46, of more bizarre work by schizophrenics than other
patients, and better results from paranoid than other schizophrenics. Within
schizophrenic groups, the coping strategy of 'sealing over' promoted the use of more
127
personally expressive images than 'integration' (44). Poor content, a totalised score of 11
separate variables, was a significant predictor of Alzheimer's disease against normal
controls (36), within which, paucity of content was one of two variables which always
occurred and bizarre content was identified as a frequent and significant indicator (36).
The suggestion from study 46, which noted qualitatively that schizophrenics used more
personal and self-centred content than other patients, was not picked up generally in this
table although study 38 also noted, but did not pick up more originality from
schizophrenics than normal controls. There are indications that depressed patients use
less problem solving strategies (21) than other patients. Some support is given from the
finding that depressed patients, produced more hopelessness (75), and also differed from
normal controls in their disinterest in self and family (75).
Summary: Subjective judgement of global content is reliable, but not when referenced
to the image. This indicates that what is interpreted has little relation to the picture,
except in the differentiation of Alzheimer's disease, where pictures were poorer in content
and more bizarre than normal controls. This could, however, reflect the physiological
signs, such as control of the media, rather than intentional imagery, as indicated by the
lack of specificity in 'bizarreness', such as confusion or hybrid imagery. There are
indications of differences within patient groups for personal content, but the evidence is
weak because of small numbers and in the vague definition of 'expression' (44). Large
differences were reported between depressed patients, normal and patient controls by 3
studies on what seems reflective of situational despair or disinterest.
128
Body Detail
Table 3: reliability statistics and discriminating variables for category of body detail in
picture.
Body detail variables (study No.) % other discriminates patient/ discriminates subgroups of patients
(f) form (1-6) rel'y (nf= no figures)
emotional indicators (c) (o)

incest markers (9) 2 Mod stat. not clinical
incest markers (10187 ) 2 NS
sex difference (75) 2 .94 depressed **
incest markers (57) 5 .71 NS
trees (c) (o)

knotholes (52) 96 NS
broken limbs or damaged trunk (52) 96 dissociative
leafless (52) 96 disorders 30%
freq.188 (nf)
size of figure (c) (o)

self (75) 2 .94 depressed **
family (75) 2 .94 depressed **
figure relationships (s)

self-other distance (75) 2 .94 depressed **
self isolation (75) 2 .94 depressed **
family isolation (75) 2 .94 depressed **
identify self image (58) (s) 94.3

(59)189 61.9 unreliable 54% (5 soc.wkers); 78%
(5 health prof) 93.4% (2 Art ther)
** p<0.01; * p<0.05
Reliability: 7 experimental studies generated 14 variables which investigated self and
family drawings. They were grouped by 3 objective and 2 subjective subcategories of
content evaluation which largely tended to separate out the studies, indicating that they
were measuring qualitatively different elements. There were only 5 variables
independently rated, 3 of which were unreliable. Reliable subcategories were: damages
187
study replicating 9.
188
dissociative disorders 30% frequency for broken limbs or damaged trunk whereas controls scored 0.
dissociative disorders frequency of 30% for leafless trees and controls 7%, but evidence of seasonal
influence.
189
study replicating 58.
129
to trees (52); size of figure (75); figure relationships (75) which all scored over 90%
percentage agreement or correlation between 2 or 3 raters. The fact that neither of these
measures gives an adequate assessment of true agreement is illustrated in the remaining
subcategories, by two pairs of studies using the same tests with better controls and more
raters. Studies 58 and 59, which identified self images, initially obtained high agreement
between 2 art therapist raters, but, subsequently, using different raters, obtained 54-78%.
The author's claim of acceptable reliability nonetheless for identification without
reference to the patient, is clearly questionable, since a likely explanation of these figures
is that subjective identification of the meaning of images probably depend on the rater's
acquaintance with the patient's personal imagery. Studies 9 and 10 reported but did not
quote 'moderate correlations' between 2 raters for their first study, whereas their second
study using 4 raters achieved such poor reliability that the authors admitted serious
doubts about their previous results. Study 57, which used the same patient groups, in
similar numbers achieved good reliability as measured by the Kappa statistic; it seems
likely that definition problems in study 10 were avoided in study 57 which focused
purely graphic features. Study 75 achieved a very high correlation with another specific
variable, sex differences. The emotional indicators subcategory was therefore judged
reliable for specific graphic elements.
Discrimination: From 11 variables between 3 studies tested for discrimination
properties, 8 results showed significant differences. Differences between controls and
depressed patients were shown in size of drawing, relationships between and sex
differences in figures (75), but not among 74 graphic features measured from figure
130
drawings by sex abused adolescents (57). Although no test was applied, trauma
indicators from drawings of trees with damages found that psychotics drew more broken
limbs or damaged trunks than normal controls (52).
Summary: emotional indicators became reliable when judged objectively on specific
graphic features. Certain features may discriminate drawings of depressed or psychotic
patients from normal controls, but they were not apparent in victims of sexual abuse, the
expected client group which is most frequently exposed to this kind of measure. Studies
9 and 10 reported most of their variables were 'statistically but not clinically significant'
for drawings from victims of sexual abuse, i.e. they were rare in that group. This finding
is consistent with the recent literature190; most studies failed to establish sex markers and
presence of genitalia were rare.
Quality
Reliability: 6 experimental studies and 1 study of validity between tests generated 15
variables, which were grouped among 2 subjective subcategories of content appraisal and
1 formal subcategory. All the tests for agreement were the same, so studies compared
well. Reliable subcategories were: presence of specific elements of drawing sophistication
(38, 35, 61, 31), and proportion of the image, in parts (38) and overall (35, 38, 36, 20).
190
Comprehensively summarised by M.M. Trowbridge (1995) Graphic indicators of sexual abuse in
children's drawings: a review of the literature, Arts in Psychotherapy, V.22(5):485-93.
131
Table 4: reliability statistics and discriminating variables for category of Quality.
Quality variables (Study No.) % other discriminates patient/ discriminates subgroups of

(o) objective (s) subjective (c) content ag't test1 nonpatient control patients
aesthetic quality (38) (s) 2 NS

pleasing/good (14) own common prefs192 NS.
poor (61) 2 .97191
care (38) 2 NS
craftsmanship (38) 2 NS
drawing sophistication (c) (o)

painterly/graphic (38) 2 >.60 NS
dry brush (38) 2 >.60 NS
brush strokes (38) 2 >.60 NS
redrawn line (35) 2 .84 NS NS
corrections (61) 2 .97
drawing sophistication, form (31) 2 .77
drawing sophistication, space (31) 2 .77
proportion (s)
object (38) 2 >.60 NS
parts (38) 2 >.60 NS
overall impairment (35) 2 .84 brain damage** NS
poor graphic quality (36, composite) Alzheimer's**
quality copy (20) 2 .78-.92 Alzheimer's193
** p<0.01; * p<0.05.
shaded section - unreliable subcategory.
The subcategory containing most contradictions was overall aesthetic quality, whether
the picture was subjectively good or poor to the rater. Study 14, which employed no
statistics, reported 'common preferences' in personal choice of pleasing/good between 20
raters over 1500 paintings, and this observation was supported by another study (61)
which tested a similar mixed patient group over 120 paintings between 2 raters. All three
unreliable variables came from the same highly controlled study (38), with a much smaller
group of patients (9 schizophrenics and 9 matched controls) where both raters were
artistically trained, so terms like aesthetic quality were vulnerable to personal
191
median r.
192
own criteria, common preferences reported between liked and disliked pictures but very poor criteria and
judgement, 10/20 criteria reported were related to personality of the judge and there were wide individual
differences amongst criteria reported. No Significance.
193
correlations: Alzheimer's shorter illness duration, better copy; higher brain weight better copy.
132
interpretation. Equally, the variation in scores for craftsmanship or care probably reflect
individual differences, which would vary with raters' experience, so this subcategory was
unreliable.
Discrimination: From 9 reliable variables tested for discrimination properties, there
were 4 significant results. There were no differences between pictures by controls and
brain damage (35) or schizophrenics (38) on elements of drawing sophistication, although
coverage of this area was very poor, nor in proportion of objects or parts of the pictures
(38) for schizophrenia. Overall, quality of the drawing from a 9 variable composite, most
discriminated Alzheimer's disease (36) and brain damage (35) from controls and among
grades in the corresponding deterioration of the image or copy with departure from
normality (longer illness and loss of brain weight in Alzheimer's (20); damage to the left
brain (which is more noticeable in normal operations) against that of the right and controls
[35]).
Summary: Subjective personal judgements of quality were unreliable. Reliability can
be achieved when the criteria are defined as elements of the drawing. Although non-
significant, study 38 noted trends towards more graphic work by schizophrenics and less
proportion between objects and parts. Global quality was a good discriminator variable
for brain disease or damage, but there were indications that the coverage of this area was
patchy.
133
Line
Table 5: reliability statistics and discriminating variables for category of line quality.
Line quality variables (Study No.) % other discriminates pat. discriminates subgroups of
(o) objective (s) subjective (c) content (f) ag't test1 /nonpat. control patients
form (1-6) rel'y (nf= no figures)
counted elements of line (f)

number of lines (38) 2 >.60 NS
number of angles (35) 2 .84 brain damage ** NS
angle production (35) 2 .84 left b. damage** left b.d. from r.+ control**
% rightangles (35) 2 .84 right b.damage* right b.d. from left+control*
% acute angles (35) 2 .84 left b.damage* left b.d. from right+control*
obtuse angle (35) 2 .84 NS NS
length (48) 99
(49) 77
long stroke (38) 2 >.60 NS
short stroke (38) 2 >.60 NS
degree short strokes (38) 2 >.60 NS
predominance long short (38) 2 NS
varied length (38) 2 >.60 NS
line quality (48) (f) 97

(49) 77
(21) 3 .32 NS
heavy/light brush (38) 2 >.60 NS
predominance thick/thin (38) 2 >.60 NS
description of lines (f)

reinforced (36) 90 5 .915 nf
1 stroke (38) 2 NS
joined (35) 2 .84 NS NS
crossed (35) 2 .84 NS NS
jagged (38) 2 NS
broken (38) 2 >.60 NS
splintered (38) 2 >.60 NS
quavery (38) 2 >.60 NS
shaky (36) 90 5 .915 nf
tremor (35) 2 .84 brain damage ** R. from L. brain damage **
sketchy (33) 82 4 .63 Grades retarded schiz2 **
Retarded schiz from non R.*
curve (38) 2 NS
straight (38) 2 >.60 NS
straight/curved predominance (38) 2 NS
straight/curved variation (38) 2 >.60 NS
purpose of line (c) (s)

aimless (36) 90 5 .915 nf
enclosure (48) 98
(49) 77
(38) 2 >.60 NS
(46, composite) NS
degree outline (38) 2 >.60 NS
for texture (38) 2 >.60 NS
for fill in (38) 2 NS
for shade (33) 85 2 .68 Schizophreniform/nuclear s.*
other marks (c) (o)

blotches for line (38) 2 NS
blotches/form, mass, decor'n, texture (38) 2 >.60 NS
smears (38) 2 NS
dabs (38) 2 >.60 NS
degree dabs (38) 2 NS
dabs for form, mass, decor'n, texture (38) 2 NS
1 - reliability tests: 1 = % agree; 2 = product moment corr.; 3 = correlation coefficient; 4 = association test Chi sq./t; 5 = Kappa; 6 = Anova.
2- mild to moderate mental retardation in schizophrenia, distinguishes amongst grades.
** p<0.01; *p<0.05.
134
Reliability: 5 experimental studies and 2 reliability studies generated 54 variables, which
were grouped between 3 formal, 1 subjective and 1 objective content subcategory.
Although only 5 variables between 3 studies actually gave individual figures for the
reliable items (the others gave the averaged test agreement statistic), the variables and
statistics within subcategories were congruous for the majority of studies. 13 of 14
unreliable variables came from one exploratory study (38), which used large numbers of
variables, sometimes promoting confusion amongst similar terms. It must be remembered
that few studies report their measurements of unreliable variables, so these measures
must take on more weight in discussion than the minority of studies they seem to
represent. The most reliable subcategories were: counted elements of lines (48, 35, 49,
38), except for predominance of short or long lines (38), which is confusing, considering
that long and short lines were identifiable. This same problem occurs in the subcategory
of description of line. Presence of straight or curved line and variation of straight or
curved line was reliable, but predominance was not. It is likely to be due to difficulties
in relative judgement, which puts the objectivity of some of the other categories in doubt:
reinforced lines were reliable (36), but not lines made with one stroke (38). Taken
together it seems that polarisation in quality of line may be discerned, by relation to the
whole and considering only the extremes. However, this technique would tend to allow
the judgement to vary according to variation in individual style and range of marks. This
subcategory was considered reliable for broad distinctions of presence. Joined or crossed
(35), broken or splintered lines (38) were scored reliably present as were shaky or sketchy
lines (38, 36, 33, 35), but not jagged (38) (which probably blurred with splintered).
135
Purpose or use of line contained one unreliable variable among 8, fill-in (38), which was
probably confused with the texture variable of the same study. Shade (33), a similar
variable, achieved acceptable reliability. Study 21 achieved a correlation coefficient of
only 0.32 on quality of line between 3 raters, whereas three other studies achieved
acceptable correlations and high agreements between 2 raters. The author of study 21
admits unresolved problems in definition and reports previous results of (0.73-0.95), so
the quality subcategory was considered reliable. The other marks subcategory (13
variables, all from study 38) was generally unreliable where decisions of degree were
made between similar variables; blotches, but not dabs (although they could be marked
present) or smears, could be reliably differentiated as used for form, mass, decoration
and texture (but not as used for line) so reliability was achieved only for presence of
blotches within the image.
Discrimination: From 27 reliable variables tested for discrimination properties, there
were only 5 differences reported among 3 reliable subcategories. There were differences
within patient groups of left or right brain damage and between patients with left brain
damage and controls in difficulty of producing angles and in number of acute angles,
within patient groups and between left brain damage and controls in right angles, but no
difference in obtuse angle production (35). There were no differences among these
groups or among schizophrenics and controls in number (35, 38) of lines, or among
schizophrenics and controls in length or quality of lines or presence of substitute marks
(38). Within groups, nuclear schizophrenics were reported to use more shading than
those with schizophreniform illnesses (33), but there were no differences in purpose of
136
lines between controls and Alzheimer's patients (36), schizophrenics and other patients
(46) or schizophrenics and controls (38). Differences among diagnostic groups were
shown in, shaky lines or tremor, probably betraying physiological damage, discriminating
brain damage from normal controls (35). Sketchy line discriminated mild from other grades
of schizophrenic retardates and schizophrenic retardates from normal schizophrenics
(33).
Summary: The reliability may vary with the range of line expressed and its relative
extremes. Overall, line does not seem to be a discriminable dimension against normal
controls for schizophrenia or Alzheimer's disease. Line does show up logical difficulties
in control, particularly in the drawing of angles by patients with brain damage. This
probably reflects loss of fine motor control rather than a distortion in concept of the
image. The deterioration of controlled line the further towards retardation in
schizophrenia may point towards a theory of regression for that group.
Shape Table 6: reliability statistics and discriminating variables
Shape variables (study no.) % other discriminates patient/ discriminates subgroups of patients
(o) objective (s) subjective (c) content ag't test1 (1- nonpatient control (nf=
(f) form 6) rel'y no figures)
paucity shape/form (36) (f) 90 2 .915 nf
differentiation of line/shape (48) (f) 98

(49) 77
variation in form (38) 2 >.60 NS
variation in mass (38) 2 >.60 NS
shape dimensions (f)

dominant shape (69) 4 Acc. NS
size of shapes (69) 4 Acc. NS
regularity of shape (69) 4 NS
similarity of shapes (69) 4 Acc. NS
flat shape (36) 90 5 .915 nf
repeated forms (38) (f) 2 >.60 NS

3+ abstract forms mannerism (56) 6 Acc. patients/schizophrenic* Schizophrenic/patients*
3+ same shape (69) 4 Acc. NS
4 shape/detail stereotype (56) 6 Acc. NS NS
137
Shape variables (study no.) % other discriminates patient/ discriminates subgroups of patients
(o) objective (s) subjective (c) content ag't test1 (1- nonpatient control (nf=
(f) form 6) rel'y no figures)
delineated form by mass, contour (f)

(38) 2 >.60 NS
delineated form by line (38) 2 NS
** p<0.01; * p<0.05.
Reliability: 4 experimental studies and 2 reliability studies generated 16 shape variables
distributed among 4 objective formal subcategories. The terms shape, form and mass
were undifferentiable between studies, so they are grouped together here. Each test used
a different agreement statistic, only one of which gave item reliabilities (48) and some did
not report figures at all. All subcategories were reported reliable. There were 2 unreliable
variables; regularity of shape, which was not close enough to any of the other 5 variables
(4 were from the same study, No.69) to compromise their reliability if withdrawn; and
delineation of form by line, which probably suffered confusion with that of contour, from
the same study (38).
Discrimination: From 12 variables tested, there was only one significant result. The
variable 3+ repetition of forms discriminated schizophrenia, other patients and normal
controls (56). However, 2 other variables testing similar terms found no differences:
among 5 patient groups including schizophrenia (69, 3+ same shape) and among
schizophrenics and normal controls (38, repeated forms), although qualitatively both
studies noted that schizophrenics repeated forms more often than controls (46, 38).
When covaried with IQ and art experience, however, differences reduced to non-
significance (46). Study 56 was not controlled for IQ, and the authors admit that IQ
variations may have confounded the results, so this result is here considered very weak.
138
Summary: Shape does not appear to distinguish any group of patients reliably. There
are ambiguities in terms from the literature which are not shown in the reliability tests,
possibly reflecting individualistic research which shows itself in lack of congruency in
type of variables between studies.
139
Colour
Table 7: reliability statistics and discriminating variables for category of colour.
Colour variables (study no.) % other discriminates patient/ discriminates subgroups of patients
(o) objective (s) subjective (c) content ag't test1 nonpatient control (nf= no
(f) form (1-6) rel'y figures)
number of colours (38) (f) 2 NS

(14) own criteria nf patients less (nf)
(75) 2 .94 depressed **
(44) 3 .63 schiz. coping strats194 *
(36) 90 5 .915 Alzheimer's less (nf)
colours used (14) (f) own criteria nf patient pref.Red/Black(nf)

actual colour (38) 2 NS
colourtype (48) 98
(49) 77
mixed colour (f)

blend (48) 92
blend (49) 77
muddy (38) 2 >.60 NS
mixed on surface (38) 2 >.60 NS
mixed colour (38) 2 >.60 NS
pure colour(38) 2 NS
thick (38) 2 NS
watery (38) 2 >.60 NS
dominant hue (69) (f) 4 Acc. psychotic depressives195 **

prominence (21) 3 .90 patient groups *196
light/dark tone (69) 4 Acc. neurotics *
brighter tone (69) 4 Acc. NS
brightness (69) 4 Acc. NS
brightness (38) 2 >.60 NS
dominant tone (69) 4 Acc. neurotics *
consistency of colour (38) (f) 2 NS

(69) 4 NS
1/6+ 1 colour (56) 4 Acc. NS NS
masses 1 colour (38) 2 >.60 NS
decoration or outline in colour (38) 2 >.60 NS
colour fit (21) (c) (s) 3 .86 NS NS

idiosyncratic colour (48) 97
(49) 77
colour harmony (69) 4 Acc. NS
colour relations (3) 3 .83 pers. disorder; dep. less (nf)
** p<0.01; *p<0.05.
Reliability: 9 experimental studies and 3 reliability studies generated 35 variables which
were grouped into 5 formal and 1 subjective content subcategory. 5 reliability tests were
194
schizophrenic subgroups, coping strategy - 'integrators' score more than those who 'seal over'.
195
psychotic depressives from 5 diagnostic groups
196
Initially significant but diminishes on pairwise comparisons (Post-hoc Scheffe test)
140
applied between studies but there was high congruency of variables within subcategories.
10 variables between 2 studies gave an item reliability score and there were 6 unreliable
variables although these were spread over 4 subcategories. Reliable subcategories were:
brightness of hue and tone (69, 21, 38) which were undifferentiable in most studies so
are grouped together here. (study 69 did differentiate them and found evaluations of
these elements highly correlated); coloured detail (38), and colour fit (21, 48, 49, 3, 69).
4 studies with the same term definition (75, 14, 36, 44) achieved high reliability on
number of colours, but correlations between raters were very low in study 38. This
study also found low correlations for colours used, found reliable by 3 other studies (14,
48, 49, although two of these used no figures). The raters for study 38 were art trained
and it is likely that there were too many delineations of colour in this study. Therefore
these subcategories are considered reliable when not too complicated. Colour mix was
reliable on premixed colour (38, 48, 49), on surface mixing (38), muddy or watery colour
(but not thick or pure, which probably denotes difficulty in decisions on relative
consistency)(38). Consistency of (i.e. the most prevalent) colour was found unreliable
by 2 studies (38, 69) and the reliability for amount of single colour was only 'acceptable'
in study 56. This was probably due to global assessment of the whole picture, whereas
specifics, such as detail in decoration or outline or masses were reliable. This category
is therefore considered reliable for specific details.
Discrimination: From 21 reliable variables tested for discriminant properties, there were
8 significant results among 3 subcategories. General psychiatric patients, Alzheimer's
patients and depressed patients (14, 36, 75) all scored less than normal controls on
141
number of colours. Furthermore within coping strategies of schizophrenic groups,
'integrators' scored more than 'sealers-over'(44). There were no tests on colours used, but
patients were reported to use more red and black (14) than normal controls. Neurotics
were differentiatedfrom other patients on 2 highly correlated variables; tone and hue (69).
Study 38 found no differences between schizophrenics and normal controls among 4
mixed colour variables and 2 details in colour variables. 2 studies found no differences
for colour fit (69, 21) but a tendency to less appropriate colour by depressed patients
with personality disorders was reported (3) although there were no test results.
Psychotic depressives were differentiated from 5 patient groups on dominant hue (69),
which concurred with initial findings of significant difference between 4 patient groups
and controls using the same test statistic (21). The author of Study 21 reports no
significance for this result because the Sheffé test did not isolate a single group, but I have
disregarded this post-hoc analysis: the test procedure increases the power of the results,
but the small numbers and overlap between groups in each of these two studies (21
N=25; 69 N=33), make complex statistical procedures inappropriate and limit the
comparability of the results, so results from study 69 and initial findings from study 21
are here considered equivalent and valid.
Summary: Normal controls generally use more and brighter colours than all patient
groups although there could be more subtle inter-group differences amongst
schizophrenics. Prominent or dominant colours or tones may offer discrimination
between patient subgroups but clear distinctions between groups have not yet been made.
142
Reality
Table 8: reliability statistics and discriminating variables for category of reality.
reality variables (study no.) % other discriminates patient/ discriminates subgroups of patients
(o) objective (s) subjective (c) ag't test1 nonpatient control (nf= no
content (f) form (1-6) rel'y figures)
overall reality (c) (o)

reality (21) 3 .88 organic dis.** NS
degree verisimilitude (38) 2 >.60 NS
representative (48) 77
(49) 77
abstract (48) 88
(49) 77
abstract symbol (48) 93
(49) 77
verisimilitude masses & forms (38) 2 >.60 NS
verisimilitude objects (38) 2 >.60 NS
ambiguous shapes (36) 90 5 .915 nf
reality in content elements (c) (s)

omissions (38) 2 >.60 NS
additions (38) 2 >.60 NS
distortion (38) 2 >.60 NS
faulty recall (36) 90 5 .915 Alzheimer's (more) nf.
displacement (35) 2 .84 R/L brain damage** R.brain-d from L.brain-d197
place error (33) 56 4 .56 Acute/Chronic schizophrenia*;
grades in mental-ret'd. schiz.**;
non-ret'd/retarded in schiz's.**
unusual place (48) 99

(49) 77
logic (21) (c) (o) 3 .92 organics ** depressed from mania+organic**

light source (38) 2 >.60 NS
connections:path, door; correctly
placed path, door, window (46)198 96 NS
horizon/ground line (c) (o)

ground line (48) 100
(49) 77
base line (46) 96 NS
horizon (56) 4 good NS NS
(46) 96 NS
** p<0.01; * p<0.05.
were grouped between 2 objective and 2 subjective subcategories of content evaluation.
There were 9 variables among 3 studies which gave item statistics, but items within
197
Right brain damage and left brain damage from controls
198
All study 16 variables in this table were tested together under a composite 'spacial representation'
category together with many variables shown individually in table 9. (f0.2 NS).
143
subcategories were congruous and all overall percentages showed good-very high
agreements with no unreliable variables. Reliable subcategories were: recognisable content
(48, 21, 49, 38, 36), horizon or base line (56, 46, 48, 49) and logical connections between
named elements (46, 21). Although measures of placement showed good agreement
generally in addition, absence, or distortion (38), placing errors (33), a term applied to
placement of the central figure in the middle of the picture, showed much lower
percentage agreement than the other studies (0.56). However, acceptable significance
levels (p<0.05) were reached using Chi Square analysis, and this was further supported
by good reliability for displacements (35). All 4 subcategories of reality were therefore
considered reliable.
Discrimination: From 19 variables tested for discrimination properties, there were 5
significant results between 4 studies, distributed among 3 subcategories. Study 21
reported depressed patients achieved higher logic scores than patients with organic brain
damage and patients with mania, but applied no corrections for unequal numbers in the
groups (5: 10) and did not report the overlap characteristics of the other patients.
Controls were significantly more likely to represent reality and their pictures were more
logical than patients with organic brain damage (21). In support of these findings, there
were no differences in 4 elements of verisimilitude (38) between schizophrenics and
controls; in ground or base line between controls and schizophrenics (56), schizophrenics
and other patients (46, all variables from study 46 in this table were tested under their
own subcategory of 'spatial representation', the results supported the null hypothesis
f0.2 NS). No differences were reported between schizophrenics and controls on
144
omissions, distortions or additions of elements (38), although the same type of departure
from reality (evidence of faulty recall) was more marked in Alzheimer's disease than in
controls (36 or 35). The displacement variable showed significant differences between
left brain damaged patients and normal controls or right brain damaged patients (35), also
between a patient group partitioned 3 ways (33): (a) non retarded schizophrenic from
retarded schizophrenics; (b) profound from other grades of mental retardation; and
between acute and chronic schizophrenia.
Summary: The polarisation of representation of reality and logic between controls and
organic brain damage seems to be supported by findings of no differences between
schizophrenics, other patients and controls on corresponding indices. It is thus
reasonable to suppose that the results for Alzheimer's disease, as it affects the brain, may
share some of the qualities of organic brain damage. Displacement of main images seems
to strongly indicate general abnormality.
Space
Reliability: 11 experimental studies, 2 reliability studies and 1 validity study generated
36 variables which were grouped between two subjective, one objective content
subcategory, and one formal subcategory. There were 6 variables between 6 studies
which gave item reliabilities and only one unreliable variable in the table. Reliable
subcategories were: coverage of the paper (49, 44, 48, 21, 75, 35, 38, 36); relations
between the main elements (3, 35, 61); presence or absence of perspective or indicators
145
(35, 46, 36, 38, 33); and indicators of dimensionality (56, 61, 36, 46, 38). The exclusion
of rotation (21) did not affect the other subcategory variables.
Table 9: reliability statistics and discriminating variables for category of space.
Spacial variables (study no.) % other discriminates patient/ discriminates subgroups of patients
(o) objective (s) subjective (c) content ag't test* nonpatient control
picture space used (f)

(48) 92
(49) 77
(44) 3 .63 NS
(21) 3 .92 NS NS
(38) 2 >.60 NS
empty space (75) 2 .94 depressed **
neglect (35) 2 .84 brain damage** right from left b.damage**
impoverishment (46, composite) 96 Schiz. from patients**
neglect (36) 90 5 .915 Alzheimer's (more) nf
spacial relations (35) (s) 2 .84 brain damage** NS

(3) 3 .89 patients less (nf) depressed pers.dis (nf)
expansive/constrictive (61) 2 .97
presence of perspective (35) (c) (o) 2 .84 brain damage** NS

(46) 96 NS
depth (38) 2 >.60 NS
proportion (36) 90 5 .915 nf
distorted perspective (36) 90 5 .915 nf
perspective elements
building top page (46) 96 NS
size errors (33) 70 4 .62 NS grades ret'n in schizophrenia*
distance small (46) 96 NS
distance systematic (46) 96 NS
foreshortening: all elements, in roads,
progressively in roads, systematically
in roads (46) 96 NS
overlap (35) 2 .84 NS NS
(46) 96 NS
+1 overlap (46) 96 NS
lines overlapping (36) 90 5 .915 nf
organisation of space (46, composite) NS
dimensions (s)
2 dimensional (primitive) (56) 4 Acc. patients * NS
3 dimensional (61) 2 .97
2 sides building (46) 96 NS
2 different angles of building (46) 96 NS
transparencies (38) 2 >.60 NS
rotation (21) 3 NS
birds eye view (36) 90 5 .915 nf
worms eye view (36) 90 5 .915 nf
* - reliability tests: 1 = % agreement; 2 = product moment correlation; 3 = correlation coefficient; 4 = association test Chi sq. or
T; 5 = Kappa; 6 = Anova.
** p<0.01; * p<0.05.
significant results distributed among all 4 subcategories. The subcategory, dimensionality
146
of elements, differentiated controls from mixed patients (56) but not within
schizophrenics/mixed patients (46, 56). The perspective subcategory did not differentiate
between schizophrenics and other patients either (46) or between left/right brain damage
(35) or between schizophrenics with and without mental retardation (33). There were
no differences either, between controls and schizophrenics on depth perspective (38) or
size errors (33) which did distinguish severe mental retardation in schizophrenia from
other grades (33). Brain damaged patients generally (left or right) were distinguishable
from controls by overall perspective but not by strategy (overlap). Patients with brain
damage (35) or personality disorder (3) used less spacial relations than controls. Empty
space, apparently, distinguished depressed patients (75), Alzheimer's patients (36) and
brain damage (35) from controls. Furthermore, study 46 reports, impoverishment in
pictures by schizophrenics compared to other patients though both patient groups were
equally poor against normal children. These results, however, were not picked up by 2
studies which reported that picture space used neither distinguishes between patient
groups of: mania, depressed, organics, schizophrenia and controls (21), schizophrenics
and controls (38).
There seem two obvious sources of confusion: Most significant findings were
from measures of neglect or emptiness (which could be taken to mean incompleteness).
Measures which gave non-significant results as proportions of media coverage were
typical of highly controlled studies, but which used very small group sizes (each group
(21, N=25; 38, N=33) so probably suffer lack of power.
147
Summary: There are unresolved definition ambiguities of the qualities measured.
Neglect measures appear to distinguish patients against controls and schizophrenia from
patients although coverage of paper does not. Mixed patients use more 2 dimensional
space than controls although there are no specific differences in schizophrenia. Patients
with brain damage use less spatial relations than controls and share some perspective
abnormalities of mental retardation, but the qualification mentioned previously in reality
above (study 33), may apply to both mental retardation and brain damage; limitations on
measurements of drawing qualities show that severe retardates make less errors because
there is observably less on the paper, so the utility of this form of measurement may be
compromised.
Energy Table 10: reliability statistics and discriminating variables for Energy.
energy variables (study No.) % other discriminates patient/ discriminates subgroups of patients
energy (21) (c) (s) 3 .60 organic ** depressed from organic**199

(3) 3 .89 patients less (nf) depressed pers. dis. (less) nf
tension (38) 2 >.60 NS
balance of motion (69) 4 Acc. paranoid from non (schiz) *
motion (44) 3 .63 coping strategies schiz.200 (p<0.10)
(48) 97
(49) 77
motion shown thru line (38) (c) (s) 2 >.60 NS

motion in objects (38) 2 >.60 NS
motion shown through colour (38) 2 NS
main subject of picture (c) (o)

energy in self (75) 2 .94 depressed **
energy in family (75) 2 .94 depressed **
human action (46) 96 NS
graphic human action (46) 96 NS
1, 2, 3 buildings, function visible (46) 96 NS
community building (46) 96 NS
good representation bldg function (46) 96 NS
1- reliability tests: 1 = % agreement; 2 = product moment correlation; 3 = correlation coefficient; 4 = association test: Chi
sq. or t; 5 = Kappa; 6 = Anova.
** p<0.01; * p<0.05.
199
control or depressed from organic
200
'integrators' score more than sealed-over' types.
148
Reliability: 7 experimental and 2 reliability studies generated 19 variables which were
grouped between 2 subcategories of subjective and 1 objective subcategory of content
evaluation. There were 3 significant variables independently tested for item reliability
between 3 studies, and only one unreliable variable appeared in the table. Reliable
subcategories were: overall energy (21, 3; 48, 44 in movement, 38 in tension and 69 in
balance of motion); specific energy in the main subjects of the picture (75 in family or self,
46 in action or function); and motion conveyed by form (line and objects), but not by
colour (38).
significant results between 2 subcategories. There was no great concordance of items
within subcategories. Neither specific function of the main picture elements nor human
energy distinguished schizophrenics from other patient groups (46) but human energy
(self or family) did discriminate depressed patients from controls (75), giving support to
the findings of discrimination in global energy ratings between depressed patients,
controls and patients with organic mental disorder (21). There were also indications that
a secondary diagnosis of depression may be discriminable (3). There were no significant
differences in global tension or balance of motion between schizophrenics and controls
(38, 69), but within patient groups, paranoid schizophrenics were distinguished from
other patient groups (69) and schizophrenics who integrated experiences were
distinguished from those who sealed over (44).
149
Summary: The effect which distinguisheddepressed patients from controls and organics
on global energy is supported by the discrimination of depressed patients from controls
on specific human energy. Although there is probably another energy factor which does
not occur under the main elements of the picture which discriminated between patient
groups.
Detail
Table 11: reliability statistics and discriminating variables for category of pictorial detail.
Pictorial detail variables (study No.(s) % other discriminates patient/ discriminates subgroups of patients
omission of detail (33) (c) (o) 63 4 .59 mild from other grades schiz'c
retardation**; schizophreniform from
nuclear schiz*; retardation from non-
ret. schiz'cs. **
missing detail (56) 4 Acc. patients ** NS
presence of detail (75) 2 .94 depressed **
(35) 2 .84 left brain damage** Left brain d. from R. **
(44) 3 .63 schiz. coping groups **
(21) 3 .80 organics ** organics and mania
presence of 14 details: civilised
objects, 2 civ objects, roads, 2 roads,
path, sidewalk, window, windows,
door, garden, nature, relief, vegetation,
shadows (46) 96 NS NS
amount of detail (38) 2 >.60
superfluous detail (c) (o)

(56) 4 Acc. NS NS
(35) 2 .84 NS NS
(36) 90 5 .915 NS
(61) 2 .97
decoration (38) 2 NS
external detail (35) 2 .84 NS NS
words (48) 100
word script (56) 4 v.good NS NS
words on building (46) 96 NS
words (49) 77
extra letters (36) 90 5 .915 NS
** p<0.01; * p<0.05.
Reliability: 10 experimental studies, 2 reliability studies and 1 validity analysis
generated 33 variables which were distributed amongst 2 objective subcategories of
content evaluation. There were 6 items which were individually tested for reliability and
150
one unreliable variable, decoration (38), which may have been confused with other similar
elements. The other items were congruent within their subcategories and gave high overall
reliabilities. Reliable subcategories were: the presence or absence of detail (56, 46, 61, 75,
35, 36, 44, 21, 33) and superfluous detail (48 56 35 46 49 36 61).
significant results which occurred only in the objective presence or absence of details
subcategory. Superfluous detail, which included words was rated universally non
significant by 5 studies and in support, study 46 included in its qualitative report, the
comment that words and microscopia are equally common in children, schizophrenics
and patient controls. All studies measuring global elements found differences. 2 studies
reported within patient group results: between the 'integration' and 'sealing over' coping
strategies of schizophrenia (44), and within 3 partitions of schizophrenic and retarded
subjects (study 33). 4 studies reported results against normal controls: Depression was
discriminated from controls (75) and left brain damage from controls (35). However,
while study 21, supported the brain damage/control difference, their control scores
overlapped those of mania, and did not discriminate depression or schizophrenia on this
index. The solution probably lies in the results of the fourth study which supports most
results, that mixed psychiatric patients were discriminable from normal controls (56), but
not schizophrenia, so, the findings of no differences in 75 counted detail elements
between schizophrenics and other patients (46) are also supported.
151
Summary: Striking variation in global subjective evaluation of detail indicates that what
is measured is not detail, but some element of completeness. The variety of patient
groups distinguished, including the patient/non-patient distinction, indicate that missing
detail is a good predictor of patient status, although brain damage patients were right/left
differentiable, but right scores overlapped those of controls.
Complexity
Table 12: reliability statistics and discriminating variables for category of complexity.
complexity/differentiation variables % other discriminates patient/ discriminates subgroups of patients

(study no.) (o) objective (s) subjective ag't test1 nonpatient control (nf= no
(c) content (f) form (1-6) rel'y figures)
regression/complexity (c) (s)

simplification (35) 2 .84 brain damage** left from r. brain damage**
childlike (56) 4 poor
developmental (21) 3 .88 organic or mania** depressed from organic **
simple/complex (38) 2 >.60 NS
differentiation (46, composite) schiz's from patients **
differentiation (c) (o) NS

variation in building detail (46) 96 NS
complexity in dwelling (46) 96
difference in: structure of building - 2,

or 3 types; dwellings, 2 different or NS
personalised; heights, widths, doors, 96
number or kind of windows (46)
** p<0.01; * p<0.05.
Reliability: 5 experimental studies generated 16 variables which were grouped between
2 subcategories of subjective and objective content evaluation. 2 variables were rated
independently for reliability and one was found unreliable, childlike elements (56, poor),
the definition of which was probably ambiguous. The other elements relate to regression
as simple or complex (35, 38) or developmental (21). The variable differentiation is a
global composite of elements from study 46.
152
Discrimination: From 16 variables tested for discrimination properties there were 2
significant results which both fell into the global regression/complexity subcategory.
Controls were differentiated from brain damage (35), which result was also supported by
study 21, differentiatingbrain damage from 4 patient and a control group but which found
mania scores overlapped the brain damage (21). Depression was also differentiated from
brain damage in the same study but not schizophrenia. There were no differences
between schizophrenics and controls (38) in another study and no differences in any of
the elemental scores for differentiation between schizophrenia and other patients (46).
Summary: There were global but not elemental significant differences in elements for
schizophrenia and other patients. This indicates an additive effect which should be
differentiable by logistic regression. Other global elements differentiated brain damage
from controls.
Control
Table 13: reliability statistics and discriminating variables for category of control.
somatic signs (study no.) % other discriminates patient/ discriminates subgroups

(o) objective (s) subjective (c) content ag't test1 nonpatient control of patients
perseveration (35) (c) (s) 2 .84 brain damage** NS

(21) 3 .54 NS
(33) NS 4 NS
pers. in line/form (36) 90 5 .915 NS
pers. in theme (36) 90 5 .915 Alzheimer's (more) nf.
** p<0.01; * p<0.05.
153
Reliability: Perseveration is a non-art term from diagnostic criteria. It was rated by 4
studies; the two with good reliability gave composite test scores (35), by structure and
theme (36). Another 2 studies used individual item ratings which were unreliable.
Perseveration is not an objective definition because a subjective decision of intent is
required to rate it. This category was considered unreliable for the remaining variables.
Summary: There are indications of effect for studies with consistent definitions of
terms, in brain damage and controls in 2 studies but there are questions of content validity
which have not yet been addressed.
Composition
Table 14: reliability statistics and discriminating variables for category of composition.
composition variables (study No.) % other discriminates patient/ discriminates subgroups of

(o) objective (s) subjective (c) content ag't test1 nonpatient control (nf= no patients
(f) form (1-6) rel'y figures)
orientation of picture (35) (f) 2 .94 NS NS

tilt (48) 99
(49) 77
centre of focus (69) (f) 4 Acc. NS

dominance of image (38) 2 >.60 NS
top/bottom (69) 4 Acc. NS
left/right (69) 4 Acc. NS
right/left/top/bottom (36) 90 5 .915 Alzheimer's (more)nf
structural relations (c) (s)

rhythm (38) 2 >.60 NS
serial elements used structurally (69) 4 NS
relation of pic to frame (38) 2 NS
integration (21) (c) (s) 3 .94 organic/manic ** organic from manic **

(48) 94
(49) 77
compositional integration (3) 3 .80 patients (less) nf. depressed/non-d pers.dis(nf)
general integration (3) 3 .91 patients (less) nf. depressed/non-d pers.dis(nf)
unity (38) 2 NS
organisation (75) 2 .94 depressed **
disorganisation (33) 4 NS
incoherence (56) 4 Acc. NS NS
fragmented gestalt (36) 90 5 .915 nf
disorganisation (36, composite) Alzheimer's **
balance (38) (c) (o) 2 >.60 NS

symmetrical balance (38) 2 >.60 NS
equilibrium (69) 4 Acc. NS
imbalance (56) 4 v.good patients more ** NS
154
** p<0.01; * p<0.05.
were grouped among 2 subjective and 1 objective content subcategories and 2
subcategories of form. 13 items were individually rated for reliability and there were 4
unreliable variables distributed among the 2 subjective subcategories. Reliable
subcategories were: orientation of the picture, location of centre of focus and balance.
Two variables in the structural relations subcategory (69, serial elements and 38, relation
of the picture to the frame) were unreliable. Although rhythm reached >.60 correlation
between 2 raters, this does not necessarily indicate good agreement, and since it was close
to and at odds with the definition from study 69, which used 3 raters, this subcategory
was considered unreliable. 9 studies produced some measure of organisation of the
picture (or integration). The positive statement (organisation or integration) was
reliably rated by 5 studies (75, 21, 3, 48, 49), and the result was supported in its
opposite, fragmented gestalt (36), and related form, incoherence (56). 6 from 8 terms
were independently rated so this subcategory is considered reliable. The unreliability of
disorganisation (33) and unity (38) probably reflect definition problems.
Discrimination: From 14 reliable variables distributed amongst 4 reliable subcategories,
tested for discrimination properties, there were 4 significant results. There were no
differences in schizophrenics and controls in centre of focus (38) or incoherence (38) or
in centre of focus or incoherence or balance (69) between patient groups, but there were
contradictory findings of no significant difference in 2 measures of balance between
schizophrenics and controls (38) and in imbalance by mixed psychiatric patients
155
(including schizophrenics) against controls (56). Both studies are equally well controlled,
but study 38 used very small numbers and is therefore open to type 2 error, the authors
qualitatively note that schizophrenics' pictures frequently show less balance and
symmetry, although this did not show statistically. This review therefore accepts the
results from study 56. Depression was distinguished from controls on organisation (75),
but not by study 21, which distinguished controls, organics and mania amongst 2 other
patient groups (depression and schizophrenia) (21). The findings of no significance
between schizophrenia and other patients, and mixed patients against controls tends to
support both results (21, 75) by suggesting overlaps between certain groups (especially
depression, schizophrenia and controls) and reduces the chance of the confusion between
a diagnostic and a patient effect. Study 3 noted but did not test less compositional and
general integration in pictures by patients with personality disorder than controls, and
study 36 used a composite variable organisation, encompassing its derivatives listed in
this table, which distinguished patients with Alzheimer's disease from controls.
Summary: The composition category is generally non discriminatory for schizophrenia
although there are indications of lack of balanced work. The most discriminable diagnosis
was Alzheimer's or brain damage on central variables and organisational, particularly
integration for brain damage. Depression also distinguished integration, but there were
indications depressed scores might overlap with schizophrenia.
Summary of reliability study
156
There were more reliable elements than unreliable, but the studies examined here do not
represent the major part of the literature in their clear, and mostly objective, definitions
of search criteria. Only 27% of the controlled test situations are represented here and
1.8% from the case studies. There were 15 formal and 37 content categories, split
between 21 subjective and 16 objective decisions. 5 subcategories were found to be
unreliable, all of them subjective.
Unreliable elements of pictures seemed to predominate in interpretation, fine
distinctions between two similar elements and global judgements. Raters could not
identify symbols, themes or the continuity of themes between pictures, whether several
ideas were expressed, differentiate ordinary from bizarre content, identify childlike
elements, incest markers or self images or use their own criteria for patient versus non
patient status judgements. They could not describe a painting, whether it was unified,
organised or coherent, nor decide whether elements were used structurally, agree on care
or craftsmanship (although they recognised quality). Detail decisions were inconsistent:
although raters could identify length of lines they could not tell if particular types
predominated, whether lines were jagged or used for fill in, whether shapes were more
regular than other shapes, amount of single colours, whether colours were thick or pure
(although they could differentiate watery or mixed colour) and the consistency or
intensity of colour. They did not agree on errors of size and placing, on omission, lack
of detail or decoration, perseveration, whether motion was conveyed by colour, line by
blotches or whether dabs were used for form, mass, texture or decoration (although they
could for blotches).
157
The studies are difficult to sum up collectively in any meaningful way as each
study examines a different selection of qualities, which makes them difficult to compare
or replicate and the final interpretation comes as a synthesis of the study. Some of the
definitions seem unclear, especially those which deal with global categories and some
studies dealing with objective qualities provide a huge unwieldy instrument where
alternative terms are difficult to differentiate201. Most conspicuously, there are
considerable problems as to the authors' use of statistics (which will be discussed next).
Mostly, the statistical bases on which the reliability is calculated contain serious
methodological flaws.
Measures of agreement
Agreement between categorical assessments compares the ability of different raters to
classify subjects into one of several groups. The reason studies use 2 or more raters is
usually to see if the raters agree well enough for one to replace another or for raters to be
used interchangeably.One consideration which would improve the quality of some of the
studies reported here would be the definition of what is meant by agreement, also the
degree of agreement.
Most reported measures of reliability gave an 'overall agreement' statistic, which
took the mean of the summed agreement percentages for each element. It is not possible,
of course, in many cases, to measure these quantities directly and the decision on what
constitutes good enough agreement must lie with the clinical conditions. However, 6
201
W.L. Wadlington and H.J. McWhinnie (1973) The development of a rating scale for the study of formal
aesthetic qualities in the paintings of mental patients, Arts in Psychotherapy, V.1(3-4):210-20.
158
studies did not even quote figures, 4 because they were too poor (50, 12, 10, 14). The
other 3 reported categories of 'very good' to 'acceptable' agreement (9, 11, 39; study 39
reported that 3 raters own criteria judgements of patient status, from 200 paintings was
10% better than chance but gives no other figures, although we know (study 14) that own
criteria judgements are based on widely differing individual values. Significant agreement
is reported, but with no indication of how this was arrived at). No study justified their
cut off points for 'good agreement' and these varied considerably from study to study.
Worse, perhaps than no figures, a good percentage of these reliability studies are
mis-analysed202. In particular, the correlation between the values reported by individual
raters or groups of raters is calculated in 9 studies (75, 35, 37, 38, 31, 10, 44, 21, 3), with
a high value of r interpreted as an indication of good agreement. Correlation is an
inappropriate analysis, firstly because the correlation coefficient is a measure of the
strength of linear association between two variables, not agreement. Agreement is
assessed directly. Secondly, there may be a high degree of correlation when the agreement
is clinically poor, as recognised by the actions of the authors of study 37, who used 7
terms with correlations below 0.31 because agreement was clinically high (but didn't drop
any clinically low ones). A high value of r can be obtained because, as for studies 3, 37,
38 and 31, there is large variation between subjects. The authors of study 37/38
recognised large differences between subjects in 37. They used a much more rigidly
defined group of subjects for study 38 and a higher cut off point for the correlation, to
202
Much of the information here is quoted from D.G. Altman (1994) Practical Statistics for Medical
Research, (4th reprint, original 1991), London: Chapman Hall.
159
indicate greater agreement (even though their earlier study had recognised the correlation
was not a good indicator of good agreement). It is clearly not reasonable to assess
agreement by a statistical method that is highly sensitive to the choice of the sample of
subjects. Similarly a famous and well quoted study203 (33) incorrectly judged agreement
by a _2 test which is also a test of association.
Another incorrect analysis appears in a well quoted study using the comparison
of means by a paired t-test, which is a hypothesis test (69). Similarly Study 56204 used
60 judges in groups of 10, to rate 5 pictures and compared the variation between scores
of 0-10 agreements between groups, using Friedman's Anova, which although it is a
category ranking test, is yet another test of association. They found few significant
differences and drew up a table of poor to good agreement categories.
Methods cannot be deduced to agree well because they are not significantly
different. A high scatter of differences may well lead to a crucial difference in means
(bias) being non significant. Using this approach, worse agreement decreases the chance
of finding a significant difference and so increases the chance that the methods will appear
to agree. Despite the authors' claims of good statistical agreement in study 69, most of
the discussion reported their difficulties with the measure seriously affected their study
results and recommended a shorter form for better reliability.
The simplest approach is to see how many exact agreements exist. 7 studies
reported percentage agreement by tables of elements or overall agreement. The
203
S.R. Kay (1978) Qualitative differention in human figure drawings according to schizophrenic subtype,
Perceptual Motor Skills, V.47:923-32.
204
S. Russell Lacy et al. (1979) An experimental study of pictures produced by acute schizophrenics
160
percentage agreement figures look reasonably high but can be unreliable when more raters
are added (see for example, study 48 and 49: 95.7% agreement for 2 raters decreased to
77% for 29; studies 58 and 59: 94.3% agreement for 2 raters decreased to 61% for 10;
studies 9 and 10: 'good' agreement for 2 raters decreased to 'poor' agreement for 4). Study
46 and study 61 report figures of '0.96' and '0.97' respectively, which, it is assumed,
represents percentage agreement as there is no other information.
The DDS205 merits some consideration, under this heading, as one of few tests
which attempt to validate, reliably rate their instrument and encourage replications.
Described as a "standardised evaluation supported by extensive research"206, only 3
interrater studies have been included in this analysis: study 48207 reports agreement
scores from 77-100% over 23 categories, giving 95.7% overall after "2 months training"
of the 2 main authors rating 30 sets of drawings by undescribed subjects. Study 49
reports only 77% agreement between 29 naive raters performing the same measurements.
Study 52 reports 96% agreement between raters of 4 details in tree drawings, by 30
patients with post traumatic dissociative disorder and 30 controls, taken from the DDS
rating guide and protocol. Other studies used peculiar methods and were not included in
this analysis.
subjects British J. Psychiatry, V.134:195-200.

205
Diagnostic Drawing Series, Cohen et al (1988) op.cit.
206
B.M. Cohen, A. Mills, A.K. Kijak (1994) An Introduction to the DDS: a standardized tool for
diagnostic and clinical use, Art Therapy, V.11(2):105-10.
207
Mills et al (1993) Reliability and Validity studies, op.cit.
161
Two weaknesses lie in the simple calculation of agreement; there is no account of
where in the table the agreement was and secondly we would expect some agreement
between raters by chance. A more reasonable answer is obtained by considering
agreement in excess of the amount by chance, which is only attempted by one study (39),
and lacks other figures. The best approach to this type of problem is that adopted by
studies 44 and 36, the kappa statistic, which may be interpreted as the chance corrected
proportional agreement, but it is important to show the raw data (which they don't). In
support of this statement, Neale's application of the DDS to children208, found a much
lower level of reliability than that reported by Mills209: only 12 variables reached
significance using the Kappa measure of agreement between 2 raters.
Conclusion
• Generally, specific decisions are more reliable than global.
• Content decisions were most reliable where objective, because they were more specific
and probably easier to define and rate. Most categories contained subjective decisions
and largely where these were global they were unreliable. This is particularly exemplified
in the category of Quality, where personal judgement was not reliable because experience
of art was clearly an influence on aesthetic appeal. Global subjective decisions became
more reliable when not referenced to the image, but suspicions must arise that the rating
208
E.L. Neale (1994) The Children's DDS, Art Therapy, V.11(2):119-26, but not included in this review
because the subjects were children.
209
Mills et al. (1993) op.cit.
162
has then little to do with the artwork itself. The tables show discriminatory properties
for drawing areas.
• Alzheimer's disease and brain damage tended to be discriminable on similar indices in
7/13 categories: omitting more essentials, poor quality, bizarre content, poor reality and
logic and poor integration, although brain damage was particularly distinguishable in
drawing angles, so it is reasonable to suppose they share similar qualities which are
particularly apparent in their artwork.
• Normal controls were also discriminable in 8/10 categories, generally supplying more
complete paintings without morbid content.
• Schizophrenics or psychotics paintings were discriminable from controls through empty
space in the picture, on their inclusion of emotional indicators (which two characteristics
also distinguished within types), and in global measurement of regression.
• It is also worth noting that against all commonly believed theory, emotional indicators
drawn as body details did not distinguish sex abuse, but thought disorder.
This organisation of the literature has helped to distinguish reliable categories of
art variables from non-reliable by contrasting similar variables measured by different
studies. However, the observed validity of the drawing procedure is delimited by the
clinical relevance and reliability of the selected drawing features. There are limitations to
those studies; they use small numbers, their interpretation of the figures is questionable,
by and large they are unreplicated, and those few which are replicated seem to produce
inconsistent results. This is consistent with the overall findings reported at the beginning
of this chapter. It is now necessary to further investigate the utility of the classifications
163
of drawing areas and to quantify whether reported discriminations of patients are
clinically meaningful and experimentally sound.
164
Chapter 3: Positive Thinking: what are the common
psychiatric characteristics of paintings?
Chapter 3 summarises the review to identify the central importance of developing
systematic, content-free assessments of psychiatric patients' paintings.
Firstly the findings from the literature review showed the kinds of measurement
which had been employed and had the best repeatability for a suitable test. These
selected papers will now be subjected to a further analysis designed to make some sense
of their contradictions and put them on an equal footing, so as to find out what kind of
effects to expect. Then, the development of a novel instrument (the DAPA) for such
assessments is presented.
Meta Analysis of reliable studies identified by the literature review
Analysis of tabulated categories and variables from the empirical literature was performed
in 2 ways:
1. The reliability and the validity of this classification system was qualitatively
assessed in Chapter 2, by discussion and comparison between all studies on
similar variables. This process of simplifying and displaying common themes
was exploratory.
2. A meta analysis was performed on studies that conformed to the minimum
scientific criteria for quantitative work to complement the discursive assessment.
165
Is Meta Analysis appropriate for this literature
The discursive summary was not as informative as it might have been either with respect
to summarised significance levels or with respect to summarised category tables, because
it reflected the conclusions of the studies, which tend to provide equivocal answers to
imprecise questions. Research environments are difficult to control, common definitions
are not always available nor accepted, and methods, techniques and sampling
characteristics vary from study to study. This situation is made more difficult by the
proliferation of studies that address common research questions (e.g. is there a difference
between pictures by abnormal groups and pictures by normal controls), but do not report
essentials such as definitions or reliability of variables, sample sizes, statistical methods
(many report 'significant'results, but not the number of tests, which variables were tested
and how many dropped), or even fully report the characteristics of their experimental
group. Furthermore their literature reviews are notorious for depending on the subjective
judgments, preferences and biases of the reviewers. Conflicting interpretation of the
evidence is common and consistent210.
There is no lack of literature but the study area shows what Rosenthal211 calls
poor cumulation, lack of orderly development building directly on the older work. Each
study seems to replicate the same process to produce conflicting results which can lead
210
See for instance: E. Ulman and B.I. Levy (1974) An Experimental Approach to the Judgement of
Psychopathology from Paintings, Am. J. Art Therapy, V.8:3-12 (reprinted 1975, 1984 and 1992) although
their results showed that health workers scored no differently and some people with no experience of
psychiatric paintings were more accurate, they concluded that diagnostic classification of pictures was a
skill which could be taught and this opinion has been related through the later literature as a proven fact.
211
Robert Rosenthal (1984), Meta Analytic Procedures for Social Research, Beverley Hills, CA: Sage, p.9-
10.
166
to no acceptable answers but conclude with calls for further research. This literature,
despite its heavy emphasis on qualitative reports, is an appropriate candidate for meta-
analysis.
Meta analysis is the application of statistical procedures to collections of
empirical findings from individual studies for the purpose of integrating, synthesizing and
making sense of them. A common metric aggregates diverse statistics across studies, and
standardised methods help to produce an unbiased assessment of the reliability of a
variable measured across studies. It addresses five methodological difficulties which have
been identified with traditional literature reviews212
(1) selective inclusion of studies often based on the reviewer's impressionistic view of the
quality of the study;
(2) differential subjective weighting of studies in the interpretation of a set of findings;
(3) misleading interpretations of study findings;
(4) failure to examine characteristics of the studies as potential explanations for disparate
or consistent results across studies;
(5) failure to examine moderating variables in the relationship.
Selection of studies for Meta-analysis
The first criterion for analysis of absolute differences between groups was that terms
should be reliable. From the pool of 51 controlled studies, 35 employed no assessment
or indication of reliability, therefore any bias would be overwhelming. Because weighting
212
Summarised by Frederic M. Wolf (1986), Meta Analysis: quantitative methods for research synthesis,
Beverley Hills, CA: Sage, p.10.
167
techniques which compensate for unreliability of variables213 require information which
is often unavailable from these studies, and because there was considerable variability in
definition of terms, I have decided that this technique would require too many estimations
of quantities which are not predictable in this range of studies and therefore be unreliable
and inappropriate214.
Method of selection of studies
31 studies from the pool of controlled studies, series uncontrolled studies, validity and
reliability studies employed more than one rater. The numbers assigned to them in
Chapter 2215 were retained through the further elimination procedures and eventual
analysis. 6 studies (11, 12, 39, 43, 65, 66) were eliminated because they reported 'hit
rates' rather than reliability between raters: that is, they compared the rating with the
actual diagnostic group, but not between raters. 25 studies were retained for further
analysis.
Replication studies which tested the reliability of former studies and proved
them unreliable (9, 14, 50, 10, 37) were eliminated and those which did not compare
groups on diagnosis (58, 59, 48, 49, 31, 20, 61), together with 2 studies which included
no figures for analysis (3, 52; study 3 did provide some figures for suicide groups of
patients with personality disorder against non-suicides, but gave no indication of the
213
J.E. Hunter, F.L. Schmidt and G.B. Jackson (1982), Meta Analysis: cumulating research findings
across studies, Beverley Hills, CA: Sage.
214
Rosenthal (1984) also considers this procedure too burdensome.
215
see Table of Authorities for numbers assigned to all control, validity and reliability studies, Appendix
3. Studies selected for meta analysis are marked (M).
168
range of tests administered. They also presented figures for patients cross classified by
diagnosis, but they gave no group numbers or indication of the range of tests performed).
This left a total of 11 studies (69, 56, 75, 35, 46, 44, 21, 57, 38, 36, 33) for meta analysis
of variables between group categories of measurable drawing elements.
There were 5 further departures from the tabulated discursive elements between
these 11 studies:
1. Unreliable variables were removed from the analysis.
2. Non significant results were included in the analysis. The procedure for
studies which did not quote figures for non-significant variables (studies
38, 69, 56216, 35, and 44) was to assume a significance value of 1.000217
(Study 38 did note frequent signs and these are marked and noted in the
table).
3. Study 44 reported p levels only for their positive results, and these were
converted to Z scores and then into effect sizes, along with results from
tests other than Chi-square or t-tests, which were converted directly to
effect sizes218.
4. Study 36 and 46 listed but did not test individual variables (they were
grouped and discussed with the other tests under the tabulated areas of
216
Study 56 also reported significant results from other tests on covered space, yellow, blending and
variety of colour, but gave no reliability figures or indication of the range of tests which proved
nonsignificant, so these results were not included.
217
Recommended by Rosenthal (1984) op.cit. p.33.
218
Rosenthal (1984) op.cit. Recommended procedure to convert t or _2 to effect size - using broad theory:
Test of = Size of x Size of p.20-21 gives examples of relationships and equations.
significance Effect Study
169
drawing evaluation with comments from the studies where frequent and
significant predictors were indicated). Tests performed are included here
under category headings as a total or category score. Study 57 provided
only a total score which was included as a single variable in the analysis.
5. Each study tested differences between patients and normal controls or
between a defined group of patients and another group of patient
controls, although there were some which tested both. In order to assess
differences between the effect size of patient/nonpatient and
patient/patient, each result was calculated separately (since there were
two tests done).
This analysis was not intended as a confirmatory statement, but as a synthesis and an
integration of the tabulated information which tried to assess the reliability of research
findings across several studies. It takes into account 4 criticisms of meta analyses
identified by Glass219:
1. No logical comparison can be made between dissimilar techniques
of measurement and operational definitions.
Tabulation of the information from several studies into similar areas goes some way
towards analogising definitions of variables and subjects from studies which used
different measuring techniques, that were previously too dissimilar in scope to compare
equally.
219
Gene V. Glass, Barry McGraw, Mary L. Smith (1981) Meta Analysis in Social Research, Beverley
Hills, CA: Sage.
170
2. Results are uninterpretable between studies using poor designs and
those with good.
Rather than making statistical compensation for poor studies, only studies which used
reliability measures for their terms were used. Design otherwise was equally poor.
3. Published research is biased in favour of significant findings
because nonsignificant findings are rarely published: the 'File
Drawer Problem'.220
Checks were made on unpublished controlled studies through private correspondence;
there is every reason to believe that unknown unpublished studies of other types than
the two which are used in this review would show similar conflicting viewpoints, poor
design and statistical rigour as those published which are subject to peer review. There
does not seem to be a lack of published nonsignificant findings, so there may be little bias
in this field. A test was applied following procedures from Wolf (1986)221 which
estimated how many additional studies with nonsignificant results would be necessary
to reverse the conclusion drawn, providing some estimate of the robustness and validity
of the findings.
4. Multiple results used from the same study bias or invalidate the
meta analysis and make the results appear more reliable than they
really are because they are not independent.
220
Not everyone is agreed on whether this point exists: a recent discussion of the various issues as to how
to estimate the proportion of conflicting evidence, in M.T. Bradley, R.D. Gupta (1997), Estimating the
Effect of the File Drawer Problem in Meta Analysis, Perceptual and Motor Skills, V.65(2_:719-22. I
followed Rosenthal's recommended checks (1984) op.cit. p.107-110.
221
Wolf (1986) Meta Analysis, op.cit. The 'fail-safe N' p.37-39, which was simpler than the calculation
from Rosenthal.
171
There are few answers to this criticism which do not lead to possible inferential errors,
and it is a question of judgement in using a procedure which is appropriate for the sample
and reflects the classification and variety of variables encompassed.
Wolf222 describes a method using only the most significant results from each
study, but this technique lends itself to type I error. Rosenthal's223 adaption of the
Stouffer method, i.e. averaging between significance levels transformed to z-scores to
produce one variable per study, are clearly not appropriate here because the standard
deviations and direction of significance of studies must be similar, and the variables non-
correlated, so that they can be weighted equally224. Furthermore, although 4 from 11
studies show a very high effect size aggregated in this way and 3 more show a small to
medium effect, 3 studies did not actually report the large numbers of non-significant
statistics, of which their study mostly consisted, and therefore estimates of p=1 would
probably contribute to artificially low averages resulting in a much too conservative
estimate.
Kulik, Rosenthal and others recommend using separate analyses for each variable,
when each study uses several of the same type of variables. There were two main
problems which made this type of analysis difficult in this study: (1) There were tests
between patients and normal controls and between patients and patient controls; and (2)
there was no way of knowing how similar variables with similar terms, which were
tabulated together, actually were. Few studies contributed variables to most of the
222
Wolf (1986) op.cit. p.46.
223
Rosenthal (1984) op.cit. p.72.
172
tabulated drawing areas, so some studies measured areas completely neglected by others
and there were no tables to which all studies contributed. The partition into tabulated
areas was useful for the qualitative part of the analysis, but more than one variable from
most studies described aspects within the same area, and there were no grounds to
assume these variables were correlated.
Glass et al.225 used multiple tests from the same studies in a single analysis, but
this technique is not popular226, since multiple results are said to inflate the sample size
and effects beyond the number of individual studies227 and increase the power of the
meta-analysis. The studies analysed here though were unrepresentative of the majority
of studies in this field, but their variables are typical of the kind of constructs usually
employed.
The practical answer, to eliminate the variables that did not fit clearly affects the
type of study included and the results; if the results within a study are averaged, it
precludes analytical examination of differences and similarities for different categories of
outcome and tends to increase the chance of type I error228. Furthermore, meta analytic
methods have recently been criticised on this basis, that treatment trials pay less
224
Rosenthal (1984) op.cit. p.33; Wolf (1986) op.cit. p.36-37.
225
M. Smith & G. Glass, (1980) Meta Analysis of research on class size and its relationship to attitudes
and instruction, Am. Educational Research J., V.17:419-33; Glass et al., (1981) op.cit.
226
for example: Rosenthal, (1984) op.cit.; Wolf (1986) op.cit.
227
J. Kulik (1983), Review of G.V. Glass et al. (1981) op.cit. Evaluation News, V.4:101-5, but the studies
represented here comprise only a tiny proportion of the field.
228
M. Strube (1985) Combining and comparing significance levels from non-independent hypothesis tests,
Psychological Bulletin V.97:334-341.
173
attention to overall effect sizes than the difference between individual studies229. The
complex issue of which set of statistics to use is largely a matter of judging the structure
of the data and applying as fair a method as possible230. This problem was dealt with
empirically by coding the characteristics for each study and comparing the different
partitions of the variables231 as tabulated in the qualitative analysis.
Tables were prepared using 2 techniques:
(1) all variables were included to produce a single aggregated case for each
experimental group in the analysis;
(2) the identified tabulated areas were compared on effect size and subsets of the
most significant tables, which retained all studies in the analysis were aggregated
for each type of control group;
Other criticisms focus on interaction effects, of which 2 are taken into account in this
analysis; small sample sizes and weighting for size of study232.
There were 4 questions to be answered:
• Is the art-test a discriminable dimension for psychiatric diagnosis for (1) patients
from non-patients; and (2) within patient groups.
229
David Healy (1998), Commentary: meta analysis of trails comparing anti-depressants with active
placebos, British J. Psychiatry, V.17:232-4; David Sohn (1997), Questions for meta analysis,
Psychological Reports, V.81(1):3-15.
230
R. Rosenthal (1998) Meta analysis: concepts, corollaries and controversies, in J.G. Adair and D.
Bellanger (eds.) Advances in Psychological Science, V.1:371-384.
231
Rosenthal (1984) op.cit; Wolf (1986) op.cit. and using procedures for calculation from Carol Taylor
Fitzgibbon and Lynn Lyons Morris (1987), How to Analyse Data, Beverley Hills, CA: Sage, Chapter 7.
Meta Analysis pp.132-145.
232
The major criticism of bias in meta analyses of treatment methods, Wolf (1986) op.cit.
174
• Do different variables show agreement in effect sizes? and if not: (3) which
drawing area showed greater effect; and (4) was there a greater effect for form or
content, objective or subjective variables?
Statistical Procedure
Mathematical procedures were facilitated by the use of SPSS, version 4 for DOS.
Treatment of the data
• Effect sizes (_) were calculated for each variable from z scores, Chi-square or t-
tests as described, between patient/normal controls and between patient/patient
controls from the results given in the papers. Cohen's d,233 the usual statistic was
adopted throughout, with a confidence interval of 95% to indicate a significant
relationship, if zero was not encompassed, at the 0.05 level.
• All reliable variables were included to produce a single aggregated case for each
drawing area according to control group (1) patient/nonpatient and (2)
patient/patient;
• Effect sizes of the identified tablulated drawing areas were aggregated and
compared between patient/nonpatient and patient/patient controls and subsets
of the most significant tables, which retained all studies in the analysis were also
compared;
• Form and content areas were compared on aggregation of effect size as were
subjective and objective areas.
233
J. Cohen (1977) Statistical Power Analyses for the Behavioral Sciences, New York: Ac.Press, p.20,
methods described in Wolf (1986) op.cit.
175
The 'File Drawer Problem' (refer back to [3] criticisms of meta-analysis), was dealt with
in the manner recommended by Wolf (1986) using Orwin's (1983) fail-safe N234, selecting
d=0.2 (small effect) as the criterion value. This provided an estimate of the number of
variables necessary to reverse the conclusion of a significant relationship and thus of the
robustness of the validity of the findings.
There were 2 compensations made:
(1) The Hedges and Olkin235 adjustment for small sample sizes, which is appropriate
since some groups were under 10 members;
(2) the weighted _ (wd) technique236 which produces an unbiased estimate of effect size
for the corrected group sizes.
Validity of drawing area Classification
The usual procedure to test the validity of my assignment of variables to the
drawing area categories would be a test of equivalence of proportion to indicate the
homogeneity of effect size for each variable and their relation237. However, this was
inappropriate here because the vast majority of the non-significant results were not
available, so the assumption of p=1 creates a false disparity between the significant and
non-significant findings, imposing hetereogeneity.
234
using Wolf's (1986) op.cit. p.39, suggestion from Orwin (1983) fail-safe N for the average effect size
that can be obtained, selecting d=0.2 (small effect) as the criterion value:
Nfs. = No. of variables with an effect size <0.2(_ - 0.2/0.2).
235
L.V. Hedges and I. Olkin (1985) Statistical methods for meta analysis, New York: Ac. Press,
(correction=1-3/4(n1+n2)-1)
236
from Wolf (1986) op.cit., p.41 for calculation and explanation (_ = sum(wd)/sum(w)).
237
(_2 = sum(w(d-_)) from Wolf (1986) op.cit. p.45.
176
Results
Row 1 of Table 1 presents the results of an aggregated analysis of the total number of
variables included in the analysis which related to performance by patients against normal
controls and row 2 against patient controls. It can be seen that the confidence levels do
not encompass zero, so we can assume a significance level beyond chance expectation
(p<0.05). Effect sizes are respectively 0.36 and 0.32; above small but below medium
effect238. this points towards a similar small to medium significant effect for
discrimination of patient art from that of controls, either patient or normal, shown in row
3.
Table 1: Results of the aggregated combination of all variables from tabulated areas for
patients and any type of control.
ES (_) LConf UConf Nfs
Patients/normal 0.3604 0.2987 0.4220 92

controls
Patients/patient 0.3166 0.2604 0.3728 59

controls
All types of 0.3365 0.2950 0.3780 148

control
ES Effect size (weighted _)
Lconf/Uconf Lower/Upper confidence limit for _.
Nfs No. of non-significant extra variables needed to reverse significance of _.
Table 2 shows the aggregated effect sizes of the individual study variables grouped by
drawing area; the best set of tables for patient/normal control and patient/patient control
are indicated by bold type, in column ES1 and column ES2 respectively.
238
Using Ogwin's (1983) recommendation of Cohen's (1977) suggestion of small effect (_=0.2); medium
177
Table 2. All variables for 11 studies from the tabulated 15 different areas of drawing
measurement.
ES1: Effect size for ES2: Effect size for patient/patient

patient/normal controls controls (confidence intervals)
Drawing (confidence intervals) and p values.
Area239 and p values.
1 0.0000 (-.2922; 0.2922) NS 0.3598 (0.1849; 0.5348) p<0.05

2* 0.8795 (0.6362; 1.1228) p<0.05 0.4202 (0.2141; 0.6264) p<0.05
3 0.8407 (0.6404; 1.0411) p<0.05 0.0000 (-.5061; 0.5061) NS240
4 0.3267 (0.0637; 0.5898) p<0.05 0.2562 (-.1620; 0.6744) NS
5 0.0000 (-.1664; 0.1664) NS 0.3369 (0.2146; 0.4591) p<0.05
6 0.0909 (-.1255; 0.3073) NS 0.1181 (-.1286; 0.3648) NS
7 0.1636 (-.0529; 0.3801) NS 0.3788 (0.1451; 0.6126) p<0.05
8 0.0191 (-.2288; 0.2671) NS 0.3870 (0.2001; 0.5739) p<0.05
9* 0.3664 (0.1481; 0.5847) p<0.05 0.2323 (0.0808; 0.3839) p<0.05
10* 0.5907 (0.2998; 0.8816) p<0.05 0.7699 (0.2529; 1.2869) p<0.05
11* 0.3128 (0.1219; 0.5038) p<0.05 0.4196 (0.2607; 0.5782) p<0.05
12 0.0000 (-.9240; 0.9240) NS 0.6615 (0.2834; 1.0395) p<0.05
13 0.6700 (0.0736; 1.2664) p<0.05 0.0000 (-.5893; 0.5893) NS
14 0.4586 (0.2733; 0.6439) p<0.05 0.0257 (-.1998; 0.2512) NS
15 1.4523 (1.0740; 1.8307) p<0.05 0.0000 (-.4762; 0.4762) NS
There were differences between patient's performance against normal controls and against
patient controls on particular variables. 4 variables overlap both groups (indicated with
(*) on drawing areas: narrative or emotional content, covered space or perspectival space,
level of energy or motion, level of drawing detail). These four areas contained variables
from all studies except one, whose variables occurred only in area 3 (body details). Shape
was non-significant for both groups.
There were two discrete findings:
(1) For variables discriminating patients from controls but not between patient groups;
patients used - fewer body details, lower quality of drawing, less control of the media,
they composed their pictures less aesthetically and had lower overall scores.
effect (_=0.5); and large effect (_=0.8) - from Wolf (1986) op.cit.
239
Drawing Area: 1. Thematic; 2. Content; 3. Body detail; 4. Quality; 5. Line; 6. Shape; 7. Colour; 8.
Reality; 9. Space; 10. Energy; 11. Detail; 12. Complexity; 13. Control; 14. Composition; 15. Overall.
240
Table 3 contained a variable from a study which did not appear in the other tables so had to be included
178
(2) For variables discriminating between patient groups but not between patients and
controls, diagnosed groups of psychiatric patients differed in: thematic content or subject
of the picture; used less or different qualities of line, less or different colour groups, their
pictures depicted reality or abstraction and were more or less complex.
Table 3 shows the aggregation of all the variables over 14 drawing areas
partitioned at whether they were categorised as content, subjective or objective, or
form241. Subjective variables seemed to produce the largest effect, but there were
demonstrable if small effects for the other two types of variable.
Table 3. Aggregated results for patients/all controls by form or content variables
Confidence limits
for _ (all significances
Variable type Effect Size (_) p<0.05)
Subjective content1 0.4283 0.3704-0.4863

2
Objective content 0.3062 0.2105-0.4020
Form variables3 0.1977 0.1217-0.2736
1
102 subjective content variables from 14 tabulated drawing areas.
2
38 subjective content variables from 14 tabulated drawing areas.
3
77 form variables from 14 tabulated drawing areas.
Discussion
Drawing Areas
11 studies were identified which fulfilled the stated criteria for meta-analysis. Although
11 is not a representative number, their 217 operationally defined variables are
representative of common concepts discussed across the field.
to retain all the studies.

241
Variable 15 was an overall score used by some tests to mark the whole picture and therefore is omitted.
179
Less than a third of the drawing areas both discriminated patients from controls
and within diagnostic group. Five drawing areas, which measured subjective content
information, were sensitive to general differentiation of patients and normal controls, but
were insensitive to diagnostic differentiation. Five drawing areas which measured
objective information were sensitive to specific diagnostic differentiation, but were
insensitive to general discriminations between patients and normal controls. This
suggests a major conceptual flaw in constructs common across the field of investigation
explaining the schematics and cognitive constructs of artwork, such as in the description
of the work of art therapy and in psychological drawing tests relating to artistic
psychopathology.
Furthermore the failure to include non-significant findings in the results and
conclusions of much of the literature suggests that current applications of research
findings to the assessment of psychiatric artwork lack construct validity and predictive
validity.
Form and Content variables
There was a demonstrable form effect and it was significant, but low. Against all
predictions from art theory, observational case and series studies and narrative personal
experiences by therapists, particularly of schizophrenics, there was a failure to show
specific effect of form superior to content. However, there were twice as many content
variables; formal variables were often inappropriate for the eventual type of analysis,
were discordant and patchy.
180
Conclusion
The type of analysis used was the most appropriate for the data; all indications
were that other methods would have introduced more methodological discrepancies.
Despite everything, there are strong indications of an effect which differentiates
not only patients from controls (which could be predicted from environment), but also,
different diagnostic classes of patients. The large observational literature and reports
from art therapists predict much larger effects, suggesting very serious measurement
problems.
Summary of the findings of the literature review
Generally, it seems that constructs common across the field of investigation into the
schematics and cognitive constructs of artwork, such as in the description of the work of
art therapy and in psychological drawing tests are only slightly related to artistic
psychopathology. Failure to demonstrate previous published systematic studies
suggests that current applications of the assessment of psychiatric artwork therefore lack
construct validity and predictive validity. Thus we cannot talk about psychopathic art
or of defined marker areas.
These findings support the introductory statement that we know nothing about
the phenomenology of art from psychiatric patients, and it is shown all through the
review that, contrary to popular opinion, there has been a complete failure to understand
the system. It is clear that there is an urgent need for immediate work on the design of
more suitable, sensitive and psychodynamic evaluation measures for psychiatric artwork.
181
Case study and controlled research has largely ignored cautions and tried to
codify symbols or signs, relationships between, and distortion of, images by relating
explanations to a theory of the unconscious in an apparent attempt to produce an
analogical translation that was largely unsuccessful.
Case studies of artists were more concerned with the debate as to intentionality
and generalisability of illustrations of what has been seen as psychopathology to other
psychiatric populations. This has also been largely unsuccessful.
The general direction of the impressionistic or discursive literature indicates that
only the patient has access to signs. The job of the therapist is to gain access to that
very personal language and delicately manipulate it. But unless the language is universal,
or at least common to a particular group, which most research insists that it isn't, it is
futile to try and chart it except retrospectively to extract general principles for the
charting of another individual course. This has now become the general direction of case
study research.
Research based on the idea that art is healing in itself, because it produces a
remote tangible communication outside the patient but from the patient to himself, rather
than from the therapist, tended toward the 'nurturing' case study. The emphasis on the
therapeutic relationship relies on the assumption of communication through the artwork
as the main outcome for the integrity of the therapy as art-related. The use of art was not
found to be inherently related to the therapy but provided a receptive atmosphere, which
could presumably be achieved in other ways.
182
The common focus has been in the interpretation of the meaning of a message but
there are no agreements as to what form the message takes. Problems occur when the
associations of the rater or therapist are not clearly distinguished from those of the
patient, which likely alternative explanation is largely ignored by the literature. It is
dangerous to make assumptions about content, especially when dealing with psychosis.
The nature of the illness affects the verbal expulsions of psychotic people and therefore
ratings based on what they say may be inconsistent and fallacious. The distinction
between response and record is important because it is a primary assumption that what
is measured comes from the patient, otherwise discriminatory properties could be due to
other related issues than to what is described, thus producing erratic results.
The majority of the literature is of poor quality especially the reliability and
consistency of terminology in previous studies because though what is measured across
studies is described similarly, for example: line quality, heaviness of line, articulation,
what is understood by the term digresses from study to study. If we cannot assume
studies measure the same aspects because they use the same terms, studies, or variables
within studies, are not comparable.
There was a demonstrable and significant form effect, although it was low.
Content measures, such as bizarre imagery, disconnections, inappropriate or disordered
colour, perseveration, inessential detail and subject matter require judgments of intention
or meaning, are difficult to validate, difficult to define, unreliable and not specific to
psychiatric populations. Formal characteristics may be seem to have differentiating
183
potential for psychiatric populations, and have the advantage of being easier to define and
rate242.
The next stage, the development of a test takes on the problems of reliability,
content validity and ambiguity of definition of the objective phenomena for the purpose
of testing these findings. It dismissed, as far as possible, interpretation by the rater of
the intention of the artist, used simple terms relative to the work which were widely
distinct from each other and the minimum number of categories to describe the work. The
Descriptive Assessment for Psychiatric Art (DAPA), uses a method which fragments the
art object into a collection of mostly formal variables. This research tries to answer one
important question which unfolded, but has not been fully answered from the review; is
psychopathological evidence from artwork sensitive?
242
For example, Wadlington and McWhinnie (1973) revised their unreliable 18 variable scale which relied
on aesthetic (and therefore content based) terms, to 4 formal dimensions which indicated reliable and
distinguishable categories.
184
Chapter Four: The Descriptive Assessment for Psychiatric Art (DAPA)
The ideal Characteristics for a new test: development of the DAPA
Differentiation of Form and Content
Studies of psychopathology have stressed the importance of distinguishingbetween form
and content243. Jaspers244 explains:
In all psychic experience there is a subject and an object. This objective element
conceived in its widest sense we call psychic content and the mode in which the
subject is presented with the object (be it as a perception, a mental image or
thought) we call the form.
Thus in describing how a subject is presented with the object (the content), we are
concerned with the description of the form, or mode of presentation of the content; i.e.
how the picture is made. Rating of content occurs when raters judge what is represented
(e.g. 'unnatural' colour, abstraction, groundlines, movement, integration).
Theory and justification for each DAPA Scale
The purpose of this section is to present a table of mostly formal characteristics, likely
to be reliable and valid, based on the literature analysis, which are said to exist in the
artwork of psychiatric patients in order to define the parameters of a test which premises
are understood universally and can be compared quantitatively. Positive characteristics
243
Karl Jaspers (1963) General Psychopathology, 7th Edition: translated, Manchester University Press;
Andrew Sims (1988) Symptoms In The Mind: an introduction to descriptive psychopathology, London:
Tindall.
244
Jaspers (1963) op.cit., p.59.
185
only are discussed (indicators which have been noted, rather than contradictory tests
which have reached no significance) with no weight given to one characteristic above
another.
Content: themes, quality of picture and specific details
Table 1 simplifies under three headings the positive findings and notations of all case and
controlled studies considered in this review relating to the content of the picture. Most
of these qualities could not be related to specific diagnoses and therefore could only be
used in a limited way to differentiate patients from controls245. They have a common
negativity, except for a few manic patients (but these were small numbers n=5) and an
odd finding for depressive pictures, of happy and complete work (but this may be related
to treatment stage).
Content characteristics were simplified to positive or negative content. The aim
of the test, to eliminate interpretation of intentions, meant totally excluding content
which would be a major omission and probably rather pig-headed. The reliability of an
acknowledged ownership of an impression by the judge was probably better than a guess
as to what the patient intended.
245
as did study 31 on distorted figures and 56 on lack of detail (except schizophrenics).
186
Table 1: to show the simplified positive findings from case and control studies reviewed
relating to content of picture.
Type Theme or subject matter Quality of picture Detail
threatening; religious or conflict1 fragmented13,

Psychosis/ Schizophrenia
developmental
illustrating symptoms13 nonintegrated3; ossified, indicators1
problem solving 3, static1 damage to trees,
separation, individuation 1 balance of pic12 broken limbs1
repeated numbers 1 displacement2 lack of detail1
disturbed images1 simplification simple shapes/
symbols1 /regression2, omissions1
mild/bizarre content21 proportion errors,
energy/ global tension 2 disconnections1
personal 2/(expressive3 1
originality 2
use of inanimate objects2.
subject broken, disruption 1 simplistic imagery 2 lack of detail (left

Archetypal images 1 (aphasic 1; dementia 1) brain damage2)
Brain Damage
less reality/logic 2 poor quality 2 (Alzheimers: faulty

no people 2 (Alzheimer's 2; also poor recall2;
(Alzheimers + cancer metaphors of loss 1) organisation) essentials omitted2)
(Alzheimer's: poor/lack of content (2)
bizarre content 2)
(autism mouth 1)
'plus phenomena' 1
1
rapid expansive euphoric
Mania
'minus phenomena'1 fragmented3, less detail 1, 2

self disclosure personal information1 nonintegrated 3 low smaller drawing, odd
expressive3 quality of execution 1 relationships between
sombre gloomy themes12 disorganised 2 sexes, few sex diffs in
Depression
disinterest /less human energy self or family 2 wild random uncontrolled figures 2;
mutilated, twisted, distorted, or aggressive figures 13 incoherent drawings, depression as
complete happy scenes with symbols, yellow sun, flowers 1 unconnected 1 secondary diagnosis is
(improvement: impressionistic, realistic with fantasy images 1) more logic than other discriminable1
less problem solving 2 less global energy 2 patients2
twisted or distorted aggressive figures 3

(anorexia good quality subject matter 1)
Anxiety
Personality
more people1 less compositional2 and

Disorder
general integration
1. case studies
2. controlled studies
3. artists studies
The DAPA Category of Emotional tone: The emotional tone of the section of picture
under examination, as it is perceived by the rater, is recorded as positive, neutral or
negative. Positivity is not a popular scale of content measurement and certainly does not
cover the content spectrum mentioned above, This method has the advantage that
187
specific areas of positivity could be compared and that these impressions are distinct
from the other variables.
Measurements of Colour from the literature analysis
The evidence suggests that normal controls generally used more colours than all patient
groups. However, few studies examined the colours used, but employed some grouping
system in the rating: darks and lights, warm and cool, tonal variations and monochromatic
variations. These divisions are all relative to the picture itself, since red and green can be
seen as 'dark' together, whereas with other colours, such as brown or black, they can seem
'lighter'. Dark can also be relative to the intensity of use and therefore these terms are
ambiguous, may require special knowledge of the behaviour of tones, and contain layers
of judgement decisions. The terms 'gloomy' and 'sombre' colours were often used as an
indication of depression, but no evidence supports such associations. Previous research
has recommended formal factors246, hue, value, chroma and tonality as likely to contain
differentiating information. Whereas the basic hue of a colour is discernable, the other
three qualities require a trained eye and may be too sensitive for an initial study. Most
of what they convey can be summed up in the quality of intensity. Particular associations
between intensity and hue may be better dealt with in the analysis, as decisions such as
dominant or prominent colour lend themselves to misinterpretations and to the subjective
associations of judges.
246
W.L. Wadlington and H.J. McWhinnie (1973), The development of a rating scale for the study of
formal aesthetic qualities in the paintings of mental patients, Arts in Psychotherapy, V.1(3-4):201-20.
188
The DAPA category of colour: The DAPA describes colour in the presence or absence
of 9 basic hues within each section examined: Red, Yellow, Orange, Green, Blue, Brown,
Purple, White and Black. Only the media is scored, not the paper.
Intensity is coded seperately as high, neutral or low.
Measurements of Line from the literature analysis
There were more different categories of line than any other, some were mixed up with
shape, the definition of which was ambiguous. No differences were shown between
normal controls and schizophrenia or Alzheimer's disease, but there were suggestions that
physiognomic difficulties in control would probably affect results although some
definitions were understood emotionally rather than visually and some were visual
transformations of expected symptomatology. The studies which attempted to interpret
the patients intentions through assessing the purpose of the line showed the most
variable reliability and results. The definition of line quality, which typically rated
internal relations within pictures; i.e. lines were rated relative to other lines within the
picture, was probably easiest to compare objectively because people tend to judge the
relative extremes. It seems reasonable to suppose that a simple note of internal variability
of line of the picture would be comparable with that of another picture and would be
difficult to invest with meaning.
The DAPA Category of Line: The DAPA describes 'Line' using 3 levels of quality:
Heavy, varied and thin. Development of the measure modified the coding method slightly
from the first study and line is now coded separately as drawn or painted. The DAPA
189
Rating Guide (Hacking & Foreman 1994) describes the division into painted line and
drawn line when estimating variability of thickness. In the first study, line was a
summary of painted and drawn lines.
Measurement of Space in the literature
There were two elements to space; coverage of the paper with the media and pictorial
space (the picture plane). Content based judgements seem to be sensitive to skill in that
patients were distinguishable from controls on their lesser use of virtual picture planes
(perspective) and it is hard to imagine how the associations and culture of the rater do
not contribute to the judgement of spacial relations between drawn objects. Formal
assessments of the amount of paper covered were affected by variability of definition of
cover of the paper (where the space was considered part of the composition in one case
and not in another, according to the rater's assessment of the intention) which found no
differences in patients and controls. Neglect measures did distinguish patients from
controls and schizophrenia from mixed patients. Therefore a measure which objectively
defined media cover of the paper without reference to the image would break new ground.
The DAPA category of Space: The DAPA area category records how much paper
within each section examined remains uncovered by media by quarters: up to 10%; 10-
25%; 25-55%; 55-80% and 80-100%.
190
Measurements relating to Form from the literature
This element covers a composite of variables which indicate mass, shape and focus.
Many disorders indicate that fragmentation, disorganisation or degeneration of the image
takes place in psychiatric illness. Lack of or dissolution of form indicating disassociation
has been graphically portrayed by artists as symptomatic of depression and other
psychiatric illness, but not of stress disorder such as anorexia. Interpretation of
regression from childlike forms has been inconclusive. Repetition of forms is said to
differentiate schizophrenia from other patients and normal controls, but repetitions are
hard to identify without aesthetic training and probably vary considerably. The simple
consideration of presence of form should differentiate at least patients from controls,
with a possibility of exclusion of stress disorder. The other characteristics require
judgements about skill or intention.
The DAPA Category of Dominant Form: Global judgements commonly try to make
an aesthetic assessment of the composition. Evidence also suggested that displacement
of main images strongly indicated general abnormality. Wadlington and McWhinnie's247
concept of significant form seemed to encompass the main elements of this commonality.
Their attempt to define it was incoherent, partly because it depended on artistic
terminology. It is adapted here, perhaps simplistically, as dominant form; the dominant
shape and the simple assessment as to where it lies. Dominant form was a later addition
to the measure and was used for the main study but was absent in the first study.
247
Wadlington & McWhinnie (1973) op.cit.
191
Table 2: Summary table of expected characteristics from the literature.
PREDICTIONS
1. All patients v Controls
2. Difference to other patients
3. Prediction of order
Positivity of 1. More negative

Emotional 2. Schizophrenics and depressives negative> all
Tone patients
3. Negativity: Schizophrenics>brain
damage/disorder>other disorders>
personality disorder>control.
Depressives mixed (most -ve) (some +ve)
Colours by 1. Less and darker colours; more red and black

hue particularly, possibly brown, green, blue.
2. Schizophrenics and depressives: red, black>
other patients; Schizophrenics and
depressives1: No. colours< other patients.
3. Black/brown: Depression>schizophrenia>
other groups> stress disorder>control;
Yellow control>patients
1
Depressives may be variable
Intensity 1. Darker colours, lower intensity

by strength 2. Schizophrenics and depressives<other
high-low patients
3. Schizophrenics<depressives<other
patients<personality disorder<stress
disorder< controls
Drawn line by 1. Patients except brain injury thicker lines and

thickness less varied lines
2. Brain injury/disorder thinner/less varied>
other patients
3. Thickness: Anxiety> schizophrenia/
depression> other disorders> controls> brain
injury
Empty Space 1. More

2. Brain damage/disorder > schizophrenics
3. Brain damage/disorder> depressed/
schizophrenia >other patients> controls
Largest most 1. Less form in total

dominant 2. Depression<other patients
Form 3. Depression<brain injury<other
patients<schizophrenia<stress<controls
192
Objectives of the test
• The main objective of the Descriptive Assessment for Psychiatric Artwork
(DAPA) was to describe an object produced directly by the patient (the painting)
so that relations with another such product, by a different patient were
comparable along the same indices.
Subsidiary objectives were:
• to find suitable dimensions of a picture so as to include as much information as
possible without making the scale unwieldy.
• that the scales should be valid; they would measure the attributes for which they
were designed.
• that the scales be reliable; several raters would not disagree significantly on
scoring.
• that the test would be useful, understandable and applicable outside the art
therapy profession.
Hypothesis
1• Formal variables will distinguish paintings by different diagnostic groups of
psychiatric patients.
2• If people with similar diagnoses use a similar characteristic style in their paintings,
then the majority of people in a given group should make pictures which are more
similar to those who suffer the same diagnostic psychiatric disorder.
193
Previous methods of assessing atomistic elements of pictures have mostly dealt with the
whole picture at once which can be complex because quite often not all of the picture is
the same and therefore focus is directed to part of the picture. The grid overlay helps to
deal with the totality of the picture elements whilst avoiding the domination of the
assessment by the content.
The DAPA Rating Guide (figure 3), gives a detailed explanation of the procedure
and method for rating (helpsheets and rating sheet with a copy of the DAPA guide can
be found in Appendix 4). The illustration below gives an example of the use of the grid
system. An element of the picture, on the left hand side, is difficult to interpret in the
conventional sense, but no aspect of the DAPA procedure requires us to either translate
it or ignore it. Red scores for each square are given below.
Red Scores from top left, reading across to bottom right. Row 1: 0, 0, 1, 1, 1. Row 2:
1, 1, 1, 1, 1. Row 3: 1, 1, 0, 0, 0. Row 4: 0, 0, 0, 0, 0.
194
Dapa Rating Guide, Version 3. Method for rating according to the Descriptive
Assessment for psychiatric artwork.
Methods Section
Organisation of methods section: There are 3 different research tests to be covered:
1. Main Study, which describes a study of spontaneous paintings with no
prescribed subject in non-test conditions by 109 subjects, 83 of whom were
psychiatric patients; instruments and procedures are described in detail.
2. Interrater study (experimenter and 6 additional raters).
3. First Study, which describes a study of self-portraits in standardised conditions
by 50 subjects, 39 of whom were psychiatric patients.
This chapter is organised into 3 sections. The Main study is presented first because
extended explanations are more appropriately discussed within the greater rigour of the
main study rather than in the initial more experimental study. The complete interrater
and initial studies are presented next, thus references and comparisons are more
comprehensible.
Section 1. Main Study
Permission and ethics: This project was submitted and passed by the North
Staffordshire Medical Ethics Committee 1995. Permission to access patients notes and
to use paintings for research was sought from consultant psychiatrists in charge of the
cases because most patients were not volunteers and there were ethical issues in some
195
cases as to whether informed consent was appropriate. There was no involvement by
S.H. with the patient, for the purposes of this research retrospective paintings were
viewed as information kept as notes on the patient, therefore they were owned by the
hospital and formed part of the records. Consent forms were used for access to casenotes
where patients were already in a painting group and staff agreed to save their paintings
for the project. These were accompanied by written explanations of the project for staff
and patients, and instructions on how to treat the paintings after collection, but there
were no refusals in these groups (samples of consent form with explanatory sheets are
attached, Appendix 5). There were no changes to the usual ward routine for the patient.
Demographic information
Patient Selection: Participants were drawn from mixed sex wards of psychiatric
hospitals serving an industrial community in North Staffordshire, England. The hospitals
accept the full range of adult psychiatric disorder requiring admission. 130 subjects for
the study came from nine wards treating in-patient substance abusers, psychotic
disorders, depressive disorders and personality disorders. Seven wards were sited in a
large country mental hospital, which included a rehabilitation unit housed separately
within the grounds of the main hospital building. The study encompassed the whole
population of the hospital's recreational art programme. The substance abuse unit was
sited in the City General hospital and the other ward was a community based mental
health centre, which dealt with adjustment, anxiety and affective disorders.
196
Controls: Staff members and nursing students from all participating wards agreed to act
as controls and completed their paintings together with the patient groups, so that control
conditions were identical to those of the patients.
Table 1: Demographics for subjects from all experimental groups
TOTAL Sex M Sex F Age Mean Age S.D.
Entire Population 109 49 60 46.17 16.50
Affective Disorder 18 3 15 58.33 13.02
Schizophrenia 35 22 13 57.8 13.69
Personality 9 3 6 32.78 7.51

Disorder
Drug Abuse 24 15 9 35.96 11.62
Controls (staff) 23 6 17 34.83 9.81
Sample: Table 1 shows demographic statistics: 86 psychiatric patients (43 males, 43
females) formed the patient group. 23 staff members (6 males, 17 females) formed the
control group and painted alongside the patients (49 males, 60 females). The mean age
of the controls compared well with the other groups although there were more females.
Choice of patients
It was not possible, due to the numbers of patients available, to randomise groups and
all suitable available patients248 within the main county hospital at the time were involved
in the study, most patients were in chronic stages of illness. The patient group available
was quite large and permitted the comparison of general effects against specific effects.
248
Those who were able and willing to paint, for whom there were facilities, and were not on a locked ward
(for security reasons). Paintings were done on the ward and in the occupational therapy dept. 10 wards
from the main hospital and 2 from the city general hospital were involved in the study.
197
It was decided to use a large mixed group of general psychiatric patients who were split
into several diagnostic groups rather than one smaller group of schizophrenicsas previous
research has done.
Exclusions: Two wards which were asked to produce pictures for the study did not:
only 4 patients from the traumatic brain injury unit produced the required number of
paintings as art groups were irregular with frequent changes of staff and patients, so they
were excluded on numbers. Wardstaff withdrew a chronic schizophrenia group from the
study due to misgivings about confidentiality because their artgroups were dynamically
rather than recreationally based. There were 2 patients on whom information was not
available (short stay patients, untraceable); and one patient who withdrew from the
study. The other exclusions were on diagnostic criteria which are shown in Table 5 under
procedures below.
Unequal group sizes
Patients: because diagnosis was only taken after the artwork had been collected,
numbers fluctuated and there were also overlaps between wards, especially with
schizophrenics.
Non-patients: All the non-patients were staff members or student nurses who worked
with the group in the same conditions and whose paintings had been saved along with the
patients. All staff members involved agreed to contribute their paintings. Most of the
control paintings came from the groups which agreed to save their paintings weekly
because many staff paintings, especially those of transient student nurses, were excluded
198
because they were difficult to identify and single, and even those of regular staff had not
been saved for long.
Measures
Age and sex were recorded and their means are shown in Table 1.
Four additional demographic variables were taken from the files249, but on examination,
discarded:
1. Marital status had changed often for some patients and there were signs to
suggest that files were often inaccurate and insensitive to patient's outside
relations, especially when the patient had been hospitalised for a long time. This
variable was discarded.
2. IQ was not recorded because it was not routinely tested, the researcher was not
clinically involved with patients and had no training for such measurement. IQ
measures are known to be unreliable with psychiatric populations, because the
illness itself interferes with the verbal component. Some studies use
developmental indicators from the pictures themselves, but there is strong
evidence to suggest that the scoring procedure is inconsistent in psychiatric
illness250.
3. Drugs was discarded: Only a handful of patients were not taking serious
medication and some patients' medication fluctuated often and the date of
249
Forms were developed so that information taken would be standardised and comparable. A sample form
is included in Appendix 5.
250
see introduction: projective tests.
199
paintings was not reliable enough to relate to it; all were inpatients, but some
were in hospital for one or two days only and there may have been other
influences, especially in the substance abuse group.
4. Chronicity of patients: There were three variables to determine chronicity: new
admission, previous admissions, and whether the patient had ever been sectioned.
It was initially decided to examine and compare work in both acute and chronic
stages of illness. The advantage of examining work by patients in acute stages
of illness, as well as the traditional chronic groups, is the comparison of indicators
which have been identified as distinguishing psychiatric illness that may be due
to the institutional environment. However, patients were difficult to classify,
even as inpatients, as their status fluctuated. Most of the wards which
participated actually contained patients with chronic illnesses, especially
schizophrenia. However, in three out of four wards which were identified
initially as dealing with acute illnesses (drug unit, rehabilitation unit, and
community mental health unit) casenotes revealed that the majority of frequent
attenders (3 paintings or more) had previous admissions and few were new to the
hospital. Another acute unit, for traumatic brain injury was excluded. This
variable was discarded.
200
Instruments
Diagnostic Tests: What is the ICD10(DCR)
The International criteria for Diagnoses developed by the World Health Organisation
(WHO) is the most widely used classification system in the world. Its development is
detailed elsewhere251. It is recognised as a standardised, easy to apply system with
excellent reliability between raters. The DSM252 system, which is more popular in art-
therapy literature represents North American modifications of the ICD sections; DSMs
must be compatible with ICD. The main differences are in the higher rate of multiple
coding of selected disorders encouraged by the use of DSM-III. Collaborative
development of ICD-10 with DSMIV has now aligned these even more closely253.
Because of the diagnostic procedure, and the experience of the clinician, for this research,
the ICD-10 classifications provided the simplest and most reliable procedures.
Reliability: All ICD-10 clinical diagnoses are organised into 10 two-character groups
(e.g. F2 for all Schizophrenic disorders). These two-character groups are subdivided into
3 character groups (e.g. F20 for schizophrenia), which in turn are subdivided into 4
character codes (e.g. F20.0 for paranoid schizophrenia). Interrater agreement can be
251
J.E. Cooper (1988), The structure and presentation of contemporary psychiatric classifications with
special reference to ICD9 and 10. British Journal Psychiatry, V.152 (suppl.1):21-28. N. Sartorius (1991),
The classification of mental disorders in the Tenth Revision of the International Classification of Diseases.
European Psychiatry, V.6:315-322. Details of planning, organisation and conduct of international field
trials are also provided elsewhere, WHO DMH Mental behavioral and developmental disorder ("clinical
descriptions and diagnostic guidelines"), in International Classification of Diseases, Tenth Revision (June
1987 Draft for Field Trials). Geneva, WHO, 1987. J. Burke (1988), Field trials of the 1987 draft of
chapter V (F) of ICD-10. British J. Psychiatry, V.152 (suppl.1):33-57.
252
American Psychiatric Association (1987), Diagnostic and statistical manual of mental disorders (3rd ed.
rev.), Washington D.C.:Author.
253
D.A. Regier, C.T. Kaelber, M.T. Roper, D.S. Rae, N. Sartorius (1994), The ICD-10 Clinical Field
Trial for Mental and Behavioral Disorders: Results in Canada and the United States, Am. J. Psychiatry,
V.151(9):1340-1350.
201
computed on any of these levels. Groups of 2 character and 3 character codes combine
related categories, and kappa coefficients at these levels tend to be higher than for more
specific 4 character categories, since they ignore some differences in diagnostic
disagreement254. For the purpose of this research, subjects were classified by 3 character
groups although diagnoses were actually made at the 4 character level, which is usual for
clinicians, as shown in table 10.
The ICD-10 DCR (Diagnostic Criteria for Research, 1993) version was used for this
research255, which is consistent and compatible with the Clinical Descriptive version and
other national classification systems (e.g. DSM-IV)256. The criteria are explicit, easy to
apply and are specified in more detail than in the more narrative equivalent statements
in the clinical descriptions and diagnostic guidelines from which they were derived. Very
high interrater agreements have been reported257, which was important for this research
as reliability of diagnoses was not statistically investigated. The criteria contain
descriptions of symptoms and other attributes of the patients, together with statements
about the frequency, relative importance and duration of symptoms. Exclusion and
inclusion statements are also provided.
254
Ibid.
255
Division of Mental Health of the World Health Organization (1993), International Criteria for Diagnoses
in the Mental and Behavioral Disorders: Diagnostic Criteria for Research (ICD-10 DCR), Geneva: Author.
256
N. Sartorius, T. Bedirhan Ustun, A. Korten, J.E. Cooper, J. van Drimmelen (1995), Progress toward
achieving a common language in psychiatry, II: results from the international field trials of the ICD10
diagnostic criteria for research for mental and behavioral disorders, Am. J. Psychiatry, V.152(10):1427-
1437.
257
Although in trials, numbers were low for some diagnostic groups. The population was not randomly
selected and the range of possible diagnoses were more limited than the field trials for the ICD-10 clinical
202
Accommodation of this project to identified weaknesses of the ICD-10 DCR in
interrater agreement.
For some categories, such as those dealing with certain polymorphic psychotic disorders
or milder forms of affective disorders, the criteria have been rated difficult and reliability
was low258. Difficulties usually came from the fact that two conditions were coded in
combination, a situation which was avoided in this research, since subjects with
secondary diagnoses were excluded. Difficulties in distinction between related states or
in fine differentiation of levels were addressed by limiting the classification to 3 characters
which allowed combination of related categories. Most subjects were in chronic state and
hospitalised, so the somewhat low agreements on polymorphic syndromes (eg acute
psychotic disorders) or milder categories, where distinction between normal and case was
vague, were avoided. Categories showing lowest kappa values tended to present the
greatest difficulty. There were obvious weaknesses in diagnosing psychiatric illness
from casenotes. The notes did not usually contain a formal ICD-10 designation for the
patient, but they did usually present a detailed description of symptoms and
observations on the patient by an experienced psychiatrist and other staff. Patients who
participated in this research had major psychiatric dysfunction, and patients with
secondary diagnoses were dropped. For this research, where there were difficulties,
ambiguities or different conclusions from that recorded in the notes, DF consulted with
the psychiatrist in charge of the case. These cases were rare.
descriptions.
258
Sartorius et al (1995), common language in psychiatry, op.cit. Although these tests were between
countries worldwide and low reliability mostly reflected North American familiarity with the DSM-111.
203
The DAPA (Descriptive Assessment for Psychiatric Artwork)
The DAPA was piloted at Post Graduate School of Medicine, Dept. of Psychiatry, Keele
University. Details of the instrument and the initial study were published in 1996259 and
the first study is described in section 3 of this chapter; Section 2 details the interrater
reliability of the instrument.
The DAPA test procedure uses a rating sheet for standardisation260, and the rating guide
describes categories as objectively as possible in observable and simple terms with
examples for comparison to minimise imposed interpretation by the rater. A full list of
operational definitions appears in the DAPA Rating Guide (Hacking and Foreman 1994:
which appears at the beginning of Chapter 4, also appendix 4)
Application - Scoring procedure
The six categories are measured by a grid drawn on a transparent overlay, of 20 squares,
consisting of 5 columns and 4 rows. The grid fits over the whole painting, corner to
corner. Its absolute size is therefore defined by the size of painting. For each square
respectively, 9 colours are recorded as present/absent (1,0); brightness or density (colour
intensity) of the media is recorded as high, medium, low (3,2,1); line is recorded as thick,
varied, or thin (3,2,1); the percentage space covered by the media is scored in quarters:
10, 25, 55, 100%; subjective emotional tone is scored as it appears to the rater as
259
S. Hacking, D. Foreman, J. Belcher (1996), The Descriptive Assessment for Psychiatric Artwork
(DAPA): a new way of quantifying paintings by psychiatric patients, J. of Nervous and Mental Disease,
V.184(7):425-430.
204
positive, neutral or negative for each square (3,2,1); and Dominant form is recorded for
each square as present or absent. This produces 20 scores for each of 15 variables.
These twenty scores are averaged for each variable over one painting. To eliminate any
further effect of content, all the paintings by one individual were again averaged providing
a subject profile of 15 scores.
Development: Appendix 4 shows early versions, labelled 1 and 2, and the developed
version of the DAPA (version 3) used in the main study and the reliability study. The
initial study used version 2.
Subordinate Analyses
Treatment of the Data: Procedures to approximate a normal distribution were taken on
the raw data and to counteract any confounding variables.
• Not all the subjects completed all the paintings. The non-parametric equivalent
of ANOVA, the Kruskal Wallis test was performed on the categorical variables of
diagnostic group by number of paintings to determine bias, as content in the early
paintings would therefore be emphasised. Additionally correlations were calculated
between all variables to show association with number of paintings done.
• There were more females in the control group, so the ANOVA procedure was
used to determine interactions of sex with significant variables.
260
Sample in Appendix 4, version 3 of DAPA.
205
• The extremes of the distribution for each variable were examined for consistent
outliers which could be eliminated, to compact the data and decrease noise; tables can be
found in appendix 2; from Chapter 5 (figs 3a-f and tables/figs 1a-l).
Analysis of the paintings: Most of the raw data was rank-ordered or classificatory, but
the final score for each subject was a ratio of the distribution of each variable over their
output of paintings, fulfilling the conditions for parametric analysis. All calculations
were done using the computerised Statistical Package for Social Sciences, version 4 for
DOS.
Analysis to differentiate groups and the importance of population distribution
The Analysis of variance test procedure was the main differentiating analysis in this
study. It allows cases to fall into different groups based on their values for one variable.
The one-way Analysis of Variance has the advantage that it is a single analysis which
compares all the data at once, rather than employing t-tests between different groups,
which is problematic when there are a number of tests. But ANOVA gives a clumsy
answer because it employs an omnibus approach which compares equality of population
means for each test variable; it assumes to 'null hypothesis', that there is no difference
between the 5 different diagnostic groups.
The test compares the variation between the means of the groups with that
expected from the variability between individuals in the groups. The comparison takes
the general form of an F test (variance ratio test); if two normally distributed populations
206
have equal variances, the ratio of the two sample variances has a sampling distribution
called the 'F' distribution, that is, the ratio of sample variances or square of ratio of the
sample standard deviations. There are two values for degrees of freedom - for each
variance, the first relates to the numerator and the second to the denominator. If the two
standard deviations are markedly different, it is unlikely that the two samples come from
populations with the same variance. ANOVA assumes two conditions and tests are
discussed below:
1. Each of the groups must be a sample from a normal population.
2. The variances within groups must be equal.
In practice the analysis of variance gives good results even if the normality assumption
doesn't quite hold but because of the imbalance in the number of observations in each of
the groups, the equal variance assumption was important. Distributions of values for
each variable were computed using the SPSS EXAMINE procedure.
The analysis of variance test does not isolate particular differing groups: it can
only tell us whether there is a difference and not where the difference lies. For this a
multiple comparison test is used. Because there were no grounds for prior hypothesis,
a planned comparison would be inappropriate with an omnibus test such as Anova.
Having observed a statistically significant effect using the oneway procedure, the
RANGE subcommand (Duncan procedure) was used to compare each group with every
other group; significance levels are attached to those groups showing most difference.
The comparisons use t-tests applied between independent samples for each variable,
comparing each pair of means in turn.
207
The difficulty with using t-tests is that multiple significance testing gives a high
probability of a type 1 error (a false positive result) because the probability becomes
much more than 5%. Duncan's multiple range test controls the overall type 1 error rate
at no more than 5% using the Bonferroni correction for multiple comparisons. The
procedure is suitable for groups with uncorrected variances and can also be adjusted for
unbalanced design261. The disadvantage of this and similar methods available on SPSS is
that they are 'conservative' so that errors are on the side of safety (non-significance).
Therefore small numbers of group comparisons (up to 5) are recommended, with
specified research objectives262. In addition, since it is likely that some of the measures
for ANOVA are correlated: in real life we can assume some correlation between multiple
tests, it is more likely that the Bonferroni estimate would be conservative, placing any
suspicion on non-significant data.
Discriminatory power between controls and patients
This final analysis aims to give distinct answers to 2 direct questions;
(i) Is the DAPA as effective as other art assessments; and
(ii) can the DAPA practically discriminate between patients and controls.
These two questions need to be attacked differently because they are respectively
conjectural and pragmatic; (i) is answered through the illustration of effect sizes from t-
test results, using the methodology explained in Chapter 2, which derived effect sizes for
261
It is a popular misconception that groups must be orthogonal for comparison tests, R. West (1991),
Computing for Psychologists (London: Harwood).
262
D.G. Altman (1994), Practical Statistics for Medical Research, London, 3rd. reprint, original 1991:
208
the most interpretable studies from 20 years review of the literature; and (ii) is answered
through the interpretation of the discriminant analysis performed on the collected data
from patients and controls.
(i) Is the DAPA a better assessment than the other tests reviewed in Chapter 2?
In order to contrast the effect from the DAPA with that of the general tenor of the
literature, the basic differences in effect size between controls and patients on each
variable from the DAPA were determined by another t-test. Each variable was treated
as though it was independent, purely for the theoretical comparison. These tests cannot
be regarded in practice as independent, as there were obvious correlations in the data and
so there was likely to be confounding errors, due to multicollinearity -one variable may
be the main predictor, subsuming those correlated with it to insignificant contributions,
thus true results for the DAPA should take account of direct relations between variables.
(ii) Can the DAPA practically discriminate between patients and controls.
Regression analysis was not applicable to this study because from the discussion of
results it was obvious that there could be interactions and correlations between one or
more of the predictor variables. The more complicated regression techniques require more
cases. The discriminant analysis is an older technique, but for 2 groups gives a similar
result. Discriminant analysis avoids the problem of multicollinearity by setting a
tolerance level which excludes variables that are highly correlated with each other. In
Chapman and Hall, p.211.
209
addition it leaves out other variables which are not necessarily non-discriminatory
independently, but their ability to add to the discrimination having taken account of the
other variables already used is judged low. It reduces the test to a subset of useful
variables from a larger set of candidates and indicates to what extent a combination of
independent variables will allow discrimination between controls and patients.
Discriminant analysis was used to find a combination of variables that
classified a large proportion of subjects into the correct group as an instrument of
allocation or diagnosis for new subjects. The analysis used the same subject group
detailed in table 1 (109 subjects: 23 controls and 86 patients). The method is robust and
makes few assumptions, but two recommendations are suggested for the sake of
interpretation263:
1. that most variables have a normal distribution with the same s.d. within each group
(although some authorities have argued that discriminant analysis is robust for binary
distributions); and
2. five times as many subjects are recommended per group as variables.
It was appropriate to consider this method, then, for 2 groups: patients and controls;
subgroup analysis would require more cases. The Mahalanobis method, which is a
variation on the stepwise method, was selected. Using SPSS, the steps of the calculation
are clearly shown. The analysis works by finding a combination of variables that
maximises the distance (D2) between the groups. It may, perhaps, do slightly less well
263
Altman (1994), op.cit. recommends that in order to correctly interpret the associated significance that
variables should have a normal distribution, but generally authorities are mixed on whether this issue is
critical.
210
than the stepwise option at correctly classifying the subjects but there is a clearer
indication of the extent to which particular variables contribute to the discrimination
process.
It was necessary to control for uneven numbers between groups as the patient
group was nearly four times the size of the control group, otherwise there wouldn't be
an even chance of allocation to either group. The PRIORS subcommand within the SPSS
program adjusts the calculation for the sizes of the groups according to the prior
probability of chance allocation to one group or another. Prior probability was thus set
to 75/25%.
Subordinate analyses
Correlations between DAPA variables
For exploratory analysis, the Pearson Product Moment Correlation (Pearson's r) is the
most commonly used measure of linear association between continuous variables. Bi-
variate scatter plots for the significant variables were generated to check the distribution
of the data because there are restrictions on the validity of the associated hypotheses
tests. The significance of the correlation coefficient is valid for random samples with at
least one normally distributed variable. 2 tailed tests were used because, although
hypotheses were made, there was little scientific reason to expect that correlations would
be in any particular direction.
Correlation is often used as exploratory analysis, but even with only a dozen
variables here, 66 r values are produced. 5 populations are tested, thus 1 value in 20 will
be significant at the 5% level purely by chance! This level of analysis was rather too
211
nebulous for reasonable conclusions and two tailed tests of significance tightened up the
data and allowed for type 1 errors. Much depends on the sample size, but significant
values of r below .6 would not contribute much to a speculative general discussion264.
Because there is little background knowledge, it would be imprudent to infer
relationships from analysis of correlations alone. It was clear from previous studies265
that some exploratory analysis was necessary, as interrelationships between the variables
could contribute to the explanation of difference in the results of this analysis from
previous work or accepted knowledge. The secondary purpose, in further development
of the test, was to identify any possible reduction of the scales to increase efficiency if
some of the scales measured the same quantities.
An analysis for the whole population as if they were the same diagnostic group
may mislead because other differences in samples, or indeed a third unknown variable
might influence ratings, bunching particular groups and inflating the correlation. In
addition in large populations, very small correlations become significant. Correlations
were calculated between reliable variables within each diagnostic group.
Procedures
264
Altman's (1994) op.cit. recommended method to modify over-enthusiasm may be adopted here; the
calculation of 100r2 on 0.7 gives 49%, the percentage of the variability of the data that is explained by the
association of the two variables.
265
For instance: the DDS (Cohen et al. 1988, op.cit) see my criticism of their results, Chapter 2;
Wadlington and McWhinnie (1973), op.cit. found significant associations between scales similar to those
used in the DAPA test.
212
Procedure for diagnoses: ICD-10 diagnoses were made from case records by Dr. D.
Foreman266, who is a Consultant psychiatrist with training in both general and child
psychiatry. D.F. was blind to the originating ward and paintings while making the
diagnoses. Disagreements were discussed with the consultant in charge of the case.
Table 2 shows category definition of case assignment to 4 types; Affective Disorder

(n=18); Schizophrenia (n=35); Personality Disorder (n=9); Drug Abuse (n=24).
ICD-10 Diagnostic categories for research (1993) N ASSIGNED

TO TYPE
Moderate Depressive Episodes (Affective Disorder) (4 x F25.2; 3 x F25.1; 2 x

F25.0, F33.3; 1 x F33.1, F32.8, F32.3, F32.1, F31.7, F31.6, F31.0). 18 3
Schizophrenia (24 x F20.3; 4 x F20.0; 4 x F20.9; 2 x F20.5; 1 x F20.2). 35 1
Personality Disorder: (3 x F60.3; 1 x F60.3 + F68.1; 3 x F10.2 + F60.3; 1 x

F10.2 + F60.9; 1 x F45.0 + F61.1). 9 5
Substance Abuse: (14 x F10.2; 3 x F19.2; 2 x F11.2, F18.2; 1 x F11.1, F13.2,

F15.2) 24 2
Table 3: 21 Patients who were excluded from the study
Diagnostic type with ICD-10 category N
Diagnosis of Affective Disorder with secondary diagnosis

(1 x F33.4 + F00.1; 1 x F33.4 + F02.3; 1 x F31.3 + F70.1; 1 x F33.2 + F22.0) 4
Diagnosis of Schizophrenia with secondary diagnosis: (1 x F20.0 + G20.0; 1 x F20.3 +

F70.1; 1 x F20.3 + F07.8; 1 x F20.9 + F70.1) 4
Diagnosis of Organic Mental Disorder: (1 x F00.1 + F31.7; 1 x 0.1 +F25.1; 1 x F01.2; 1

x F07.0) 4
Diagnosis of Anxiety Disorder, Eating Disorder: (1 x F41.2 + F10.2; 1 x F10.2 + F50.3;

2 x F50) 4
Diagnosis of Mental Retardation: (2 x F71.1) 2
Procedure for Painting Generation: All patients and staff who had attended art
groups run by nurses, as part of the recreational program of the hospital in the wards
266
Dr. D.M. Foreman, M.Sc., MRC Psych., Clinician and Senior Lecturer, Psychiatry Dept., Post
Graduate School of Medicine, Keele University. Dr. Foreman supervised this Ph.D. research.
213
identified were included in the study. The art groups took place at the same place and
time each week in daylight hours for one hour a week. They contained up to 8
participants who were either patients or staff from the ward. In each case the most recent
10 paintings produced by the subject were used for the study, these varied in date
because although the study was initially retrospective, paintings by patients were not
kept by all wards267. Where it was a practise to dispose of the work, art groups agreed
to keep and label the work for a specified period. Paintings were identified with a number
by the nurses at the time and a separate sheet was provided a key to names and staff
identification, which was kept separately until after the scoring period. S.H. collected all
the paintings from the nurses weekly, but was unaware of diagnosis, which paintings
were by staff members and unacquainted with the group. No themes or subjects were
set268 and the group leaders followed their own agendas or used free painting. Art
materials were those available to the group leaders, pencil and paint, but were not
standardised, although labelling instructions did indicate that all the basic colours should
be available to the patients if possible. Most of the paper provided was white 17" x 12",
but some used white 8" x 12".
267
This is surprising if art work is considered as information relating to the patient, but actually few
patients are given true art therapy due to the shortage of therapists. Most 'art therapy' is given by nurses
who have taken short courses. Paintings were discarded because they contribute to fire hazard and also
fat-file disease: the patient's file gets thicker the longer the hospital stay.
268
But where suggestions were asked for, S.H. made the recommendation of a self portrait.
214
Summary
After the pictures were drawn/painted and collected and measured according to the
DAPA specifications above, there were 6 stages to the analysis of the study data, their
applications are divided between results and discussion.
RESULTS:
• The data was transformed, so that the distribution of the majority of variables
approximated normal. Variables with low frequencies were excluded from the
analysis.
• A variance analysis was applied to 13 scores representing 6 measured dimensions of
paintings obtained from the DAPA procedure to determine whether the instrument
differentiated between controls and 4 patient groups of different diagnostic types.
• The Duncan procedure identified where differences lay.
• The discriminant analysis determined the predictive value of differences between
patients and controls.
• Subordinate correlational analysis was used to determine the within cells correlations
for the 13 variables from the DAPA procedure, to assess the validity of the
categories.
• T-tests for each variable were calculated using the same procedure to determine effect
sizes for comparison with the best studies from the literature.
215
DISCUSSION
• The validity of the DAPA categories was examined, strengths and limitations of the
procedure.
• The results were explained and compared and contrasted with those detailed in the
literature review and the results of the pilot study, in which the content was
controlled.
• The interactions and correlations of the 13 variables from the DAPA procedure were
discussed and compared with impressions from the literature taking account of the
limitations of the procedure for the effect sizes produced by the t-test.
• The discriminant procedure was discussed and compare the final outcome with
previous investigations and predictions.
Section 2: Reliability Study
An abbreviated version of this study, together with the first study (section 3) appeared
in an article by S. Hacking, D. Foreman and J. Belcher (1996)269.
Purpose of the Study
The amount of rating in this set of studies was considerable. A little over 1000 paintings
were rated for the main study and the first study by the author for this research. It was
necessary to find out if the rater's judgement of pictures was a contributing factor to
significant differences in discriminating variables. There are various ways of conducting
inter-rater reliability tests on human subjective judgements. There is nothing unscientific
269
S. Hacking, D. Foreman and J. Belcher (1996), The Descriptive Assessment for Psychiatric Art: a new
216
about subjective judgments but care is needed in making them credible. It is essential to
be able to demonstrate that at least two people can independently come to fairly similar
judgments. Multiple rating of the whole test would be time consuming, costly and
impractical since it is better to employ more than two people; two people closely
involved can reach an understanding which is not apparent in the written material and
over hundreds of ratings, the significance of small deviations decreases. The more people
employed, the greater the risk of individual variation on rating areas which are not clearly
defined.
Inter-rater reliability statistics judge the extent to which agreement is reached,
usually by reporting the correlation between raters, together with a summary of the
agreements and disagreements on level of rating. This study took a small sample of
pictures (1%) from the total amount of pictures previously rated by the author, and used
a relatively large number of judges. The object was to find out if several people
independently could give the same or similar scorings using the DAPA scale to the
scoring given by the author; if so, it can be reasonably deduced that the author's rating
was consistent within the test categories.
Choice of Subjects
Raters: 7 first year art students (6 females 1 male 19-24 yrs.) from a local University
were recruited as raters. They had no previous knowledge of the DAPA or of other art
tests. Art students were chosen because the training would take some time, concentration
way of quantifying paintings by psychiatric patients, J. Nervous and Mental Disease, V.184(7):425-9.
217
and the test used terminology which would be familiar to them. 1 rater was dropped
during training because his responses were inappropriate to the task. Raters received 2
hours training with the rating guide used in the main study (Version 3, shown in Chapter
3). This was in the form of a workshop, which took them through the guide, included
explanations, examples of terms and the rating of one training painting before using the
scale.
Picture Selection: 25 paintings were selected by the author from paintings rated some
months previously as part of a study with large numbers of other such work. The
paintings showed a range of different subjects and treatment of media. They were each
by different long term psychiatric inpatients from a local mental hospital, or by staff
from the same facility. Each rater on arrival selected one painting from the study pool
and these paintings were used for the study (ratings made by the author for the selected
paintings were retrieved at the analysis stage for the comparison and were not available
at the time).
Method
Raters were given the opportunity to discuss the categories with the author in training
as indicated. They all rated the same training picture at the end of the training session to
iron out any inconsistencies and misunderstandings, and then individually rated seven
pictures, in series, in different orders, referring to the rating guide and helpsheet provided
by the author. They worked by themselves at separate desks so that they could not
discuss their ratings, they changed over pictures with the next person until they had
218
finished the set. They were asked for their comments and suggestions. Most
participants took about 10 minutes for the whole process as described in the DAPA
rating guide (Chapter 3) per painting by the end.
Analysis: treatment of the data
A point by point comparison of every category per gridsquare would have been
ridiculously long and complicated. The propriety of different methods of agreement are
discussed at the end of Chapter 2 (reliability). Altman270 recommends Kappa for
categorical variables, and warns against the misapplication of the correlation coefficient
to measure agreement for categorical scales. However, a disadvantage of kappa is that it
takes no account of disagreements and is not useful for numbers of raters, numbers of
categories, non-ordinal scales and large tables, often requiring considerable collapsing of
the data and thus not for this study. A categorical comparison was therefore both
unwieldy and unnecessary, since it is the final mean score, used as continuous data,
which is the hub of the DAPA process. The questionable propriety of the correlation co-
efficient for analysis of agreement, as expounded by Altman, is that although it indicates
linear association, how nearly the scores are ordered in the same way, it does not indicate
whether the level of the scores have changed. This is important because ordinal
positioning is not relational and therefore particularly makes nonsense of categorical
correlations.
270
D.G. Altman (1994), Practical Statistics for Medical Research, London, 7th ed. originally 1991:
Chapman Hall, p.284, and 409.
219
How the data were structured
Although ordinal scales are often treated as though they were interval scales, only very
limited mathematical and statistical operations make sense using ordinal data. However,
a common quasi-legitimate procedure271 was applied to scores from the DAPA, both for
the main tests and for the reliability test. Normality was assumed in the underlying
distribution and the interval units of the scale were adjusted to match the average
observation for the whole picture (over 20 squares), which makes sense, because there
is a maximum limit for each variable over the painting (e.g. Range of Red = 0 - 1). Even
though, pragmatically, the limitations of the measurement method must be taken into
consideration in the final analysis, statistical advantages of parametric analysis allow
more powerful techniques of comparison.
The raw scores for colour and form for each picture (count of up to 20
gridsquares) were scaled 0-20 and had two possible scores for each square, but the scores
for Intensity, Painted Line, Drawn Line, and Emotional Tone were scaled 0-60 with 4
choices and those for Space, 1-100 with 5 choices272. It was therefore necessary to align
the scores on the same scaling points for comparability of repeated measurement. The
usual testing procedure reduces the scores to an average gridsquare rating over the whole
set of paintings, but this was inappropriate to test the scoring procedure273. To keep the
data as simple as possible, a count per picture for colours was used; scores from the 0-60
scales, were divided by a factor of 3, and the 1-100, by a factor of 5.
271
The same as that done with IQ data in order to convert it to an interval scale.
272
There weren't any zero scores (no marks at all).
220
Measuring accuracy
Altman's recommendation to plot the differences against the average score, for continuous
measures, seemed clear and appropriate. Tables 1-15a (appendix 2) show rater's scores,
discrepancy levels, the mean score for each subject and differences to that of the author.
Plots of the distribution of the raters' scores (Figs 1-15 appendix 2) show concordance
with the mean rating; for clarity the same minimum and maximum limits are used
throughout. It must be remembered that the principal rating (R7 by the author) is not the
true value, which is unknown, and for this purpose, the average of the mean trainee rating
and that of the author274, acts as the best estimate for the unknown true value. A
summary of these scores, the standard differences are tabulated below (table 16).
Table 16: Standard deviation of the differences between the mean of the 6 trainee raters
and the author ratings over 7 paintings
95% limit of agreement;

S.Diff (expected differences by scale points);
Variable Mean Std Dev Min Max and likely direction of discrepancy
RED -.02 1.35 -1.50 2.67 -2.68 to 2.70 (<3) equal

YELLOW 1.12 1.21 .00 3.00 -1.30 to 3.54 (<2) high
ORANGE -.24 .42 -1.00 .00 -1.06 to 0.58 (<1) low
PURPLE -1.26 2.09 -5.33 1.00 -5.44 to 2.92 (<4) low
GREEN -.86 1.20 -3.00 .17 -3.26 to 1.54 (<2.5) low
BLUE -1.36 1.23 -3.00 .00 -3.82 to 1.10 (<2.5) low
BROWN -1.07 2.51 -5.83 2.17 -6.09 to 3.95 (<5) low
WHITE -.24 .63 -1.67 .00 -1.5 to 1.02 (<1) equal
BLACK -.07 .69 -1.17 1.00 -1.45 to 1.31 (<1.5) eq'l
INTENSITY 1.02 1.54 -.89 3.83 -2.06 to 4.10 (<3) high
PAINT LINE 1.21 1.26 -.33 2.72 -1.31 to 3.73 (<2.5) hi'
DRAW LINE -.06 .11 -.28 .00 -0.28 to 0.16 (<0.2) eq'l
SPACE -.65 .68 -1.77 .00 -2.01 to 0.71 (<1.5) low
EM-TONE .17 2.01 -2.17 3.11 -3.85 to 4.19 (<4) equal
FORM -.31 .68 -1.33 .67 -1.67 to 1.05 (<1.5) low
273
The paintings were by different patients and fluctuations in scoring needed to be made clear.
274
Author + Raters
2
221
How well does the method agree?
Table 16 shows a summary of the standard differences (S.diff) between the 6 trainee
raters and the author's score (column 1), plotted in Figs 1-15275 (Appendix 2). The
scatter of differences remains constant and does not increase with the mean, so the
differences can be further investigated in the raw state276. A test of association would
be inappropriate at this stage as we cannot deduce that methods agree well if they are not
statistically different. There were large variations in the sample which may have
regressed the mean and may well lead to important differences seeming non-significant
(see tables 1-15 accompanying figs. 1-15, appendix 2).
The S.diff. can be used as a measure of agreement by itself, but it is more useful
to construct a range of values from it, which covers the agreement between the raters for
most cases.
For reasonably symmetric distributions we can expect the range mean +-2 S.D.
to include 95% of the observations. We can therefore take mean +-2S.Diff. as a 95%
range of agreement for individual paintings. This range defines the 95% limits of
agreement (shown in Table 16, column 2). For the present data, from the 95% ranges,
the author is expected to score within 1 point of scores from independent raters on drawn
line, orange and white; within 2 on yellow, black, space, and form, with a slight bias
towards higher scores; and within 3 points on a further 5 variables: red, green, blue,
intensity, and painted line, with discrepancies likely in either direction. 3 variables have
275
against Author+RATS/2.
276
Rather than translation to logarithmic scores.
222
wider ranges: purple and brown, which had 4 or 5 point limits, are mixed colours which
are harder to define and therefore more variable to rate; raters tended to score lower. And
emotional tone, which had 4 points limit, depended on the associations of the rater
(discrepancies equal).
So, how can we define good agreement?
For this research, the standard deviation of the differences as a measure of agreement is
appropriate because the subjects themselves define their own limitations. However, this
does not facilitate comparison of the measure. Interpretation of agreement depends upon
the circumstances, it is not possible to use statistics to define acceptable agreement; it
is more important to quantify the variability of the individual data points. But it is still
necessary to define some answer to the question: how well do the raters agree? within
the larger context which gives it meaning of, how do we compare this agreement with
other measures? It is a complicated question, and there are two components to the
answer.
(1) The mean difference is an estimate of the average bias of the raters relative to the
principal rater. Here the means are mostly negligible and we can say that agreement is
excellent on average.
(2) It is essential to consider the agreement for an individual painting for which purpose
the standard deviation of the differences (S.diff; Table 16) can be used.
A rough comprehensive overall statistic can be deduced from examination of the
raw data (middle columns of tables 1-15, appendix 2). A total 480 out of 630 decisions
223
- 76% - of the scales were rated within one scale point of the author's score; the number
of exact agreements was 58% (365); and a further 10% within 2. These figures are well
within the expected limits of agreement shown in Table 16 (column 5) for 86% of the
data. Ordering of the most reliable to least reliable DAPA categories (table 18 below) was
based on the above considerations.
Table 18. Ordering of DAPA variables for Reliability
Most reliable categories

over 2
Variable / agreement within 1 points
point of R7score diff's.
Best Agreements limits

Draw-Line 88% .2 2%
Form 91% 1.5 2%
White 95% 1 5%
Orange 88% 1 12%
Black 86% 1.5 4%
Green 86% 2.5 7%
Moderate Agreement
Purple* 81% 4 14%
Yellow 79% 2 14%
Red 78% 3 17%
Space 73% 1.5 8%
Lower Agreement
Brown* 67% 5 21%
Blue 60% 2.5 23%
Paint-Line 55% 2.5 26%
Intensity 50% 3 31%
Em-Tone+ 40% 4 39%
*the actual figures within 1 point for brown and purple are acceptable because there were some wide fluctuations
in the estimate which brings the mean figure up.
+Emtone was a more subjective variable, but 61% of the data is consistent within 2 points.
But there still remains the question of comparability with other measures. There is error
in every measurement. The amount of error in a measure is indicated by various
estimates of the reliability of the measure. A test with a low reliability of, for example,
60, has more error than a test with a high reliability of, say, .80.
224
Authorities differ on recommended methods of inter-rater reliability statistics,
and there are few previous good examples in this field277. A supporting equivalence test,
such as Cronbach's alpha, used to demonstrate internal consistency between items
measuring the same attribute is recommended278.
Table 17. to show means and standard deviations* of rater scores for each variable over
the sample of 7 pictures. There is a maximum of 20 point scores for each variable.
Simple counts are used.
Variable
name Rater 1 Rater 2 Rater 3 Rater 4 Rater 5 Rater 6 Rater 7
Red 5.29(4.31) 6.86(5.52) 6.14(4.88) 6.86(4.26) 5.00(4.00) 5.57(4.20) 6.43(5.16)

Yellow 7.43(5.47) 7.57(5.00) 7.14(4.49) 7.86(5.61) 7.57(5.38) 7.57(5.88) 8.14(5.64)
Orange 3.57(7.16) 3.57(6.88) 3.71(6.97) 2.71(7.18) 3.14(7.08) 2.57(6.80) 3.14(7.08)
Purple 5.29(7.57) 4.86(5.90) 4.00(5.45) 4.71(6.78) 5.00(6.88) 3.57(4.79) 4.14(5.70)
Green 6.86(4.88) 6.86(4.95) 6.29(4.96) 5.57(4.04) 6.29(4.54) 6.43(4.47) 5.86(4.45)
Blue 9.29(6.63) 9.71(6.50) 8.86(6.23) 8.71(5.94) 10.43(6.35 10.00(6.35 8.14(5.34)
Brown 5.28(5.50) 3.43(4.58) 3.00(5.20) 4.86(5.43) ) ) 3.14(5.40)
White 0.86(2.27) 1.00(2.65) 1.00(2.65) 1.00(2.65) 3.29(4.72) 5.43(6.40) 0.00(0.00)
Black 12.14(6.31 11.86(6.31 11.43(6.21 12.14(6.54 1.00(2.65) 11.86(6.59)
Intensity ) ) ) ) 0.57(1.51) 11.71(6.45 16.67(3.35)
Paint-Line 15.38(4.46 14.48(2.57 16.19(4.03 16.33(3.41 11.29(6.52 ) 7.76(4.74)
Draw-Line ) ) ) ) ) 14.67(4.23 0.76(2.02)
Space 5.62(4.41) 7.19(4.64) 6.19(3.80) 7.19(4.84) 16.86(3.57 ) 7.34(4.11)
Em-Tone 0.81(1.86) 0.62(1.50) 0.62(1.64) 1.38(3.65) ) 6.29(3.82) 13.76(4.95)
Form 8.46(5.36) 8.11(4.79) 8.49(4.97) 7.00(3.96) 6.81(4.98) 0.71(1.89) 4.57(5.88)
13.05(4.01 13.86(2.62 15.62(3.75 13.52(3.90 0.81(2.14) 7.94(4.66)
) ) ) ) 7.97(4.61) 13.00(3.21
5.57(5.56) 4.86(5.96) 4.71(5.88) 12.52(4.94 )
4.57(5.88) ) 4.86(5.52)
4.71(5.88)
*S.D. in parenthesis
Table 19. Inter-rater reliability showing Cronbach alpha score for internal consistency
of scores between raters; and correlation coefficient for linear association between scores
of raters.
Variables Cronbach Intra-Class

Alpha
Red .987 .975

Yellow .994 .988
Orange .995 .991
Purple .993 .986
277
Graham Dunn (1989), Design and Analysis of Reliability Studies: the statistical evaluation of
measurement errors, London: Arnold, recommends the correlation coefficient; Carol Taylor-Fitzgibbon &
Lynn Lyons-Morris (1987), How to analyse Data, Beverley Hills, CA: SAge, echo the concerns of Altman
that linear association does not imply agreement and suggest additional notes of discrepancies and
difference statistics.
278
Fitzgibbon & Morris (1987) op.cit.
225
Green .994 .988
Blue .993 .984
Brown .966 .934
White .994 .988
Black .998 .995
Intensity .962 .926
Painted line .950 .905
Drawn line .983 .966
Space .993 .987
Em Tone .961 .925
Form .992 .984
Table 19 presents the results of the inter-rater correlations analysis. The two
statistics support each other and give scores for each of the 15 elements of the test and
are comparable with every other study which has been covered in the literature analysis.
As the significance of a reliability co-efficient is its absolute size, the closer to 1.00 the
better, the overall reliability for raters was excellent for each element across the range of
paintings (alpha >.98): Bausell's recommended reliability floor of .60 is well exceeded279.
However, Altman's point on the inadequacy of the correlation coefficient is well taken,
since the variation in the subject matter (pictures 1-7) is quite large (see raw data tables
1-15, which show the data count for each rater for each variable, appendix 2), and this has
possibly falsely increased the value of r, because of large fluctuations. It is
inappropriate to use a measure which is sensitive to variation in the subjects and Altman
extends this criticism to the use of regression analysis for the same purpose. It is
however wise to use a correlation index, cautiously for support, to check for negative
correlations; even though the level of scoring may be close, its rhythms may vary. It
remains to say that the most informative statistics we can get for this study are those
279
R. Barker Bausell (1986), A Practical Guide to Conducting Empirical Research, New York: Harper
Row, p.204-6.
226
shown in table 16, the mean difference and limits of agreement, which provide a good
summary of the data.
Conclusion
It may seem that I have gone into too many tests in this section, but the importance of
method comparison is paramount here for the individual subject and it is important to
show why this method rather than another is used; there is little point in taking
measurements between groups if the measurement method has poor repeatability, or if
judgements may be made at different levels since systematic variation will occur.
The limitations of this type of test and the resources available must be
remembered here. For unreplicated studies it is difficult to compare the repeatability of
the measurement and thus also the resulting statistics because there are no other studies
with a similar systematic approach which publish enough information to allow it. In
some ways the test defines itself: if 6 raters are used, they have either learnt the method
or not, and the variation in their scores will indicate the limits of agreement. The general
trend of the measure indicates that the method is repeatable, but the raters are
inexperienced, they were less motivated than I should have liked and the sample size was
smaller. Good agreement can only be reached when all raters are accurate. The
correlations were high and the level of agreement only varied within 1 points for 76% of
the scale, and within 2 points for 86%. I therefore claim good reliability was achieved.
Weaknesses of the instrument and problems with rating
227
All of the scales were understood by the raters at the time except for FORM, where the
basic rating criteria were not followed, rendering analysis irrelevant, so it was not
reported at that time, pending further research. Further research amongst professional
artists found that the terminology referred to an artistic application which visual
description or definition varied considerably even according to their own criteria280.
There was theoretical agreement that significant or dominant form referred to dominating
structural regular shapes. Wadlington and McWhinnie281 also found that the term
Dominant Form caused much confusion amongst raters, their advice was to discard the
term 'dominant', but this merely fogs the form definition and removes the essential
element, in my opinion. A further test, done with 7 similar University students (2 male,
5 female age 19-24), without an art background and with a more detailed explanatory
sheet282, produced a reliability score of 0.99. The students needed to look at the picture
as a whole first, and the position of the term dominant form at the end of the rating sheet,
and the previous sectioning into grids may have influenced the previous raters'
understanding of the process, so repositioning of the form element was indicated.
280
see appendix 5: Artist's form questionnaires, sample copy. I used these among 15 trained and training
artists to determine how the parameters of my definition should change.
281
Wadlington and McWhinnie (1973) op.cit.
282
see Appendix 5 again, more detailed explanation, category slightly changed.
228
3. Study 1
Permission and ethics: This project was submitted and passed by the North
Staffordshire Medical Ethics Committee 1994. Permission to access patients notes and
to use the paintings for research was sought primarily directly from patients themselves
through written or oral consent and also from the consultant psychiatrists in charge of
their case. Consent forms explained the project in simple terms, that patients would not
be identified and that the project had no connection with the treatment of patients.
Sample consent forms and explanatory notes for patients can be found in Appendix 5.
Oral consent was taken by hospital staff from the ward with whom the patient was
already acquainted. One patient withdrew her pictures from the study pool although she
attended the groups and made pictures with the rest until the end.
Patient Selection: 39 participants were drawn from mixed sex wards of a psychiatric
hospital serving an industrial community in North Staffordshire, England. The hospital
accepts the full range of adult psychiatric disorder requiring admission. Four self-
contained specialised wards were selected to provide subjects for the study. These wards
treated substance abusers, the psychiatric consequences of brain injury, and psychotic
disorders. The substance abusers were out-patients who attended a general hospital ward
weekly; the other three wards were in-patient acute admission. The brain injury and one
rehabilitation ward were sited in a large country mental hospital, the other psychotic
ward in a community based mental health centre.
229
Table 1: Demographics for experimental groups. Study 1
Total Sex M Sex F Age Age S.D.

Mean
Entire Population 50 33 17 34.8 11.0
Affective Disorder 9 6 3 38.0 11.0
Non-Affective Psychosis 10 7 3 36.8 11.4
Brain Injury 11 10 1 38.4 14.6
Drug Abuse 9 7 2 32.2 6.4
Controls (staff) 11 3 8 29.0 8.2
Table 1 shows demographic statistics: 39 psychiatric patients and 11 controls made
paintings in the same conditions according to the same set criteria with standardised
materials.
Choice of subjects
Patients: The groups of patients were chosen for availability and ease of access. Only
patients who were judged able to give their consent and who volunteered participated.
There were no larger groups of patients with a single diagnosis available, but primarily
this investigation was to test the sensitivity of the measure - and also to give an idea
whether general effects (patients against controls) against specific effects shown in the
literature could be investigated (diagnostic differences). Most of the patients were in
acute stages of illness.
Controls: 11 staff members from the Substance Abuse ward and from the Community
Mental Health Centre, these included student nurses with no experience of therapy
groups, agreed to act as controls and completed their paintings together with the patient
230
groups, so that control conditions were identical to those of the patients. The advantage
of the same conditions and environment outweighed unequal numbers.
Exclusions: Most patients identified were included in study 1 and there were no
exclusions for missing data. The study was voluntary and therefore did not encompass
the whole population of the identified wards. One patient who was found to suffer a
psychiatric disorder other than those mentioned was dropped from the study. 2
unidentified pictures which were probably by student nurses were also dropped from the
study.
Measures
Age and sex were recorded and their means are shown in Table 1.
IQ was not recorded as IQ was not routinely tested and the researcher was not clinically
involved with patients and had no training for such measurement. In addition, such
measures are known to be unreliable with psychiatric populations, chronicity and drugs.
Drugs: patients were mostly under assessment and were on low or no drugs although this
was not always true, many were suffering from the effects of previous use of unidentified
substances.
Chronicity of patients: It was initially decided to examine work by new patients in
acute stages of illness and wards were selected with this aim to control for traditionally
identified indicators which have been described previously as common to the institutional
environment or the long term effects of drugs. However, patients were difficult to
231
classify, even as in and out patients. The wards selected dealt with acute illnesses, but
casenotes revealed that although most patients were in acute stages, the majority had
previous admissions and few were new to hospital admission.
Diagnosis
The ICD10 clinical diagnostic classifications were taken from patients hospital records.
Description of the use of ICD10 for the purposes of this research appears in the
instruments section of the Main Study.
Inter - rater reliability - DF. made all the clinical decisions, but decisions which differed
from what appeared in the patient record were discussed with the psychiatrist in charge
of the case.
The DAPA
The DAPA rating guide version 2 was used which appears in Appendix 4. This was
essentially similar to that presented with the Main study, however there were
differences:
1. One statistic appears for Line as a summary of painted and drawn lines. Although
drawn line was distinguished from painted line when estimating variability of
thickness, the two types of line posed relational problems in judgment. They
were separated in the rating guide when interrater reliability was measured. The
method of summarising was; squares would be scored as varied if either a drawn
or painted line was of variable thickness; or there was a thick drawn line together
232
with a thin painted line; or where a thick painted line appeared together with a
thin drawn line;
2. There was no form measurement; and
3. Space was rated as an estimate of how full the picture was in tenths, whereas
further development changed to the more successful 'bubble method' presently
used in Version 3 (main study) and interrater study. Version 2 of the DAPA
rating guide can be found in Appendix 4. Scoring procedures were the same.
Treatment of missing data
Painting Combination: Not all the subjects completed all the paintings. This could
produce bias, as content in the early paintings is therefore emphasised. A Kruskal-Wallis
ANOVA performed on the groups and the number of paintings each patient completed
suggested a trend (_2 9.22, df=4, p=0.056). The number of paintings from each patient
was collapsed into three ordered categories (1; 2, or 3; 4 or 5), and two-way ANOVAs
(No. of paintings by diagnostic type) were performed on four significant variables. The
variable scores did not vary with the number of paintings (F=0.02-0.52, df=2, N.S.), and
there were no significant interaction effects (F=0.43-0.59, df=6, N.S.).
Outliers: no extreme values were excluded in study 1 as this was an exploratory study
and numbers were too small to determine whether these were important.
Distribution of data: There was no need for transformation of data for the initial study
as the Kolmogorov-Smirnov goodness of fit test revealed a normal distribution over the
variable spread. Most of the raw data was rank-ordered or classificatory, but the final
233
score for each subject was a ratio of the distribution of each variable over their output of
paintings, fulfilling the conditions for parametric analysis.
Comparison of groups: Statistical procedures are the same as those covered in the main
study. Analysis of variance tests compared the variances for individuals within and
between groups and tested the differences between the means of five diagnostic types
over each of the 13 variables. However, Anova assumes the same variance between all
groups and there may have been variance differences between groups not apparent
because of the small samples, which would mask differences. The Multiple Range Test
(Duncan procedure), which applies t-tests between each independent sample for each
variable and which used the Bonferroni correction for multiple comparisons, highlighted
the most different groups as before. This use of the Bonferroni is most suitable for
groups with uncorrected variances. If differences of variances exist, it is likely that
variances between groups are different as whole.
Procedure
Procedure for diagnoses: ICD-10 diagnoses were made in the same way as the main
study, from case records by Dr. D. Foreman D.F. was blind to the originating ward and
paintings while making the diagnoses.
Table 2: Diagnosis: Assignment to type.
ICD-10 DIAGNOSTIC CATEGORIES (1993) N Assigned

to type
Moderate Depressive Episodes: (1 X F31.6, F32.1, F32.10; 3 X F33.1). 6 1
234
ICD-10 DIAGNOSTIC CATEGORIES (1993) N Assigned
to type
Schizophrenia/Psychosis: (1 X F10.73, F16.7, F19.5, F19.7, F20.0, F20.1, 10 2
F25.0, F25.2; 2 X F20.5).
Organic Brain Injury: (1 X F06.3, F06.8, F10.6; 5 X F07.0). 8 3
Substance Abuse: (1 X F10.4, F11.2, F12.2, F18.2, F19.3; 4 X F10.2) 9 4
Moderate Recurrent Depression + Alcohol Dependency: (F33.1 + F10.2). 1 1
Specific Personality Disorder: (F33.1 + F60.8). 2 1
Huntingdons + Dementia: (G10 + F02.2). 2 3
Organic Psycho Syndrome + Epilepsy: (F07.9 + G40). 1 3
Diagnostic types: (1) Affective Disorder, (2) Non-Affective Psychosis, (3) Brain Injury, (4) Drug Abuse
Table 2 shows category definition of case assignment to 4 types; Affective
Disorder (n=9); Non-Affective Psychosis (n=10); Brain Injury (n=11); Drug Abuse
(n=9). This includes six cases with multiple diagnoses whose assigned categories are also
shown. Type assignment was made on the basis of the clinically presenting
psychopathology on admission; e.g. a case presenting drug dependency and psychosis,
not resulting from immediate drug toxicity was categorised as Non-Affective Psychosis.
All the patients available for art in the identified wards were used. This meant that some
patients had secondary diagnoses and may have overlapped groups.
Painting Generation: The paintings were produced in art familiarisation groups, run
as part of the recreational program of the hospital. All painting procedures were
discussed with the region's art therapist to maximise the experiential and reducing
similarity to psychotherapeutic sessions.
The art groups took place at the same place and time each week in daylight hours,
took one hour a week for 5-6 weeks, and contained up to 8 participants who were either
patients or staff from the ward. I knew the patients from the non-patients but was
unaware of diagnosis and therapeutically unacquainted with the group. I ensured that
235
each participant received the same materials and instructions and maintained a neutral
supportive atmosphere in collaboration with a member of the hospital's therapeutic team
in each ward. The work was collected and rated by me at the end of the series.
Participants painted in rooms where there were no pictures visible. They worked in
groups of two and three, placed so that they could not see each others work without
effort. Table tops rather than easels were used so that art could take place in the usual
environment of the ward rather than in a special place which may have proved difficult
for some participants. Two of the wards had not previously been offered art, but this
approach limited disruption to ward routine. The other two groups had used this format
before.
Themes were set to hold the content constant and provoke personal involvement
from the patients, because it is recognised that sometimes methods such as free painting
can be demanding for people with functional impairments and they often produce no
picture at all283. The thematic focus was self portraiture: previous research on draw-a-
person studies has demonstrated that figure drawing works across a wide variety of
abilities, and suggests some personal involvement with the work. Staff were instructed
to be encouraging but not to make comments or suggestions. The same subject matter
was specified in all groups for 5 sessions based around self portraiture: (1) Draw yourself
(2) Draw yourself as you would look if you were an animal (3) A picture which shows
you doing something you enjoy (4) A picture of your life with future and past (5) A
picture which shows how you are feeling now. One person with cerebral injury used 5
283
J.B. Couch (1994), DDS Research with older people diagnosed with organic mental syndrome and
disorders, Art Therapy, V.11(2):111-115.
236
sessions for the self portrait because of his extreme slowness in manipulation, producing
only 2 paintings in all. All the other participants were asked to finish their paintings
within the hour. Most participants made one painting per session, although one or two
individuals drew two or more for the first session. All groups had a mixture of art
materials; wax crayon, tempera paint, pencil and thick and thin brushes so that the range
of colours and line quality was available. Most of the paper provided was white 17" x
12", but some 24" x 17" was also available. Materials were set on the table from the
start.
237
Results
Interaction effects: The mean age of the staff was only slightly lower than that of the
other groups but there was a clear predominance of males in the sample (see table 1).
Only one variable, Space, was found to be influenced by Sex. Space was initially
identified as a variable which distinguished between groups, but there was an interaction
effect with Sex. When co-varied (2-way ANOVA F=0.89, df=4, P=0.47) neither variable
turned out to be significant by itself. No other variable was influenced by sex.
Paintings: Table 3 identifies differentiating variables in bold type, using the Duncan
procedure; significant ANOVA results are indicated.
Table 3: Multiple ranges: group means significantly different at 0.05% level. Dncan
Procedure.
Groups Affective Non-Affective Brain Injury Drug Abuse Controls

Disorder Psychosis
n = 10
n=9 n = 11 n=9 n = 11
VARIABLE mean SD mean SD mean SD mean SD mean SD
Red .24 .17 .42 .19 .22 .17 .25 .16 .42 .33
Purple .08 .11 .05 .11 .13 .23 .14 .18 .05 .11
Green .34 .22 .28 .20 .23 .19 .27 .24 .32 .27
Blue .37 .25 .28 .19 .34 .26 .31 .17 .44 .16
Brown .20 .19 .16 .14 .13 .23 .33 .18 .14 .17
White .08 .11 .05 .09 .10 .13 .12 .09 .11 .21
Black .60 .27 .45 .27 .40 .28 .44 .23 .50 .32
Space 7.71 1.79 5.81 2.65 5.84 2.85 7.42 1.92 7.90 1.74
Em tone 1.83 .22 1.95 .26 2.04 .13 1.83 .20 1.90 .39
Yellow+ .14 .11 .18 .15 .12* .15 .29 .16 38* .33
Orange+ .13* .14 .04* .07 .04* .06 .37 .13 .07* .09
Intensity+ 1.92 .53 1.99 .40 1.96 .46 2.00 .48 2.50 .36
Line+ 1.38 .50 1.73 .28 1.13* .70 1.56 .37 1.99* .72
df = 4.
+ Variables identified by ANOVA as Significantly differentiating groups at the 5% level: yellow (p<0.02)
orange (p<0.00) colour intensity (p<0.02) line (p<0.01).
* Groups differentiated by the multiple range test as significantly different p<0.05
Orange, Yellow, Intensity and Line all distinguished between diagnostic categories
(p<0.02). There were, furthermore, appreciable differences between the control group
and all groups of patients. Substance abusers showed differences in their greater use of
238
orange. Brain Injury were the next most distinguishable type, and there was least
difference between non-affective psychosis and affective disorders.
Discussion
Much of the first study was done on an exploratory basis and some procedures could
have been better controlled. The group containing mostly patients with brain injury and
also the affective disorder group made a small number of paintings on coloured paper,
which may have influenced the choice of colours. However, this effect was minimised
through averaging between paintings for each patient. The paintings were rated from the
obvious 'right way up' and from the identification procedure which marks the back right
hand corner of the work, but orientation of the paper to landscape/portrait might have
had distortion effects on composition, thus influencing the space score, especially with
the brain injury group. Better control would have been achieved by specifying particular
orientation of the paper.
Few dimensions from previous studies actually compared with the variables of
this study. However, the meta-analysis of the literature, supported by the qualitative
analysis, showed significant differences in ratings of form variables relating to patient
status and between patient groups. The results of this study were consistent with these
findings, although not with the conclusions and 'common knowledge' implied in the
literature, especially for depressed patients: their use of black was similar to that of other
patients, but they did use more orange than psychotics, normal controls and brain injured
patients; their paintings did not seem more negative than those of other patients. There
239
was no evidence of impoverishment for Depressed or Schizophrenic patients. Unlike
previous literature284, space filled did not discriminate groups. However, the size of
paper used was not standardised and varied between 17" x 12" and 24" x 17". This had
the effect that the media became more widely distributed over the picture plane, thus
variably reducing the score for space. Emotive tone did not produce a discriminable
dimension, possibly because it was measured as a distribution over the picture plane.
This would tend to even out positive and negative scores to neutral.
The diagnoses were consistent with the ICD-10 (1993), but patients with
multiple diagnoses were included. This may have blurred the distinction between groups
and so produce conservative errors. Some non-significant results could easily be due to
lack of power, owing to small group size. However, this does not explain the positive
results.
Conclusion and limitations of the study
This study presented a reliable method of describing paintings for research in an
appropriate systematic way suitable for analysis. The method is general enough to be
used by investigators with different theoretical backgrounds and shows promise for
future development. The sample size of this study was only sufficient to categorise
differences in patients and controls as the clinically differentiated groups were very small
and included mixed diagnoses. There were suggestions, however, that this measure may
284
A. Kirk & A. Kertesz (1989), Hemispheric contributions to drawing, Neuropsychologia, V.27(6):881-6;
J.H. Wright & M.P. Macintyre (1982), The Family Drawing Depression Scale, J. Clin. Psychol.,
V.38(4):853-61; M. Milkjkovitch & G.M. Irvine (1982), Comparison of drawing preferences of
schizophrenics, other psychiatric patients and non-schizophrenic children on a draw-a-village task, Arts in
Psychotherapy, V.9:203-16; and N.M. Knapp (1994), Research with diagnostic drawings for normal and
Alzheimer's subjects, Art Therapy, V.11(2):131-8.
240
detect formal differences in the painting of patients with different psychiatric diagnoses.
The study also showed selection bias, which, although impossible to quantify, merits
some consideration due to the nature of volunteer groups.
241
Chapter 5. Results
This chapter presents the results of the main analyses for study 2. There are 3 sections:
1. Treatment of the data, which details the preliminary procedures to prepare the
raw data for analysis; control of potential confounding variables, and
transformation to normal distributions where appropriate;
2. Results of the main analyses.
3. Results of the subordinate analyses.
Preparation of the data
Transformation of the data: Tables and figures 1a-l, 2a-f and 3a-f can be found in
Appendix 2. This set of statistics presents the raw data before and after transformation.
Each variable is shown as: (i) Boxplots, for easy comparison between groups; (ii) Tables
of means, for each group and whole population; (iii) Spreadlevel plot of the logarithmic
co-ordinates for each group from which the Levene statistics are calculated. Other tables
which summarise the information are presented in text.
Variables which did not show a normal distribution
There was marked heterogeneity of variance within groups for 9 untransformed variables;
red, yellow, orange, purple, brown, white, painted line, drawn line and form. Tables and
figures 1a-i (appendix 2) show the raw data for variables which were transformed or
deleted. Levene test results and projected transformations of the data to achieve normal
distributions are presented in table 4 below.
242
Table 4, showing projected transformations for data based on computations designed to
verify the assumptions of the ANOVA test.
Tests of homogeneity of variance [df1=4; df2=104]
Dependent Levene Statistic and Power for Action

variable significance level transformation
Red 3.0023 (p=0.02) .329 SQRT

Yellow 4.2948 (p=0.00) .709 SQRT
Orange 5.4983 (p=0.00) .529 SQRT
Purple * * *
Green 1.9975 (p=0.10) .789 LEAVE
Blue 1.2702 (p=0.29) -.198 LEAVE
Brown 3.1268 (p=0.02) .544 SQRT
White * * *
Black 2.7400 (p=0.03) 1.391 SQUARE
Intensity 2.5948 (p=0.04) 0.502 SQROOT
Paint-Line * * *
Drawn-Line 2.9744 (p=0.02) 1.241 SQUARE
Space 1.6085 (p=0.18) 4.756 LEAVE
Em-Tone 2.4954 (p=0.05) 1.622 SQUARE
Form 6.0704 (p=0.00) 0.657 SQROOT
* Median not positive so LN of Spread vs LN of Level is not plotted.

Homogeneity of variance not tested. Insufficient unique spread/level pairs to compute the regression slope.
Table 5, showing transformed data based on computations designed to verify the

assumptions of the ANOVA test.
Tests of homogeneity of variance [df1=4; df2=104]
Dependent Levene Statistic and Action

variable significance level
Red 0.6942 (p=0.5976) RETAIN

Yellow 1.8480 (p=0.1253) RETAIN
Orange 4.7938 (p=0.0014) +
Brown 1.2466 (p=0.2959) RETAIN
Black 5.0957 (p=0.0009) *
Intensity 2.8094 (p=0.0292) +
Drawn line 1.8426 (p=0.1263) RETAIN
Em tone 2.4488 (p=0.0508) +
Form 1.0938 (p=0.3636) RETAIN
* Squaring the data did not produce appreciable difference and the removal of outliers did not affect the
distribution. Therefore no clear appropriate transformation of this figure emerged.
+ Although there was some improvement on Orange, values remained highly significant so this variable
was dropped. The other 2 variables, Emotional Tone only gained slightly and was only just significant
in its original state so was judged better left within tolerance (0.05); Intensity became significant on
transformation (p=0.04) so it was also left.
Variables left untransformed
Transformation achieved no better results for homogeneity in the population than the
original statistics for 3 variables: black, intensity, emotional tone (tables/figs 2a-f,
243
appendix 2) and these were left in their original state along with those that showed
homogeneity in the Levene tests: green, blue, space (table 4 below).
Transformed variables
6 variables were successfully transformed: red, yellow, brown, painted285 and drawn line,
form, (tables and figures 3a-f, appendix 2). Levene calculations for homogeneity
appear in table 5 above.
To summarise, twelve variables which remained in the final analysis, transformed
or not (tables 2a-f and 3a-f). Two variables, Purple (see table/fig. 1d, appendix 2) and
White (1h, appendix 2), were dropped at this stage for 2 reasons; (1) their values were
not plottable because of insufficient use, and (2) homogeneity tests within the analysis
of variance (Bartletts-Box, detailed later in this chapter, table 8) showed their range was
unacceptable. Plots of their standardised differences (plots 7b and c,) showed
concentration of cases below the mean. White was obviously irredeemable; the plot (7a,
appendix 2) showed concentrations at 0 for all groups. Purple however (7b), looked more
promising: although there were concentrations below the mean (at very low levels) for
most groups, group 4 showed a wider scatter of differences. Cutting off all values of
Purple above 0.28 (9 cases) did not redeem the median from negative but Bartletts-Box
showed acceptable homogeneity (F = 1.751; p=0.136). However, all previous
significance disappeared when the ANOVA was calculated (F = 1.81; p=0.132). These
285
Painted line was retained because, although the square root transformation of Painted Line had a
negative median, the calculation for the Bartletts Box test (table 8) placed the variance within acceptable
levels.
244
findings are unreliable because cases were mostly removed from one group: 6 cases from
the control group, 2 from group 5 and one from group 3, so purple was dropped.
There were 2 further variables, Orange and Black ((table/fig 2a and 2b, appendix
2), which showed significant heterogeneity in the groups. Transformation of the data did
not produce appreciable difference and the removal of outliers did not affect the
distribution. Therefore no clear appropriate transformation of these figures emerged.
The assumption that the groups came from populations with the same variance is
important: the standard differences from the mean of each variable by group was plotted
(Plots 6a-m and 7a-c, appendix 2). The plot for Orange (7a) clearly shows that diagnostic
groups 1 and 4 have a much wider scatter of differences than the others and there are
cases concentrated below the mean. The plot for Black (6f) shows only one group
(controls) with wide variance and no concentrations of cases. The results of the
Bartletts-Box Homogeneity of Variance Test286 (table 8 below) showed the range was
unacceptable for Orange and it was dropped from the analysis, but was within tolerance
for the ANOVA for Black which was retained.
Normality of the final distribution
There were 12 remaining variables (tables/figures 2a-f and 3a-f, appendix 2 show mean
values, standard deviations and standard error of the mean (how much the sample means
vary in repeated samples from the same population)). Most of the standard errors were
286
Bartletts test is an extension of the F test for assessing the null hypothesis that more than two samples
come from populations with the same variance, recommended with ANOVA: P. Armitage and G. Berry
(1987), Statistical Methods in Medical Research, Oxford: Blackwell, p.209.
245
fairly small, less than 0.1, indicating homogeneity within groups. There were no
consistent outliers which could be easily eliminated and at this early stage it was not clear
exactly what was important, so it would be unwise to change the data, and possibly the
assumptions, merely to decrease the noise in the data.
5 plots of group variances (plots 6a-m shown as the standard differences from
each group's mean, Appendix 2) showed a wider scatter of differences for diagnostic
group 4 (controls) generally, and five show a smaller scatter for group 2 (depressed). Six
plots showed concentrations of group 1 (schizophrenics) cases below the mean, but
generally the plots show a similar overall distribution for each of the five groups on every
variable. A certain amount of deviation does not compromise the ANOVA test, even in
unbalanced designs, providing group sizes result from chance fluctuation as fits the case
here.
The Main Analyses: comparison of Groups
Table 9 identifies 10 variables as significantly different, using the results of an ANOVA
performed among the 4 patient groups and the control group, pairwise comparisons are
indicated using the modified LSD procedure, which compensates for multiple tests. F-
values are shown in table 8.
246
Table 8: showing results of analysis of variance for the purpose of identifying diagnostic
grouping variables between 4 groups of psychiatric patients (total n=86) and 1 control
group (n=23) on 13 formal measures of their paintings.
DAPA mean (S.D.) Confidence Bartlett-Box F. F.

Variable Interval Homogeneity Ratio Prob.
of variance
(sig. level)
Blue .26 .20 0.22-0.30 1.62 (0.17) 1.00 .409

Brown .30 .24 0.26-0.35 0.75 (0.56) 1.64 .170
Orange .09 .12 0.07-0.11 6.42 (0.00) 1.63 .172
Red .45 .26 0.40-0.50 1.00 (0.41) 4.33 .003

Yellow .38 .25 0.34-0.43 0.95 (0.44) 2.62 .039
Green .25 .23 0.20-0.29 1.79 (0.13) 4.25 .003
Black .46 .28 0.41-0.51 2.24 (0.06) 8.12 .000
Intensity 1.96 .48 1.87-2.05 2.45 (0.05) 3.41 .011
Paint Line .31 .49 0.42-0.60 2.37 (0.05) 3.21 .015
Drawn Line 1.03 1.05 0.83-1.23 2.05 (0.09) 3.86 .006
Space 2.00 .48 1.91-2.09 0.96 (0.43) 3.05 .020
Em'Tone 2.14 .36 2.07-2.21 2.48 (0.04) 5.34 .001
Form .39 .21 0.35-0.43 1.25 (0.29) 6.31 .000
Table 9: Multiple Comparisons: Duncan Procedure
GROUPS Affective Schizophrenia Personality Drug Abuse Controls

Disorder Disorder
n = 18 n = 35 n=9 n = 24 n = 23
VARIABLE mean SD mean SD mean SD mean SD mean SD
blue .21 .16 .25 .18 .26 .15 .24 .20 .33 .26
brown .29 .24 .24 .24 .34 .16 .30 .21 .39 .27
Red☺ .47 .25 .43 .26 .47 .26 .30* .18 .59* .26
Yellow☺ .45 .26 .30* .24 .40 .20 .35 .20 .49* .29
Green☺ .26 .25 .21* .22 .21* .16 .16* .16 .40_ .27
Black☺ .50*# .27 .30_# .21 .43# .27 .66*$ .18 .48*# .32
Intensity☺ 2.04 .51 1.75_ .52 2.09* .36 1.96 .29 2.17* .51
Linepaint☺ .59* .47 .55 .52 .50 .55 .22_ .29 .69* .53
Linedraw☺ .84* .69 .93 1.16 1.39# 1.27 1.62_# 1.00 .57*$ .79
Space☺ 2.07* .54 2.00 .47 2.22* .29 2.13* .47 1.73*_ .43
Em tone☺ 2.14* .20 2.11* .29 2.16* .38 1.94* .42 2.38_ .36
Form☺ .23_# .18 .37*# .16 .39*# .19 .41* .19 .53*$ .25
Analysis of Variance
df = 4; ranges 2.81-3.12; harmonic mean cell size = 17.8327
☺ Variables identified by ANOVA as significantly differentiating groups (p<0.01)
☺ Variables identified by ANOVA as significantly differentiating groups (p< 0.03)
Duncan procedure
_ Variable 1 identified as significantly different from other marked(*) variables at 0.05 level.
$ Variable 2 identified as significantly different from other marked(#) variables at 0.05 level.
General results: The only variables from 12 tested which did not differentiate groups
at the 5% level were Blue and Brown.
247
Red, Green, Black, Drawn Line, Emotional Tone and Form all distinguished
diagnostic categories at high levels of significance (p<0.01, see table 2), and 3 of these at
very high levels (p<0.001)287. A further 4 elements: Yellow, Intensity, Painted Lines and
Space were all statistically significant (p<0.05). Multiple comparisons (Duncan
procedure) highlighted appreciable differences between pairs of groups (bold figures in
table 9) which were particularly apparent in the paintings of the control group (all 10
elements highlighted, and 4 sole differences) and in drug abusers (7 from 10, 3 sole
differences) and to a lesser extent through the other 3 groups (personality disorder 7 from
10, others on 6 from 10 variables). The confidence intervals for all groups were plotted
and significant differences between means are detailed below (plots 10a-l: specific
differences). Differences are marked in the same way as in Table 9 according to the
identification by the Duncan procedure
Substance abusers seem to have slightly lower standard deviations generally, but
small variations are not a problem for ANOVA. The confidence intervals for the total
population, shown in table 8, between Red, Black, Painted Line and Form, are generally
quite similar -ranging about 10 points and suggest there may be correlations between
these measures. None included 0, so even the 'non-significant'variables were contributing
to an effect.
Specific differences:
287
Although most statisticians do not recommend quoting significance levels above 0.01 as they are
unreliable and may fluctuate with minor changes.
248
Colour: Red, Yellow and Brown are distinguished by *T* (meaning transformed). The
normal distribution was achieved by taking the square root transformation; the lower
values were pushed from zero (no red) towards 1 (colour in every part of the picture).
The greatest effect was to compress the latter half of the scale (half covered - fully
covered), so that a score of 0.75 reveals that half the picture has the colour in it. The
dotted line indicates a half way point on each plot. The plots are divided in two. The
upper section shows those groups showing significant differences, with the differential
single group in bold, and the whole group is marked '*'. Where there are two differences,
there are two bold differentials; group* first, the second group is marked '#'.
10a. Confidence intervals and means by diagnostic type

for variable RED *T*
______________________________________
_ : _
*2_ •_|__• : _2 Substance abuse
_ : _
T *4_ •___|___•: _4 Controls
Y _ : _
P ______________________________________
E 1_ •__|__• : _1 Schizophrenia
_ : _
3_ •____|___• : _3 Depression
_ : _
5_ •______|_____• : _5 Personality disorder
_ : _
______________________________________
0 .25 .5 .75 1 *(p<0.05) identified by the
Duncan RED procedure as
significant
*T* Red: Red is a warm colour. Chapter three's summary of the literature reports
expectations that schizophrenics and depressed patients would use less warm or bright
colours, other patients and controls, more.
249
1. Neither schizophrenics nor depressives were distinguishable from other patient groups
or controls.
2. Substance abusers used hardly any red, were the lowest scoring patient group, and
scored significantly lower than controls.
3. Diagnostic differences were not distinguishable between patient groups; personality
disorder spanned all groups.
4. As expected, the mean of the controls was higher than all patient groups (although not
significantly different from any except substance abusers).
There was no evidence for red as a predictor of schizophrenic or depressive diagnosis.
10b. Confidence intervals and means by diagnostic type

for variable YELLOW *T*
______________________________________
_ : _
*1_ •__|__• : _1 Schizophrenia
_ : _
T *4_ •___|___• : _4 Controls
Y ______________________________________
P 2_ •__|_• : _2 Substance abuse
E _ : _
3_ •___|___• : _3 Depression
_ : _
5_ •____|____• : _5 Personality disorder
_ : _
______________________________________
Duncan YELLOW procedure as
significant
*T* Yellow: Yellow is a bright warm colour. Schizophrenics and depressives were
reported to use dark, gloomy colours and expected to use less yellow than controls.
250
1. Schizophrenics but not depressives used very little yellow and significantly less than
controls.
2. Diagnostic differences were not distinguishable between patient groups.
3. Against expectations, depressives covered the same range as the controls, so therefore
there was no indication of low quantities of yellow as a predictor of depressive diagnosis.
10c. Confidence intervals and means by diagnostic type

for variable GREEN
______________________________________
*4_ •__|___: _4 Controls
_ : _
*1_ •_|__• : _1 Schizophrenia
T _ : _
Y *2_ •_|_• : _2 Substance abuse
P _ : _
E *5_ •___|___• : _5 Personality disorder
_ : _
______________________________________
_ : _
3_ •___|___• : _3 Depression
______________________________________
Duncan
GREEN procedure as significant
Green: Green is a darker colour. Schizophrenics and depressives could be expected to
use more green than other groups.
1. All patients except depressives used significantly less green than controls.
2. Diagnostic differences were not distinguishable between patient groups although
substance abusers used least.
3. Depressives used as much green, but not more than controls so more green was not
a depression indicator and less green was not a schizophrenic indicator since
251
schizophrenia was indistinguishable from other patient results. The lowest mean was for
substance abusers. Patient status could be inferred from less green but not depression.
10d. Confidence intervals and means by diagnostic type

for variable BLUE
______________________________________
1_ •_|_• : _1 Schizophrenia
_ : _
T 2_ •__|__• : _2 Substance abuse
Y _ : _
P 3_ •_|__• : _3 Depression
E _ : _
4_ •___|___• : _4 Controls
_ : _
5_ •___|___• : _5 Personality disorder
_ : _
______________________________________
Duncan
BLUE procedure as significant
Blue: Blue is a dark cool colour so patients, especially depressive and schizophrenics
could be expected to use more than controls.
1. There were no significant differences within or between patients and controls so blue
was not an indicator for patient status.
10e. Confidence intervals and means by diagnostic type

for variable BROWN *T*
______________________________________
1_ •__|__• : _1 Schizophrenia
_ : _
T 2_ •__|__• : _2 Substance abuse
Y _ : _
P 3_ •___|___• : _3 Depression
E _ : _
4_ •___|___• : _4 Controls
_ : _
5_ •___|_• : _5 Personality disorder
_ : _
______________________________________
Duncan
BROWN procedure as significant
252
*T* Brown: is a dark, sombre and neutral colour, commonly understood as a dead colour,
associated with waste and particularly excretion. More use of brown in pictures by
depressives and schizophrenics than other patient groups could be expected, and more
from patients than controls.
1. There were no significant differences within patient groups or between patients and
controls.
2. Against expectations, the control group mean was the highest (although not
significantly higher) than patient groups. There was no evidence to support indications
of schizophrenia, depression or patient status from use of brown. All groups used
equally low quantities.
10f. Confidence intervals and means by diagnostic type

for variable BLACK
______________________________________
*1_ •_|_• : _1 Schizophrenia
_ : _
*2_ : •__|__• _2 Substance abuse
T _ : _
Y *3_ •____|___• _3 Depression
P _ : _
E *4_ •____|:___• _4 Controls
_ : _
5_ •______|______• _5 Personality disorder
_ : _
______________________________________
Duncan BLACK procedure as
significant
253
Black: Black is the darkest colour and has a common association with death and
emptiness. Depressives were expected to use most, schizophrenics next, other patients
could be expected to use less black and controls least.
1. Depressives were not differentiated from controls on use of black.
2. Schizophrenics used least black, significantly less than depressives and controls.
3. Depressives, schizophrenics and controls used significantly less black than substance
abusers. These results indicate support indicators of schizophrenia for small quantities
of black, which is against expectations. The highest score was from substance abusers,
who spread black consistently throughout more than half of the picture surface and were
differentiated from all other groups. Controls and depressives were not differentiable
from non-schizophrenic other patients on high or low use of black.
254
10g. Confidence intervals and means by diagnostic type
for variable INTENSITY OF COLOUR
________________________________________
*1_ •__| • _1 Schizophrenia
_ : _
*4_ : •__| • _4 Controls
_ : _
*5_ : •___|__• _5 Personality disorder
T _ : _
Y ________________________________________
P 2_ : •|• _2 Substance abuse
E _ : _
3_ : •__|__• _3 Depression
_ : _
________________________________________
0 1 2 3 *(p<0.05) identified by the
Duncan
INTENSITY procedure as significant
Intensity: commonly understood as brightness or tone of colour, and here also related to
saturation of colour. Schizophrenics and depressives were expected to use subsets of
low scoring, dark, mixed colours or weak and watery, gloomy and often monochrome
tones; other patients were expected to be mid-range. Controls were expected to use
bright saturated colours.
1. Against expectations, controls were indistinguishable from depressives.
2. Schizophrenics scored significantly less than controls and less than all patients, were
indistinguishable from depressives as expected, but were also indistinguishable from
substance abusers.
There was no evidence to support the diagnosis of depression, or indeed, patient status
from dark, muddy or watery pictures, but there was a tendency for lower intensity
pictures in schizophrenia. This probably also reflects a proportion of neutral scoring like
255
the other groups since no confidence interval takes in 1(low) or 3(high).
Structural variables
Line: was understood as a defining border: outlines, lines used in pattern, dots, writing,
broken line, straight ruled lines, and not blocks of colour intended for shading or close
patterned pencil lines for shading which were treated as blocks. It was rated light/thin,
varied (where thin lines appeared with thick), thick/heavy.
Line quality was split into painted and drawn lines for ease of rating, since where
pencil line coincided with painted line, the relative difference in thickness always
polarised the pencil to thin and the painted to thick, thus creating ambiguities in the
information. The scoring task asked for relative thickness of the lines within the picture.
The literature tends towards expectations of thick or heavy lines for patients.
Controls were expected to have more range, and substance abusers, speculatively, might
suffer difficulties in control similar to people with brain injury, which are said to produce
thin or shaky lines.
10h. Confidence intervals and means by diagnostic type

for variable PAINTED LINES
_______________________________________
_ : : _
*2_ •__|_• :t :v t_2 Substance abuse
_ :h :a h_
T *3_ •____|___• :i :r i_3 Depression
Y _ :n :i c_
P *4_ •____|___• : :e k_4 Control
E _ : :d _
_______________________________________
1_ •___|___• : : _1 Schizophrenic
_ : : _
5_ •________|________•: : _5 Personality Disorder
_______________________________________
.25 .75 1.25 1.75 *(p<0.05) identified by the
Duncan
0 .5 1 1.5 procedure as significant
PAINTED LINES
256
Painted lines: The normal distribution was achieved by taking the square root
transformation, the effect of this is to push the lower values, below one, up from zero
towards 1, and compress 1-3, so the maximum score becomes 1.73 (thick lines covering
the paper).
1. No group's paintings were characterised by thick painted lines.
2. Controls were not separable from other patient groups other than substance abusers.
3. In line with expectations, substance abusers scored less than all other groups, but
scores indicate lack of use of line rather than thin lines; they were not separable from
schizophrenics. There was no evidence to support the diagnosis of depression,
schizophrenia, patient status or control status from thick or thin painted lines. Scores
indicate lack of use rather than proliferation of thin lines.
10i. Confidence intervals and means by diagnostic type

for variable DRAWN LINES
_______________________________________
_ : : _
*2_ •|• : _2 Substance abuse
_ :t :v t _
*4_ •| • :h :a h _4 Control
T _ :i :r i _
Y *3_ •| • :n :i c _3 Depression
P _ : :e k _
E 5_ •___|__• :d _5 Personality Disorder
_______________________________________
1_ • |• : : _1 Schizophrenic
_ : : _
_______________________________________
0 2 4 6 8 *(p<0.05) identified by the
Duncan
DRAWN LINE procedure as significant
257
Drawn line: The normal distribution was achieved by squaring the results, so as to push
lower values which bunch just below one (thin lines), down the scale towards 0, and to
expand the range from varied lines (4) to thick, the maximum score (9: thick lines covering
the picture).
1. No group's paintings were characterised by thick drawn lines.
2. Substance abusers used significantly more lines than controls and depressives.
3. Controls used less drawn lines than any group.
4. Schizophrenics were not differentiable from controls, or from substance abusers, they
either used thin or no lines, but their range, in line with expectations was similar to that
of depressives.
There was no evidence to support the diagnosis of depression, schizophrenia or patient
status from thick drawn lines, which were rarely used even by controls. Patients with
personality disorder showed the greatest variability in use of drawn line but were still
predominantly in the thin range, however this result is probably compromised by small
numbers. The division of drawn/painted line is supported because the groups changed
relative positions, particularly controls and schizophrenics which reversed their
orientation.
10j. Confidence intervals and means by diagnostic type

for variable SPACE
______________________________________
*4_ •|• _4 Controls
_ _
T *2_ •| • _2 Substance abuse
Y _ _
P *3_ • | • _3 Depression
E _ _
*5_ •|• _5 Personality disorder
258
______________________________________
1_ •|• _1 Schizophrenia
_ _
______________________________________
0 1 2 3 4 5 *(p<0.05) identified by the Duncan
SPACE procedure as significant
Space: here understood as the amount of paper uncovered by media, but measures of
space in the review differ. For each gridsquare the largest single uncovered area was
estimated on a scale of 1-5 using increments of up to 10%, 10-25%, 25-55%, 55-80%, 80-
100%. This gave an estimate of the proportion of media coverage, distributed through
the picture. There was no firm consensus on what to expect, since previous measures
have mostly relied on the virtual space within the picture as it conforms to perceived
visual perspective (the picture plane) and results have been equivocal. With these
methods, it is difficult to estimate whether a 'space' is unused, because uncovered paper
may be part of a picture by implication. Generally depressed and schizophrenic patients
were expected to leave more empty space than controls and other patients as there was
evidence for more 'impoverished' work.
1. As expected, controls left significantly less empty space than depressives and
substance abusers and patients with personality disorder.
2. Against expectations neither depressives nor schizophrenics were differentiated from
other patient groups.
3. Schizophrenics were not differentiable from controls.
4. No group consistently left a large proportion of their pictures empty.
Controls did cover more of the picture surface than most patient groups, but there was
no evidence to support the diagnosis of schizophrenia from either high or low
259
proportions of empty space in the picture. Patient status may be indicated from
consistent empty space in the picture, but not depression.
10k. Confidence intervals and means by diagnostic type

for variable SUBJECTIVE EMOTIONAL TONE
_______________________________________
*4_ • | • _4 Controls
_ _
*1_ •|• _1 Schizophrenia
_ _
*2_ • | • _2 Substance abuse
T _ _
Y *3_ •|• _3 Depression
P _ _
E *5_ •__|___• _5 Personality disorder
_ _
_______________________________________
0 1 2 3 *(p<0.05) identified by the
Duncan
SUBJECTIVE EMOTIONAL TONE procedure as significant
Content: The rater was asked to first look at the picture as an integrated whole, including
the content, as to which areas communicated a positive or negative (or more simply -
happy or sad) feeling to the rater. The same gridsquares were used to section the positive
and negative areas of the picture. Obviously this element could not wholly encompass
content, but is simply a crude and simplistic measure of emotional tone of the picture.
The paintings of schizophrenics and depressives were expected to look more negative
than other patients and patients pictures were expected to look more negative than
controls.
1. As expected, the pictures by controls were significantly more positive than those of
all patients.
260
2. Schizophrenics and depressives were not differentiable from other patients.
3. The lowest scores by patients (although not significantly lower) were from the
pictures of substance abusers.
There was no inclination towards negative for patient status but controls did score
positively relative to patients. There was no support for the diagnosis of schizophrenia
or depression from high levels of negative emotional tone.
10l. Confidence intervals and means by diagnostic type

for variable DOMINANT FORM
______________________________________
*3_ •__|__• : _3 Depression
_ : _
T *4_ •___|__• : _4 Controls
Y _ : _
P *1_ •| • : _1 Schizophrenia
E _ : _
*2_ •__| • : _2 Substance abuse
_ : _
*5_ •____|____• : _5 Personality disorder
_ : _
______________________________________
Duncan
DOMINANT FORM procedure as significant
Dominant Form: This element aimed to cover a composite of variables which indicate
mass, shape and focus and composition; the rating criteria asks for the largest regular
shape which defines the structure of the picture. The literature review indicates that
disturbance or degeneration of form was one of the salient features of psychiatric illness
generally, especially in schizophrenia. Pictures by patients were expected to show little
form and controls the most. Between patients, schizophrenics should show less form
than other patients.
261
1. Depressives showed significantly less dominant form in their pictures than any other
group.
2. As expected, the pictures of controls showed the most dominant form (significantly
more than depressives, schizophrenics and personality disorder).
3. Substance abusers' pictures were not significantly lower than controls (but they were
significantly higher than depressed).
4. Against expectations, schizophrenics showed significantly more dominant form in
their pictures than depressives.
There was no evidence to support the diagnosis of schizophrenia rather than any other
patient group from lack of form, but depression may be indicated by such. Controls did
score more than any patient group, but this may not be an indicator of health as such,
because substance abusers overlap these scores.
Summary of results by characteristics of typical pictures from all other groups:
• Schizophrenia: pictures showing very little black, of low intensity with some
dominant form.
• Substance abuse: high levels of black, low green, drawn lines not painted, some
dominant form.
• Depression: moderate levels of black (less than half the picture, but more than a
quarter), no dominant form.
• Personality disorder: less than half the picture black, low green, higher intensity,
some dominant form.
262
• Controls: more positive emotional tone, and half or more of the picture contains
the dominant form.
Additional characteristics of controls: more red, yellow and green than other
paintings, more intense colours, painted rather than drawn line and less empty
space.
Predictive value of the DAPA for patient status
In order to find a combination of variables that classified a large proportion of subjects
into the correct group so as to have good chance of allocating (diagnosing) new subjects
correctly, the Discriminant Analysis technique was used to determine predictive value
of the DAPA. A preliminary attempt between patient groups used the whole sample of
109 and yielded the percentage of grouped cases correctly classified as 81%. However,
some caution was warranted in interpreting this figure because the classification functions
were derived from the group of study; most authorities recommend reserving an
independent data set on which to assess the fitness of the model288.
A much sounder approach, at this stage was to divide the whole sample into two
samples patients and non-patients and derive the classification functions using one of the
samples and then, using these functions, to attempt to classify those subjects in the
second sample as either controls or patients. Table 11 presents the results of the
classification for the section which derives the functions and for the reserved section
(which acts as the independent data set) repeated with five different partitions. The
288
D.G. Altman (1994), Practical Statistics for Medical Research, London, 5th Ed. original 1991:
Chapman Hall, p.359.
263
function contributed significantly to classifying the cases because the groups differed
significantly. The Wilks lambda was typically around 0.4 which indicates around 60%
discriminative power, which is not particularly high, but moderate. The derived Chi
Square statistics were typically 34, which was highly significant (p=0.000). This model
therefore had moderate discriminative power.
No variables were correlated with the discriminant function higher than 0.6 and
more typically 0.3-0.5, so there is no simple interpretation from one or two influencing
factors, more a complex interaction of the contribution of different variables.
The final part of the analysis was the classification of cases according to the
derived function. SPSS predicts which group a subject belongs to by calculating which
of the mean values of the discriminant function it is closest to. This classification
appeared to be highly successful on the data set from which it derived the function, and
overall was 86-97% correct. Using the derived function on an independent data set (half
the sample) it proved 75-95% correct classification, which is reasonable considering the
numbers.
The next chapter will discuss the implications of these results, their relation to
what is already known and augment them with exploratory and confirmatory subordinate
analyses.
264
TABLE 11: Discriminant analysis to classify controls or patients. Classification
functions from the first sample are used to classify the second sample. Repeated 5 times
with different partitions of the data set. 86 PATIENTS 23 CONTROLS.
Actual Cases selected for use in the analysis Cases not selected for use in the analysis
Group
No. of Predicted Group Membership No. of Predicted Group Membership

Cases ill well Cases ill well
ill 42 40 2 44 43 1
95% 5% 98% 2%
well 10 2 8 13 3 10
20% 80% 23% 77%
correctly classified: 92% correctly classified: 93%
ill 40 48 0 38 37 1
100% 0% 97% 3%
well 18 7 11 5 1 4
39% 61% 20 80%
ill 44 43 1 42 39 3
98% 2% 93% 7%
well 13 5 8 10 5 5
38% 62% 50% 50%
ill 38 38 0 48 39 9
100.0% 0% 81% 19%
well 9 1 8 14 6 8
11% 89% 43% 57%
ill 42 40 2 44 41 3
95% 5% 93% 7%
well 10 5 5 13 5 8
50% 50% 38% 62%
Comparison of effect with the previous literature
The results of the t-test indicate that 6 variables: 4 structural and 2 colour, discriminate
patients from controls at a highly significant level (p<0.01) and a further 2 colour and 2
structural variables at an acceptable level of significance (p<0.05). Only 2 colour
variables do not differentiate patients from controls, blue and black, but black has been
shown to indicate inter-group differences and it is one of the differentiating variables for
265
the discriminant analysis. It will be noted that 2 variables have a negative t-value, which
indicates the direction of the results (using a 1-tailed test, the differences lie on the other
tail, therefore the tabled p-value was halved).
Table 12: t-test results for significant differences between means of variables measured from
paintings/pictures by patients against those of non patients as though they were independent.
variable from Patients non-patients F 2 T- Sig.ce

DAPA n=86 n=23 Value tail value level
mean SD mean SD df=107 prob
Red 0.4064 0.243 0.5945 0.262 1.16 0.606 3.25 0.002

Yellow 0.3567 0.233 0.4895 0.286 1.51 0.185 2.31 0.023
Green 0.2063 0.204 0.4018 0.267 1.72 0.083 3.81 0.000
Blue 0.2413 0.178 0.3307 0.259 2.13* 0.015 1.56 0.131*
Brown 0.2761 0.223 0.3944 0.270 1.46 0.219 2.16 0.033
Black 0.4542 0.264 0.4767 0.320 1.47 0.217 0.35 0.729
Intensity 1.9036 0.462 2.1725 0.508 1.21 0.526 2.42 0.017
Painted line 0.4618 0.476 0.6929 0.528 1.23 0.496 2.02 0.046
Drawn line 1.1494 1.077 0.5667 0.787 1.87 0.096 -2.42 0.008+
Space 2.0721 0.466 1.7304 0.430 1.17 0.695 -3.17 0.001+
Em Tone 2.0735 0.332 2.3846 0.363 1.20 0.543 3.92 0.000
Form 0.3567 0.185 0.5332 0.246 1.78 0.065 3.77 0.000
*Significant level of p from F-test, indicating non-homogeneous groups, therefore this variable used the separate variance T-test
(df=27.8) rather than the pooled variance.
+direction of sign indicates direction of results so the significance level is 2-tailed.
Table 13a: the separate effect size for each variable from the DAPA test, based on the calculation of D =
SQRT * 1/n1 + 1/n2 * t-value (patients/nonpatients).
Variable D (Effect V Lower/Upper weight W*ES = WD

size) confidence limits W=1/V
Red 0.7629 .0578 0.5226 - 1.0033 17.3082 13.2059

Yellow 0.5423 .0565 0.3047 - 0.7799 17.7132 9.6053
Green 0.8944 .0588 0.6519 - 1.1368 17.0139 15.2170
Blue 0.3662 .0557 0.1302 - 0.6023 17.9464 6.5721
Brown 0.5071 .0563 0.2698 - 0.7443 17.7666 9.0086
Black 0.0822 .0551 -0.1527 - 0.3170 18.1366 1.4901
Intensity 0.5681 .0566 0.3302 - 0.8060 17.6720 10.0383
Paint 0.4742 .0561 0.2373 - 0.7111 17.8134 8.4469
Em-tone 0.9202 .0590 0.6773 - 1.1631 16.9519 15.5993
Form 0.8850 .0587 0.6427 - 1.1273 17.0361 15.0769
TOTAL 0.595 175.36 104.26
sigma =0.08 Conf. interval (0.4465 - 0.7426) homogeneity stat 11.4075 (p>0.5 Chi-sq 8.34 df=9)
Positive T-Values
best estimation of sum(wd) = 104.26 = 0.595
effect size sum(w) 175.36
266
Table 13b: the separate effect size for each variable from the DAPA test, based on the
calculation of D = SQRT * 1/n1 + 1/n2 * t-value (patients/nonpatients).
Variable Effect size Lower/Upper weight W*ES

D V confidence limits W=1/V = WD
Draw -0.5681 .0566 -0.8060 - -0.3302 17.6720 -10.039

Space -0.7441 .0576 -0.9842 - -0.5041 17.3472 -12.909
TOTAL -0.656 35.02 -22.95
sigma = 0.17; Conf. interval (-0.9865 - -0.3241); Homogeneity stat. 0.2714 (p<0.5 Chi-sq 0.45 df=1)
Negative T-Values
best estimation of sum(wd) = -22.95 = -0.655
effect size sum(w) 35.02
All variables were included in the evaluation of effect size of the study. 6 colours and 4
structural variable with positive values of t gave an aggregated effect size of 0.60, and 2
structural variables with negative values of t gave an aggregated effect size of 0.66. The
positive and negative values are separated following the recognised procedure289.
It can be seen that all variables except Black have a confidence level which does
not include 0, and therefore reach significance above the 5% level. The derived effect size
is therefore above medium effect according to Cohen290 (rough guidelines d= .2 [small];
d=.5 [medium]; d=.8 [large]), where studies from Chapter 2 were around 0.40 for the
best, most interpretable studies. It is advised that we take our guidance directly from the
prevailing acceptable levels in the literature, so the DAPA test represents a high effect
for this field and a considerable overall improvement on previous tests. It covers most
of the categories identified as common to the literature except those specifically
separating items of content.
289
Rosenthal (1984) op.cit. recommends this procedure rather than ignoring the t-test signs when
calculating effect size.
290
Cohen 1977, quoted by F. Wolf (1986), Quantitative Methods for Research Synthesis, Beverley Hills:
Sage.
267
Subordinate Analyses
Interaction effects
Sex: The demographics showed more females than males, especially in the control group.
Two variables, Emotional Tone and Yellow were found to be influenced by Sex. When
co-varied (2 way ANOVA; yellow - F=0.10, df=4, P=0.98; emotional tone - F=1.14,
df=4, P=0.34), this was found to be a function of the combination of the main elements,
and neither variable was significant by itself.
Painting Combination: Not all the subjects completed all the paintings. This could
produce bias, as content in the early paintings is therefore emphasised. A preliminary
Kruskal-Wallis ANOVA performed on the groups and the number of paintings each
patient completed seemed to indicate a covariate influence (_2 17.30, df=4, p=0.0017)
from the raw (i.e. untransformed scores). The number of paintings from each patient was
collapsed into three ordered categories (1 or 2 paintings; 3-5 paintings or 6+), and two-
way ANOVAs (No. of paintings by diagnostic type) were performed on the final scores
for each variable to determine interaction effects for the number of paintings on the score
for any variable remaining in the analysis.
Table 14 shows that interaction effects were not significant and variance was
mostly explained by differences in diagnostic grouping. Additionally, table 15 shows that
only one variable from 13 was correlated with the number of paintings done (p=0.01, for
the Substance abuse group). We can safely ignore one significant score from 65 on the
268
basis that multiple tests produce the odd significant figure. Therefore the number of
paintings done did not affect the average score.
Table 14: Results of 2 way ANOVA - diagnostic groups by No. of paintings from each
patient to show the influence of number of pictures on differences between groups was
insignificant.
Variable Source of Variation Covariate Explained

(Diagnostic Type) (No. of Pictures)
df=4 df=1 df=5
F value and sig.(p) F value and sig. (p) F. Value and sig.(p)
Red 4.913 (p=.001) 0.131 (p=.718) 0.957 (p=.003)

Yellow 2.521 (p=.046) 3.473 (p=.493) 2.112 (p=.070)
Orange .986 (p=.419) 0.369 (p=.545) 0.862 (p=.509)
Green 3.897 (p=.005) 0.272 (p=.262) 3.372 (p=.007)
Blue 1.897 (p=.469) 0.404 (p=.527) 0.798 (p=.554)
Brown 2.604 (p=.040) 1.547 (p=.216) 2.392 (p=.043)
Black 9.469 (p=.000) 2.507 (p=.116) 8.077 (p=.000)
Intensity 4.765 (p=.001) 1.364 (p=.246) 4.085 (p=.002)
Line-Draw 3.757 (p=.007) 0.291 (p=.591) 3.064 (p=.013)
Area 2.731 (p=.033) 1.275 (p=.262) 2.439 (p=.039)
Em-Tone 5.052 (p=.001) 1.339 (p=.250) 4.309 (p=.001)
Form 7.128 (p=.000) 0.352 (p=.554) 5.773 (p=.000)
269
Table 15: showing correlations between No. of pictures within each group with each
variable.
Variables Schizophrenia Substance Affective Controls Personality

Abuse Disorder Disorder
n=35 n=24 n=18 n=23 n=9
Red .0535 .3558 .4304 .2143 -.3182

Yellow .1611 -.1658 -.1925 .2584 -.2029
Orange .0789 .1916 -.0063 .3820 -.3976
Green .0282 .1450 .1010 .0561 -.6751
Blue .1560 -.1978 .5046 -.1138 -.5477
Brown .1376 .2329 .5935* .3874 -.6028
Black .3339 .1735 -.0318 .3458 .3055
Intensity .3276 .0852 .0870 .2964 .2777
Line-Draw .1493 .0451 -.1239 .0302 -.5823
Area .2396 -.3166 .0188 -.0313 .2632
Em-Tone .1938 -.2097 .2522 .1694 -.4022
Form .2216 .3340 .4596 -.1506 .1234
Descriptive analysis: associations between variables
Correlations within groups: Bi-variate scatter plots for the significant variables showed
a reasonably elliptical pattern indicating a normal distribution of the data so the validity
of the associated hypotheses tests were not violated. The non-significant scatter plots
were checked for unusual patterns, which the Pearson's r is likely to underestimate. The
purpose of this analysis was to describe the association of the variables from the DAPA
test to provide information for the discussion of differences in the results of the DAPA
test to those of the literature and general expectations. Correlation tables for each
diagnostic group 16-20 measuring (a) colour and (b) structure can be found at the end of
appendix 2. Summary information is presented here.
There were most associations between variables for schizophrenics' paintings, especially
for colour:
1. All colours were correlated with intensity except black and brown.
2. Green was correlated with all colours except black.
270
3. Painted line correlated with red and green.
4. Yellow with brown and blue.
Intensity showed a relationship to bright colour and green appeared most consistently,
whereas only black was independent. The structural variables were mostly independent.
There were least associations between variables for paintings by substance abusers:
1. Only green and brown were correlated from colours.
2. Blue showed a strong negative relationship with form.
3. There were no associations of colour with intensity.
There were associations between variables for paintings by depressed patients:
1. Green showed a moderate correlation with black.
2. Green and yellow were moderately correlated with intensity.
3. Painted line negatively correlated with drawn line.
There were associations between variables for the paintings of controls:
1. Red and yellow were moderately correlated.
2. Intensity showed a correlation with red.
There were associations between variables for the paintings by patients with personality
disorder:
1. There were no correlations between colours.
271
2. Intensity showed a correlation only with red.
3. Drawn line was negatively correlated with painted line.
272
Chapter 6: Discussion
The question Is there sensitive psychopathological evidence presented in the artwork of
mental illness? has been answered. The bare results tell us that pictures by people with
psychiatric disorder contain some characteristic structural and content differences from
those of normal controls and furthermore, some of these characteristic differences are
specific to certain psychiatric disorders. The DAPA test has proved effective in that it
has been sensitive enough to detect differences relating to diagnostic grouping. But this
question has been answered before, and also proved positive if weak291.
Generally the DAPA test results agree with the other major contemporary
studies in the field, which is to say that they agree with the general direction of
assumptions of the literature. However, a close look at the areas of differentiation, each
of which are discussed below, gives very different discrimination factors. Therefore
another question presents itself How closely do the answers from the DAPA test resemble
what is generally 'known' from the rest of the field and if they do not what reasons have
we to think that the interpretation of the DAPA test answers are more valid than this
accumulated experience?. The answer to some of this question must be sought in what
is reported in Chapter 2. The DAPA uses formal measurements of structure whereas the
other tests were predominantly biased to content, in line with the clinical use of such
measures in the assessment of art therapy. The other tests are remarkably variable in the
291
See B. Cohen, J.S. Hammer and S. Singer (1988), The Diagnostic Drawing Series: a systematic
approach to art therapy evaluation and research, Arts in Psychotherapy, V.15(1):11-21, and my discussion
of their results, Chapter 2.
273
quality and reliability of their measurement, in the definition of their criteria, and their
results are often uninterpretable because of flawed methodology.
The DAPA, however, cannot simply claim a higher status if the test establishes
only the same general results but leaves questions relating to differences with what is
generally accepted from the accumulated experience of clinical professionals and other
major statistical studies open. The answer must be accompanied by the answer to these
subsidiary questions, one of which must be Why should we use the DAPA rather than
other tests?
If the DAPA results show a great divergence from established opinion, that
difference needs to be explained. The discussion explains the results from the DAPA and
their relation to the literature in 4 parts:
1. The discussion of the results tries to relate the findings of group differences
identified by the ANOVA and the complementary corrected t-tests (Duncan
procedure) to what are generally accepted as psychiatric characteristics from the
literature. It explains differences and correspondences with that literature and
speculates on how these elements are interpreted. Interrelations between the
DAPA variables, identified by the subordinate analyses from the Results section,
are discussed to determine associations which might affect the results and
possibly explain some of the deviations from established knowledge;
2. The findings of Study 1 (Chapter 4) are related to those of Study 2, exploring and
explaining the differences to find common correspondences;
274
3. The comparison of effect sizes with those of the literature review, from the
Results section, is discussed; and
4. The predictive value and derivations of the functions from the discriminant
analysis.
1. Comparison of the results with the predictions
Note on comparison with the literature: Generally, the style and format of the
literature reviewed in Chapter 2 of this thesis used content appraisal with selective
illustration of typical examples. Few studies measured any formal qualities, and these
were usually interpreted through a theoretical framework. Embedded in content appraisal
were assumptions that stylistic or formal features of the paintings of the patients were
reflective of mental disorder. These associations were not overt, and often described as
global or 'intuitive' assessment, and combining personal and objective dimensions. Often,
pictures were reproduced instead of explanations as 'obvious' examples of thought
disorder, or as illustration of the process of recovery, in which their descriptions were not
explicit (Where explanations occurred, they depended on the interaction of two or more
formal elements out of context292). Colour associations were rarely mentioned unless
important to the general message, were usually supported by the reported comments of
the patient about the work and differed considerably between studies. Furthermore most
authors advise that colour associations with content are individual. Therefore comparison
of the DAPA results with characteristics of underlying assumptions of the field, as well
292
Such as 'inappropriate colour', i.e. green faces, or structural anomalies, i.e. falling apart trees.
275
as being unreliable, would be methodologically difficult to justify. References to
interpretations of elements in single studies as typical examples would take comments
out of context and intention. Most 'tests' relate to protocols for art therapy practice, for
which the DAPA is not designed. The DDS approach to assessment cannot be compared
because they have produced no interpretable results so far, although their protocol is
widely used for art therapy assessment, the assessment process remains with the
experience and interpretations of the art therapist, not the 'test'. Therefore I have
concentrated on the theoretical influences of assumptions and 'intuitions' of all these
approaches in my comments on comparison of the DAPA scores with the literature or
to studies which use explicit descriptions or statistical evidence, using two of the most
influential and well known authors to disseminate research results on distinguishing
features of art to contemporary general and research literature, Wadeson and Amos293.
Both present easily digestible tabulations of common structural and content
characterisations and are regularly cited in recent literature.
Organisation of this discussion
The purpose of this discussion is to explore and discuss possible explanations for
differences in the results of the DAPA test to what has previously been found. The
secondary purpose, in further development of the test, was to determine any reduction
of the scales to increase efficiency if some of the scales measured the same quantities.
293
H. Wadeson (1980) Art Psychotherapy, New York: Wiley; (1987), The Dynamics of Art Psychotherapy,
New York: Wiley; (1992) (ed.) A Guide to Conducting Art Therapy Research, Mundelein, ILL: Am. Art
Therapy Assn; and Stephen Amos, The Diagnostic, Prognostic, and Therapeutic Implications of
Schizophrenic Art, Arts in Psychotherapy 1982, V.9:131-43.
276
The scales are explained in two sections; (a) colour and (b) structure. Section (a) includes
colour intensity because it adds to the conclusions for colour rather than for structure.
Summary Table of Results: Table 1
Red controls> substance abuse
Yellow controls> schizophrenics
Green controls> all patients except depressives
Black substance abusers> depressed/controls /pers'y disorder> schizophrenics
Intensity controls/ personality disorder> schizophrenics
Painted Line depressives /control>substance abuse
Drawn Line substance abusers> control or depressives; personality disorders> control
Empty Space control <all patients except schizophrenics
Form substance abusers/control> schizophrenics /personality disorder> depressed
Em. Tone control> all patients
The information generated by the DAPA naturally divides between two obvious
points: controls used more and brighter colours (except black), more line, form, space,
were more positive than other groups; and schizophrenics or substance abusers scored
least. Information from the correlation matrices between each group help to confirm,
explain or elaborate on earlier points from other data. To limit 'data dredging', the most
obvious hypotheses tests were the predictions from the discussion of the literature. The
expected associations were:
• Between bright colours and between dark colours reflecting their use together and
a negative correlation between bright and dark colours generally reflecting the
opposing emotional tone of the picture.
• Bright hues would generally correlate with intensity.
277
• There would be a correlation between all or most of: emotional tone, hue,
intensity and form reflecting increased aesthetic harmony with greater structure
and positivity of the picture.
• Between blue and brown reflecting their neutral status.
• Painted line would negatively correlate with drawn line because patients used little
painted and more drawn line.
Differences between groups - Colour
The focus is on the most important findings: Black differentiated substance abusers from
all other groups and schizophrenia from 3 other groups; green differentiated controls from
3 other diagnostic groups. Additionally, there were differences in colour associations
between diagnostic groups; Figure 3 summarises these relations. Art therapy research
has provided support for the assumption of a consistent relationship between colour and
emotion294, so the work of people with psychiatric disorders, which are often
characterised by mood disorder should differ from normal controls. It has been suggested
that colour usage is related to the adequacy of individual resources for integrating affective
experience295, a facility rarely developed in schizophrenics, so within group differences
should be expected. Presented here is a summary (table 2) by Amos, of the work of
Tarmo Pasto, 1968296, empirically developed from experience with the use of art in
294
Bernard I. Levy (1984), Research into the psychological meaning of colour, Am. J. Art Therapy, V.23,
(reprinted from V.19, July 1980, pp.87-91).
295
D. Rapaport, M. Gill and R. Schafer (1946), Diagnostic Psychological Testing, Chicago: Year Book
Publishers.
296
Tarmo Pasto (1968), The bio-mythology of colour: a theory, in I. Jakob, ed., Psychiatry and art: Art
278
diagnosis and therapy with psychiatric groups, which probably represents the common
knowledge of the field. Amos gives the qualification that hypotheses are of little
consequence without corroboration from other factors so there is very little emphasis on
this speculation where differences are not obvious.
Table 2: Interpretations of the use of colour in artistic productions: from S.P. Amos.
Colour Interpretation
Red Self, ego development, active relation to reality, physical-

emotional balance.
Yellow Inner emotionalism, frustration, threat to ego, identity with violent

inner forces.
Orange Aggressive resistance to dependency.
Blue Aloofness, lack of emotionality, spirituality, overtly controlled,

emotional blocking.
Green Suffering, resisting emotion, positive, dogmatic, insecure.
Violet- The psycho-sexual self, lack of proper sexual identification,

red troubled by sexual drives, emotionalism tied to sexual
frustrations.
Purple Passivity, uninvolved, tendency to depression, may represent

paranoid tendencies.
Black Absence of extrinsic emotion, hostility, bound, denying,

aggressive, fearful.
White Negation of both physical and emotional being, passivity,

receptiveness, spiritualness.
of interpretation and art therapy (Vol.2) New York: Karger, tabulated by in S.P. Amos, (1982) op.cit.
279
Figures 3. Map of Associations between colour variables measured between diagnostic
groups from the results of the DAPA test.
_____________________________________________________________________
a. Schizophrenics b. Substance abusers
red red
brown gree black brown gree black
yello blue yello blue
c. Depressives d. Personality Disorder
red red
brown gree black brown gree black
yello blue yello blue
e. Controls
red
brown gree black
yello blue
280
Figure 3 shows the results of the DAPA correlations as a map of associations between
colour variables. It is immediately apparent that each group differs within colour
associations, which informs the discussion of differences identified by the ANOVA
procedure. Controls used more of all colours than the patients, except black, in line with
expectations, they used lots of red and yellow, bright colours together (plot 3e), and
moderate dark colours, so their pictures probably looked brighter and fuller than the
patients. Depressives were nearest to controls, but there were associations between
green and black, dark colours, although these were little used. Personality disorder were
next; substance abusers and schizophrenics showed least use of colour. This finding
supports the general consensus which reports 'impoverishment' of work by
schizophrenics297 but does not support more frequent reports for work by depressives298
or by patients generally299.
297
Examples of later studies, see M. Miljkovitch, M. Irvine, (1982) Comparisons of drawing performances
of schizophrenics, other psychiatric patients and normal schoolchildren on a Draw-A -Village task, Arts
in Psychotherapy, V.9:203-16 differentiated schizophrenics from other patients; M.B. Morris (1995), The
DDS and the Tree Rating Scale: an isomorphic representation of Multiple Personality Disorder, Manic
Depressive and Schizophrenic populations, Art Therapy, V.12(2):118-128; Wadeson (1976, cited 1980,
op.cit.) found both complete and impoverished pictures in schizophrenia and noted impoverishment was
traditionally associated with psychotic depression, p.193; Amos (1982) op.cit. states that many of the
properties of Manic Depressives found by H. Wadeson and W.E. Bunney (1970), Manic Depressive Art:
a systematic study of differences in a 48 hour cyclic patient, J. Nervous and Mental Disease, V.150:215-
31 are also present in schizophrenia and "reflect dimensions important to diagnosis, prognosis and/or
treatment", p.141.
298
See H. Wadeson (1975), Suicide: expression in images, Am. J. Art Therapy, V.14:75-82; (1980)
op.cit., characteristics of unipolar depression by Wadeson, also tabulation of traditional literature, p.190
reprinted from Wadeson and Carpenter (1976), A comparative study of the art experience of schizophrenic,
unipolar depressive and bipolar non-depressed patients, J. Nervous Mental Disease, V.162(2):334-44; Later
example: H.Wright and M.P. McIntyre (1982), The Family Drawing Depression Scale, J. Clinical
Psychology, V.38(4):853-61; and Amos (1982) op.cit., endorsed and reprinted Wadeson & Bunney's
(1970) Mania/Depression table, low colour, closed forms, hopeless, empty.
299
S. Russell-Lacy et al. (1979) An experimental study of pictures produced by schizophrenic subjects, B.
J. Psychiatry, V.134:195-200 found that schizophrenics and other patients performed equally poorly when
compared with normals; C. Bergland & R.M. Gonzalez (1993), Art and madness: can the interface be
quantified, Am. J. Art Therapy, V.31:81-90, compared patients with personality disorder with normals
although they also found an effect for cross classified depression.
281
Schizophrenic pictures showed correlations between consistent and associated
moderate use of red and low yellow, green, blue and brown indicating multiple use of
colours, but from the results of the ANOVA, we can see that they used little of any
colour but red, so their pictures probably looked more monochromatic and bare.
Substance abusers tended to use only small amounts of muddy colours together (green
and brown), with a little bright colour (red or yellow) and lots of black, so their pictures
probably seemed dark and dramatic with sharp contrasts. Depressives used a little green
together with moderate black and bright colours so their pictures probably looked fairly
balanced. Colours used by patients with personality disorder showed balance in colour
but no associations; they used bright and dark colours moderately but little green and
mostly were not differentiable from the other groups. Blue and brown were used in
equally low quantities by all groups, but proportionally they would tend to add more to
the darker colours in the paintings of schizophrenics and substance abusers. There were
three obvious and important obvious discussion points in variations of use of colour
within groups in this study: (1) the use of green and (2) red in controls and schizophrenia
and the use of (3) black in all groups, but especially substance abusers and
schizophrenics. (4) Minor differences are discussed after.
Use of Green: Green was important in schizophrenic paintings. Green appeared with
all colours but black, especially yellow and multiple colours300. These findings are mildly
supported by impressionistic reports of a preference for, or inappropriate use of, green
300
Yellow was highly correlated with green and moderately with blue and brown, but not red. So given
that green was used most with yellow, and yellow turned up with blue and brown, multiple rather than
singular use of colours are indicated.
282
from the literature301. However, green was more apparent only relatively in
schizophrenics' pictures, because only a little more green was used than in other patient
groups; both schizophrenics and substance abusers used significantly less than controls,
who used twice as much. Depressives covered a wider range, but still used much less
green than controls. Judging from the placement of the groups, the interpretation of
suffering for green seems unlikely.
The use of red: Previous associations and preferences in patients have been found for
red and black302 especially for anger. In this study, controls used much more red than
patients (although they were differentiatedonly from drug abusers, who used least). The
confidence intervals for the use of red by depressives and patients with personality
disorder were wide (Figure 11a, results) so use was quite varied in these groups although
mean values show moderate amounts of red as in schizophrenia where the use was more
consistent.
The balanced use of bright and dark colours by depressives indicates that
diagnostic impressions of dark, sombre colours303 in clinical depression are unjustified.
301
Roberta H. Shoemaker (1978), The significance of the first picture in art therapy, Proceedings of the 8th
Annual Conference of the Am. Art Therapy Ass., (p.156-62) provides a good example of green used in
a bizarre way, especially for people. She describes the unnatural colouring of relatives faces in green as
particularly significant.
302
Frances F. Kaplan, Previous reports of preferences for red and black among patient groups (R. Langevin,
M. Raine, D. Day, K. Waxer (1975), Art, intelligence and formal features in psychotics' paintings, Arts
in Psychotherapy, V.2(2):149-158) may be explained through recent studies of representations of anger
(Frances F. Kaplan (1994), The imagery and expression of anger: an initial study, Art Therapy, V.11:139-
143). Kaplan found 52% of the 'angry' paintings of students presenting this combination and 33% more
only black or hot colours; Further research in 1996 (Positive images of anger in an anger management
workshop, Arts in Psychotherapy, V.23(1):69-75) reported that deliberately modifying these images
showed marked decrease in these colours and increase in blues and greens and 30% eliminated black and
red. Kaplan's qualification that colours were probably related to current mood state rather than propensity
for anger may indicate a lack of affect in depressives.
303
Wadeson (1980), op.cit. p.190 and Amos (1982) op.cit. p.140 summarises the majority of the literature
on the subject; for examples of these principles see D. Arrington (1991), Thinking systems- seeing
283
The DAPA results for depression are consistent with some studies showing brighter
colours used by depressives in treatment304.
Red was used by schizophrenics more than any other colour and thus could have
been clinically noticeable, supporting preferences for red in this group, but not for black,
which confidence interval was much shorter than the other groups and lower down the
scale (Figure 10f, results).
Use of red and black: Of the other groups, substance abusers alone consistently used
large amounts of black, but depressives, controls and personality disorder all used
moderate amounts with a much wider variability.
Generally then, there was no evidence of general patient preference for red, or
indeed black (except for substance abuse), but there were within-group differences. This
finding confirms the value of within-group comparisons, since findings for the whole
population would combine these quite different characteristics. Additionally, the
interpretation for red in table 2 is consistent with a more positive control position and
with the conclusions reached by those studies which found brighter colours in depressive
presentations.
systems: an integrative model for systemically oriented art therapy, The Arts in Psychotherapy, V.18:201-
211; M.D. Cagnoletta (1983), Artwork as a representation of object relation in the practice, Pratt Institute
Creative Arts Review, V.4:46-52; D. Heine and M. Steiner (1986), Standardised paintings as a proposed
adjunct instrument for monitoring mood states: a preliminary note, Occupational Therapy in Mental
Health, V.6(3):21-7, using modified Wadeson's table of characteristics.
304
Shoemaker (1978) op.cit. describes bright warm colours as the depressive patient touches her emotional
intensity in the process of treatment; S. Buchalter Katz (1985), Observations concerning the art
productions of depressed patients in short term psychiatric facilities, Arts in Psychotherapy, V.12(1):35-38
describes bright colours and happy scenes reflecting hope.
284
Use of Black: All groups except schizophrenics used more black than other colours.
Amongst the range of colours used by schizophrenics, black was not unusually low; the
variation is because schizophrenics used low levels of all colours but red.
Black wasn't correlated with any other dark colour, except in depressives, which
group showed a significant positive association between green and black. This linear
relationship occurs in no other group (plot 3c); other results show weak negative
correlations, which confirm that black was used rather more separately than any other
colour in other groups. The position of the depressives, as indistinguishable from
controls and below the much greater use by substance abusers, does not support the
commonly held belief that large values of black indicate depression305, since both
schizophrenics306 and depressives should then exhibit more of the characteristic than
other groups, and controls should exhibit less.
The DAPA results for black support the empirical conclusions of Kaplan307, that
black denotes strong affect in concurrent expression of anger; together with the
interpretation, from table 2 above, of aggression, fear or hostility, which includes the
absence of extrinsic emotion (which subjectively, may well characterise the drug
305
There is no doubt that angry, depressed and emotionally traumatised people do use large amounts of
black paint in their expressive work, a recent description of paintings by Soviet post-earthquake
traumatised children clearly contrasts their obsessive use of white, red and especially black with their
previous normal work and their gradual return to full spectrum (V.S. Gregorian, A. Azarian, M.B.
DeMaria and L.D. McDonald (1996), Colors of disaster: the psychology of the "black sun", Arts in
Psychotherapy, V.23(1): 1-14). However, Kaplan, and others providing hard data (including the above
study) used normal subjects.
306
Wadeson (1980), op.cit. reports her 1976 study of schizophrenics (Wadeson & Carpenter, op.cit.) 52
out of 56 patients drew designations of depressed feelings, describing typical black self-images.
307
Kaplan, 1994, 1996 op.cit. characteristics of anger.
285
abusers308, but not the schizophrenics). Thus the DAPA results agree with other
empirical studies.
The measurement procedures of the DAPA may have contributed to the
polarisation of scores between schizophrenia and substance abuse. There could be large
variations in quantity applied to an area and quality of tone, for example, a range from
pure black, rated as high intensity, and pencil lines, rated at low intensity. Large amounts
of pencil line would be rated at a very consistent intensity of black, which would make
it inconsistent with the fluctuations of the other colours. This explanation does fit with
the low negative correlations for black throughout. Schizophrenics are said to produce
fragmented and dissolute compositions309, indicating lack of or less certain outlines with
a corresponding low score and drug abusers could similarly have produced more pencil
lines. If this was the case then black scores should correlate with form or with drawn line
for schizophrenics and substance abusers; this hypothesis is examined in the discussion
of structure.
Minor differences:
yellow: All groups used moderate yellow except schizophrenics, but as before,
schizophrenics used little colour. This finding contradicts previous findings of increased
yellow in paintings by schizophrenics310, but this could easily be explained by
308
Communicated to the author in discussion with group and hospital staff post experimental period.
309
Wadeson (1980), op.cit. table of characteristics of schizophrenia, p.190; Amos (1982), op.cit. provides
typical examples.
310
Russell-Lacy et al. (1979) op.cit. found schizophrenics and normal controls used more yellow and
blending than other patients. Russell-Lacy mentioned that a 'template' was used to determine
286
differences in measurement systems. The finding that paintings of schizophrenics were
both low in yellow and black, according to table 2 seems to be contradictory.
'Neutral' colours: Blue and brown were indistinguishable for all groups and the range of
scoring was not wide. Blue was used moderately and brown was little used, controls used
less than any other colour, although they used more than patients (but not significantly
more). The groups most expected to use brown, seen as a dark dismal colour, were
schizophrenics and depressives, but they used less than any other colour. There was
thus no support for the use of blue or brown as an indicator of depression, psychosis or
patient status.
Indications for removal of colours/alterations: The removal of green, which was
associated in three patient groups; and blue and brown, which were non-discriminatory,
would effectively eliminate related colours in patient groups. Removal of associated
colours in controls would eliminate discriminatory factors. It would be useful to
discriminate pencil lines from black to eliminate ambiguity of media.
Summary for colour
It was expected that there would be correlations between bright and warm colours: red,
yellow and green and between any or all of green, blue, brown and black. Patients
generally, but especially schizophrenics and depressives, were expected to produce less
on the paper, use less colours, show preference for red and black and controls for
multiple colours, especially the brighter warmer colours.
quantification of colour and space, but generally this method and how many colours were measured was
undescribed. One result out of a possible 10 would not exceed chance expectations.
287
Control pictures showed the only association between the brighter colours, red
and yellow, but they were not the only group to use multiple colours: schizophrenics
showed association between all colours but black. Three of the other four groups showed
associations with green. There was no polarisation to darker colours/brighter colours for
any or all of the patient/control groups. The separation between controls and the
patients on quantity of colour is clear, especially in red and green. No colours, including
black, isolated depression or personality disorder. There were some positive indicators:
• Large quantities of black indicated substance abuse
• Small quantities of black indicated schizophrenia.
• Large quantities of red and green (and possibly yellow) indicated control.
Most of the literature seemed to suggest more chromatic variation311, but comparison of
the DAPA procedure with other major studies is difficult since they group colours or use
a system which includes opinion, such as 'inappropriate colour'312. Studies claim to be
supported by reference to the patient, but the assumption that the patient is an informed
source must surely be questionable, especially as most of the practical literature insist
that the art process is an unconscious one, that the associations are made afterwards, and
cannot be made by the patient alone313. This research generally refutes the diagnostic
311
W. L. Wadlington and H.J. McWhinnie (1973) The development of a rating scale for the study of
aesthetic qualities in the paintings of mental patients, Art Psychotherapy, V1(3-4):201-20, tested chromatic
variation between 5 patient groups (in value and tonality) but schizophrenics were separated from paranoid
schizophrenics. They found most depressives and neurotics scored higher than schizophrenics and patients
with adjustment reaction.
312
The DDS, Cohen, Hammer and Singer (1988), op.cit.; Linda Gantt (1990)A validity study of the
Formal Elements in Art Therapy Scale (FEATS) for diagnostic information in patients' drawings,
Unpublished Doctoral Dissertation, University Pittsburgh, Pennsylvania - 'colour fit'; The SPAR scale,
Bergland & Gonzalez (1993), op.cit. - expressive 'developmental' level.
313
T. Dalley and C. Case (1992), Handbook of Art Therapy, London: Routledge. This subject is addressed
288
interpretation of the meaning, quality of colour and emotional associations314 which have
appeared in the literature and are summarised in table 2. Taking into account the
diagnostic expectations,few of the common interpretations of the meaning or associations
of colours made sense within the placement of diagnostic groups in this study;
observations and experience reported in the literature probably related the colour more
to the content and associations from the subject. The explanation that the affect value
of a colour varies with some other characteristic of the painting315 would probably
demand a greater variation in the confidence intervals, so cautions from authors presenting
these theories which recommend support from other case related aspects, as with the
interpretations from Tasco are well founded. Generally the controls used more of all
colours except black. This tends to cast suspicion generally on the table of
interpretations since normality should not represent an extreme. Where agreement with
the interpretation was indicated, it was between patient groups but some indications were
contradictory. The lower extremes were split between substance abuse and
schizophrenia.
in the introduction.
314
R.R. Crane and B.I. Levy (1962) Color scales in responses to emotionally laden situations, J.
Consulting Psychology, V.26(6):515-9, different emotional situations lead to different colour scaling; I.G.
Martin, Universal vs learned emotional responses to colors: afterthoughts to thesis research, Arts in
Psychotherapy, V.9:245-7 discusses theoretical confusion of the literature on the relationship between color
and affect, whilst broadly supportive of universal meanings of colour.
315
Levy (1984/1980), op.cit. reported that colour and emotion were related, advised art therapists to
consider colour "yet another source of information about our clients, a valuable guide in forming helpful
reactions based on our clients' art work".
289
Structural variables
Figures 4a-e. Map of association of structural variables measured between diagnostic

groups using the DAPA test. denotes negative correlation.
_____________________________________________________________________
Schizophrenia Substance abuse
yellow red
Painted Drawn blue form

intensity Line Line
blue green
Depression PersonalityDisorder
yellow
Painted Drawn Painted Drawn

intensity Line Line Line Line
green
Controls
red
Painted Drawn
intensity Line Line
290
There were two obvious important associations between structural variables: associations
between intensity and colour for three groups, together with the association of painted
line and red/green for schizophrenia;and negative associations between painted and drawn
line.
Differences between groups - Intensity
The order of brightness was much the same as that of amount of colour: controls,
depressives, personality disorder, substance abusers and schizophrenics. We could
expect relations between hue and intensity because the first qualities are contained by the
latter, although not necessarily explicitly, but previous studies have found high
correlations for intensity with colour316. Figures 4a-e show associations in three groups
between intensity and different colours for each diagnostic group, confirming that
intensity was actually measuring brightness of colour. So colour analysis alone cannot
fully answer the question whether patients paint darker, or gloomier, pictures than
controls317.
Different colours in the paintings of patients and controls did vary systematically
and supported the combination of measurements of hue and chroma, rather than tone
316
Wadlington and McWhinnie (1973) op.cit., found correlation in hue and chroma and intensity of colour.
317
R. D'Andrade and M. Egan (1974) found that emotional associations with colour existed but were not
confined to hue but to the degree of saturation and brightness in normal populations, The colours of
emotion, American Ethnologist, Feb. 1(1):49-63. There are also indications, from preference studies, that
different psychiatric groups may see different colours as dark, such as depressives but not controls grouped
blue with dark colours in a study by M.J. Garvey and M. Luxenberg (1987), Comparison of color
preference in depressives and controls, Psychopathology, V.20:268-271.
291
directly, to answer this question. In combination with reference to the results for colour,
it can be deduced that:
• Schizophrenics scored mostly neutral, towards low;
• Substance abusers used extremes of high and low intensity;
• Controls and depressives used more variety in colour and intensity.
Personality disordered patients used a range of tone, but these scores were not
interpretable due to small numbers in the group.
The fact that there were no associations with black and intensity probably
reflected the use of pencil. More pencil (scored as black) would not score higher in
intensity, neither would large quantities of pink (scored as mixed red).
Scores for schizophrenia indicated that most colours used were bright, especially
green and yellow, since as more colour was used, the score for intensity increased.
None of the substance abusers' colour scores related to intensity. The confidence
interval for substance abusers was very short which indicated a high degree of conformity
in the group. They scored only slightly higher than schizophrenics on intensity (who
scored the least), therefore colours were mainly used as neutral (mixed). The explanation
of equal coverage of high (3 saturated) and low intensity colour (1 mixed muddy or
watery colours) is possible but it is unlikely they would consistently use every colour
in this way.
Depressives used bright green and yellow but not red (Figure 4c), indicating some
bright colours but muted reds and greys, not a prevalence of dark, gloomy, low intensity
292
colours as predicted, which would show up as a correlation between dark colours and
intensity.
Controls used bright red consistently, but not bright yellow or green (the reverse
of depressives), because intensity was correlated only with red. There is a correlation
between high red and high yellow (figure 3e; but increases were more variable,
scatterplots 17: results) which implies they were used together but high scores on
intensity had more to do with the presence of red. Therefore there was minimal influence
on judged intensity from yellow as for green, blue, brown and black nor negative
influence. This indicates more muted colours for controls and not bright colours as
previously thought (except red), but it is likely that controls used more mixed colours,
thus creating a more positive 'feeling' of light and harmony, which probably positively
influenced emotional tone and intensity ratings.
Evidence supports the suggestion that the domination of the picture by gloomy
and low intensity colours (not black) indicates disturbance of thought, but not depression
or substance abuse. Controls did prefer bright colours; they were not, however,
characterised by lack of use of the 'gloomy' colours and they used a varied range of
intensity. These results suggest varied hues would be appropriate rating criteria for
controls.
There was evidence to support the sectioning of patients into high and low
intensity by diagnostic type, even though the high category included black, since it
seemed to isolate certain patient groups, but it would probably increase diagnostic rigour
to eliminate neutral from the intensity category. Although intensity correlated with red,
293
yellow and green, its removal would remove a discriminating variable for schizophrenics,
and in combination, intensity may contribute to the qualitative interpretation of the
structural variables. It would probably be better to incorporate it into a reduced colour
list.
Differences between groups - Line quality
Older studies mention thick heavy line for patients, especially schizophrenics318. In the
DAPA study, thick line was notably absent: if thick lines were scored, they were
swamped by the lower scores in the production of averages, which seems likely because
there were inconsistencies in homogeneity of scores for painted lines within groups319.
Contemporary studies tend to show no differences between diagnostic groups on line
quality320, and the results from the DAPA agree insofar as they show there was a limited
range of line for all groups for both types of line, but the DAPA did pick up differences
in this limited range. The distribution statistics suggested little use of painted or drawn
line but the information is ambiguous because there is little difference between DAPA
measures of few lines and thin lines. The confidence intervals for all groups in painted
318
Amos (1982), op.cit. schizophrenics with prominent paranoid tendencies, produce drawings with heavy
overall line emphasis, p.135.
319
The Levene statistic was not computable because painted line was infrequently used in some groups.
Bartletts box (table 8, results) put scores for painted line just within the range for discrimination
purposes.
320
Gantt (1990), op.cit. found no differences in 4 groups of patients and a control group in line quality;
the DDS, Cohen et al. (1988), op.cit. found no differences in 3 types of patients to controls; Langevin et
al. (1975) op.cit. found no differences in schizophrenics and normal controls and Miljkovitch et al. (1982),
op.cit. found no differences in line with schizophrenics and other patients.
294
lines ranged from 0-thin and a little higher in drawn lines, indicating a greater proportion
of zero scores (lack of use).
Painted line: Only schizophrenic pictures showed association of line with colour: either
painted lines were red and green, or they were inconsistent in colour and bright green or
red was consistently present for some other reason. This provides an opportunity for
further investigation for clinical utility.
There may have been an element of lack of control of paint by patients and
especially substance abusers, who scored least, which was concealed by the non-use of
painted line by patients, although controls' use was still low. The order of scores for
drawn line was the opposite of that for painted and there was a strong negative
correlation between painted and drawn line in every group except substance abusers (who
used the least painted lines and the most drawn) thus subjects used either drawn or
painted line, not both at once.
Drawn Line: Controls should have been mid-range in drawn line, but instead, scored less
than other groups. In fact, the confidence interval for controls remained consistent
through painted or drawn lines, it was the patients' strategies that changed (this further
supports the division of drawn and painted line for patients). It is possible that thick and
thin lines were always scored together (varied = 2) so reducing the mean score to neutral,
but most groups scored in the 0-1 range indicating a greater proportion of 0 scores (no
line present). Drawn lines were more prevalent in substance abusers and patients with
personality disorder.
295
Schizophrenics used little colour except red, they used low intensity colours, and
little line. This implies some other activity than colour was filling the space (since from
the results, space was filled). The correlation of drawn line with space may be
underestimated since the plot showed a non linear relationship, unusual in that there was
a loose correlation up to about half filled with drawn line, so drawn line was most used
at that point and then as space increased, drawn line decreased. This pattern is consistent
with the negative correlation between painted and drawn lines shown by most groups.
The space was filled with either colour or line (and none consistently as there were no
correlations with space). Line was likely to be light pencil (possibly writing321), which
fits with the score for low intensity black and predominantly thin line.
321
Many studies report 'writing in' as a frequent indicator of schizophrenic drawings, Amos 1982 gives
examples, op.cit., or patient status, Cohen et al. 1988, op.cit., but others have found no differences
Russell-Lacy et al. 1979, op.cit., or infrequency Miljkovitch et al., 1982, op.cit.
296
Differences between groups - Space
There wasn't as much variation as expected between the controls and the patients and no
other variable had an effect on space left uncovered in the picture. Small but significant
differences existed, but all groups' paintings lay within the 25-55% space bandwidth and
no group consistently left large amounts of empty space. These findings are curious in
view of the reports from the literature which diverge widely so some explanation is
needed.
I have already indicated the variety of definition of space in the literature, the
most common is perspectival space. Psychiatric patients have been distinguished from
controls on dimensionality of elements or deformation of perspective322, but traditional
views of disintegration of perspective, especially in schizophrenic art have latterly been
challenged323, although some latter-day studies have also found differences in odd placing
of elements and objects or figures 'floating in space'324. The general understanding of this
'space' is difficult to define because it assumes that paper left uncovered is orientated
322
Patient groups are differentiated from controls: for example, the SPAR scale found that patients with
personality disorder scored lower than normal controls on perspectival space (Bergland and Gonzalez
(1993, op.cit.); Miljkovitch and Irvine (1982 op.cit.) found no differences between schizophrenics and
other patients but poor performance generally on space from all patients, and schizophrenics were more
likely to draw planned views than others.
323
Amos (1982) op.cit., reviews most of the essential 1960s and 1970s literature which characterise
schizophrenic disintegration of hierarchical perspective, proportion and logical spatial organisation under
the subheading of 'composition'; Russell-Lacy et al. (1979 op.cit.) found schizophrenics used more two
dimensional space than normal controls although they weren't differentiable from patient controls.
Disagreement in later views: Wadeson's table of characteristics of schizophrenia, depression and mania
report disorganisation, disturbed spatial organisation, disintegration for schizophrenia agree with Amos,
but her own experiments (1976) with schizophrenics showed wide variations (cited in Wadeson 1980,
op.cit. p.190-192); Gantt's experiments with the FEATS study show no differences in use of perspectival
space between 5 groups including controls (1990 op.cit.).
324
Cohen, Hammer and Singer (1988) op.cit.; Bergland and Gonzalez (1993), op.cit.; J.B. Couch (1994),
The Diagnostic Drawing Series: research with older people diagnosed with organic mental syndromes and
disorders, Art Therapy, V.20(3):231-241.
297
directly to the environment; assessment includes the objects within it so that it appears
widespread, whereas a simple groundline would have 'located' the objects325. The DAPA
uses a definition of covered area of the picture, as a less common but recognised objective
assessment326 and does not distinguish between these kinds of visual representation. The
patient scores indicate they produced less on the paper, but also indicate sketchy work,
which is often seen as empty because it lacks richness, solidity and detail. A thin yellow
wash could be described as empty space to someone looking for a depiction of a visual
plane, and filled, by someone looking for floating objects or a ground, but the DAPA
would record that 'space' as filled without exception. No group in this study consistently
produced much uncovered space. Any mark within the field was included and the 'space-
bubble' was estimated around it327 - if there were two spaces in the square, only one was
included. Thus sometimes the picture would look as if it had more space than the score
for space indicated.
Alternative explanations offered for results from the discussion of intensity and
line that the type of measurement may have obscured the results when they were
extreme, cannot apply here. The weighting of 5, given to empty squares would have
given a higher average score if applied throughout the picture. Therefore there must have
been a considerable portion of the population with 55-75% filled space. It could be
325
See explanations of this definition in Cohen, Hammer and Singer (1988), op.cit.; Gantt (1990), op.cit.
326
Wright and McIntyre (1982, op.cit.) found significant differences in depressive and normal controls
using a similar method; Russell-Lacy et al. (1979, op.cit.) used 'a template' (the only description) to
quantify space and found differences in patients and controls on covered paper; the DDS - Cohen, Hammer
and Singer (1988, op.cit.) found that patients mainly used '33-99%' of paper, but the actual range covered
was indeterminable as it allowed an inch around the perimeter of the paper for the extra 1%!
327
see definition for space DAPA rating guide 1994, methods section.
298
argued that the procedure of taking the mean of several paintings might have simply
produced a neutral score from wildly different paintings. Three points refute this: (i) the
scale point in the middle and with the widest interval was 3(25-55%), whereas scores for
space centred on 2 (10-25%); (ii) the confidence intervals are very small indicating very
little variation within groups; and the ANOVA between paintings showed no significant
differences between paintings (Results section).
Differences between groups - Emotional Tone
Comparison with other studies is difficult here because it is assumed that the content is
decodable and assumptions about the meanings of what is portrayed form the basis of
most studies. Generally the patient picture is expected to score much lower: to distort
proportion, perspective and to show more negative content than the control328; there are
said to be reflections of thought disorder in schizophrenia, hopelessness and despair in
depression329. Although the DAPA results agree with the general tone of the literature,
that controls score higher than patients, there was a narrower band of variation than this
literature suggests. All patient scores hovered around neutral and there were no
correlations with other variables, suggesting that structure and colour had no separable
328
Distinguishing features of psychotic art reported in the literature, collected by Wadeson (1980), op.cit.
p.190 although she does not endorse all of these characteristics, especially that disorganised behaviour
reflects in the drawings. She does note that hopelessness and emptiness, enclosed trapped feelings
predominate in the themes of depressed patients' paintings; Amos (1982), op.cit., in a synthesis of the
1960s and 1970s literature suggests content reflects the schizophrenic's world view of unusual or
maladaptive experiences, impaired reality sense, no baseline reference, disconnected and bizarre images,
especially human, heavy line emphasis, and words, disintegrated composition without regard for
perspective, primitive style and inappropriate or uncontrollable use of colour.
329
Shoemaker (1978 op.cit.) provides a sensitive 'guidelist' of how to examine a painting by a patient for
visually available dimensions 'within which the specific definitions of psychopathology may fall, as a step
towards measurement'; she suggests: synthessence, space, substance, time, energy, relativity, reflection
of perception and expression.
299
influence on apparent negativity. Where precedents for the DAPA results exist, they
used systematic methods330 and it is not certain that previous studies have taken the
effect of quality judgements into consideration331, even though the justification for
selection of features may be theoretically remote.
A probable explanation for these findings lies in the test procedure. Other studies
may have placed increased emphasis on negative indicators thus influencing the view of
the whole painting as negative, whereas corresponding or small positive parts are ignored.
The DAPA scores tell us that no group consistently produced negative indicators over
the whole picture surface. Where negative scores were given, they must have been
balanced by positive scores, because of the centring on neutral. The confidence intervals
were very short in the groups most expected to produce negative paintings: schizophrenia
and depression, indicating little variability within group and we know that the sequence
of paintings did not show fluctuations from negative to positive332.
330
Russell-Lacy et al. (1979 op.cit.) found differences isolating schizophrenics from both controls and other
patients in repetitions of abstract forms (mannerism) only, between patients and controls only in these
form variables: imbalance, detail, two dimensions and space covered between patients and controls. There
were no differences in relationship of imagery, focal points, monochromism, perspective, words or
portrayed houses in the picture; Wadeson (1980, op.cit.) warns that casual observation alone revealed no
particular patterns of content in diagnostic groups; E.L. Phillips, S.K. Geller and M. Ireland (1983),
Research on the use of art therapy in a university setting, Am. J. Art Therapy, V.23(1):26-9 were unable
to assess whether themes in artwork were sequential.
331
examples of previous studies finding no relationship in thematic content after quality judgements were
accounted for have been; R. Langevin and L.M. Hutchins (1973), An experimental investigation of judges'
ratings of schizophrenics and non-schizophrenics paintings, J. Personality Assessment, V.37(6):537-543,
results from 13 judges ratings of 200 paintings as schizophrenic/normal were only 10% greater than chance
using their own criteria which was subsequently found to be art quality; E. Feher, L. Vandicreek, H.
Taglasi (1983), The problem of art quality in the use of human figure drawings, J. Clinical Psychology,
V.39(2):268-275, although 8 from 16 judges were warned on quality, all returned a 58% hit rate on
quality.
332
Different paintings by individuals were compared by analysis of variance (see results section) in order
to determine the propriety of taking the mean value for each subject, results were non-significant.
300
The DAPA considers the area of negative tone within the context of the whole
painting. This may not be clinically relevant for interpretations, since although a negative
area may be small, it may dominate and give focus to the painting subjectively. However,
there seems little indication of clinical depression from a large proportion of negative
areas as measured by the DAPA, since the groups predicted as most likely to score
negative: schizophrenicsand depressives,who actually occupied the same range according
to the DAPA, scored less negative than the substance abusers. Recent research on
emotional associations with image intensity shows some correspondence with these
results and suggests that pictorial intensity reflects current feelings rather than general
tendencies333. These results support Wadeson's334 contention that schizophrenics
present with typical pictorial signs of depression. The implication is then that substance
abusers might subjectively feel more depressed than all groups. The confidence intervals
for personality disorder are much wider than the other groups, indicating greater
variability, and more inclination towards positivity (but this probably reflects
inadequacy of the smaller sample size).
Comparison of form
The lower scores for dominant form in depressives and the higher use in controls
gives support to the general view of dissolution or lack of form in depressive illness
333
Kaplan, Imagery and expression of anger (1994 op.cit.), found that black and red associate with feelings
of anger and image intensity reflects current angry feelings rather than propensity.
334
Wadeson (1980, op.cit.) p.193, 324.
301
rather than for schizophrenia335. This might have been more obvious in content and
influenced the judgement of emotional tone, so a negative correlation between emotional
tone and form might have been a reasonable expectation. There is, however, no such
evidence; small non-significant positive correlations indicate that the judgement of the
positivity of the painting was not influenced by form.
The position of substance abuse, which scored significantly more form than
depressed, indicates that form should be a true predictor of depression, unlike most of
the other elements which put substance abuse further down the scale than depression.
Patient groups exhibited some dominance of form, but their focus covered less of the
surface than that of controls, who tended to use about half the page; this probably
accounts for the confusing results when untrained raters are apparently able to distinguish
patients from controls slightly better than chance using their own criteria, which usually
turn out to be quality. Higher levels of form, though, are not necessarily an indication of
health as the pictures of substance abusers were not distinguishable from controls.
Substance abusers did not use more blue or form than other groups, but there was
a high negative association between blue and form. The plot for blue and form is unusual
in that very little blue, when half filled with form decreases to no blue as form increases;
it is likely that blue was deposed by the form, being a background colour (sky?) rather
335
Amos (1982, op.cit.) reports Billig's 1969 observations of a schizophrenic recovery "beginning with
random scribblings" and generally dissolution of form in schizophrenia; Wadeson's (1980, op.cit.)
categorisation of psychopathology from the literature shows schizophrenics were thought to produce
disorganised and deteriorated compositions, but she reports experiments from 1976, which disagree. She
found the majority of schizophrenic pictures full formed and developed, depressive-like qualities such as
colourless, emptiness, were noted in a few paintings from manic/depressive and schizophrenics also.
Wadlington and McWhinnie (1973), op.cit. found no differences between patient groups (including
schizophrenia and depressives) on dominant form and size relations.
302
than a fill colour, but no colour is particularly associated with form so there was no
consistent fill or outline colour.
Conclusion for the discussion of results
The results from the DAPA scales follow the general direction of the empirical literature
in that psychiatric pictures were shown to use less colour, were of lower intensity, fewer
lines were drawn and painted, they left more space, were less positive in content and
contained less dominant form than pictures by controls. However, the results do not
agree with most of the diagnostic differentiations between patient groups suggested by
the early impressionistic literature. DAPA results also disagree in the magnitude of the
patient/control differences.
Summary: There are two related likely explanations which have probably polarised the
patient/control differences and suggested other differences between patients because they
are antithetical strategies:
1. Reports from the literature could have emphasised the importance of part of a
picture because of the overwhelming influence of content on subjective
judgement;
2. The way the DAPA scores pictures reduces the importance of part of a picture
because it measures the distribution of an element over the picture plane, rather
than concentrating on how a message is conveyed over part of it. If small, the
focus point of a picture could have quite intense scores but the picture would
score mainly from the material surrounding it, in the production of averages.
303
Supporting this point, the focus area is usually encompassed by the dominant
form, which is considerably smaller for patients than for controls.
This last is an important point because there is no standard form for the way we
look at and describe pictures, so it seems quite acceptable for us to attend to details in
one group and whole paintings in another. Judgement may occur on different indices,
individually and subjectively according to what the judge finds important, or worth
considering in that group especially in impressionistic reports336. There may indeed be
differences in the pictures, but if, for example, red is actually distributed equally in both
groups but being attended differently in the focus group because it denotes unsatisfactory
or violent content (maybe as blood/danger in patients, but cheerful flowers in control),
what is being reported as amount of red may actually denote something else.
Unsatisfactory aspects of the procedure for rating
There are several unsatisfactory issues in the DAPA procedure. The structuring process
was not essentially statistical. The statistical process was applied afterwards and is
constrained by its categorical organisation. This difficulty cannot be resolved from
outside; more experience with statistics has changed my approach to these processes and
a similar programme would have the statistical procedures organised integrally from the
beginning.
336
J.K. Dent and H.Y. Kwiatkowska, (1970), Aesthetic preferences of young adults for pictures drawn by
mental patients and by members of their immediate families, Sciences d'L'art, V.7(1-2):43-54. found that
20 judges of 1500 paintings by mixed psychiatric patients trying to describe the paintings and indicate
their preferences showed wide individual differences in what they attended to and very poor criteria and
judgement, out of 20 common descriptive elements, 10 were related to the personality of the judges.
304
Effect of the distribution of elements over the picture plane
It is possible that a lot of empty space could swamp a small amount of information
generated by the DAPA. Presently it is difficult to distinguish a consistent small amount
of media from a concentrated area in one part of the picture from individual scales,
although it can be deduced from a combination of related scales.
Further development of the DAPA should consider the issue of distribution of
a small amount of material over the picture. The averaging process between all 20
sections of the grid works for the colour and form measures of presence/absence, but
intensity, line, space and emotional tone would have a nil rating for empty space,
confusing measures of little with none as it has for line. I have tried to avoid this problem
by scoring empty squares on the emotional tone and intensity scale as neutral, but this
has probably biased the scoring range towards neutral and may even obscure strong
contrasts. If the mean of line, emotional tone and intensity were taken between occupied
squares by treating the empty squares as missing data, it would obscure how much of the
picture was taken up. A better answer would be to reduce the subvariables (low, neutral,
high) to 2 values (low and high) effectively eliminating neutral. Later development will
enable different parts of the picture to be considered separately. A better way would
probably record missing values and average between as many grid sections filled. It
would also be useful to correlate records of position of the Dominant Form so that
persistent compositional devices could be measured as products of Space/Form.
Rating problems.
305
Several kinds of difficulties were encountered, especially in the attitude of professionals
towards a content-free measure of art. The positive points were that the form and length
of the instrument, although training was required, were satisfactory. Raters' agreement
was high and they found the instrument understandable and reasonably easy to use in a
systematic way, although tedious, so there were no obstacles to the judges rating. Close
adherence to the rating guide improved reliability and in this respect art students may not
have been the best raters, since they already had their own concepts of the terms used by
the DAPA, especially for form, and were not well disposed towards quantitative ratings.
None of the raters could suggest any further formal dimension upon which the picture
could be rated.
There were 3 areas of discussion of weaknesses of the procedure. They are
presented here with development possibilities:
(i) Colours: The rating instrument probably gives too much emphasis to colour,
however, there seems no obvious grouping system since the traditional dark/light
separation was not found to relate well to diagnosis, and is subjective since colours look
lighter and darker with changes in environment. The alternative is to measure only those
colours which have high discriminatory properties and which do not strongly correlate
with other variables, so that results are independent. Orange, purple and white were
eliminated due to infrequent or inconsistent use; blue and brown were non-discriminatory.
The elimination of green could further remove associations between colours in
schizophrenia, but equally it may be that the effect of the combination with the other
colours may be important in discrimination and other associations would occur. The
306
pattern of associations itself might be important. Colours measured would otherwise be
reduced to red, yellow and black, which might be too few. Pencil line might have
influenced scores for black, so it should be scored differently.
(ii) The information value of Painted line was conveyed by the strong negative
relationship to drawn line in the majority of groups. The normality of the distribution
of painted line was questionable, and elimination would make intensity independent for
schizophrenia.
(iii) Form was a particularly difficult area for non-art trained people, and even art
trained people found it difficult to objectify. The initial explanation of form was
misunderstood, so further development went on. The rating guide (appendix 4) shows
the final explanation for form. Speculatively though, a simplified 'most intense focus area'
explanation might point out the crucial focus of the picture in four adjacent squares which
form a box shape would probably limit the training and provide a more accessible
explanation, but this requires further development.
Relation of the results from Study 2 to Study 1
Differences between methods
Study 2 used more clearly differentiated subjects and larger groups so differences should
be more obvious, some differences are expected because of the overlap between subject
types in Study 1. Study 2 was retrospective, conditions were not standardised and
content was free, where study 1 held the content constant to some extent with self-
307
portraiture, so it is difficult to say which of these elements probably contributes the most
to differences between diagnostically similar groups on specific variables for study 2.
Differences in scores from the first study: three variables were transformed, and this
commentary describes the usage figures (transformed back) so as to make better sense
between relations to figures from Study 1. Five findings from study 1 were generally
supported; two of the non-significant findings (blue and brown) and three out of four
significant variables identified in study one (yellow, intensity and line), which showed
only slight changes in study 2 (the other significant variable, orange, was too infrequent
to be used).
• There was no signiicant difference between the findings of Studies 1 and 2 for
brown or blue. Patients used more brown in study 1, this put them equal with controls
who used roughly the same amount in study 1 as 2; depressed patients used more blue
in study 1 and controls less, but these small fluctuations did not affect the outcome of no
significant difference between groups.
• There was little difference in the findings of studies 1 and 2 for yellow. Both
depressed patients and schizophrenics scored only slightly higher than brain injury in
study 1 which group was not included in study 2. Controls used slightly less yellow in
study 2, but were still differentiated from schizophrenics, the group who used least.
• Generally the scores for intensity hovered around the same point, neutral for both
studies. Controls scored much higher than the patients in study 1; in study 2 the
schizophrenic score was lower than the rest and this is probably attributable to better
308
diagnostic grouping, but the controls' score was also reduced, so these two groups were
identified as significantly different, by approximately the same proportion in both
studies.
Two study variables were subjected to a change of scoring procedure for study
2, so they cannot be accurately compared, but general findings are similar although
sharper distinctions are drawn.
• There were significant differences in line in both study 1 and 2 between controls
and patients. Study 1 records more variation than study 2. This is probably due to the
combined assessment of painted and drawn line in study 1 which tends to see painted line
as thick and drawn as thin when adjacent, but then judges on relative thickness when
separated. The position of controls was reversed when the painted line was separated
from the drawn line, from most (painted) to least (drawn), which probably explains their
thick line scores in study 1, when there were no thick line scores in study 2 in either
painted or drawn line.
• The rating for space was made simpler for study 2, so scores cannot be so
accurately compared. The scores indicated the same sort of media coverage of the surface
area (the scores for study 1 represented the average percentage coverage of square, and
in study 2, the average space per square); no group had predominantly empty pictures.
So generally scores for study 2 were similar to those for study 1 except that
schizophrenic pictures seemed to cover more surface area and thus the controls were not
differentiated. This could be an effect of another group characteristic secondary to
schizophrenia but it is likely that this was an effect of the scoring procedure for study
309
1, as generally the scores for schizophrenia were stable in other areas, indicating a similar
percentage of space used. The groups showed more 'bunched' positioning in study 2 at
around 25-30% space, this had the effect of isolating the controls at around 10-20% space
in study 2.
There were slight differences in four variables which produced distinctions from the
results of study 2: there were trends but no significant differences for study 1.
• Although controls and depressives used about the same amount of red in both
studies, substance abusers and particularly schizophrenics used much more red in study
1. Some schizophrenics and some substance abusers for study 1 also had personality
disorder, which tends to scatter the results (from study 2). Study 2 isolated the controls
from substance abusers and put the schizophrenics level with depressed, who had not
fluctuated and were a more discrete group.
• Apart from substance abusers whose score reduced considerably in study 2, there
were only minimal differences in green between study 1 and 2, but it was enough to
isolate the controls, who scored slightly more than most of the patients.
• Substance abusers scored much more black in study 2, which isolated this group
as significantly higher scoring than all other groups. This could be an effect of better
grouping. Depressives showed slightly higher scores for black in study 1 but some
secondary diagnoses were alcohol related; the schizophrenic group in study 1 included
psychosis due to drug and alcohol use. In study 2, the majority of the substance abuse
was for alcohol and the schizophrenic group did not include psychosis: if drug use pushes
up the black score, it would explain both higher scores. The drug abuse group scored
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much less in study 1, but the sample were mostly outpatients using varied substances in
a recovery state, whereas for study 2, they were inpatients, more homogenously alcoholic
and mostly in an acute state. This different group explanation does cover the
possibilities, an alternative could have been that content influenced work, but this is
unlikely because the controls who worked in the same surroundings at the same time
remained constant. These results support the explanation of differences between groups
for study 2 (at the beginning of this chapter) suggesting that substance abusers may
communicate more subjective unhappiness through their work than other groups.
• Emotive tone should certainly be affected by content and differences were
expected between studies 1 (fixed content) and 2 (free content). All groups were slightly
negative in study 1, with no significant differences; in study 2, all groups were slightly
positive except substance abusers, whose pictures contained more large quantities of
black, but whose rating remained stable but relatively lower than other patients.
Schizophrenics increased their score only slightly, but the pictures of depressives and
controls were both more positive. The only thing that changed in free content was that
controls were differentiated as more positive than all patients.
Summary: Generally, trends from study 1 were followed in study 2, and mostly, groups
remained surprisingly constant in their use of colour and structure in their pictures, with
one or two exceptions from particular groups. However, fluctuations due to changes in
the painting generation procedure, the sharper definition of the patient groups and greater
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numbers resulted in differentiation for study 2, where study 1 showed no differences.
In study 1:
• Controls showed 8 small fluctuations, 6 were probably attributable to content:
From 4 colour variables, less red, yellow and brown and more blue, only red made
a significant difference. Their paintings were viewed as less positive and more
intense. The other two were attributable to changes in the measure: they left
more space and they used more or thicker lines.
• Substance abusers used more green, less black and yellow. These were all large
fluctuations and probably attributable to better grouping in study 2.
• Depressives used more blue and brown, less yellow, more line and their paintings
seemed more negative. They were small fluctuations probably attributable to
content and made no significant difference.
• Schizophrenics used more red and black and less yellow; their paintings showed
more space and were less intense. These fluctuations were probably attributable
to better grouping in study 2.
All these fluctuations resulted in 6 changes of significance level for study 2, which mostly
followed the trends from study 1. Although there were differences in the methodology
of the study, the way some of the categories were rated, the sampling and the results
from the items rated the general conclusions remained the same:
• Controls were most different from substance abusers and schizophrenics.
• There was least difference between Schizophrenia and Depression.
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• Patients were clearly differentiated from non-patients.
In addition, the differences reported from the findings of the DAPA to what is regarded
as common knowledge in the literature were maintained:
• There was no greater use of black in depressives compared with other groups.
• Depressive paintings were not more negative than those of other groups.
• There was no consistent impoverishment in the pictures of depressives or
schizophrenics compared with other groups (although pictures by patients
generally covered slightly but significantly less picture area than those of controls
in study 2, and schizophrenics used less colour).
Generally then, the conclusions of Study 1 are supported by study 2. The effect
of content seemed to be greater on the controls, which was against expectations, and
better grouping seemed to affect the scores of substance abusers and schizophrenics
most.
This measure has the facility to clearly distinguish psychiatric patients from
controls and also different diagnostic groups from combinations of variables (see results
section; identification of groups by characteristic). Patients and controls were clearly
differentiated by most colour ratings and all structural ratings. The findings from study
2 are consistent with results from study 1. In addition, preliminary finding from study
1 of inconsistencies in commonly believed characteristics of pictures by patient groups
were supported.
In Study 2, 6 from 12 variables, which appeared frequently enough to measure,
were identified as discriminating groups at very high levels of significance and 4 variables
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at or above the usual level. Personality disorder was particularly hard to differentiate, but
this may reflect wide symptom variability in diagnosis. In the early stages of
experimentation, it would be more appropriate to use groups which are more clearly
differentiable diagnostically. Difference in content did affect formal measures of
paintings, but not as much as predicted by Amos337. There were however, large
differences for emotional tone, the only content variable. It seems that pictures were
more discriminable using free subjects than with content held constant, so this study also
predicts possible discriminable differences in content, the measures for which, as
presented in the published literature, presently do not compare well with the DAPA in
reliability and discrimination. This study points towards a common metric which could
contribute to art assessments and complement the present analytic or dynamic methods.
Discriminatory power between controls and patients
This part of the chapter examining the comparison between results of the DAPA and
what is generally accepted as art characteristics of patients by the psychotherapy
literature discusses the validity of the discrimination between patients and controls using
(i) comparison of effect sizes with the literature and (ii) the discriminant analysis.
(i) Is the DAPA a better assessment than the other tests reviewed in Chapter 2?
Effect sizes
337
This study clearly refutes the statement by Amos (1982), op.cit. that "prognostic and therapeutic
implications for the content of schizophrenic drawings remain largely a matter of interpretation and clinical
judgment. This will be the case for composition, style and use of colour also".
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The magnitude of the relationship (effect size) for characteristics of pictures was
calculated in Chapter 2 for the 11 studies which gave interpretable results as though they
were independent. This strategy was perhaps controversial as an assessment of the
papers judged because of interrelationships between the variables. It was justified
because it gave an indication of the type of characteristics measured by the vast majority
of studies which give either insufficient information or whose methodology obviously
compromised the results. There would be a vast degree of multicollinearity in these
relations, but it is impossible to sort out because of many reasons, not least these major
contributions to confusion:
• Most of the categories, which were put together by the author from similar
indices of different studies, were probably heterogeneous within tables. This
means that where 'line' was measured in one study, 'line' in another study was not
the same element;
• All studies used different variables from each other, and different diagnostic
groups, so it was impossible to compare even pairs of studies. Replications often
brought up different results.
Of 14 categories from the literature review (effect sizes calculated in Chapter 2),
the categories of line, form and colour achieved negligible effect sizes (below _=0.02)
where the DAPA effect sizes were medium and large for line and form and averaged above
medium effect for colours, which were measured separately (large effects on red and
green) and a medium effect for the DAPA category of intensity which was also measured
separately; the space category from the literature review achieved a small-medium effect
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size (_=0.36) which contrasts wildly with the medium-large effect from the DAPA
(_=0.74); 7 other separate categories were encompassed under the DAPA emotional tone
category: three categories, those of themes, reality and complexity which seemed very
close in meaning but were measured separately by most studies, showed negligible effect;
quality showed a low effect; energy and composition, medium effect. Only content as
defined by counts of specific psychiatric indicators showed a high effect comparable to
the general category of emotional tone. The other high effect from the literature review,
body details was not included in the DAPA, there was a medium-high effect on control
which was not included in the DAPA test and neither was detail in other areas (which
achieved a small effect).
The deletion of negligible effects from the literature review set of categories gave
a subset of 8 significant areas of measurement of drawing with a medium effect size
(_=0.57), and is still lower than that of the DAPA, but it only covers two DAPA
categories and was relatively overloaded on content. The DAPA test therefore seems
more sensitive to different areas of measurement of a painting and is potentially a more
effective discrimination tool. However, the t-test does not take account of
interrelationships between variables, nor the number of tests performed338 so this
analysis is limited to a theoretical comparison of independent effect of the variables with
that produced in Chapter 2 and is not an appropriate measure to predict practical
discriminations.
338
We could use the Bonferroni correction here, but it merely confuses the data and the problem of
correlation of the variables remains and it is better to use the following analysis.
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(ii) The Discriminant analysis technique - Which variables discriminate between
patients and controls?
There were 6 common variables which turned up 3 or more out of 5 times in the
derivation of the function from 5 different partitions of the data set: most of which
variables showed the largest effect sizes identified above. Step 1 used Emotional tone,
which had the largest effect (_=0.92) or green (_=0.89), which had the highest F to enter.
The other variables in order of their appearance were: Form (_=0.88), Space (_= -0.74),
Drawn line (_=-0.56), and Black (n.s.). Painted line, which did not appear, was highly
negatively correlated with Drawn line and so the effect must have been accounted for
with the entry of Drawn line as it is unlikely that the F value was not high enough on
Painted line. It is a mystery to me, given the small effect size, why Black was chosen as
a discriminating variable, unless it was because it took the large effect of Red because of
the high negative correlation. The results for the ANOVA show that controls were not
differentiated on either high or low black from the patients. Red was highly correlated
with intensity, which also wasn't included. On the two occasions Red did turn up, none
of the 6 common variables were consistently absent, so it was probably excluded because
its effect became negligible after accounting for other variables. The middle effects were
not included; Yellow, Brown, Intensity, Painted line, although Drawn line (_=0.57) was
included and Blue (_=0.36), so these low effects were probably due to correlation with
Green, although they all showed F less than 1 when the analysis stopped. The
discrimination set therefore contained most of the variables with high effect sizes and was
generally consistent with the independent t-tests for effect size. The best discrimination
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sets had all the identified high effect variables involved in the discrimination, and the least
had only 3. Therefore, the best discrimination probably includes most of the variables,
which was consistent with their correlation with the discriminating function; so
interactions were complex and there was no major influence from one or two variables.
Using the information from the discriminant analysis and the t-tests we can say
that content is a powerful discriminatory index, it comes first in the discrimination
analysis and it has the highest effect size in both the DAPA and the reviewed literature
analysis, but that the caution with which most authors regard molecular analysis is
justified, because few of the molecular measures of content in the review analysis actually
discriminated. The highest effect from the review, for counts of psychiatric
characteristics, was highly subjective and probably difficult to operationalise, whereas
the DAPA global judgement was equally effective and did not require rigorous
procedures. Green was highly discriminative, but the tests in the review used a different
index; i.e. 'quality of colour' tests, in which some subset or other partial preprocessed
colour judgement was made, often mixed up with subjective content judgements, and this
may explain the difference in effect for colour. Black was included in dark colours. The
next most valid discriminator was form, only one study in the review actually used it as
a compound339; different spectrums of shape and composition from other studies were
found inconsistent. Space, which was mainly measured by perspective in the review,
distinguished mental retardation but was not as effective as total cover, and of the rest,
the difference in effect can be explained in that no other study produced a reliable strategy
339
But raters found their measure difficult to understand and produced inconsistent responses.
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for estimating cover. Line was measured in many ways and inconsistently- many studies
had to be excluded because of reliability issues and the main point of the line review was
that line was difficult to measure objectively without relation within the picture.
Because the other variables from the DAPA test are not included in the
discriminant analysis does not necessarily render those non-significant, especially for
inter-patient discrimination. The analysis worked slightly differently each time with each
partition of the data removing certain variables for others. There were medium effects on
colours and a different system of combining these might remove confounding correlations
and it would also be useful to use a bigger sample of controls. These other variables may
be important but the problems of multicollinearity must be addressed. This is a task for
more extensive statistics which would not be appropriate on this sample.
Weaknesses of the study
The study was not able to control for medication, or IQ/ability; measures were recorded
but casenotes were too inconsistent, so more independent measures could fine these
results. The size of the control group was too small for proper comparison with each
patient group and was not matched for age and sex, but these variables were statistically
controlled and did not invalidate the main findings. Because the staff could not be
assumed not to understand the purpose of the study, and as with any other such study,
could have produced deliberately different paintings than the patients, two control
measures were taken: most of the study was done on retrospective work - the staff and
patients had already produced paintings as part of the recreational programme of the
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hospital; the mean of up to 10 paintings by each person was taken, and all comparisons
were between groups, so a considerable number of the control group would have had to
be deliberately and consistently altering their style to seriously affect the results.
It must be restated here that diagnoses were necessarily quite distinct because
ICD-10 classifications were made from casenotes, which included lists of observations
of the patient by trained psychiatrists but nevertheless, some diagnoses may have been
made from uncertain criteria. These circumstances were controlled as much as possible;
difficult to classify cases and dual diagnoses were excluded, the groups were as widely
distinct as possible and patients were usually in severe states requiring hospitalisation.
Controls were as far as could be determined, functioning members of the working
population, so existing mental health problems would have been mild and quite distinct
from the patients.
Strengths of the study as a whole
• Through a careful review of the literature, this study showed that traditionally the
study of art has fallen into the domain of the subjective rather than the objective.
Attempts to externalise subjective and probably non-verbal responses have usually relied
on explanations which are longer and more complicated than the picture itself and
influenced by expectation. The argument has been that significant indices of the quality
or direction of a painting can be indicated by attending to intuitions and a combination of
knowledge of style, skill and history of the maker that usually serves an encounter with
art. In this sense mental projection onto the object is intrinsic to the nature of how the
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painting is made and viewed. But it has been shown that subjective impressions are
rather more questionable when they are taken to be an interpretation of fact.
• The DAPA study took a scientific approach to look at what is produced as artwork,
objectively and did not take account of mental projections onto the object. It attempted
to measure on externally observable criteria what was publicly verifiable using quantified
information, which made it easier to specify which aspect of the observation was being
attended.
• Unlike other studies the DAPA took account of normal distribution of variables in
order to adhere to the assumptions of the testing procedure and produce valid
interpretation of the results.
• This study produced a reliable scale through the elimination of subjective decisions,
which was consistent and unambiguous, and demonstrated a method of comparing
agreement that was valid, unambiguous and more appropriate than previous studies. •
A careful and thorough testing procedure compared the essential elements with those of
the previous literature and found some consistencies and gave coherent explanations for
the discontinuities.
Strengths of the DAPA
It was important to establish whether the removal of content from judgements of
paintings allowed diagnostic distinctions. The DAPA demonstrated an ability to make
distinction between paintings from different diagnostic groups. This is consistent with
previous findings using mixed form/content scales but the use of form increases the
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reliability of the test and shows the neglect of the literature in this area since formal
measurements previously employed have been piecemeal and ineffective. The literature
review showed that content measures can be reliable where such variables are carefully
described and operationalised. The effect size for this study far exceeds that of previous
content only measures and thus justifies further research.
The DAPA can be used as a complementary assessment which does not interfere
with normal art therapy programmes. It uses standard scientific terminology and
produces quantitative continuous scores rather than ordinal or graded sections thus
allowing more powerful statistical comparisons than previous tests. The DAPA does not
require specific materials and does not need specialist art-trained staff. It does not
require information from the patient about the painting, therefore inconsistencies are
minimalised; the systematic approach eliminates attempts to interpret or judge intention
and it is independent of the theoretical origins of the investigator. The DAPA is primarily
a descriptive system which provides a standardised medium for a variety of uses and has
potential for development.
Although the assessment is quite difficult and training was required, interrater
results were well ahead of the field. This study therefore supports the use of systematic
art measures, especially in circumstances where additional verbal material is not available.
Effectiveness of The DAPA: Error types, 1 and 2, can be related to mistakes in clinical
testing; 1. To diagnose someone as psychiatrically unstable who is normal; and 2. to
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diagnose someone as normal who is psychiatrically unstable. The DAPA is more likely
to err on type 1, which is on the side of caution.
Variation was minimal in patient discrimination and ranged only from 95-100%
on the selected cases and from 81-98% on the independent data; but the control sample
ranged from 50-88% for identification on the selected sample and from 50-80% (although
the average was 65%) on the independent data set using the function derived from the
selected data. When the control sample size was bigger, i.e. when the function derived
from the control group of 18 was applied to the independent set of 5, it produced a better
discrimination. The sample size therefore looks like the most influential variation factor;
greater numbers should improve discrimination. The correct classifications yield is
comparable with other systems in use such as the G.H.Q. and the MSE, even though the
patient sample included some with diagnoses which were widely scattered (personality
disorder). It can be seen from the breakdown of specific differences earlier in this
chapter, the widest confidence intervals were for patients with personality disorder, they
most often spanned other groups and were hardest to identify so it is likely that the
removal of these patients would increase the effectiveness of the discrimination.
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Chapter 7. Conclusion
This thesis represents an attempt to devise an empirical measure for art products that
was theoretically coherent.
Literature Review
Chapter One argued that the approach to psychiatric art has neglected rigorous empirical
study of psychopathology in favour of phenomenology.
The literature review reported that impressionistic papers provided some
theoretical consensus that a change in the patient was reflected in the artwork of the
patient, but there was little sequential comparison offered or relation to the method to
direct the change, and no evidence of a coherent system to access the artwork. Claimed
benefits were independent of assessment of the patient or the work, aims or descriptions
of the therapy and explanatory theory.
There were 4 routes of access to the image from Case studies:
1. Most therapists who claimed the artwork produced expressed feelings did not
define this term, nor present their rationale for relation of feelings to the image.
They described their use of paintings to monitor progress and develop
communication, but there was no common base for interpretation.
2. Signposts Content characteristics identified were dependent upon the importance
of associations assigned by the therapist. Formal characteristics were overladen
with emotional terminology, often negative, and there were conflicting findings
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from different studies using slightly different definitions. Both of these categories
lacked standard objective definitions of visual phenomena.
3. Studies emphasising the therapeutic relationship were all based on a allegorical
model of activity which did not relate to the picture at all.
4. Studies which emphasised behaviour change simply described the environment
of the art room as a relaxing or useful friendly site for implementation of new
patterns of behaviour.
Contrary to the contemporary recommendations towards accumulation of this
kind of reportage as 'data' to be compiled later340, there was little transferable information
relevant to the investigation of the decoding process; it was reported obscurely,
subjectively, and inconsistently. Benefits reported were subjectively described by the
reporter and there was no independent evidence. Benefits were found to be unrelated to
the methods used and the treatment given often bore little relationship to the assessment.
There was agreement that aspects of visual art did indicate psychiatric status and that
therapy based on art was beneficial to the patient, but not on description of
characteristics of paintings, nor on how art related to the therapy.
Controlled studies
When the one rater studies, invalid instruments and unreliable variables had been removed
for the meta-analysis, content measures showed a higher overall effect than form,
340
Among others: A. Gilroy (eds.) (1992), Research in Art Therapy, in D. Waller and A. Gilroy, Art Therapy: A
Handbook, Buckingham: Open University, p.238 advocates the comparison of amassed case 'evidence', but has not
attempted such herself. L. Gantt (1986), Systematic investigation of artworks: some research models drawn from
neighbouring fields, Am. J. Art Therapy,V.24(4):111-8, recommends case studies as the optimum research mode
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probably because the form variables were fewer, widely scattered and defined more
explicitly. Additionally, it was shown that the structures and conceptual fields in which
drawings were assessed, which were adopted by most studies, may be irrelevant. Thus
the conclusions of the case studies were repeated - art is sensitive, but we cannot say to
what it is sensitive.
There was a significant effect for most of the elements which were assembled into
the drawing categories defined by the reliablity tables; they differentiated patients from
controls and patients from other patients. The instruments reviewed discriminated
controls better than patients. Empirical studies which found no difference were fewer,
were less controlled and used less valid instruments, with more content-based scales than
those which found differences. Subjective categories which required interpretation, fine
distinctions and global judgments were the most unreliable. There were widespread
conceptual mistakes in the use of mathematical language, flaws in the testing procedure,
validation of the measure, the analysis and the interpretation of results.
The DAPA: Development of a valid instrument
From the literature analysis, it was reasonable to suppose that if the object presented
some discriminable quality which was consistently encoded in the structure of the work,
proper analysis of the object would reveal traces of it.
Objective formal categories were more reliable and accessible than content
categories. The DAPA presented a more systematic method than most tests currently
for therapists, as others, see introduction.
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in use because it distributes the elements over the whole painting rather than
concentrating on a part of the image to be subjectively decoded. This systematic and
objective system is innovative since previous instruments have always placed the
emphasis on meaning and therefore concentrated on part of the object. It has been
recognised, although not very widely, that statistics for drawing tests are often unreliable
because there is physically less, or less definable image, on the patient side341, as well as
a limiting effect because of inadequate translation of intention. This was not a problem
for the DAPA because the avoidance of subjective identification of elements of content
throws the focus on the structure of the work, no translation is required.
Effectiveness and validity of the DAPA
The DAPA was developed as a psychiatric assessment to objectively define and describe
psychopathological criteria of paintings. It comprised 6 rating scales of mostly formal
elements derived from predicted psychiatric symptoms from clinical observations of
psychiatric pictures and from the literature: colour, intensity, line, space, emotional tone,
form.
In three studies, the DAPA has proved:
• reliable
• flexible enough to be used retrospectively
• discriminatory: between patients and nonpatients and to a lesser extent
341
Stanley R. Kay (1978), Qualitative differences in human figure drawings according to schizophrenic subtype,
Perceptual and Motor S kills, V.47:923-932 - reporting floor/ceiling effects in retarded schizophrenics. This effect
is often reported as 'statistically but not clinically significant'.
327
between different groups of patients.
The Main Study
The main study reported a validation experiment with 109 subjects, in which there were
no specific instructions to patients and where there would be no interference with the
therapeutic milieu. It was hypothesised there would be significant difference between
two or more diagnostic categories of patients or controls on each of the 12 remaining
subscales after 3 infrequent colours were removed: colour (1-6) - red, yellow, green, blue,
brown, black; intensity (7); line (8-9) - painted and drawn; space (10), emotional tone
(11) and form (12).
Paintings were collected from controls and hospitalised adult patients mid-
treatment. Patients fit the ICD10 categories for: schizophrenia, major depression,
substance abuse, personality disorder.
Results: Analysis of variance showed significant difference between two or more groups
on ten subscales from 12. The Duncan pairwise post-hoc comparison showed differences
in patient/control pictures and between patient groups.
Patients were significantly different from controls on:
• Schizophrenics on 6 variables: yellow, green, black, intensity, emotional tone and
form.
• Depressives on 3 variables: space, emotional tone and form.
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• Personality disorder on 5 variables: green, drawn line, space, emotional tone and
form.
• Substance Abusers on 7 variables: red, green, black, painted line, drawn line,
space, emotional tone.
Within patient significant differences:
• Schizophrenics from depressives on 2 variables: black and form; from substance
abuse on black.
• Personality disorder from depressives on form; from schizophrenics on intensity;
from substance abuse on black.
• Substance abusers from depressives on 4 variables: black, painted line, drawn line,
form; from schizophrenics and personality disorder on black.
Only three variables showed differences that isolated diagnoses - black (2 diagnostic
groups isolated); emotional tone, and dominant form. It seemed likely the other groups
could be isolated through combinations of variables. The discriminant analysis technique
was the most appropriate instrument for predictive analysis, but entry for significant
variables was complicated by association between measures. The functions derived
varied from 3-6 variables, and suggested that most of the variables contributed to the
result. The analysis consistently differentiated differences between patient and controls
80-90% accurately. Unlike the measures from the literature, the DAPA differentiated
patients better than controls. This was encouraging for further development of the
measure and suggested that formal analyses of paintings provide a extra dimension,
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previously unexplored, which complement traditional content interpretation and may
contribute considerably to the research knowledge of the field.
The findings do not support the traditional view of colour interpretation. They
do support the broader picture of artistic impoverishment in psychiatric populations.
It was important to establish whether the removal of subjective content from judgements
of paintings allowed diagnostic distinctions. The DAPA demonstrated an ability to make
distinction between paintings from different diagnostic groups. This is consistent with
previous findings using mixed form/content scales but the use of form increased the
reliability of the effect and showed the neglect of the literature in this area since previous
attempts at systematic measurements have been piecemeal and ineffective. The effect
size for this study far exceeds that of content only measures and thus justifies further
research. Though the DAPA worked well, the view of the majority of the literature,
of content based scales as more sensitive than formal elements, is nonetheless supported,
because it was the content features of the DAPA: emotional tone and form which gave
the best and most accurate discrimination.
The main findings of this study are augmented by the literature review in that it
was shown that there was no evidence of privileged knowledge available to art
therapists342. Thus the concept of privileged knowledge was unhelpful to the
development of appropriate theory for this area of investigation, and therefore small
samples with long texts on personal interpretation have not been helpful to identifying
342
This has already been recognised for years in the experimental literature, but is not generally acknowledged.
Study by B.I. Levy and E. Ulman (1967) Judging psychopathology from paintings, J. Abnormal Psychology,
V.72(2):182-7.
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the features of psychopathology. This finding, and the fact that some traditional
gradations of drawing features were ineffective as discriminators opens up a whole new
area of primary exploration in both formal and content evaluation.
Is the DAPA better than other art assessments?
The question whether the DAPA is better than other art assessments is meaningless.
Previous assessment methods have tried to do two jobs: to provide a standardised format
for art therapy approaches, and also to provide immediate accessible lists of
characteristics from an individual picture for the art therapist. The DAPA assessment
requires much processing and is not suitable for these purposes. No immediate
impression can be gained from its indices. However, no other published art assessment,
to my knowledge, provides a replicable, reliable and effective discrimination between
patient groups. Effect size comparison between patients and controls places the DAPA
far above the rest of the field. The majority of other tests assess content as a whole and
then relative to parts; the other apparent structural indexes are hardly mentioned,
although they are commented on qualitatively. The DAPA results show that the raw
data for a simplified objective measure of content (emotional tone) only just satisfied the
assumptions for ANOVA and the energy-focus of the picture (form) did not satisfy the
criteria. Simplified statistics therefore are not appropriate for these measures and as far
as I know, none have taken account of distribution bias or of correlations between the
variables. This problem of multicollinearity, in addition to the problem of misused
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statistical tests and missing data makes most studies uninterpretable and therefore
incomparable with this study.
Where do we go from here?
Improvements and further development of the instrument:
Replication studies should take into account the weaknesses already mentioned in the
rating procedure, and use better criteria for patient diagnoses. It is obvious that content
measures are inescapable even though their rating is difficult and can be inconsistent.
Greater complexity in description and fine discriminationssimply promote confusion and
do not add significantly to the discrimination properties of the instrument. Furthermore
human beings cannot simply attend to form and discard the image. Gibson explains that
a person can:
notice only the information for the perception of what is represented or he can pay
attention to the picture as such, the medium, the technique, the style, the
composition, the surface, and the way the surface has been treated, what is 'in' the
picture or to the picture itself .... a person can never fully attain to the
representational attitude and wholly exclude from attention such features of the
picture itself as its surface texture or its arrangement of line and colour.
What is needed for further development is a very simple level of measurement at which
form and content become one. Form in the DAPA context is not a simple matter of
configuration. Any picture has properties referring to itself and referring outside it when
relating to something else. The discardable concepts can be understood as those which
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relate the picture to external things. What is needed could be synthesised in a new
concept of feature, where content is measured through the formal internal properties of
the picture rather than relating to the external, like the measures of dominant form and
emotional tone already employed on the DAPA, so that they specifically and
consistently relate to the observer and not to other associative mental projections. This
is basically what has been attempted all along by previous empirical studies which have
developed so-called 'formal' analyses. Many describe the 'measurement of pictures' as
if it was self evident how and what was being measured, often without going through the
rigorous process of testing the measure appropriately and use evasive and immaterial
concepts; this is not the answer. The attempt to evolve a metric of visual form through
the problem of measuring visual form or pattern is a subject ideally addressed by
objective or scientific research. It may well be a mistake to suppose that expression
always lies outside the reducible qualities of measureable dimensions. The incorporation
of 'feature', using the objective internal relation to the picture, offers a potential bridge
between form and content and is already regularly and reliably used in projective testing,
such as the appearance of, for example, figures in a painting, and their relative size,
without going into the psychodynamic inferences.
The future for measures of psychopathology
The validity of the sole use of assessments which rely on an interpretative
construct by the therapist must be questionable, especially in cases where the patient is
verbally compromised. If there is no relation or an indirect relation between visual and
verbal symptomatology in the patient, then we cannot use verbal explanations of visual
333
psychopathology in clinical diagnosis. There are two main arguments to map its
characteristics:
a) All the advances in psychiatry have been based on a careful and complete descriptive
psychopathology of phenomenology. A phenomenology that does not include
visuospatial elements cannot be a complete description.
b) The verbal phenomenology under Mental State Examination is hidden in many
disturbed patients e.g. drug addicts; conduct or behaviourial disorders in children;
personality disorders and some emotional disorders. If the verbal differential is lacking,
then the case is diagnosed solely on the history. The descriptive psychopathology of
artwork by the patient may show other phenomenology which may be categorisable and
assist differential diagnosis in difficult situations.
Thus the future must be towards greater distinction and more precise
measurements. The obvious development here would be to adapt this system for a
computer programme, using more section divisions, to take advantage of the greater
facility of scanning technology and repetitive consistent decisionmaking.
Further development taking account of the weaknesses of the study, replication
and refining of the instrument is indicated.
334
Appendix 1
List of Variables for Analysis of Commonalities
1. Impressionistic/Theoretical Studies
2. Case Studies - therapeutic benefit - expression of feelings
3. Controlled Studies
4. Validity Studies
335
6 scales to categorise commonalities in impressionistic, theoretical or experiential papers
which report therapeutic effects or benefits of art for psychiatric patients.
One category for each scale, except benefit, where the most emphatic four benefits were
selected.
1. Origin of study material, descriptive Information:

Opinion - Author's philosophy with no specific support, but might
reference others.
Discussion - Argues two or more sides of an issue.
Experience - Report of a specific personal experience using art in
therapy with psychiatric patients, sometimes illustrated
and called a 'case report', but with no patient information.
Programme - Description or update of an arts therapy hospital
programme.
2. Diagnosis: under these groups from information in the paper:

1 schizophrenia; 2 traumatic stress/sex abuse; 3 substance abuse; 4 psychotic; 5
Alzheimer's/dementia/brain damage; 6 emotional disorder; 7 depression; 8 conduct
disorder; 9 normal; 10 retarded; 11 undifferentiated psychiatric patients; 12 sex
abnormalities/abusers; 13 personality disorder.
3. Theoretical base:
Psychotherapeutic - supportive, interpretive, humanistic, therapeutic.
Psychoanalysis - using psychoanalytic language (may not have been
traditional or valid).
Environmental - using the art environment for educational or functional
support or stimulation.
Social/ using the social group for interaction, providing an
developmental accessible activity, using behaviourial treatment in the group
environment.
Energy theories - suggestions that the patient can be affected by the power
of the unconscious mind whilst engaged in art, and that the
therapist can be a conductor of the power.
Assessment - diagnostic drawings, using art as an initial interview with
the patient.
4. Author's personal explanation of how art promotes therapeutic change

Signposts Patient illustrates their trauma or illness, objectifying it,
allowing access for therapist.
Self healing Art as healing in itself, or the therapist as a conductor for
power from the unconscious.
Group interaction - Observing behaviour of the group or of an individual whilst
patient drawing.
336
Insight New perception of the patient's problems through
representation of self.
Transfer of skill - Transfer of learning from one area to another. Thus patient
may paint angry feelings and explore visually possibilities
of containment which may be used practically later.
Communication By visual presentation things patient finds difficult to say,
increasing understanding through image.
No explanation Author assumes agreement or no offer of explanation.
5. Any four benefits derived from art, for the patient, where the author mentioned
these kind of words:
Expression of feelings - cathartic expression of feelings, representation of
the unconscious, psychic energy, expression of
trauma, self expression and projection.
Development of a skill - social benefits, practical confidence through skill,
problem solving strategies, self mastery, creative
skill, record of progress (for the therapist).
Communication Cuts through verbal defences, diagnostic,
verbal/visual bridge, promotes understanding (of
the patient) and support.
Self awareness self documenting, reality testing, promotes insight,
promotes body awareness, male/female issues,
cognitive gain.
Symptom Relief healing, resolution of conflict, reduction in anxiety,
promotes growth, remission of illness.
Relationship - counter/transference, nonthreatening, friendly,
alliance.
6. Against - Observations of negative effect on the patient or the therapist.

Resistance by patient, limitations of patient, withdrawal or
confrontation.
Therapist limitation - Method too powerful, limitations of the therapist,
individual theory, projective guesses, respect for
patient's interpretations.
Standards Low status of art therapy.
Patient approach Structure of the session wrong, aggression,frivolity
and setting wrong.
5 scales to categorise commonalities in 67 case studies with primary benefit of

expression of feelings; papers report illustrations of the images drawn by the client
with some demographic and diagnostic information.
Descriptive information: Age: adolescent (under 18); adult (18+ below 60);old (over 60)
Sex: male, female, mixed (group). Diagnosis - as impressionistic studies.
337
Orientation of the researcher, what were the intentions:
Not known or stated
Cognitive -
Projective - projective methods, designed to elicit information about the
patient's problems, interpreted pictures as representation of self.
Occupational art as a stimulating or pleasurable activity for the patient.
Analytical used psychoanalytic theory and language to interpret patient's
painting in terms of archetypal imagery, universal symbols etc.
(may not have been traditional or valid).
Method of Study, description of the practical techniques of eliciting expressionisticwork:

Projective Used a projective test or protocol with some standard meanings
for content.
Psychoanalytic Interpreted using psychoanalytic language and concepts (may
not
have been valid or intelligable).
Expressive Primarily eliciting emotional responses and individual expression.
Occupational Used art as stimulation activity or educational/social activity.
Comparitive Compared one painting or set with another on formal, content or
other grounds directly.
Form of Study, what type of material did the researcher extract from the study:
Formal Objective or stylistic elements.
Content analysis Interpretation of subjects of painting, of relationships
between elements of painting as representing patient.
Mix of content and style.
Behaviour Analysis of how the patient behaved in the session,
emotional, quiet etc.
Verbal analysis Psychotherapy with the pictorial element as a backdrop.
Other
Benefit to the patient, through expression of feelings from the making of art:
Cathartic/ Intense emotional sense of
reflective release with new insight.
Communication Able to talk about or refer to emotional experience.
Healing/symptom Patient feels better, disturbing
relief behaviour declines.
Developmental/ Patient behaves more emotionally
social mature, and interacts socially.
Relationship Patient draws comfort/value from the relationship with the
therapist.
13 scales to categorise Controlled Studies. Papers reported an empirical study of a psychiatric group with
one or more normal or patient control groups.
338
Demographic
Sex, Age, Diagnosis all as cases.
Number of subjects in experimental group
Total no subjects in study
No. judges in study: authors, other than authors.
No. independent measures in this study
Orientation - What the therapist was trying to achieve/ type of therapy offered by the therapist.
Comparison test only between groups
Expressive To elicit expression of feelings through the artwork.
Therapeutic/ To help the patient solve problems or gain insight through
self actualising rendition of experience through art.
Behavioural/ Provide peaceful/friendly environment where patient feels
non-art comfortable or can be active.
Measurement method - what the instrument was designed to measure

Direct Comparison of visual characteristics of the patient/control artwork, e.g. circles
or shapes or lines or colour.
Meaning Therapist interprets patient's artwork and compares meaning, e.g. happy or
lonely.
Mixed Mixed visual and interpreted characteristics.
non-art Non-projective, non-art measure of behaviour, e.g. quiet, lively.
verbal Verbal interactions, where therapist records quantity, or quality of language.
Design of the study

Pre and post intervention
Post intervention only
Direct comparison of current artwork
Retrospective comparison of artwork.
Derivation of the main study measure

One test used, developed for this study
One test used, adapted from a previous test
Established and validated test used
Measure by observation of patient
Measurement form, what type of elements of the picture was the measure actually sensitive to.
Form observable visual detail, including DAP
Content subjects or themes
Mix of form and content
Behaviour of subject
Verbal elements explained by the subject verbally
Expressive elements of the pictures which the therapist felt expressed the emotional tenor
of the patient
Results
Difference in experimental group and control
Difference in subtypes of the same diagnostic group
No difference
Therapy groups (effect of therapy recognised)
No association between score and criterion, inconsistent
339
Validity Analysis of controlled studies. 70 studies reported criterion validity of art test.
5 fields were tested.
Demographic
Sex, Age and Diagnosis as before.
No. of criterion measures - Diagnosis and test = 1, any more added on.
Form of Art Test - Form of information the art test collected.

KFD Emotional indicators.
DAP Cognitive/Developmental indicators
Formal other
Copy Copy drawing test measuring Control
Other theme
Free Spontaneous artwork no theme/instruction
Form of criterion measure.

Diagnosis
Picture or self Objective visual (DAP) or descriptive.
report
Content or story Meaning of visual image or narrative.
Mix content/form
Non projective Non-art measure; I.Q. etc.
behavioral;
Verbal Patient describes experience articulately.
Comparison: the type of quality the instruments were compared on.

Cognitive function Ability or intelligence level.
Emotional function Expressive assessment.
Development According to set criteria.
Diagnosis
Statistics:
Percentage agreement
Correlation coefficient
Mann-Whitney or _2 (non parametric association)
Kappa
Analysis of variance
Results: association of the art test with the main criterion measure
Differentiation among grades
Differentiation towards objective elements
Differentiation towards subjective elements
Significant association no direction
Test did not match or no significant association.
340
Standard differences from the mean for DAPA variables from the results section, Chapter 5.
6a. Standard differences from mean of each diagnostic group
PLOT OF TRED
________________________________________
_ 1 _
_ 1 1 _
.4_ 1 _
_ 1 1 1 1 _
_ 4 1 2 4 1 _
_ 3 3 1 5 1 _
R _ 7 8 5 4 _
E 0___7________3_______1_______2________1__
D _ 1 2 2 4 _
_ 1 2 1 _
_ 3 3 3 _
_ 1 4 1 _
-.4_ 5 _
_ 2 _
_ 3 _
________________________________________
1 2 3 4 5
Diagnostic group
6b. Standard differences from mean each diagnostic group

PLOT OF YELLOW
________________________________________
_ 1 _
_ _
_ 1 _
.35_ 3 1 1 _
_ 5 3 2 _
_ 4 2 1 3 1 _
Y _ 1 3 4 5 2 _
E _ 3 5 2 1 2 _
L 0___3________2_______2_______1 ________2__
L _ 2 2 1 1 _
O _ 3 2 2 3 _
W _ 1 2 1 1 _
_ 10 1 1 _
-.35_ 3 _
_ 2 1 _
_ 4 _
________________________________________
1 2 3 4 5
Diagnostic group
6c. Standard differences from mean of each diagnostic group

PLOT OF GREEN
________________________________________
.75_ _
_ 1 _
_ _
_ 1 _
_ 2 1 _
G .375_ 1 1 1 _
R _ 1 2 1 1 1 _
E _ 2 1 1 2 1 _
E _ 4 2 1 3 _
N _ 2 2 3 4 _
0___2________3_______1_______3________2__
_ 4 6 3 1 4 _
_ 9 7 1 1 _
_ 7 4 1 1 _
_ 2 _
-.375_ 5 _
________________________________________
1 2 3 4 5
Diagnostic group
6d. Standard differences from mean of each diagnostic group
PLOT OF BLUE
________________________________________
_ 2 1 _
341
_ 2 _
_ _
_ 2 _
.3_ 1 1 _
B _ 2 1 2 _
L _ 2 1 2 _
U _ 3 1 2 1 2 _
E _ 3 8 2 4 _
0___7________________3_______2________1__
_ 4 6 2 3 1 _
_ 4 3 2 1 _
_ 2 2 1 _
_ 7 4 2 2 1 _
-.3_ _
_ 4 _
________________________________________
1 2 3 4 5
Diagnostic group
6e. Standard differences from mean of each diagnostic group

PLOT OF BROWN
________________________________________
_ _
_ 1 _
_ 1 _
_ 1 1 2 _
.325_ 1 1 3 2 _
_ 1 1 1 2 _
B _ 4 1 1 1 1 _
R _ 4 6 2 2 1 _
O _ 5 2 1 2 3 _
W 0___1________3_______3_______3________2__
N _ 1 2 1 2 _
_ 1 1 _
_ 1 1 _
_ 14 6 1 _
-.325_ 6 1 _
_ 5 _
________________________________________
1 2 3 4 5
Diagnostic group
6f. Standard differences from mean of each diagnostic group

PLOT OF BLACK
________________________________________
_ _
_ 1 1 _
_ 1 2 _
.35_ 2 2 2 1 _
_ 2 2 1 _
B _ 2 3 2 1 1 _
L _ 3 6 2 1 1 _
A _ 8 5 1 1 1 _
C 0___1________1_______1_______4________1__
K _ 2 3 3 1 _
_ 5 2 1 1 _
_ 5 2 1 1 _
_ 4 2 1 1 _
-.35_ 1 1 1 _
_ 1 1 _
_ 1 1 4 _
________________________________________
1 2 3 4 5
Diagnostic group
342
g. Standard differences from mean of each diagnostic group
PLOT OF COLOUR INTENSITY
________________________________________
I _ _
N _ 1 _
T .8_ 3 1 1 _
E _ 3 1 _
N _ 3 1 3 5 _
S _ 2 2 2 3 _
I _ 4 4 3 5 2 _
T 0___6________6_______3_______1________2__
Y _ 5 6 1 1 _
_ 1 3 2 4 _
_ 3 1 1 _
_ 2 1 1 2 _
-.8_ 1 2 1 _
_ 1 _
_ 2 1 _
_ _
________________________________________
1 2 3 4 5
Diagnostic group
6h. Standard differences from mean of each diagnostic group

PLOT OF PAINTED LINE
________________________________________
_ 1 _
_ 1 _
_ 1 _
_ 3 1 1 _
.6_ 3 1 3 _
P _ 6 2 1 4 1 _
A _ 1 1 1 1 _
I _ 3 5 1 _
N _ 2 1 2 _
T 0___3________1_______3________________2__
E _ 2 1 1 1 _
D _ 13 2 _
_ 4 1 1 _
L _ 3 _
I -.6_ 12 5 _
N _ 7 _
E ________________________________________
1 2 3 4 5
Diagnostic group
6i. Standard differences from mean of each diagnostic group

PLOT OF DRAWN LINE
________________________________________
_ _
4_ 1 _
_ _
_ _
_ 1 _
_ 1 _
D 2_ 1 3 _
R _ 1 1 2 _
A _ 2 2 1 _
W _ 2 1 3 4 1 _
N _ 2 5 1 2 _
0___5________3_______4________________1__
L _ 6 4 4 15 _
I _ 14 6 4 _
N _ 2 4 _
E _ _
________________________________________
1 2 3 4 5
Diagnostic group
343
6j. Standard differences from mean of each diagnostic group
PLOT OF SPACE IN PICTURE
________________________________________
S _ _
P _ 1 _
A 1_ 1 _
C _ 2 3 1 _
E _ 2 1 2 _
_ 3 4 2 3 _
_ 6 6 2 5 4 _
0__10________3_______1_______2________3__
_ 3 3 3 3 1 _
_ 6 3 3 5 _
_ 1 2 1 _
_ 1 2 2 _
-1_ 1 1 _
_ _
_ 1 _
_ _
________________________________________
1 2 3 4 5
Diagnostic group
6k. Standard differences from mean of each diagnostic group

PLOT OF SUBJECTIVE EMOTIONAL TONE
________________________________________
E _ 1 _
M _ _
O _ 1 _
T .6_ 1 2 1 _
I _ 1 3 _
O _ 3 5 1 1 _
N _ 4 2 3 2 2 _
A _ 6 2 3 2 1 _
L 0___5________1_______3_______5_______1___
_ 10 4 6 3 _
T _ 1 2 1 1 _
O _ 2 1 4 1 _
N _ 1 3 1 1 _
E -.6_ 1 _
_ 2 _
_ 1 1 _
________________________________________
1 2 3 4 5
Diagnostic group
6l. Standard differences from mean of each diagnostic group

PLOT OF DOMINANT FORM
________________________________________
_ 1 _
_ _
.35_ 1 1 _
_ 2 2 1 1 1 _
_ 1 1 2 _
_ 5 3 2 3 1 _
F _ 8 6 3 4 1 _
O 0___6________5_______4_______1________3__
R _ 7 5 1 3 2 _
M _ 1 3 _
_ 2 5 2 _
_ _
-.35_ 3 _
_ 3 1 _
_ _
_ 2 _
________________________________________
1 2 3 4 5
Diagnostic group
344
7a. Standard differences from mean of each diagnostic group
PLOT OF ORANGE
________________________________________
_ _
.4_ 1 _
_ 1 _
_ 2 _
O _ _
R _ 2 1 _
A .2_ 1 2 _
N _ 2 1 3 _
G _ 2 1 _
E _ 2 3 1 _
_ 3 2 1 3 _
0___6________8_______3________________2__
_ 3 9 1 2 _
_ 16 9 1 1 _
_ 10 3 _
_ 1 _
________________________________________
1 2 3 4 5
Diagnostic group
7b. Standard differences from mean of each diagnostic group

PLOT OF PURPLE
________________________________________
_ _
.45_ 1 _
_ _
_ _
P _ 1 _
U _ 1 1 _
R .225_ 1 1 _
P _ 3 1 1 1 _
L _ 2 1 2 _
E _ 3 2 2 _
_ 4 1 1 1 1 _
0___1________7_______2_______2___________
_ 10 14 11 2 1 _
_ 12 2 3 _
_ 1 2 _
_ 7 _
________________________________________
1 2 3 4 5
Diagnostic group
7c. Standard differences from mean of each diagnostic group

PLOT OF WHITE
________________________________________
_ _
_ 1 _
.35_ _
_ _
_ _
W _ 1 _
H _ 1 _
I .175_ 1 2 _
T _ 1 1 _
E _ 4 1 1 _
_ 3 1 1 1 _
_ 1 2 1 _
0___1________1______17________________7 _
_ 25 19 1 _
_ 14 _
_ _
________________________________________
1 2 3 4 5
Diagnostic group
345
Correlation table 16 for DAPA variables measured from the pictures of Schizophrenics: a. colours, and b. structure
DAPA variables 1. Pearson's Product Moment Correlation Analysis

N of cases: 35 2-tailed Signif: * .01 # .001
Red Yellow Green Blue Brown Black

Red 1.0000 .3604 .4498* .3409 .2366 -.2392
Yellow .3604 1.0000 .7880# .5083* .5327# .0984
Green .4498* .7880# 1.0000 .6074# .6303# -.0796
Blue .3409 .5083* .6074# 1.0000 .2706 .0213
Brown .2366 .5327# .6303# .2706 1.0000 -.0111
Black -.2392 .0984 -.0796 .0213 -.0111 1.0000
Intensity .5791# .6586# .6732# .5751# .3489 .2365
Line-paint .4853* .3902 .4364* .4036 .0879 -.2120
Line-draw .1772 .2616 .2699 .2713 .3247 .0383
Space .2521 -.0318 .0166 .0264 .1028 .0745
Em-Tone .0116 .1564 .0404 .1680 -.0354 .0151
Form .2649 -.0718 -.1720 .1975 -.2605 .0271

N of cases 35 2-tailed sig *.01 #.001
Intensity Line-pnt Line-draw S pace Em-Tone Form

Red .5791# .4853* .1772 .2521 .0116 .2649
Yellow .6586# .3902 .2616 -.0318 .1564 -.0718
Green .6732# .4364* .2699 .0166 .0404 -.1720
Blue .5751# .4036 .2713 .0264 .1680 .1975
Brown .3489 .0879 .3247 .1028 -.0354 -.2605
Black .2365 -.2120 .0383 .0745 .0151 .0271
Intensity 1.0000 .3566 .3319 .4098 .3551 .1667
Line-paint .3566 1.0000 -.4563* .1008 .1048 .0714
Line-draw .3319 -.4563* 1.0000 .1408 .0047 .1381
Space .4098 .1008 .1408 1.0000 .4216 .1353
Em-Tone .3551 .1048 .0047 .4216 1.0000 .2572
Form .1667 .0714 .1381 .1353 .2572 1.0000
Correlation table 17 for DAPA variables measured from the pictures of Substance Abusers: a. colours, and b. structure


Red 1.0000 .1202 .1591 .0345 .2509 -.0975
Yellow .1202 1.0000 .2480 -.2749 .3064 .0492
Green .1591 .2480 1.0000 .3457 .6377# -.0064
Blue .0345 -.2749 .3457 1.0000 -.0055 -.5103
Brown .2509 .3064 .6377# -.0055 1.0000 .1927
Black -.0975 .0492 -.0064 -.5103 .1927 1.0000
Intensity .2696 .2968 -.0543 -.3901 .3358 .2510
Line-paint .2723 .0004 .3538 .0279 .3176 -.0047
Line-draw .0087 -.4361 -.1727 -.3542 .0441 .3803
Space -.0542 -.1900 -.5125 -.1555 -.3847 -.0569
Em-Tone .3369 .3586 .3802 .1277 .3853 -.2912
Form -.0218 .1279 -.5107 -.7608# -.1848 .3760

Intensity Line-paint Ln-draw Space Em-Tone Form

Red .2696 .2723 .0087 -.0542 .3369 -.0218
Yellow .2968 .0004 -.4361 -.1900 .3586 .1279
Green -.0543 .3538 -.1727 -.5125 .3802 -.5107
Blue -.3901 .0279 -.3542 -.1555 .1277 -.7608#
Brown .3358 .3176 .0441 -.3847 .3853 -.1848
Black .2510 -.0047 .3803 -.0569 -.2912 .3760
Intensity 1.0000 .2961 .0519 -.2999 -.1355 .3715
Line-paint .2961 1.0000 .0461 -.4074 -.0350 .0193
Line-draw .0519 .0461 1.0000 .2736 -.0167 .1786
Space -.2999 -.4074 .2736 1.0000 .1562 -.0363
Em-Tone -.1355 -.0350 -.0167 .1562 1.0000 -.4231
Form .3715 .0193 .1786 -.0363 -.4231 1.0000
346
Correlation table 18 for DAPA variables measured from the pictures of Depressives: a. colours, and b. structure
DAPA variables Pearson's Product Moment Correlation Analysis


Red 1.0000 .2190 -.2439 .4108 .3544 -.5008
Yellow .2190 1.0000 .5233 .0933 .0456 .0773
Green -.2439 .5233 1.0000 .2061 -.1223 .6256*
Blue .4108 .0933 .2061 1.0000 .3385 -.0127
Brown .3544 .0456 -.1223 .3385 1.0000 -.1375
Black -.5008 .0773 .6256* -.0127 -.1375 1.0000
Intensity .2665 .5996* .6132* .0600 -.1543 .3504
Line-paint .4585 .3449 .1690 .2415 .0960 -.0436
Line-draw -.3769 -.0852 .2575 -.2248 -.0563 .5134
Space .3684 -.1372 -.4742 -.1645 .1790 -.1690
Em-Tone -.1489 -.3002 .0787 .0370 .0386 .2029
Form .2613 -.2483 -.4253 -.1762 .5708 -.2897
DAPA variables Pearson's Product Moment Correlation Analysis

N of cases: 18 2-tailed sig *.01 #.001
Intensity Line-pnt Line-draw Space Em-Tone Form

Red .2665 .4585 -.3769 .3684 -.1489 .2613
Yellow .5996* .3449 -.0852 -.1372 -.3002 -.2483
Green .6132* .1690 .2575 -.4742 .0787 -.4253
Blue .0600 .2415 -.2248 -.1645 .0370 -.1762
Brown -.1543 .0960 -.0563 .1790 .0386 .5708
Black .3504 -.0436 .5134 -.1690 .2029 -.2897
Intensity 1.0000 .5619 .0912 .1631 -.1758 -.1220
Line-paint .5619 1.0000 -.6944* .1272 -.0563 .1079
Line-draw .0912 -.6944* 1.0000 .1170 -.0541 -.1363
Space .1631 .1272 .1170 1.0000 .0990 .4917
Em-Tone -.1758 -.0563 -.0541 .0990 1.0000 .1832
Form -.1220 .1079 -.1363 .4917 .1832 1.0000
Correlation table 19 for DAPA variables measured from the pictures of Controls: a. colours, and b. structure


Red 1.0000 .5257* .3993 .2524 .0536 -.1223
Yellow .5257* 1.0000 .4753 .2503 .0811 -.3953
Green .3993 .4753 1.0000 .4316 .3416 -.4588
Blue .2524 .2503 .4316 1.0000 -.1899 -.3905
Brown .0536 .0811 .3416 -.1899 1.0000 .0919
Black .1223 -.3953 -.4588 -.3905 .0919 1.0000
Intensity .6164* .4570 .3484 .3894 .1098 .1566
Line-paint .4431 .0635 .2293 -.1029 .2745 .1564
Line-draw -.0201 .0065 -.1370 .1684 -.2170 -.0372
Space -.0202 .0456 -.0338 -.2078 .0489 .0488
Em-Tone .1988 .3496 .0326 -.0338 .0822 -.1170
Form .2761 .0479 .0446 .4472 -.0955 .1224


Red .6164* .4431 -.0201 -.0202 .1988 .2761
Yellow .4570 .0635 .0065 .0456 .3496 .0479
Green .3484 .2293 -.1370 -.0338 .0326 .0446
Blue .3894 -.1029 .1684 -.2078 -.0338 .4472
Brown .1098 .2745 -.2170 .0489 .0822 -.0955
Black .1566 .1564 -.0372 .0488 -.1170 .1224
Intensity 1.0000 .5254 -.2455 .1009 .3627 .3111
Line-paint .5254 1.0000 -.6305* -.0161 .2395 -.0204
Line-draw -.2455 -.6305* 1.0000 .2629 -.1978 .1931
Space .1009 -.0161 .2629 1.0000 .1603 -.1115
Em-Tone .3627 .2395 -.1978 .1603 1.0000 .1114
Form .3111 -.0204 .1931 -.1115 .1114 1.0000
347
Correlation table 20 for DAPA variables measured from the pictures of Patients with Personality Disorder: a. colours, and b.
structure


Red 1.0000 .4291 .1037 .2665 .5060 -.7479
Yellow .4291 1.0000 .0803 .6943 .6450 -.3775
Green .1037 .0803 1.0000 .5832 .6699 -.1882
Blue .2665 .6943 .5832 1.0000 .6532 -.4694
Brown .5060 .6450 .6699 .6532 1.0000 -.5087
Black -.7479 -.3775 -.1882 -.4694 -.5087 1.0000
Intensity .0062 .4293 .0112 .5181 .1394 -.4951
Line-paint .1697 .2417 -.1492 .2956 .1385 -.5908
Line-draw .0238 -.0723 .5020 .0131 .2875 .3169
Space -.1395 .0427 -.6277 -.3151 -.2847 .2442
Em-Tone -.2327 .5180 .3585 .6741 .5307 -.2249
Form .1801 -.1023 .2526 -.2675 .1488 .1142


Red .0062 .1697 .0238 -.1395 -.2327 .1801
Yellow .4293 .2417 -.0723 .0427 .5180 -.1023
Green .0112 -.1492 .5020 -.6277 .3585 .2526
Blue .5181 .2956 .0131 -.3151 .6741 -.2675
Brown .1394 .1385 .2875 -.2847 .5307 .1488
Black -.4951 -.5908 .3169 .2442 -.2249 .1142
Intensity 1.0000 .6197 -.6751 -.1665 .4921 -.2190
Line-paint .6197 1.0000 -.8182* .4452 .3427 -.6997
Line-draw -.6751 -.8182* 1.0000 -.4715 -.0352 .5385
Space -.1665 .4452 -.4715 1.0000 -.1114 -.6429
Em-Tone .4921 .3427 -.0352 -.1114 1.0000 -.3661
Form -.2190 -.6997 .5385 -.6429 -.3661 1.0000
348
Appendix 2: Tables summarising raw data from the text of the thesis.
Chapter 2
Table 3: Summaries of impressionistic studies of or about artists.
Table 4: Summaries of papers reporting changes or signs in the theme/content of the
artwork.
Table 6: Summaries of papers reporting changes or signs in the form of the artwork.
Table 7: Summaries of papers reporting the most important feature of art therapy was
the therapeutic relationship.
Crosstabulations 1-6: contingency tables for Chi-square calculation to indicate

associations between method of study, form of expression and benefits for categorised
commonalities of 67 studies which claimed 'expression of feelings' as main benefit for art
therapy.
Reliability Study Chapter 4 - Methods. Tables and Plots 1-15.

Tables 1-15 by variable showing: column 1, Raw data scores for each variable each rater
( r1-7) over 7 pictures in sequence.
Column 2, scoring differences between 6 raters and author on 7 rated pictures.
Column 3, mean differences for raters 1-6 and standard difference to rater 7 (author).
Plots 1-15 by variable showing individual rater differences around average rating of 6
independent raters and author.
Results from Study 2.
Tables and Figures 1a-i showing abnormal distribution of DAPA variables which were
transformed or deleted.
Tables and Figures 2a-f showing normal or near normal distribution of DAPA variables
which were left in their original state.
Tables and Figures 3a-f showing normal distribution of DAPA variables after
transformation.
Figures 6a-1 showing standard differences from the mean for each diagnostic group for
DAPA variables with normal distribution.
Figures 7a-c showing standard differences from the mean for each diagnostic group for
DAPA variables which were dropped because of infrequent use.
Correlation tables 16-20 for each diagnostic group for 12 DAPA variables.
Correlation table 16 for DAPA variables measured from the pictures of Schizophrenics:
a. colours, and b. structure
Correlation table 17 for DAPA variables measured from the pictures of Substance
Abusers: a. colours, and b. structure
Correlation table 18 for DAPA variables measured from the pictures of Depressives: a.
colours, and b. structure
349
Correlation table 19 for DAPA variables measured from the pictures of Controls: a.
colours, and b. structure.
Correlation table 20 for DAPA variables measured from the pictures of Patients with
Personality Disorder: a. colours, and b. structure
Chapter 2
Table 3: Summaries of impressionistic studies of or about artists.
Table 4: Summaries of papers reporting changes or signs in the theme/content of the
artwork.
Table 6: Summaries of papers reporting changes or signs in the form of the artwork.
Table 7: Summaries of papers reporting the most important feature of art therapy was
the therapeutic relationship.
Crosstabulations 1-6: contingency tables for Chi-square calculation to indicate

associations between method of study, form of expression and benefits for categorised
commonalities of 67 studies from the literature which claimed 'expression of feelings' as
main benefit for art therapy.
350
Impressionistic studies, TABLE 3: summarising studies of or about artists, common concepts and assumptions
about their work.
Artist or subject Interpretation of picture or artwork, signs and relation of work type of study
to psychiatric symptoms
1 Similarities between Understood in terms of phytogenetic and ontogenetic discussion

schizophrenic art, surrealism development of the personality structure
and tribal art of Australia and
Africa
2 Spontaneous art contains Stimulates individual expression and interpersonal reaction, theory
symbols and messages whose example van Gogh.
meaning may be more relevant
than artist realises.
3 Depression and art Reactivates the nondominant hemisphere of the brain, theory
psychohygienic effect of particularly in chronic or recurrent depressions also opens up
exorcising own suicidal new perspectives for the solution of the problems that drive to
impulses and thoughts depression, example Goethe
4 Aesthetic and psychological Identity conflicts. Description. case

conflicts in work of prof art
student 4 yrs. therapy
5 Similarities and differences in 3 assumptions - motivation of patient is compulsive, artist makes speculation
the paintings of action painters free choice; patient painting is incoherent and random, artist has
and schizophrenics. The artist periods of emotional detachment/ intellectual consideration of
deliberately attempts to work; the art final product is an integrated whole, but not
relinquish intellectual control in patient's.
order to express inner drives in
the freest manner possible.
Many mental patients paintings
unconsciously expressed in the
same way.
6 Outsider art, individuals outside Because many practitioners emotionally disturbed, some discussion
fine arts circles and outside generalisation of conclusions to all mental patients
society.
7 73 yrs male artist agnosia Despite inability to recognise scene or object subject was able to case
following occipital cerebral copy the display well. When displays were recognised or if
vascular accident - memory given name of object, no effect shown. Postmorbid drawings
disturbance but essentially similar to early works, but features such as insufficient
intact linguistic and cognitive differentiation of figure from ground, over elaboration of detail
capacities, effects on artists and areas of neglect revealed effect.
capacity to draw examined
8 Argued that quality of Middle period of Munch best known previously repressed drive case
creativity in paintings by derivatives found full expression in his imagery. At the end of
Munch not compromised by his this period disruptive personal factors contributed to the failure
hospitalisation. of his defensive structures. Psychiatric intervention prevented
further psychopathology and led to an altered artistic focus.
9 Charles Filiger's work A painter's psychosis may stimulate an original creation, valid in case
represents characteristic traits its own right as a work of art. Effects of disorder not
of schizophrenic psychosis. necessarily destructive and work may go beyond the personal
Exceptional man sparse problems of the creator and acquire meaning for spectators.
biographical data, total isolation
from world amid persecution
delirium ending in suicide.
10 Describes 12 collections of Concept of 'psychopathology of expression' represents a discussion

psychiatric art distortion of truth in whatever the artists inner experiences
were, their expressive faculty remained intact or grew stronger
to encompass them
11 Rembrandt. Photo electric lux Differences in light and darkness in Rembrandt's self portraits case
measurements from would reflect his mood (particularly depression) in conformity
reproductions with various life events. Results were inconclusive.
12 Joan Miro. Explores the There seems a connection between feelings of despair and case
relation of Miro's spiritual inner torment and the evolution of his art. Depressed state
351
beliefs to depression. cannot be matched to specific artworks, yet the author feels it is
revealed in many paintings.
13 Picasso and pathology of Represents less stylistic or formal revolution than partially case
cubism. successful attempt to come to terms with certain conflicts.
Unwittingly therapeutic, gave him psychological control.
14 Modigliani's works Illustrates expression of psychodynamic forces, principally case

resistance against emotional closeness and indications of
superego pathology. Paintings exemplify defense mechanisms
which dealt with anxiety.
15 Van Gogh, diagnosed by Portrait of Cachet is discussed as to how it expresses Gachet's discussion
Gachet as melancholic. own melancholia.
16 Goya - reviews the literature Detailed knowledge and depictions of mental hospital scenes description
on illness and dynamic and recent data from Real y General Hospital in Zaragoza
interpretations. support affective psychosis indicate mental illness in family.
17 Mondrian. Determines Symbolistic and psychiatric perspective. To best appreciate the discussion
connection between the man art, his personality should be disregarded. Artists' bio-graphical
and the art. data considered poor indicators of creation.
18 Compares schizo-phreniform Challenges view of disordered thought of schizophrenia as discussion

symptoms, aspects of modern manifestation of developmentally primitive modes of
art and literature, to emphasise consciousness.
the defensive /disruptive role of Similarities in theme and formal structures of patients to modern
forms of self-consciousness art and thought are delineated.
(pathological reflexivity).
19 M. Ramirez, little known Artwork is more than clinical material, but has expressive case
Mexican final 25 years of vitality and coherence from which one can relate its testimony
severe psychosis. to the universal psychological meaning of the struggle to be born
from the forces of nonbeing and chaos. Expresses the
archetypal movements within our personal psychology that can
be construed as sickness, but may be that which ultimately heals
blindness to the depths of the soul.
20 Correlation between early life Munch's art reflected his attempts to recreate the image of his case
of Munch and subsequent dead sister. Disappointing relationships with women resulted in
psychodynamics as revealed in heavily affect laden paintings. Later work showed women
his life and art. more positively and aggression. Munches transitional
relationship with his paintings helped him deal with his fear of
ego-fragmentation, serving function of completion and
autonomy.
21 Jochen Seidel Artist attempted to resolve deep-seated psychological conflicts case

Psychotic episodes through painting. Material from life illustrates efforts to deal
with loss, depression, guilt and anxiety through art. Creative
work is a response to loss and an effort at self-healing.
Negative relationship between creativity and psychosis assumed
by psychoanalytic studies is challenged.
22 Prevalence of mood an mind Data collected from published biographies and archival discussion
disorders in 14 modern abstract material. Over 50% of artists had some psychopathology,
expressionist artists who, using predominately mood disorders and preoccupation with death,
psychic automatism to reveal often compounded by alcohol abuse. Subjects tended to die
unconscious material, created young from suicide, accidents, other causes. 40% sought
psychologically and spiritually treatment and 20% were hospitalised for psychiatric problems.
significant art that addressed Results suggest depression inevitably leads to turning inward and
mythic themes of creation, to painful reexamination of the purpose of living and the
birth, life and death. possibility of dying and may have put these artists in touch with
the mystery that lies at the heart of the tragic and timeless art
that the abstract expressionists tried to produce.
23 Mark Gertler Psychoanalytic interpretation using historical material and work. case
Viccitudes of his career, Gertler's art expresses the tensions between stillness and
depression and suicide with motion, inanimate and animate and the one and the many
reference to primal scene represented a struggle with the sequelae of early primal scene
trauma. trauma.
24 Meaning of images of doors in Human being's relationship to the environment are explored and discussion
20th C. paintings of mostly balance, intimacy separation, limits and boundaries are
completely normal artists. considered. Doorways are seen as metaphors for the artists'
352
Compared with untrained internal psychic worlds, dialectical integration of inside and
therapy clients. outside. Artwork of patients also seen as doorway to inner
world not accessed by words.
25 Michelangelo depression. The attempt to destroy the Florentine Pieta and immediate and case
sustained creative effort of his last 10 years to recreate another
Pieta, whilst cutting it up, represent sublimation of the main
infantile conflicts of his life: loss of mother in early infancy and
abandonment by parents. Influence of these conflicts on his
character and creativity and lifelong depression and confusion
about the role of parental images and self-image.
26 Female painter and female Central aim to bring clients to a realisation of their creative cases
sculptor case reports to forces. Inappropriate reasons that many artists use to avoid
illustrate Jungian analytic therapy. Jungian psychology considers the relationship between
concepts the conscious and the unconscious to be creative and analysis
may help some artists overcome disturbances that hinder them in
fully realising their creative potential.
27 Vincent Van Gogh as artist Explores the psychoanalytic sources of the intensely personal case
quality and powerful sense of communion with nature in
Vincent Van Gogh's art. Life was saga of disappointment,
disillusionment and failure. Dominated by spectre of stillborn
brother from early life, fantasy motif in later years. Art
replaced all other attachments, goals, ambitions or meaningful
involvements as van Gogh struggled with sense of self.
Immersion and devotion to nature may be connected to
dynamics of idealised cosmic image of nature substitutes for
idealised parent. So, art may serve as form of transitional
relatedness to the mother of his infant experience.
28 82yrs male artist stroke, Special measures to free the artist from preconceived notions, case
aphasic, paralysis pressures and expectations. Successful - renewed creative
energies and desires.
29 Artist not willing to use his Illustrates some of the conflicts and complications inherent in art case
work as part of the therapy therapy for artist. Patient used the therapist as a stimulus to
creativity, but as an artist he was not willing to use his work as
part of the therapy. He was unable to separate himself from his
artistic productions and it continued to be important for him to
suffer in order to paint and work.
353
Table 4: summarising changes or signs predominantly reported in the theme/content of the artwork.
Study Case description/ diagnosis Summary themes reported in Interpretation

artwork
1 13y. male Parental Abuse Theme of ambivalence* often. Illustrates responses to life changes
2 Adult female Static and sparse Impoverished and incongruent with

Psychotic (American Indian) instructions
3 70y. mute female - 49 year Hostility,* suspicious, disorientated Illustrates progress of therapy
hospitalisation. 6m. art therapy, to well orientated, thoughtful.
Paranoid Schizophrenia
4 14y. male. 5 years of Selected from 1,250 drawings Mouth as archetypal image. Early drawings
treatment. almost all circular forms, comments show the struggle* to rise out of the dark
Emotional disorder referred to mouth, cat, dragon and chaos of unconscious, become more focused.
star. Preocc with mouth in autism. Theory mouth
is primary site of psycho -sexual - social
injury. Analogy of myth motifs and rituals to
symbolic themes of mouth and transition from
autistic phase ego development to symbiotic
phase.
5 21y. female Chronic Religious themes and sexual Shows changes of affect, ego functions
Schizophrenia on conflicts*, from threatening and strengthened
lithium treatment dark to lighter
6 Case studies mixed adults. Results indicate directional trends- Minus phenomena in dep., plus properties in
Manic/Depressive tested on mutilated figures in depressive mania. Dynamic drawing tests useful for
serial drawings of human phase, strong dense lines in manic. tracing changes in patient's state during
figure Regression in primitive childlike therapy or as a prognostic tool
characteristics/ younger figures.
7 36y. female Pictures contained personal Paralleled and contributed to improvement,

Reactive Depression information, self disclosure more precise diagnosis
8 24y. male Empty simple pictures, repeated Broken land symbolises disruption of brain
Brain Injury, car accident theme broken land, disruption* damage. Body image relates to figures.
became unified with colour as Primary benefit relationship with therapist
progress toward normal
consciousness
9 40y. male with 20y. hospital Symbol formation which resulted in Through internalisation, S experienced a
record psychosis. new, more balanced, less holding environment, now able to verbalise
6 week mural program egocentric, more differentiated feelings
schema than at start of project
10 5 male 5 female adults Separation/individuation symbols Significance of numbers may relate to the
Psychosis especially when representation of number of visual symbols produced.
'three' occurred repeatedly Work expresses present situation of patient
11 71 y. female Alzheimer's, Loss metaphors similar to cancer Unconsciously knew she was dying
diagnosed cancer patients
12 10 mixed adults Depressed: less freq. creative, Illustrates illness, reflects disturbance in
Manic/Depressive sombre gloomy themes /colour, activity and thought
summary drawings. Manic:
rapid/expansive euphoric, warm
bright colour
13 Family, 2 adults 1 male 11y. Kwiatkowska methods. Unusual Focus treatment and understand problem.
conjoint team 6 pics evaluated.. family portraits - other indicators Focus changed from boy to mother
14 72y. male Difficult to recognise complex Requires different techs communication to

Aphasic imagery interpret expression
15 Mixed adults over many years/ Bright colours, complete scenes, Symbolic of realistic hopes expressed in
variety of settings. happy. Repeated symbols - yellow artwork, starting point for therapy
Depression sun, flowers, trees, houses, grass
16 Nearly 2000 pics from Multiple extracted 10 thematic, structural and To aid therapist's diagnosis of multiple
Personality Disordered patients process, categories: system, personality disorder, but all indicators not
354
over 9 years fragmentation, barrier*, switching, present.
threat*, alert, deception*, therapy,
trance, abreaction
Table 5: summarising general signs of psychiatric disturbance reported in case studies.
No. Case description/ Summary description of form reported in Interpretation

diagnosis artwork
29 39 adult psychiatric Tendency to circle in a clockwise direction Closely associated with childhood
inpatients (torque) psychosis, existing sensorimotor
deficits and early cognitive
dev'ment
30 177 16-71y. psychiatric Constricted or expanded figures, drawn Drawing styles were found to
outpatients along edges of paper, disorganised placing correlate with personality traits
31 34 adult inpatients Right hemispheric inhibition, deformation of Deformation might be based on a

depression & the whole perceptive space with nonlinear distortion of the
Schizophrenia compression of the right and extension of the perceptive space with
left. Left hemispheric inhibition caused displacement of the initial
Dot-to-dot geometrical initial and final parts shift to right. coordinate point to the right from
figure its geometrical centre.
355
Table 6: summarising changes or signs predominantly reported in the form of the artwork.
S Case description/ Summary description of form Interpretation

T diagnosis reported in artwork
U
D
Y
No.
17 30y. male 2 sets of figure drawings 10 years Detailed scoring of elements

decline in behaviour apart. Regression, lack detail, demonstrating decline intellectual &
function/ simpler shapes, omissions etc. behavioral function for later pics
psychological
decompensation
18 58y. female Degeneration of image, childlike Severe regression, intrapsychic reactions

dementia (Alzheimer forms
type)
19 Adult female artist Childlike forms, fragmentation, Art reflects mental state over years -
Borderline personality affect, disorganisation, splitting strength/ego impairment and marked
disorder improvement reflected in drawings
20 22y. female Black & white or pencil rigid, well Trauma in self relates to object relation,
Depressed defined. Post therapy mother not good enough, no internal
impressionistic, realistic with models. Therapist plays different
fantasy images in colour mothers. Drawings represent possibility
of new more satisfying object relations
illustrated
21 Adolescent female Poor verbal interaction, good Art can be a bridge to verbal interaction
Anorexia quality complete drawings/paintings illustrates issues, conflicts and defenses
with colour and subject matter
22 24y. male Subtle differences in 30 self Important learning took place although
Impaired short term portraits patient couldn't recall. Paintings provide
memory and Brain access to patient's personality
Damage
23 36y. female Wild, random, uncontrolled, Express disorientation, turbulence, lack

Nervous Depression incoherent drawings showing lack of connections, coherence, etc. shows
of connections, no centre of focus. state of mind. Progressive focus,
art and music therapy Post-therapy structured, focused, structure and organisation of art
coherent promotes form and order in other areas
and dialogue. Contributes to the healing
process. Creative art therapy is not
psychological but artistic
24 3 female Adults Dark, sombre, gloomy pictures Reflect mood state of patient
Depression + other depressive, bright colours not
psychiatric state depressed
25 100 mixed sex Adult Patients asked to draw illness, no All were able to graphically
Alexythymia correlation with scores on TAS communicate illness but drawing
(depression) promotes therapeutic alliance provides
symbolic visual means to express
recognise discuss feelings
26 Adult male 1. Ossified, static, fragmentary. Drawing type agrees with formal
Schizophrenia symptoms therefore diagnosis correct.
Adult male 2. Clear structure The formal symptoms disagree with
Schizophrenia drawing puts diagnosis in doubt
27 13 mixed sex Distortion of form, perseveration, These signs show evidence of initial
Schizophrenia simplification, proportion errors, diagnosis but also suggest organic
disconnections, limited colour, disorder.
confusion from directions 11/13 further tested showed organic signs
28 10 Adult (19-55) Improvement with treatment on Some patients show typical features and
Manic Depressive quality of drawing; head, mouth, pictures reflect improvement or
essential detail, richness of deterioration in patient
356
features, execution
Table 7: summarising information for case studies which considered the therapeutic relationship as the most
important feature of art therapy
No. case description/ Therapy type/ patient reaction art benefits explained by study relationship
diagnosis type
1 15y. male Individual art sessions, initial greater sense of mastery and insight to nurturing
conduct disorder resistance but progressed to focus primarily on reality psycho-
(fostered, firesetting) good relations therapeutic
'Acting out'
2 23y. female Painting together providing empathetic response denied nurturing

multiple personality as child psycho-
disorder + childhood therapeutic
sex abuse by father
3 30y. male art, writing and verbals helped through visual imagery and mirroring, nurturing non
Chronic Schizophrenia the therapist to understand S art helped the subject and therapist intrusive
more clearly and recognize and establish a symbiotic relatedness and
work with his ego defenses, nonverbal modality conducive to a
deficits and strength therapeutic holding envm't
4 lesbian couple, Drawing, psychodrama and clay psychodynamic - from the notes by psycho-
deaf+suicidal, other sculpture with S's written patient, countertransference had therapeutic
hearing afterthoughts taken place
5 22y. female Drawing together, therapist and art provides graphic record of merger nurturing
Anxiety Neurosis subject experience 'merging and increases receptivity to treatment, psycho-
with another person' enhances participation, corrective therapeutic
experience, continues psychological
growth
6 14y. male Drawing and Painting to reverse Artwork and therapist served as self- nurturing -
Behavioral Emotional narcissism and ego regression objects that helped nourish his inner psycho-
Disturbance self and emotional needs, promote therapeutic
growth
7 25y. female clay molding and drawing to helped to unite the subject and nurturing -
Schizophrenia reorganise and restructure the therapist and provides a psycho-
pathological development nonthreatening environment for therapeutic
experience of the subject and mutual trust and therapeutic alliance.
encourage growth of ego
functions.
8 24y. male Drawing and interaction help patient express suffering and communi-
Catatonic observing interaction good for staff cative
Schizophrenia relations, accept patient human-being
severely regressed
9 27y. male black Drawing sexualised transference and use of communi-

Chronic Paranoid energy toward relationship cative contact
Schizophrenia
10 15y. male Drawing images of growth and Gesticulations showed S knew the communi-
Paranoid mourning for termination of therapist was separate and imperfect. cation and
Schizophrenia therapy Efforts at separation accelerated as release to
termination progressed. Disruptive indepen-dence
behaviour coincided feelings of
disorganisation and despair.
11 15y. female Use of materials, control over growing mastery of materials supportive of
Borderline personality materials generalised to mastery of her goal directed
+ suicidal environment interaction
12 26y. male black Drawing and painting in self Supported patient emotionally for eye Supportive
Alcoholic. Afraid of situations for fear. operation and detox clinic. S became emotionally
treatment + emotional aware of himself in nonthreatening
problems Treatment incomplete but manner and art clarified vaguely
357
progressed further than other perceived situation
approaches
13 22y. male combined cognitive behavioral Goal to alter self-image of violent Supportive
Violence and and expressive therapy. patients helps develop alternative emotionally
substance abuse response patterns
14 institutionalised combined art modalities not participation changes subject's Supportive

retardates: 30y. male psychoanalytical. perception of internal control by emotionally
profound quadriplegic; providing opportunity express or
10y. female, severe; reflect on inner perceptions and
27y. male, mild feelings
16 4 16-25y. males providing open, accepting, both processes reflected underlying supportive
Autistic respecting atmosphere for growth in self confidence and emotionally
expression. Subjects progressed autonomy. Reflected commonality in
from inhibition to spontaneity all human beings
and from overactivity to self
control
17 17y. male black Mild Drawing/painting self issues. S achieved a sense of mastery through supportive -
Retardation Subject demonstrated improved art, resulting in praise and opportunity for
functioning and more successful encouragement improved self-esteem, creative
negotiation of the behaviour supported ego-building, reorganisation interaction
mod system and improved behaviour
18 3 males 22y., 29y., Opportunity for creativity environment values divergent supportive
32y. Retarded. thinking, subjects considered rigid and opportunity for
concrete thinkers successfully engage creative
in creative process, no rewards/punish interaction
and natural interactions
358
Table 8: summarising reported behaviour changes for case studies.
No. case description/ summary description of reported Interpreted

diagnosis method
1 group 14y. mixed sex video-taped early later art sessions. Greater awareness of needs/feelings of
Emotional/ behavioral Unstructured art sessions. Sharing others. Showed greater co-operation non
problems noted, minimal displacement interference behaviour and more focused
activity activity
2 28y. female Mild Guided imagery and art S achieved sense of accomplishment and
retardation experiences. Used beh observation internal control less feeling helpless.
form, better; work production
average, increase; and House Tree
Person drawing test
3 2 females 13 and 15y. Storytelling and drawing tasks. Blocking revealed deficiency in carrying
Disorganised Verbal deficits form and content of out plans, poverty of content of speech
Schizophrenia speech and nonverbal deficit in reflected central deficit in planning.
logical thinking and drawing. Central cognitive processing deficits
sensitive to relative social/cognitive
demands of context.
4 24y male Schizophrenia Exercise left parieto-occipital Lowest levels of hallucinatory behaviour,
function, verbal expression of aggressive verbal outbursts and physical
spatial relations. Exercise right aggression in right hem exercises.
hemisphere; drawing.
359
Crosstabulations 1-6: contingency tables for Chi-square calculation to
indicate associations between method of study, form of expression and benefits
for categorised commonalities of 67 studies from the literature which claimed
'expression of feelings' as main benefit for art therapy.
Crosstabulation 1: ORIENTATION By METHOD OF STUDY METHOD

OF STUDY -> 1.Illustrative; 2. projective/express; 3. behaviour; 4. psychoanalytic; 5.
educational/experiential
Std Res 1 2 3 4 5 Row Total
______________________________________________________
ORIENTATION 0 _ 0 _ 1 _ 0 _ 1 _ 1 _ 3
_ .0% _ 33.3% _ .0% _ 33.3% _ 33.3% _ 4.5%
unknown _ .0% _ 2.6% _ .0% _ 14.3% _ 7.7% _
_ -.4 _ -.6 _ -.4 _ 1.2 _ .5 _
______________________________________________
1 _ 1 _ 1 _ 1 _ 1 _ 2 _ 6
cognitive _ 16.7% _ 16.7% _ 16.7% _ 16.7% _ 33.3% _ 9.0%
_ 25.0% _ 2.6% _ 25.0% _ 14.3% _ 15.4% _
_ 1.1 _ -1.3 _ 1.1 _ .5 _ .8 _
______________________________________________
2 _ 2 _ 28 _ 2 _ 1 _ 4 _ 37
projective _ 5.4% _ 75.7% _ 5.4% _ 2.7% _ 10.8% _ 55.2%
_ 50.0% _ 71.8% _ 50.0% _ 14.3% _ 30.8% _
_ -.1 _ 1.4 _ -.1 _ -1.5 _ -1.2 _
______________________________________________
3 _ 0 _ 0 _ 0 _ 0 _ 1 _ 1
phenomen'l _ .0% _ .0% _ .0% _ .0% _ 100.0% _ 1.5%
_ .0% _ .0% _ .0% _ .0% _ 7.7% _
_ -.2 _ -.8 _ -.2 _ -.3 _ 1.8 _
______________________________________________
4 _ 0 _ 3 _ 1 _ 1 _ 4 _ 9
social/ _ .0% _ 33.3% _ 11.1% _ 11.1% _ 44.4% _ 13.4%
occupational _ .0% _ 7.7% _ 25.0% _ 14.3% _ 30.8% _
_ -.7 _ -1.0 _ .6 _ .1 _ 1.7 _
______________________________________________
5 _ 1 _ 6 _ 0 _ 3 _ 1 _ 11
analytical _ 9.1% _ 54.5% _ .0% _ 27.3% _ 9.1% _ 16.4%
_ 25.0% _ 15.4% _ .0% _ 42.9% _ 7.7% _
_ .4 _ -.2 _ -.8 _ 1.7 _ -.8 _
______________________________________________
Column 4 39 4 7 13 67
Total 6.0% 58.2% 6.0% 10.4% 19.4% 100.0%
Chi-Square D.F. Significance Min E.F. Cells with E.F.< 5

26.29640 20 .1562 .060 26 OF 30 ( 86.7%)
Number of Missing Observations = 0
360
Crosstabulation 2: ORIENTATION By FORM OF EXPRESSION
FORM OF content style content behav.l verbal other

EXPRESSION -> + style Row
Std Res 1 2 3 4 5 6 Total
_______________________________________________________________
ORIENTATION 0 _ 2 _ 0 _ 0 _ 1 _ 0 _ 0 _ 3
_ 66.7% _ .0% _ .0% _ 33.3% _ .0% _ .0% _ 4.5%
unknown _ 6.1% _ .0% _ .0% _ 5.9% _ .0% _ .0% _
_ .4 _ -.2 _ -.5 _ .3 _ -.6 _ -.3 _
_______________________________________________________
1 _ 2 _ 0 _ 0 _ 3 _ 1 _ 0 _ 6
_ 6.1% _ .0% _ .0% _ 17.6% _ 11.1% _ .0% _ 9.0%
cognitive _ 33.3% _ .0% _ .0% _ 50.0% _ 16.7% _ .0% _
_ -.6 _ -.3 _ -.7 _ 1.2 _ .2 _ -.4 _
_______________________________________________________
2 _ 21 _ 0 _ 3 _ 10 _ 3 _ 0 _ 37
projective _ 56.8% _ .0% _ 8.1% _ 27.0% _ 8.1% _ .0% _ 55.2%
_ 63.6% _ .0% _ 60.0% _ 58.8% _ 33.3% _ .0% _
_ .7 _ -.7 _ .1 _ .2 _ -.9 _ -1.1 _
_______________________________________________________
3 _ 0 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1
phenomenological _ .0% _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.5%
_ .0% _ .0% _ 20.0% _ .0% _ .0% _ .0% _
_ -.7 _ -.1 _ 3.4 _ -.5 _ -.4 _ -.2 _
_______________________________________________________
4 _ 3 _ 0 _ 1 _ 3 _ 1 _ 1 _ 9
social/ _ 33.3% _ .0% _ 11.1% _ 33.3% _ 11.1% _ 11.1% _ 13.4%
occupational _ 9.1% _ .0% _ 20.0% _ 17.6% _ 11.1% _ 50.0% _
_ -.7 _ -.4 _ .4 _ .5 _ -.2 _ 1.4 _
_______________________________________________________
5 _ 5 _ 1 _ 0 _ 0 _ 4 _ 1 _ 11
analytical _ 45.5% _ 9.1% _ .0% _ .0% _ 36.4% _ 9.1% _ 16.4%
_ 15.2% _ 100.0% _ .0% _ .0% _ 44.4% _ 50.0% _
_ -.2 _ 2.1 _ -.9 _ -1.7 _ 2.1 _ 1.2 _
_______________________________________________________
Column 33 1 5 17 9 2 67
Total 49.3% 1.5% 7.5% 25.4% 13.4% 3.0% 100.0%

35.43668 25 .0806 .015 33 OF 36 ( 91.7%)
361
Crosstabulation 3: ORIENTATION By BENEFIT
BENEFIT -> 1. cathartic/reflective; 2. communication; 3. healing/symptom relief; 4.
developmental/social; 5. relationship
______________________________________________________
ORIENTATION 0 _ 1 _ 1 _ 0 _ 0 _ 0 _ 2
_ 50.0% _ 50.0% _ .0% _ .0% _ .0% _ 3.4%
unknown _ 6.3% _ 5.0% _ .0% _ .0% _ .0% _
_ .6 _ .4 _ -.6 _ -.5 _ -.4 _
______________________________________________
1 _ 2 _ 3 _ 0 _ 1 _ 0 _ 6
cognitive _ 33.3% _ 50.0% _ .0% _ 16.7% _ .0% _ 10.2%
_ 12.5% _ 15.0% _ .0% _ 12.5% _ .0% _
_ .3 _ .7 _ -1.0 _ .2 _ -.7 _
______________________________________________
2 _ 12 _ 11 _ 6 _ 3 _ 3 _ 35
projective _ 34.3% _ 31.4% _ 17.1% _ 8.6% _ 8.6% _ 59.3%
_ 75.0% _ 55.0% _ 60.0% _ 37.5% _ 60.0% _
_ .8 _ -.3 _ .0 _ -.8 _ .0 _
______________________________________________
3 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1
phenomen'l _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.7%
_ .0% _ 5.0% _ .0% _ .0% _ .0% _
_ -.5 _ 1.1 _ -.4 _ -.4 _ -.3 _
______________________________________________
4 _ 0 _ 1 _ 3 _ 3 _ 0 _ 7
social/ _ .0% _ 14.3% _ 42.9% _ 42.9% _ .0% _ 11.9%
occupational _ .0% _ 5.0% _ 30.0% _ 37.5% _ .0% _
_ -1.4 _ -.9 _ 1.7 _ 2.1 _ -.8 _
______________________________________________
5 _ 1 _ 3 _ 1 _ 1 _ 2 _ 8
analytical _ 12.5% _ 37.5% _ 12.5% _ 12.5% _ 25.0% _ 13.6%
_ 6.3% _ 15.0% _ 10.0% _ 12.5% _ 40.0% _
_ -.8 _ .2 _ -.3 _ -.1 _ 1.6 _
______________________________________________
Column 16 20 10 8 5 59
Total 27.1% 33.9% 16.9% 13.6% 8.5% 100.0%

20.57888 20 .4223 .085 27 OF 30 ( 90.0%)
362
Crosstabulation 4: METHOD OF STUDY By BENEFIT


______________________________________________________
METHOD 1 _ 1 _ 2 _ 0 _ 0 _ 0 _ 3
_ 33.3% _ 66.7% _ .0% _ .0% _ .0% _ 5.1%
illustrates _ 6.3% _ 10.0% _ .0% _ .0% _ .0% _
progress _ .2 _ 1.0 _ -.7 _ -.6 _ -.5 _
______________________________________________
2 _ 9 _ 11 _ 7 _ 3 _ 4 _ 34
projective _ 26.5% _ 32.4% _ 20.6% _ 8.8% _ 11.8% _ 57.6%
expressive _ 56.3% _ 55.0% _ 70.0% _ 37.5% _ 80.0% _
_ -.1 _ -.2 _ .5 _ -.7 _ .7 _
______________________________________________
3 _ 3 _ 0 _ 0 _ 0 _ 0 _ 3
behaviour _ 100.0% _ .0% _ .0% _ .0% _ .0% _ 5.1%
_ 18.8% _ .0% _ .0% _ .0% _ .0% _
_ 2.4 _ -1.0 _ -.7 _ -.6 _ -.5 _
______________________________________________
4 _ 2 _ 1 _ 2 _ 1 _ 0 _ 6
psycho- _ 33.3% _ 16.7% _ 33.3% _ 16.7% _ .0% _ 10.2%
analytic _ 12.5% _ 5.0% _ 20.0% _ 12.5% _ .0% _
_ .3 _ -.7 _ 1.0 _ .2 _ -.7 _
______________________________________________
5 _ 1 _ 6 _ 1 _ 4 _ 1 _ 13
education/ _ 7.7% _ 46.2% _ 7.7% _ 30.8% _ 7.7% _ 22.0%
experience _ 6.3% _ 30.0% _ 10.0% _ 50.0% _ 20.0% _
_ -1.3 _ .8 _ -.8 _ 1.7 _ -.1 _
______________________________________________
Column 16 20 10 8 5 59
Total 27.1% 33.9% 16.9% 13.6% 8.5% 100.0%

19.52039 16 .2426 .254 22 OF 25 ( 88.0%)
363
Crosstabulation 5: FORM OF EXPRESSION By METHOD OF STUDY
METHOD OF STUDY -> 1.Illustrative; 2. projective/express; 3. behaviour; 4.
psychoanalytic; 5. ed.l/experiential
Std Res 1 2 3 4 5 Total
______________________________________________________
FORM OF 1 _ 3 _ 19 _ 1 _ 5 _ 5 _ 33
EXPRESSION _ 9.1% _ 57.6% _ 3.0% _ 15.2% _ 15.2% _ 49.3%
_ 75.0% _ 48.7% _ 25.0% _ 71.4% _ 38.5% _
content _ .7 _ -.0 _ -.7 _ .8 _ -.6 _
______________________________________________
2 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1
style _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.5%
_ .0% _ 2.6% _ .0% _ .0% _ .0% _
_ -.2 _ .5 _ -.2 _ -.3 _ -.4 _
______________________________________________
3 _ 1 _ 2 _ 0 _ 0 _ 2 _ 5
content _ 20.0% _ 40.0% _ .0% _ .0% _ 40.0% _ 7.5%
and style _ 25.0% _ 5.1% _ .0% _ .0% _ 15.4% _
_ 1.3 _ -.5 _ -.5 _ -.7 _ 1.0 _
______________________________________________
4 _ 0 _ 11 _ 2 _ 0 _ 4 _ 17
behaviour _ .0% _ 64.7% _ 11.8% _ .0% _ 23.5% _ 25.4%
_ .0% _ 28.2% _ 50.0% _ .0% _ 30.8% _
_ -1.0 _ .4 _ 1.0 _ -1.3 _ .4 _
______________________________________________
5 _ 0 _ 5 _ 1 _ 2 _ 1 _ 9
verbal _ .0% _ 55.6% _ 11.1% _ 22.2% _ 11.1% _ 13.4%
_ .0% _ 12.8% _ 25.0% _ 28.6% _ 7.7% _
_ -.7 _ -.1 _ .6 _ 1.1 _ -.6 _
______________________________________________
other 6 _ 0 _ 1 _ 0 _ 0 _ 1 _ 2
_ .0% _ 50.0% _ .0% _ .0% _ 50.0% _ 3.0%
_ .0% _ 2.6% _ .0% _ .0% _ 7.7% _
_ -.3 _ -.2 _ -.3 _ -.5 _ 1.0 _
______________________________________________
Column 4 39 4 7 13 67
Total 6.0% 58.2% 6.0% 10.4% 19.4% 100.0%

14.50528 20 .8040 .060 26 OF 30 ( 86.7%)
364
Crosstabulation 6: FORM OF EXPRESSION By BENEFIT

______________________________________________________
FORM OF 1 _ 9 _ 8 _ 4 _ 2 _ 4 _ 27
EXPRESSION _ 33.3% _ 29.6% _ 14.8% _ 7.4% _ 14.8% _ 45.8%
_ 56.3% _ 40.0% _ 40.0% _ 25.0% _ 80.0% _
content _ .6 _ -.4 _ -.3 _ -.9 _ 1.1 _
______________________________________________
2 _ 0 _ 1 _ 0 _ 0 _ 0 _ 1
style _ .0% _ 100.0% _ .0% _ .0% _ .0% _ 1.7%
_ .0% _ 5.0% _ .0% _ .0% _ .0% _
_ -.5 _ 1.1 _ -.4 _ -.4 _ -.3 _
______________________________________________
3 _ 1 _ 3 _ 1 _ 0 _ 0 _ 5
content _ 20.0% _ 60.0% _ 20.0% _ .0% _ .0% _ 8.5%
and style _ 6.3% _ 15.0% _ 10.0% _ .0% _ .0% _
_ -.3 _ 1.0 _ .2 _ -.8 _ -.7 _
______________________________________________
4 _ 4 _ 4 _ 3 _ 3 _ 1 _ 15
behaviour _ 26.7% _ 26.7% _ 20.0% _ 20.0% _ 6.7% _ 25.4%
_ 25.0% _ 20.0% _ 30.0% _ 37.5% _ 20.0% _
_ -.0 _ -.5 _ .3 _ .7 _ -.2 _
______________________________________________
5 _ 2 _ 3 _ 2 _ 2 _ 0 _ 9
verbal _ 22.2% _ 33.3% _ 22.2% _ 22.2% _ .0% _ 15.3%
_ 12.5% _ 15.0% _ 20.0% _ 25.0% _ .0% _
_ -.3 _ -.0 _ .4 _ .7 _ -.9 _
______________________________________________
6 _ 0 _ 1 _ 0 _ 1 _ 0 _ 2
_ .0% _ 50.0% _ .0% _ 50.0% _ .0% _ 3.4%
other _ .0% _ 5.0% _ .0% _ 12.5% _ .0% _
_ -.7 _ .4 _ -.6 _ 1.4 _ -.4 _
______________________________________________
Column 16 20 10 8 5 59
Total 27.1% 33.9% 16.9% 13.6% 8.5% 100.0%

12.29713 20 .9055 .085 27 OF 30 ( 90.0%)
365
Reliability Study Chapter 4 - Methods.
Tables and Plots 1-15.
Tables 1-15 by variable showing: column 1, Raw data scores for each
variable each rater( r1-7) over 7 pictures in sequence.
Column 2, scoring differences between 6 raters and author on 7 rated
pictures.
Column 3, mean differences for raters 1-6 and standard difference to rater
7 (author).
Plots 1-15 by variable showing individual rater differences around average
rating of 6 independent raters and author.
366
Tables showing mean differences between 6 raters and author on 7 rated pictures.
Raters R1-7 score for RED, agreement exact mean for raters 1-6
pics 1-7 - R7 = author* (x); ±1 point (1); and difference to
±2 points (2) R7 ratings
R1 R2 R3 R4 R5 R6 R7* x 1 2 mean diff.

R1-6 R7
0 0 0 0 0 0 0 6 .00 .00
6 6 6 6 6 6 6 6 6.00 .00
5 9 9 8 5 6 9 2 1 7.00 2.00
10 15 12 12 8 11 14 0 1 2 11.33 2.67
5 7 5 5 5 7 6 0 6 5.67 .33
0 0 0 5 0 0 0 5 .83 -.83
11 11 11 12 11 9 10 5 1 10.83 -.83
----------
Total 24 9 2
Total % 57 21 5
1. Difference in mean interrater score/author score for RED (RATS - A)

plotted against average (RATS + A)/2.
________________________________________
d 4_ _
i _ _
f _ 1 _
f _ 1 _
e _ _
r 0_1__________2___________________________
e _ 1 1 _
n _ _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
Average 6 rats + author
Raters R1-7 score for YELLOW agreement exact mean for raters 1-6
±2 points (2) R7 ratings.

R1-6 R7
5 5 8 5 5 5 5 5 5.50 -.50
4 5 3 5 5 3 5 4 2 4.17 .83
6 6 6 5 6 6 6 5 1 5.83 .17
16 14 13 16 16 17 16 3 1 1 15.33 .67
13 13 10 13 13 13 13 5 12.50 .50
0 0 0 0 0 0 0 6 .00 .00
8 10 10 11 8 9 12 0 1 2 9.33 2.67
-----------
Total 28 5 3
Total % 67 12 7
fig 2. Difference in mean interrater score/author score for YELLOW (RATS - A)

________________________________________
d 4_ _
i _ _
f _ 1 _
f _ _
e _ 1 1 1 _
r 0_1__________1___________________________
e _ 1 _
n _ _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
367
Raters R1-7 score for ORANGE, agreement exact mean for raters 1-6

R1-6 R7
00 0 0 0 0 0 6 .00 .00
00 0 0 0 0 0 6 .00 .00
19 18 18 19 19 18 19 3 3 18.50 .50
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
6 7 8 0 3 0 3 1 4.00 -1.00
-----------
Total 34 3
Total % 81 7
fig 3. Difference in mean interrater score/author score for ORANGE (RATS - A)

________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ 1 _
r 0_5______________________________________
e _ 1 _
n _ _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for PURPLE, agreement exact mean for raters 1-6

R1-6 R7
0 0 0 0 0 0 0 6 .00 .00
0 0 0 1 0 0 0 5 1 .17 -.17
17 14 11 14 17 9 13 0 2 1 13.67 -.67
15 12 12 15 12 11 11 1 3 12.83 -1.83
0 0 0 0 0 0 0 6 .00 .00
5 5 5 3 5 5 5 5 0 1 4.67 .33
0 3 0 0 1 0 0 4 1 .67 -.67
-----------
Total 27 7 2
Total % 64 17 5
fig 4. Difference in mean interrater score/author score for PURPLE (RATS - A)

________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ _
r 0_3________1_____________________________
e _ 1 1 _
n _ 1 _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
368
Raters R1-7 score for GREEN agreement exact mean for raters 1-6
R1 R2 R3 R4 R5 R6 x 1 2 mean diff.
R7* R1-6 R7
1 5 4.83 -.83
5 5 4 5 5 5 4 3 2 1 12.67 .33
12 14 13 11 13 13 13 5 1 2.83 .17
3 3 3 2 3 3 3 6 .00 .00
0 0 0 0 0 0 0 1 0 2 10.00 -3.00
13 11 11 7 9 9 7 6 10.00 .00
10 10 10 10 10 10 2 4 4.33 -.33
10 -----------
5 5 3 4 4 5 4 24 12 3
57 29 7
Total
Total %
fig 5. Difference in mean interrater score/author score for GREEN (RATS - A)

________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ _
r 0_1____1__1_________1____1_______________
e _ 1 _
n _ _
c _ _
e _ 1 _
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for BLUE, pics agreement exact mean for raters 1-6
1-7 - R7 = author* (x); ±1 point (1); and difference to
R7* R1-6 R7
8 8 8 8 8 8 6 8.00 .00
8 1 1 2 14.83 -1.83
16 16 14 13 15 15 6 .00 .00
13 1 0 2 12.00 -3.00
0 0 0 0 0 0 4 2 4.33 -.33
0 3 1 9.00 -2.00
11 14 9 11 14 13 0 0 4 18.33 -2.33
9 -----------
4 5 4 4 5 4 21 4 8
4 50 10 19
7 7 8 7 13 12
7
19 18 19 18 18 18
16
Total
Total %
fig 6. Difference in mean interrater score/author score for BLUE (RATS - A)

________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ _
r 0_1_______1______1_______________________
e _ _
n _ 1 1 _
c _ 1 _
e _ 1 _
369
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for BROWN, agreement exact mean for raters 1-6
R7* R1-6 R7
6 .00 .00
0 0 0 0 0 0 0 4 1 1 .50 -.50
1 2 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 2 5.83 -5.83
8 0 0 8 7 12 0 2 0 1 2.50 -2.50
4 2 0 3 0 6 0 3 1 7.83 2.17
10 10 9 10 4 4 10 2 1 2 12.83 -.83
14 10 12 13 12 16 12 -----------
25 3 4
Total 60 7 10
Total %
fig 7. Difference in mean interrater score/author score for BROWN (RATS - A)

________________________________________
d 4_ _
i _ _
f _ 1 _
f _ _
e _ _
r 0_2______________________________________
e _1 1 _
n _ _
c _ 1 _
e _ _
-4_ _
_ _
_ 1 _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for WHITE, agreement exact mean for raters 1-6
pics 1-7 – R7 = author* (x); ±1 point (1); and difference to

R1-6 R7
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
6 7 0 7 7 4 7 3 1 5.17 1.83
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
---------
Total 39 1
Total % 93 2
fig 8. Difference in mean interrater score/author score for WHITE (RATS - A)

________________________________________
d 4_ _
i _ _
f _ _
f _ 1 _
e _ _
r 0_6______________________________________
e _ _
n _ _
370
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for BLACK, agreement exact mean for raters 1-6

R1-6 R7
12 12 12 12 9 12 12 5 11.50 .50
14 15 14 14 14 14 14 5 1 14.17 -.17
8 8 6 9 8 8 9 1 4 7.83 1.17
19 20 18 20 18 19 20 2 2 2 19.00 1.00
19 17 18 18 19 18 18 3 3 18.17 -.17
1 1 1 0 0 0 0 3 3 .50 -.50
12 10 11 12 11 11 10 1 3 2 11.17 -1.17
-----------
Total 20 16 4
Total % 48 38 10
fig 9. Difference in mean interrater score/author score for BLACK (RATS - A)

________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ 1 1 1 _
r 0___________________________1______1_____
e _1 1 _
n _ _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for INTENSITY, agreement exact mean for raters 1-6

R1-6 R7
11 14 14 17 19 14 19 1 0 1 14.83 3.83
16 17 20 18 19 15 18 1 2 2 17.44 .89
20 15 20 20 18 20 20 4 0 1 18.83 1.17
19 13 17 15 19 14 16 0 2 1 16.22 -.22
14 12 13 15 15 12 15 2 1 1 13.44 1.89
9 11 10 10 9 8 10 2 3 1 9.56 .44
20 18 20 19 18 20 18 2 1 3 19.22 -.89
-----------
Total 12 9 10 29 21
Total % 24
fig 10. Difference in mean interrater score/author score for INTENSITY (RATS - A)
________________________________________
d 4_ 1 _
i _ _
f _ _
f _ 1 _
e _ 1 1 1 _
r 0______________________________1_________
e _ 1 _
n _ _
c _ _
371
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
372
Raters R1-7 score for PAINTED agreement exact mean for raters 1-6
LINE, pics 1-7 (x); ±1 point (1); and difference to
R7 = author* ±2 points (2) R7 ratings.
R1 R2 R3 R4 R5 R6 R x 1 2 mean diff.
7* R1-6 R7
0 1 2 8.78 2.56
8 12 9 7 7 9 0 3 6.83 .17
11 0 3 1 5.22 1.78
4 6 6 15 4 6 0 2 2 11.72 1.61
7 1 2 8.94 2.72
6 6 6 4 5 4 6 .00 .00
7 3 2 1 4.33 -.33
14 14 11 7 15 9 -----------
13 10 13 6
4 8 8 12 11 11 24 31 14
12
0 0 0 0 0 0
0
4 4 3 5 6 4
4
Total
Total %
fig 11. Difference in mean interrater score/author score for PAINTED LINE (RATS - A)
________________________________________
d 4_ _
i _ _
f _ 11 _
f _ 1 1 _
e _ _
r 0_1_______1____1_________________________
e _ _
n _ _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for DRAWN agreement exact mean for raters 1-6
LINE, pics 1-7 - R7 = author* (x); ±1 point (1); and difference to

R1-6 R7
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
0 0 0 0 0 0 0 6 .00 .00
5 4 4 10 6 5 5 2 3 5.61 -.28
1 0 0 0 0 0 0 5 1 .17 -.17
-------
Total 37 4
Total % 88 10
fig 12. Difference in mean interrater score/author score for DRAWN LINE (RATS - A)
________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ _
r 0_6_________1____________________________
e _ _
n _ _
373
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for SPACE, agreement exact mean for raters 1-6

R1-6 R7
15 14 15 10 14 13 12 0 1 3 13.37 -1.77
10 9 9 5 10 9 8 0 3 2 8.67 -.87
4 4 4 4 4 4 4 6 4.00 .00
6 7 8 7 6 6 6 3 2 1 6.80 -1.00
4 4 4 4 4 4 4 6 4.00 .00
16 15 15 15 14 16 14 1 3 2 15.13 -.93
4 4 4 4 4 4 4 6 4.00 .00
-----------
Total 22 9 8
Total % 52 21 19
fig 13. Difference in mean interrater score/author score for SPACE (RATS - A)
________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ _
r 0________3_______________________________
e _ 1 1 1 _
n _ 1 _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for Agreement exact mean for raters 1-6
EMOTIONAL TONE, pics 1-7 - (x); ±1 point (1); and difference to
R7 = author* ±2 points (2) R7 ratings.

R1-6 R7
11 11 18 14 12 13 15 0 1 1 13.28 1.39
15 16 19 18 16 16 15 1 3 16.56 -1.22
19 18 20 17 19 16 20 1 2 1 18.17 1.83
7 10 11 9 7 9 7 2 0 2 8.83 -2.17
10 14 10 8 9 8 8 2 1 2 9.83 -1.83
14 14 15 16 17 16 18 0 1 2 15.22 3.11
15 14 16 13 8 13 13 2 1 1 13.28 .06
-----------
Total 8 9 9
Total % 19 21 21
fig 14. Difference in mean interrater score/author score for EMOTIONAL TONE (RATS - A)
________________________________________
d 4_ _
i _ 1 _
f _ _
f _ 1 1 _
e _ _
r 0_________________________1______________
e _ _
n _ 1 1 _
c _ 1 _
e _ _
374
-4_ _
R-A ________________________________________
0 5 10 15 20
Raters R1-7 score for FORM, agreement exact mean for raters 1-6

R1-6 R7
0 0 0 0 0 3 0 5 .50 -.50
7 8 8 7 7 7 8 2 4 7.33 .67
5 7 5 7 7 5 5 3 0 3 6.00 -1.00
0 0 0 0 0 0 0 6 .00 .00
8 0 0 0 0 0 0 6 1.33 -1.33
16 16 16 16 16 16 16 6 16.00 .00
3 3 3 3 3 3 3 6 3.00 .00
------------
Total 34 4 3
Total % 81 10 7
fig 15. Difference in mean interrater score/author score for DOMINANT FORM (RATS - A)
________________________________________
d 4_ _
i _ _
f _ _
f _ _
e _ 1 _
r 0_1____1_______________________1_________
e _1 1 _
n _ 1 _
c _ _
e _ _
-4_ _
R-A ________________________________________
0 5 10 15 20
375
Appendix 3
Table of Authorities
1. Impressionistic/Theoretical Studies
2. Case Studies of Artists
3. Case Studies - change of theme or content elements
4. Case Studies - change of objective or formal elements
5. Case Studies - change of behaviour
6. Case Studies - therapeutic benefit - relationship
7. Case Studies - therapeutic benefit - expression of feelings
8. Controlled Studies
376
Table of Authorities
Impressionistic studies
Abraham, A. (1990), The projection of the inner group in drawing, Group Analysis, Dec., V.23(4):391-
401.
Adler, R.F., Fisher, P. (1984), My self ... through music, movement and art, Arts in Psychotherapy, Fall,
V.11(3):203-8.
Adelman, E., Castricone, L. (1986), An expressive arts model for substance abuse group training and
treatment, Arts in Psychotherapy, Spr., V.13(1):53-9.
Albert-Puleo, N. (1980), Modern psychoanalytic art therapy and its application to drug abuse, Arts in
Psychotherapy, V.7(1):43-52.
Albert-Puleo, N., Osha, V. (1976), Art therapy as an alcoholism treatment tool, Alcohol Health and
Research World, Win., V.1[2]28-31.
Allan, J., Clark, M. (1984), Directed art counselling, Elementary School Guidance and Counselling, Dec.,
V.19(2):116-24.
Allen, P.B. (1983), Group art therapy in short-term hospital settings, Am. J. Art Therapy, Apr.,
V.22(3):93-5.
Allen, P.B. (1985), Integrating art therapy into an alcoholism treatment program, Am. J. Art Therapy,
Aug., V.24(1):10-12.
Amos, S.P. (1982), The diagnostic, prognostic, and therapeutic implications of schizophrenic art, Arts
in Psychotherapy, Sum., V.9(2):131-143.
Arrington, D. (1991), Thinking systems-seeing systems: an integrative model for systematically oriented
art therapy, Arts in Psychotherapy, V.18(3):201-11.
Atlas, J.A., Smith, P., Sessoms, L. (1992), Art and poetry in brief therapy of hospitalized adolescents,
Arts in Psychotherapy, V.19(4):279-83.
Assael, M., Popovici-Wacks, M. (1989), Artistic expression in spontaneous paintings of depressed
patients, Israel J. of Psychiatry and Related Sciences, V.26(4):223-243.
Assael, M. (1978), Spontaneous painting: means of communication, Confinia Psychiatrica, V.21(1-3):10-
24.
Avstreih, A.K., Brown, J.J. (1979), Some aspects of movement and art therapy as related to the analytic
situation, Psychoanalytic R eview, V.66(1):49-68.
Ba, G. (1988), Strategies of rehabilitation in the day hospital, Psychotherapy and Psychosomatics,
V.50(3):151-6.
Bender, L., Wolfson, W.Q. (1983), Boats in the art and fantasy of children, Am. J. Art Therapy, Jul.,
V.22(4):125-8.
Benveniste, D. (1985), Picture-time: a nondirective approach to art psychotherapy, Arts in Psychotherapy,
Fall, V.12(3):171-180.
Betensky, M. (1978), Phenomenology of self-expression in theory and practice, Confinia Psychiatrica,
V.21(1-3):31-36.
Betensky, M. (1973), Patterns of visual expression in art psychotherapy, Art Psychotherapy, Fall,
V.1(2):121-9.
Billig, O. (1973), The schizophrenic "artist's" expression of movement, Confinia Psychiatrica, V.16(1):1-
27.
Bishop, J. (1978), Creativity, art and play therapy, Canadian Counsellor, Jan., V.12(2):138-146.
Bowers, J.J. (1992), Therapy through art. Facilitating treatment of sexual abuse, J. of Psychosocial
Nursing and Mental Health Services, Jun., V.30(6):15-24.
Breslow, D.M. (1993), Creative arts for hospitals: the UCLA experiment, Patient Education and
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Slap, J.W. (1976), A note of the drawing of dream details, Psychoanalytic Quarterly, V.45(3):455-6.
Smith, D.D. (1983), The art evaluation: a triage function on a psychiatric emergency admissions unit, Arts
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Smith, G.M. (1985), The Collaborative Drawing Technique, J. Personality Assessment, Dec.,
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Spitz, E.H. (1989), The world of art and the artful world: some common fantasies in creativity and
psychopathology, Arts in Psychotherapy, Win., V.16(4):243-251.
Strand, S. (1990), Counteracting isolation: group art therapy for people with learning difficulties, Group
Analysis, Sep., V.23(3):255-263.
Swenson, A.B. (1991), Relationships: art education, art therapy, and special education, Perceptual and
Motor Skills, Feb., V.72(1):40-42.
Syristova, E. (1989), The creative potential of schizophrenic psychosis: its importance for psychotherapy,
Studia Psychologica, V.31(4):283-294.
Talerico, C.J. (1986), The expressive arts and creativity as a form of therapeutic experience in the field of
mental health, J. Creative Behavior, V.20(4):229-247.
Tate, F.B. (1989), Symbols in the graphic art of the dying, Arts in Psychotherapy, Sum., V.16(2):115-
120.
Tate, F.B., Allen, H. (1985), Color preferences and the aged individual: implications for art therapy, Arts
in Psychotherapy, Fall, V.12(3):165-169.
Taylor, J.W. (1990), The use of nonverbal expression with incestuous clients, Families in Society, Dec.,
V.71(10):597-601.
Temple, S. (1988), Erickson's model of personality development related to clinical material, British J.
Occupational Therapy, Nov., V.51(11):399-402.
Tokuda, Y. (1973), Image and art therapy, Art Psychotherapy, Win., V.1(3-4):169-176.
Tokuda, Y. (1980), Theory and practice of image art psychotherapy, Confinia Psychiatrica, V.23(4):193-
208.
Ulman, E. (1977), Art education for the emotionally disturbed, Am. J. Art Therapy, Oct., V.17(1):13-16.
Vaccaro, V.M. (1973), Specific aspects of the psychology of art therapy, Art Psychotherapy, Fall,
V.1(2):81-89.
Van-Krevelen, D.A. (1975), On the use of the family drawing test, Acta Paedopsychiatrica, V.41(3):104-9.
Vassiliou, G.A. (1983), Analogic communication as a means of joining the family system in therapy, Int.
J. Family Psychiatry, V.4(3):173-9.
Vogl, J.M., Vogl, G.M. (1983), Group art therapy: an eclectic approach, Am. J. Art Therapy, Jul.,
V.22(4):129-135.
Wadeson, H. (1973), Separateness, Art Psychotherapy, Fall, V.1(2):131-3.
Wadeson, H. (1975), Suicide: expression in images, Am. J. Art Therapy, Apr., V.14(3):75-82.
Wadeson, H. (1976), Combining expressive therapies, Am. J. Art Therapy, Jan., V.15(2):43-6.
Wadeson, H. (1976), The fluid family in multi-family art therapy, Am. J. Art Therapy, Jul. V.15(4):115-
8.
Wald, J. (1983), Alzheimer's disease and the role of art therapy in its treatment, Am. J. Art Therapy, Jan.,
V.22(2):57-64.
Wald, J. (1986), Art therapy for patients with dementing illnesses, Clinical Gerontologist, Feb.,
V.4(3):29-40.
Weininger, O. (1987), The Differential Diagnostic Technique, a visual motor projective test, Perceptual
384
and Motor Skills, Aug., V.65(1):76-8.
Weiss, J.C. (1984), Expressive therapy with elders and the disabled: Touching the heart of life, Activities,
Adaptation and Aging, May, V.5(1-2):213.
Wilkinson, S. (1985), Drawing up boundaries: a technique, J. Family Therapy, May, V.7(2):99-111.
Willmuth, M., Boedy, D.L. (1979), The verbal diagnostic and art therapy combined: an extended
evaluation procedure with family groups, Art Psychotherapy, V.6(1):11-18.
Wilson, L. (1985), Symbolism and art therapy: I. Symbolism's role in the development of ego functions,
Am. J. Art Therapy, Feb., V.23(3):79-88.
Wilson, L. (1985) Symbolism and art therapy: II. Symbolism's relationship to basic psychic functioning,
Am. J. Art Therapy, May, V.23(4):129-133.
Wilson, L. (1977), Theory and practice of art therapy with the mentally retarded, Am. J. Art Therapy,
Apr., V.16(3):87-97.
Wittels, B. (1978), Jung, art therapy and the psychotic patient, Art Psychotherapy, V.5(3):115-121.
Wittels, B. (1975), The use of art to master symptoms as demonstrated in the art work of acutely
psychotic patients, Art Psychotherapy, V.2(3-4):217-224.
Wittenberg, D. (1974), Art therapy for adolescent drug abusers, Am. J. Art Therapy, Jan., V.13(2):141-9.
Wolf, R. (1979), Re-experiencing Winnicott's environmental mother: implications for art psychotherapy
of anti-social youth in special education, Art Psychotherapy, V.6(2):95-102.
Wolff, R.A. (1975), Therapeutic experiences through group art expression, Am. J. Art Therapy, Apr.,
V.14(3):91-8.
Ziegler, R.G. (1976), Winnicott's squiggle game: Its diagnostic and therapeutic usefulness, Art
Zigmund, J. (1986), Relating developmental level to art materials in work with paranoid and schizoid
personalities, Pratt Institute Creative Arts Therapy Review, V.7:1-12.
Zlatin, H.P. (1979), "I never had a chance": Art therapy at a geriatric center, Art Psychotherapy,
V.6(2):119-123.
Case studies of artists

9 Bader, A. (1971), Psychopathological discovery of Charles Filiger, symbolist painter, Confinia
Psychiatrica, V.14(1):18-35.
1 Billig, O. (1972), Is schizophrenic expression art? Confinia Psychiatrica, V.15(1):49-54.
26 Dreifuss, G. (1978), Artists in the creative process of Jungian analysis, Confinia Psychiatrica, V.21(1-
3):45-50.
16 Fernandez, A., Seva, A. (1994), A discovery throwing light on the illness of F. de Goya Lucientes,
History of Psychiatry, Mar., V.5(17 part 1):97-102.
14 Gaillard, J.M. (1992), The expression of psychodynamic forces in the paintings of Modigliani,
International J. of Short Term Psychotherapy, Apr., V.7(2):109-122.
4 Garai, J.E. (1974), The use of painting to resolve an artist's identity conflicts, Am. J. Art Therapy, Jan.,
V.13(2):151-164.
28 Genser, L. (1985), Art as therapy with an aging artist, Am. J. Art Therapy, Feb. V.23(3):93-99.
24 Junge, M.B. (1994), The perception of doors: A sociodynamic investigation of doors in 20th century
painting, Arts in Psychotherapy, V.21(5):343-357.
10 MacGregor, J.M. (1977), European collections of psychiatric art: A brief chronological and very
personal account of a 1-month tour of collections in Switzerland, Italy, Germany and Austria undertaken
in March and April, 1976, Confinia Psychiatrica, V.20(1):1-9.
19 Martin, S.A. (1988), Martin Ramirez: Psychological hero, Arts in Psychotherapy, V.15(3):189-205.
27 Meissner, W.W. (1994), Vincent Van Gogh as artist: a psychoanalytic reflection, Annual of
Psychoanalysis, V.22:111-141.
Miller, R. (1990), Empathy and hierarchy: a response to Sass, New Ideas in Psychology, V.8(3):305-7.
29 Muenchow, D.C., Aresenian, J. (1974), An artist in turmoil during art therapy, Am. J. of Art Therapy,
Oct., V.14(1):18-23.
5 Or-Halbreich, T., Halbreich, U. (1977), A comparison between mental patients' paintings and the action
painting movement, Art Psychotherapy, V.4(1):15-18.
6 Parsons, P. (1986), Outsider art: patient art enters the art world, Am. J. of Art Therapy, Aug.,
V.25(1):3-12.
25 Peto, A. (1979), The Rondanini Pieta: Michelanelo's infantile neurosis, International Review of
385
Psycho-Analysis, V.6(2):183-200.
3 Poldinger, W. (1986), The relation between depression and art, Psychopathology, V.19 suppl.2:263-8.
11 Postma, J.U. (1993), Did Rembrandt suffer from depressive periods? A photo-analytic study of his self
portraits, European J. of Psychiatry, Jul-Sep., V.7(3):180-184.
21 Roman, M., Stastny, P. (1987), An inquiry into art and madness: The career of Jochen Seidel, Annual
of Psychoanalysis, V.15:269-291.
18 Sass, L.A. (1985), Time, space, and symbol: A study of narrative form and representational structure
in madness and modernism, Psychoanalysis and Contemporary Thought, V.9(1):45-85.
22 Schildkraut, J.J. (1994), Hirshfeld, A.J., Murphy, J.M., Mind and mood in modern art: II. Depressive
disorders, spirituality, and early deaths in the abstract expressionist artists of the New York School, Am.
J. of Psychiatry, Apr., V.151(4):482-488.
12 Schildkraut, J.J., Hirshfeld, A.J. (1995), Mind and mood in modern art I: Miro and "melancholie",
Creativity Research J., V.8(2):139-156.
23 Simon, N. (1977), Primal scene, primary objects and nature morte: A psychoanalytic study of Mark
Gertler, International Review of Psycho-Analysis, V.4(1):61-70.
15 Starobinski, J. (1993), A modern melancholia: Van Gogh's portrait of Dr. Gachet (Trans. M.
Bradshaw), Psychological Medicine, Aug., V.23(3):565-568.
2 Syristova, Eve (1989) The creative potential of schizophrenic psychosis: its importance for
psychotherapy, Studia Psychologica, V.31(4):283-294.
13 Taylor, B. (1981), Picasso and the pathology of cubism, Arts in Psychotherapy, V.8(3-4):165-173.
7 Wapner, W., Judd, T., Gardner, H. (1978), Visual agnosia in an artist, Cortex, Sep., V.14(3):343-364.
20 Warick, L.H., Warick, E.R. (1984), Transitional process and creativity in the life and art of Edvard
Munch, J. of the Am. Academy of Psychoanalysis, Jul., V.12(3):413-424.
17 Wijsenbeek, H. (1978), The art of Pieter Mondrian, Confinia Psychiatrica, V.21(1-3):156-160.
8 Wylie, M.L., Wylie, H.W. (1989), The creative relationship of internal and external determinants in the
life of an artist, Annual of Psychoanalysis, V.17:73-128.
Case studies - change of sign/theme - subjective measures

14 Bauer, A., Kaiser, G.(1995), Drawing on drawings, Aphasiology, Jan-Feb., V.9(1):68-78.
3 Benveniste, D.(1983), The archetypal image of the mouth and its relation to autism, Arts in
15 Buchalter-Katz, S. (1985), Observations concerning the art productions of depressed patients in a short-
term psychiatric facility, Arts in Psychotherapy, Spr., V.12(1):35-38.
16 Cohen, Barry M., Cox, Carol T. (1989), Breaking the code: identification of multiplicity through art
productions, Dissociation Progress in the Dissociative Disorders, Sep. V.2(3):132-137.
8 Dodd, F.G. (1975), Art therapy with a brain injured man, Am. J. Art Therapy, Apr., V.14(3):83-89.
12 Enachescu, C. (1971), Aspects of pictorial creation in manic-depressive psychosis, Confinia
7 Forrest, G. (1978), An art therapist's contribution to the diagnostic process, Am. J. Art Therapy, Apr.,
V.17(3):99-105.
1 Galbraith, N. (1978), A foster child's pictorial expression of ambivalence, Am. J. Art Therapy, Jan.,
V.17(2):39-49.
13 Garcia, V.L. (1975), Case study: Family art evaluation in a Brazilian guidance clinic, Am. J. Art
Therapy, Jul., V.14(4):132-9.
6 Hardi, I. (1972), Reflection of manic-depressive psychoses in dynamic drawing tests, Confinia
10 Levinson, C.P. (1986), Patient drawings and growth toward mature object relations: Observations of
an art therapy group in a psychiatric ward, Arts in Psychotherapy, Sum., V.13(2):101-6.
2 Lofren, D.E. (1981), Art therapy and cultural difference, Am. J. Art Therapy, Oct., V.21(1):25-30.
4 Lowe, M.E. (1984), Smoke gets in your eyes, sometimes, Arts in Psychotherapy, Win., V.11(4):267-
277. mute 1912
11 Mango, C. (1992), Emma: Art therapy illustrating personal and universal images of loss, Omega J.
of Death and Dying, V.25(4):259-269.
9 Martineau, M. (1986), From symptom to symbol: Group intervention as a catalyst in establishing an
effective holding environment, Pratt Institute Creative Arts Therapy Review, V.7:22-30.
5 Perez, L., Marcus-Ofseyer, B. (1978), The effect of lithium treatment on the behavior and paintings of
386
a psychotic patient with religious and sexual conflicts, Am. J. Art Therapy, Apr., V.17(3):85-90.
Case studies - change of sign theme - objective measure

23 Aldridge, D., Brandt, G., Wohler, D. (1990), Toward a common language among the creative arts
therapies, Arts in Psychotherapy, Fall, V.17(3):189-195.
20 Cagnoletta, M.D. (1983), Art work as a representation of object relations in the therapeutic practice,
Pratt Institute Creative Arts Therapy Review, V.4:46-52.
26 Cronin, S.M., Werblowsky, J.H. (1979), Early signs of organicity in art work, Art Psychotherapy,
V.6(2):103-8.
19 Fink, P.J. (1973), Art as a reflection of mental status, Art Psychotherapy, Apr., V.1(1):17-30.
27 Gerevich, J., Ungvari, G., Karczag, I. (1979), Further data on the diagnostic value of spontaneous
drawing, Confinia Psychiatrica, V.22(1):34-48.
28 Hardi, I. (1977), Alcoholic diseases in the light of dynamic drawing tests, Psychiatrica Fennica, p.47-
61.
25 Heiman, M., Strnad, D., Weiland, W. (1994), Art therapy and alexithymia, Art Therapy, V.11(2):143-
6.
24 Heine, D., Steiner, M. (1986), Standardized paintings as a proposed adjunct instrument for longitudinal
monitoring of mood states: a preliminary note, Occupational Therapy in Mental Health, Fall, V.6(3):31-7.
22 Hendrixson, B.N. (1986), A self-portrait project for a client with short-term memory dysfunction, Am.
J. Art Therapy, Aug., V.25(1):15-24.
30 Holmes, C.B. (1983), Memory For Designs drawing styles of psychiatric patients, J. Clin.
Psychology, Jul., V.39(4):563-566.
29 Kay, S.R. (1979), Significance of torque in retarded mental development and psychosis: relationship
to antecedent and current pathology, Am. Psychologist, Apr., V.34(4):357-362.
31 Nikolaenko, N.N., Menshutkin, V.V. (1993), Co-ordinate displacement and visual space compression
during right hemisphere inhibition, Human Physiology, Mar-Apr., V.19(2):104-8.
17 Roback, H.B., Gunby, L. (1984), A ten year comparison of human figure drawings by a
psychologically decompensating patient, International J. Symbology, Nov., V.8(3):103-111.
18 Wald, J. (1984), The graphic representation of regression in an Alzheimer's disease patient, Arts in
Psychotherapy, Fall, V.11(3):165-175.
21 Wolf, J.M., Willmuth, M.E., Watkins, A. (1986), Art Therapy's role in treatment of anorexia nervosa,
Am. J. Art Therapy, Nov., V.25(2):39-46.
Case studies, behaviour change

Bowen, C.A., Rosal, M.L. (1989), The use of art therapy to reduce the maladaptive behaviors of a
mentally retarded adult, Arts in Psychotherapy, Fall, V.16(3):211-218.
Gale, I.G. (1990), Neuropsychological rehabilitation technique with a chronic schizophrenic patient,
Behaviour-Change, V.7(4):179-184.
Goren, A.R., Fine, J. (1995), Manaim, H., Apter, A., Verbal and nonverbal expressions of central deficits
in schizophrenia., J. Nervous and Mental Disease, Nov. V.183(11):715-719.
Olive, J.S. (1991), Development of group interpersonal skills through art therapy, Maladjustment and
Therapeutic Education, Win., V.9(3):174-180.
Case studies - main therapeutic benefit - relationship

7 Bondesen, C.L. (1984), Transference and countertransference in schizophrenia: The paranoic defense
against homosexuality, Pratt Institute Creative Arts Therapy Review, V.5:22-32.
8 Buck, L.A., Goldstein, F., Kardeman, E. (1984), Art as a means of interpersonal communication in
autistic young adults, J. Psychology and Christianity, Fall, V.3(3):73-84.
13 Davis, D.L., Boster, L. (1988), Multifaceted therapeutic interventions with the violent psychiatric
inpatient, Hospital and Community Psychiatry, Aug., V.39(8):867-869.
18 Dreifuss, E. (1978), Some notes on a relationship between art therapist and patient, Am. J. Art
Therapy, Jan., V.17(2):57.
17 Dunne, M. (1993), The integration of two theoretical models in treatment with art therapy, Pratt
387
10 Fagin, I. (1983), Images of growth and mourning in the process of termination, Pratt Institute Creative
Arts Therapy Review, V.4:53-60.
6 Ferrara, N. (1992), Adolescent narcissism and ego regression: an art therapy case illustration, J. Child
and Youth Care, V.7(1):49-56.
12 Forrest, G. (1975), The problems of dependency and the value of art therapy as a means of treating
alcoholism, Art Psychotherapy, V.2(1):15-43.
9 Gunther, M. (1992), Eros and the ego: the use of ego assessment in creatively addressing a sexualized
transference, Pratt Institute Creative Arts Therapy Review, V.13:31-40.
4 Horovitz-Darby, E.G. (1992), Reflections: Countertransference: Implications in treatment and post
treatment, Arts in P sychotherapy, V.19(5):379-389.
3 Izhakoff, S. (1993), Symbiosis and symbiotic relatedness: A bridge to schizophrenia, Pratt Institute
Creative Arts Therapy Review, V.14:25-33.
5 Kaplan, F.F. (1983), Drawing together: Therapeutic use of the wish to merge, Am. J. Art Therapy, Apr.,
V.22(3):79-85.
2 Shapiro, J. (1988), Moments with a multiple personality disorder patient, Pratt Institute Creative Arts
14 Stamelos, T., Mott, D.W. (1983), Learned helplessness in persons with mental retardation: art as a
client centred treatment modality, Arts in Psychotherapy, Win., V.10(4):241-249.
19 Stamelos, T., Mott, D.W. (1986), Creative potential among persons labelled developmentally
delayed:II. Meditation as a technique to release creativity, Arts in Psychotherapy, Fall, V.13(3):229-234.
11 Teirstein, E.G. (1991), Developing: Art, mastery, self, Pratt Institute Creative Arts Therapy Review,
V.12:16-29.
1 Wolf, R. (1975), Art psychotherapy with acting-out adolescents: an innovative approach for special
education, Art Psychotherapy, Vol.2(3-4):255-266.
Case studies - main therapeutic benefit - expression of feelings

Alanko, A. (1973), Psychosis and art, Psychiatria Fennica, p.153-158.
Bemtovegna, S., Schwartz, L., Deschner, D. (1983), Case study: the use of art with an autistic child in
residential care, Am. J. Art Therapy, Jan., V.22(2):51-6.
Berkowitz, S. (1990), Art therapy with a Vietnam veteran who has post traumatic stress disorder, Pratt
Bertoia, J., Allan, J. (1988), Counselling seriously ill children: use of spontaneous drawings, Elementary
School Guidance and Counselling, Feb., V.22(3):206-221.
Blasco, S.P. (1978), Case study: art expression as a guide to music therapy, Am. J. Art Therapy, Jan.,
V.17(2):51-56.
Branch, J. (1992), Depression and feminine personality development, Pratt Institute Creative Arts Therapy
Review, V.13:9-15.
Cardone, L., Marengo, J., Calisch, A. (1982), Conjoint use of art and verbal techniques for the
intensification of the psychotherapeutic group experience, Arts in Psychotherapy, Win., V.9(4):263-268.
Carozza, P.M., Heirsteiner, C.L.(1982), Young female incest victims in treatment: stages of growth seen
with a group art therapy model, Clinical Social Work J., Fall, V.10(3):165-175.
Ciornai, S. (1983), Art therapy with working class Latino women, Arts in Psychotherapy, Sum.,
V.10(2):63-76.
Cohen, F.W. (1974), Art therapy in the diagnosis and treatment of a transsexual, Am. J. Art Therapy,
Oct., V.14(1):3-11.
Cohn, R. (1984), Resolving issues of separation through art, Arts in Psychotherapy, V.11(1):29-35.
Colli, L.M. (1994), Aims in therapy and directives in society: observations on individuation and
adaptation (Trans. J. Leyland), Arts in Psychotherapy, V.21(2):107-112.
David, I.R., Sageman, S. (1987), Psychological aspects of AIDS as seen in art therapy, Am. J. Art
Therapy, Aug., V.26(1):3-10.
Drachnik, C. (1978), Case study: art therapy with a girl who lived in two worlds, Am. J. Art Therapy,
Oct., V.18(1):19-27.
Eskridge, J.H. (1993), Healing the wounded female self, Pratt Institute Creative Arts Therapy Review,
V.14:50-55.
388
Evans, E. (1986), Facilitating the reparative process in depression: images for healing, Pratt Institute
Creative Arts Therapy Review, V.7:43-53.
Evans, E. (1984), Transpersonal aspects of transference and countertransference,a Jungian perspective, Pratt
Fleming, M., Nathans, J. (1979), The use of art in understanding the central treatment issues in a female
to male transsexual, Art Psychotherapy, B.6(1):25-35.
Fogle, D.M. (1980), Art and poetry therapy combined with talking therapy with a family of four in an
outpatient clinic, Arts in Psychotherapy, V.7(1):27-34.
Gillespie, A. (1986), "Art Therapy" at the Familymakers project, Adoption and Fostering, V.10(1):19-23.
Glaister, J.A. (1994), Clara's story: post traumatic response and therapeutic art, Perspectives in Psychiatric
Care, Jan-Mar., V.230(1):17-22.
Green, P., Bertrand, D. (1975), Art therapy with a schizophrenic patient, Bulletin of the Menninger Clinic,
Jan., V.39(1):83-92.
Greenspoon, D.B. (1984), The role of the art therapist as an adjunctive member of a residential treatment
team, Residential Group Care and Treatment, Spr., V.2(3):15-31.
Greenspoon, D.B. (1982), Case study: the development of self expression a severely disturbed adolescent,
Am. J. Art Therapy, Oct., V.22(1):17-22.
Halbreich, U., Assael, M., Dreifus, D. (1980), Premonition of death in painting, Confinia Psychiatrica,
V.23(2):74-81.
Harriss, M., Landgarten, H. (1973), Art therapy as an innovative approach to conjoint treatment: a case
study, Art Psychotherapy, Win., V.1(3-4):221-228.
Hatfield, F.M., Zangwill, O.L. (1974), Ideation in aphasia: the picture-story method, Neuropsychologia,
Jul., V.12(3):389-393.
Heiney, S.P. (1991), Sibling grief: a case report, Archives of Psychiatric Nursing, Jun., V.5(3):121-127.
Hook-Wheelhouwer, J. (1991), Protective custody: a lifestyle in prison, Pratt Institute Creative Arts
Jones, D.L., Rush, K. (1979), Treatment of psychotic patients with preoccupations of demon possession,
Katz, S.L. (1987), Photocollage as a therapeutic modality for working with groups, Social Work with
Groups, Win., V.10(4):83-90.
Kornreich, S. (1988), An Alzheimer patient's use of art as a form of constancy, Pratt Institute Creative Arts
Kunkle-Miller, C. (1978), Art therapy with mentally retarded adults, Art Psychotherapy, V.5(3):123-133.
Landgarten, H. (1975), Art therapy as primary mode of treatment for an elective mute, Am. J. Art Therapy,
Jul., V.14(4):121-5.
Landgarten, H. (1975), Group art therapy for mothers and daughters, Am. J. Art Therapy, Jan.,
V.14(2):31-35.
Levick, M., Herring, J. (1973), Family dynamics - as seen through art therapy, Art Psychotherapy, Apr.,
V.1(1):45-54.
Lehtonen, K., Shaughnessy, M.F. (1992), Projective drawings as an aid to music therapy, Acta
Paedopsychiatrica International J. of Child and Adolescent Psychiatry, Dec., V.55(4):231-233.
Lubart, L. (1985), The use of structured art and movement with chronic schizophrenic adults, Pratt
Marinow, A. (1980), Symbolic self-expression in drug addiction, Confinia Psychiatrica, V.23(2):103-8.
Mashiah, T. (1996), Painting as language for a stroke patient, Art Therapy, V.13(4):265-9.
McIntyre, B.P. (1990), Art therapy with bereaved youth, J. Palliative Care, Spr., V.6(1):16-25.
McNiff, S. (1975), Anthony: a study in parallel artistic and personal development, Am. J. Art Therapy,
Jul., V.14(4):126-131.
Mills, A. (1985), Art therapy on a residential treatment team for troubled children, J. Child Care,
V.2(4):61-71 - reprint J. Child and Youth Care, 1991 V.6(4):49-59.
Moffat, J.P., Friedman, I. (1973), Utilization of art therapy in the hospital management of a schizophrenic
patient, Art Psychotherapy, Win., V.1(3-4):301-6.
Musick, P.L. (1980), Creativity: abreaction for the therapist, Arts in Psychotherapy, V.7(3):197-199.
Myers-Garrett, E.A. (1987), The role of contours in symbol building with a victim of sexual abuse, Pratt
389
Naitove, C.E. (1986), "Life's but a walking shadow": treating anorexia nervosa and bulimia, Arts in
Nelson, A. (1986), The use of early recollection drawings in children's group therapy, Individual
Psychology Journal of Adlerian Theory, Research and Practice, Jun., V.42(2):288-291.
Pitak, S. (1982), Bridging isolation: a synthesis of Eastern and Western perspectives in creative group
work with addiction recovery unit patients, Pratt Institute Creative Arts Therapy Review, V.3:67-76.
Potocky, M. (1993), An art therapy group for clients with chronic schizophrenia, Social Work with
Groups, V.16(3):73-82.
Quail, J.M., Peavy, R.V. (1994), A phenomenologic study of a client's experience in art therapy, Arts in
Robbins, A. (1984), The struggle for self-cohesion: an analytically orientated art therapy case study, Art
Therapy, Oct., V.1(3):107-118.
Shennum, W.A. (1987), Expressive activity therapy in residential treatment: effects on children's behavior
in the treatment milieu, Child and Youth Care Quarterly, Sum., V.16(2):81-90.
Sikelianos, M. (1975), The use of symbolic drawing, metaphor and illusion in a therapeutic-creative
process, Israel Annals of Psychiatry and Related Disciplines, Jun., V.13(2):142-161.
Sinai, J. (1997) The use of metaphor by an artless first time psychotherapist, Am. J. Psychotherapy,
Spring, V.51(2):273-88.
Small, J., Greenway, M. (1988), The rediscovery of the lost twin: an account of therapy for a child and
his parents, British J. of Psychotherapy, Fall, V.5(1):19-28.
Stember, C.A. (1978), Change in maladaptive growth of abused girl through art therapy, Art
Uhlin, D.M. (1977), The use of drawings for psychiatric evaluation of a defendant in a case of homicide,
Mental Health and Society, V.4(1-2):61-73.
Tyler, J. (1998), Nonverbal communication and the use of art in the care of the dying, Palliative Medicine,
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67
Controlled studies
[C controlled studies; V Validity study; R Reliability Study; M Meta analysis]
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390
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391
psychotics, Perceptual and Motor Skills, Apr., V.50(2):583-590. [V]
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54. Rosal, M.L. (1993), Changes in locus of control in behaviour disordered children, Arts in
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392
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393
Appendix 4
Development of the Descriptive Assessement for Psychiatric Artwork

(DAPA)
DAPA version 3: the rating guide used in the main study.

Rating sheet for DAPA version 3.
Helpsheet for DAPA rating guide version 3.
Rating sheet for casenotes (main study).
DAPA version 2: the rating guide used in the pilot study.
Research questionnaire on dominant form for artists.
Research rating sheet on dominant form for re-rating of form version 3.
394
Page 1. Rating guide
DAPA Version 3. The rating guide used in the main study
DESCRIPTIVE ASSESSM ENT FOR PSYCHIATRIC ART
RATING GUIDE
S. HACKING AND D. FOREMAN 1999.
395
D.A.P.A. DESCRIPTIVE ASSESSM ENT OF PSYCHIATRIC ARTWORK - S.
HACKING AND D. M . FOREMAN © 1999.
RATING GUIDE
The pictures must be rated for the presence of 15 elements on 6 scales: colour, intensity,
line, space, emotional tone and form.
A 5 column x 4 row grid drawn on acetate lies over the picture dividing it
into 20 squares whatever the size of the paper. Borderlines done by the
painter are ignored. This is laid according to the intended ‘right way up’
of the picture. The rating is done on the rating sheet which corresponds to
the grid. Each scale in each division offers a choice which is marked off
by the rater. Colour rating forces a present/absent in that square decision
on each of 9 colours; the other scales use gradations of high/medium/low.
A total of 300 decisions are required to rate one picture. However, time
for picture rating typically varies from 5-15m.
Each of the 20 scoring squares on the rating sheet contains 5 rows of boxes. Rows are
identified left. Colour; Intensity; Line; Space; Emotional Tone. Example below. To score
a box use diagonal line corner to corner.
Each rating square scores the same grid square on the picture. If a picture square is unused,
cross the whole rating square completely through.
R Y O P G B N W K
COLOUR
INTENSITY H N L
PAINTED H V N
LINE
1 2 3 4 5
DRAWN LINE H V
N
396
COLOUR
COLOUR R Y O P G B N W K
Colour is simple, one you know what the letters mean! Red, Yellow, Orange, Purple,
Green, Blue, browN, White, blacK.
DEFINITION: Colours are defined by their hue. Mark the letter of any colour appearing
in the grid square no matter how little. Writing by the painter is included. Grey and
pencil marks are scored ‘blacK’. The colour of the paper is not scored. See HELP for
more information on colour description and examples.
397
INTENSITY
INTENSITY H N L
DEFINITION: Firstly, the brightness or pureness of the media used; secondly, the
densit over the area covered by the media (not the unused portion of the square). If two
intensities occur in the same square, use whichever covers the most area. If there is equal
cover, score the highest.
H – High strong, dense saturated colour – e.g. thick pure paint or very heavy pressured
pencil or crayon.
N – Neutral. ‘Muddy’ colour; e.g. the colour has been ‘greyed’ or toned down, perhaps
mixed to darker or lighter shades. Medium pressure pencil lines are scored as ‘neutral’.
L – Low intensity or ‘watery’ colour (especially paint), little pigment over a large area,
e.g. light pressured crayon or pencil. See HELP for examples.
If colour is used in a single intensity or pressure, i.e. felt pen, pencils,

crayon, neutral is scored when lines are deliberately overmarked in
different colours. I.e. yellow overscored with black forms a ‘muddy
yellow’ as it would if mixed together.
LINE
L PAINT H V N
I
DRAW H V N
N
E
Line is scored for Paint (media which fill the area; paint, pastel) and Draw (media which
use marks such as crayon, pencil, felt tip). Both lines or one line can be used.
DEFINITION: A line must be a distinct drawn or painted mark, loose scribble covering
an area, pattern marks such as dots, outlines and writing ARE lines. Two areas of colour
which come together or thin filled shapes or areas of colour tightly filled by drawing
media ARE NOT lines. Leave blank if no lines appear in the square.
Guideline: Scan the whole picture to identify the range of line. If the line appears
constant, do not make very sensitive discriminations. Differences should be apparent.
Lines such as pencil or felt pen used at the same pressure over the whole picture score
as thin. Thick lines must be distinct. If the line is emphasised, i.e. redrawn 2 or 3 times,
even at the same pressure, mark as thick. Refer to HELP for examples of varied lines.
398
H – Majority of tHick, or heavy lines with high pressure.
V – Varied lines when both thick and thin lines are present in roughly the same quantity.
N – ThiN, or the majority at light pressure.
399
SPACE
>10% >25% >55% >80% >100%
DEFINITION: The largest UNUSED area of the square.
Guideline: Identify the largest UNMARKED area in the square. It doesn’t matter if
there are 2 or 3 unmarked areas, use only one. Imagine drawing a bubble shape around
this space (bubbles can bend, be triangular, circular, square or elipse, but if you have a
bubble with a narrow waist, you have two areas!). Does the bubble represent (1) 0-10%;
(2) 10-25%; (3) 25-55%; (4) 55-80%; (5) 80-100% of the area of the square.
Simply by quarters. (1-2) up to _; (3) up to _; (4) _ to _ ; (5) more than _ . Empty
squares score 5.
EMOTIONAL TONE
E-TONE + 0 -
Guideline: Scan the picture as a whole, decide which elements of the picture, taking
account of what communicates TO YOU of the maker’s intent in content, colour,
intensity, line and form. (+) positive or (-) negative. Mark the squares containing these
elements first. The other squares are (0) neutral. Leave empty squares blank.
DOMINANT FORM
DEFINITION: A shape enclosed by a boundary, explicit or implicit. It should be

exceptional in, size or colour (contrasting hue, intensity or saturation). It is not always
a recognisable shape or person. It is a LARGE SINGLE SHAPE. When multiple,
400
there is NO dominant form! The shape may be repeated, but repetitions will be smaller
or less intense.
Guideline: Scan the picture as a whole, decide where the dominant form is. Use closure
for open forms. If more than 25% of the square is covered by the form, shade the
corresponding square in the small grid at the top of the rating sheet .
Half Rating sheet for DAPA. Template. 1999 Hacking and Foreman ©
FORM ---!
COLOUR R Y O P G B N W K R Y O P G B N W K
INTENSITY H N L H N L
L H V N H V N
PAINT
I
H V N H V N
N DRAW
SPACE 1 2 3 4 5 1 2 3 4 5
E-TONE + 0 - + 0 -
L H V N H V N
PAINT
I
H V N H V N
N DRAW
SPACE 1 2 3 4 5 1 2 3 4 5
E-TONE + 0 + 0
L H V N H V N
I H V N H V N
N DRAW
SPACE 1 2 3 4 5 1 2 3 4 5
E-TONE + 0 + 0
L H V N H V N
PAINT
I
H V N H V N
N DRAW
SPACE 1 2 3 4 5 1 2 3 4 5
E-TONE + 0 401
- + 0 -
Part 2 Rating Sheet for DAPA: Hacking and Foreman 1999 ©
R Y O P G B N W K R Y O P G B N W K R Y O P G B N W K
H N L H N L H N L
H V N H V N H V N
H V N H V N H V N
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
+ 0 + 0 + 0
H N L H N L H N L
H V N H V N H V N
H V N H V N H V N
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
+ 0 - + 0 - + 0 -
H N L H N L H N L
H V N H V N H V N
H V N H V N H V N
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
+ 0 - + 0 - + 0 -
H N L H N L H N L
H V N H V N H V N
H V N H V N H V N
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
+ 0 + 0 + 0
402
Help Sheet for DAPA version 3. Main study. Hacking and Foreman 1999 ©
403
Rating Sheet for Casenotes DAPA version 3. 1999.
KEELE UNIVERSITY STAFFORDSHIRE. DEPT. OF PSYCHIATRY, SCHOOL OF

P.G. MEDICINE. ICHRC. N. STAFFORDSHIRE HOSPITAL.
UNIT NAME
WARD M/F MARRIED/SINGLE/SEP RACE AGE
ICD-10 MEDICATION
DIAGNOSIS
OCCUPATION/TRADE
ED LEVEL
ECT YES/NO INPATIENT/OUT EVER SECTIONED
404
Rating Guide Version 2. S. Hacking and D. Foreman 1994. ©
Descriptive Assessment for Psychiatric Art.
Rating Guide Descriptive Assessment for Psychiatric Art

V.2
Used in the Pilot Study 1996.
405
D.A.P.A. DESCRIPTIVE ASSESSM ENT OF PSYCHIATRIC ARTWORK Pilot Study
- S. HACKING AND D. M . FOREMAN © 1994.
RATING GUIDE
The pictures must be rated for the presence of 13 elements on 5 primarily structural
areas: colour, intensity, line, area, emotional tone. These items are designed to describe
the picture as objectively as possible. A grid is drawn over the picture forming 20
squares. Rating looks at each category one at a time in each division. Colour rating offers
two options forcing a present/not present decision; the others offer optional descriptors
of the form high, medium or low. A total of 260 decisions are required to rate one
picture. However, time for picture rating typically varies from 5-15m. A transparent
overlay divides the picture into 20 squares; 5 across and 4 down, taking account of the
intended ‘right way up’. The squares are drawn from the edge of the paper, ignoring
borderlines done by the painter.
Each of the 20 scoring squares on the rating sheet contains 5 rows of boxes. Each row is
identified on the left; Colour; Intensity; Line; Area; Emotional Tone. See the example
below
R Y O P G B N W K
COLOUR
INTENSITY H N L
LINE H V
N
10 20 30 40 50 60 70 80 90
100
AREA
Colour
COLOUR R Y O P G B N W K
406
Colour is simple, one you know what the letters mean! Red, Yellow, Orange, Purple,
Green, Blue, browN, White, blacK.
DEFINITION: Colours are defined by their hue. It doesn’t matter if the shade is dark
or See HELP for more information on colour description and examples. If the colour
appears anywhere in the square mark the identifying letter. Only the media on the paper
is scored, not the colour of the paper. Writing on the picture done by the painter is
scored in the same way. Pencil is scored black.
407
Intensity
INTENSITY H N L
DEFINITION: The brightness or pureness of the media used, not the surrounding
space. If a hgih intensity dot sits in the middle of an otherwise empty square, the square
is scored high. If the surrounding area is slightly tinted, however, the square is scored
low. Durll and strong mixes of colour occurring in the same square are scored on
whichever covers most of the area. If there is equal cover, score whichever colour is
highest. Leave blank if the square is empty.
H – High strong, dense saturated colour – e.g. thick pure paint or very heavy pressured
pencil or crayon.
N – Neutral or neither, also ‘muddy’ colour; e.g. the colour has been ‘greyed’ or toned
down, perhaps mixed to darker shades.
L – Low intensity or ‘watery’ colour especially paint, little pigment, e.g. light pressured
crayon or pencil or thinly scattered media over the area. See HELP for examples.
Line
LINE H V N
DEFINITION: - Refer to help for examples. A line must be a distinct drawn or painted
mark. A line is not two areas of colour which come together. Line can be used for
scribble covering an area or pattern marks, but is not used to describe thin shapes filled
with paint. Leave blank if no lines appear in the picture.
Scored as H – Majority of tHick, or heavy lines with high pressure; V – Varied lines
when both thick and thin lines are present; N – ThiN, or light pressure.
Area
AREA 10 20 30 40 50 60 70 80 90 100
Guidelines: Estimate how much of the square is covered by the media and mark the
coverage on the scale in tenths or by 10%. A used area has media over it, no matter how
408
thin or scattered. An unused area is completely empty.
Emotional Tone
E-TONE + 0 -
DEFINITION: subjective overall assessment of whether the square, its colour, intensity,
line and content TO THE RATER seems (+) positive or happy; (0) neutral or neither
(-) negative or sad. This is the only category where if the square is empty, score as 0 or
neutral. DO NOT LEAVE BLANK.
409
Form sheet for Artists. Side 2. DAPA development 1994 © sue Hacking.
Age Sex m/f
Art Training (tick) A level; Foundation; Degree; Post Grad.

Currently practising?
Media most used: paint; print; sculpture; 3d; design; other write
This test takes about 5 minutes.
Thank you for your co-operation in this test. I am seeking to understand what is meant
by artistic terms in practice. Please answer both questions as clearly as possible.
1. Look at the sheet of reproductions of works of art (other side).
For each picture, delineate in red, the dominant form, as closely as you can to the
contours of what you see as the single most dominant form in that picture. If the
question is inapplicable to the picture, write ‘none’ at the bottom.
2. What do the words ‘dominant form’ mean to you in the above sentence? Give a brief
definition of your understanding of what a form is. You may refer to the pictures if
you wish. You can take from 2 to 3 sentences to half a page.
410
3. Research Questionnaire on Dominant Form for Raters. Test sheet1. DAPA Hacking
and Foreman 1999 ©
Dominant Form
This study is part of an experiment to find ways of describing a picture. This is not the
whole of the study but one of the elements being tested. Please try to understand the
explanation given by the experimenter as if you were part of a group trying to score
exactly the same as everyone else.
DEFINITION:
An object or space enclosed by a boundary, explicit or implicit.
It should be exceptional in
Size and/or
Colour
Contrasting hue/intensity/saturation.
It should be single (there must not be two opposing forms).

The shape may be repeated, the repetitions will be smaller or less intense. It is usually
a regular shape.
What is going on in the picture (the content or narrative) is secondary to the structure.
It need not be a recognisable shape or a person.
When you have understood the explanation to the experimenter’s satisfaction, you will
be asked to rate some pictures. Keep this explanation by you and refer to it every time.
The experimenter will now describe the grid system.
Please look at the picture as a whole first, can you see a shape which is large, singular and
whose outline is generally echoed throughout the picture?
Point out to the experimenter which squares the shape occupies. Cut off extremeties
which are not integral to the regular shape. The shape must occupy more than 25% of
the square to be counted.
411
Appendix 5
Permission for study, information for participants, and instructions for group leaders
on treatment of pictures
Consent forms for all participants in the pilot and for those in the main study who were
saving their pictures from therapy groups were the same, pages 2 and 3 (oral and written).
Information sheet for pilot study and for those in the main study who gave consent were
the same (p.4).
Instructions for group leaders in pilot study (p.5).
Instructions for group leaders in main study (p.6).
412
North Staffordshire Health Authority
Research Ethics Committee
PERSONAL CONSENT TO THE CONDUCT OF A RESEARCH

INVESTIGATION
STUDY TITLE Describing pictures by different groups of patients

NAM E OF CLINICIAN Dr. D. Foreman and M s. S. Hacking
The aims and procedures of the clinical investigation in which I have been asked to take
part have been explained to me by ward staff. I have read and understood the patient
leaflet set out overleaf, and have been informed about the possible benefit to myself and
about any foreseeable risks or discomfort.
I have had the opportunity to ask questions and to consider the answers given.
I understand that participation in the study is voluntary and that I may withdraw from the
study at any time of my own accord. If I do withdraw it will not affect the future care and
attention which I will receive from my doctors.
I agree that the relevant parts of my medical records may be disclosed to Dr. Foreman
provided they agree not to reveal my name.
I hereby freely give my fully informed consent to taking part in this clinical investigation.
Name ……………………………….. Signature …………………………….

Date ………………………………….
I confirm that I have explained the nature of the above investigation to the above named
patient.
Name ……………………………….. Signature …………………………….
Date ………………………………….
413
North Staffordshire Health Authority
Research Ethics Committee
ORAL CONSENT TO THE CONDUCT OF A RESEARCH INVESTIGATION
STUDY TITLE Describing pictures by different groups of patients

NAM E OF CLINICIAN Dr. D. Foreman and M s. S. Hacking
NAM E OF PATIENT
I have explained the aims and procedures of the above clinical investigation to the above
named patient. He/she was informed of the possible benefits to him/herself and about any
foreseeable risks or discomfort (and the information in the patient leaflet was also
explained).
He/she was given the time and opportunity to ask questions and to consider the answers
given.
The voluntary nature of participation in the study was emphasised, as was the right to
withdraw from the study for any reason without prejudicing his/her relationship with
myslef or any other of his/her medical advisors.
I have explained that relevant parts of my medical records may be disclosed to Dr.
Foreman. Names will not be disclosed.
On this basis, I declare that the above named patient freely gave his/her consent to taking
part in this clinical investigation.
Witness to Oral Consent
Name ……………………………….. Signature …………………………….
JOB TITLE OR RELATIONSHIP TO PATIENT ……………………………..
Date ………………………………….
414
Information sheet. Research into Art Therapy
Painting for pleasure can have healing effects. Paintings may express what is deep inside
the mind, that may not be easily put into words.
Our understanding of a picture is often brought about through talking to people about it,
but people's comments about their paintings are sometimes not helpful. This research is
trying to discover a way of looking at the pictures themselves rather than what is said
about them.
We will be looking at a lot of pictures by people with the same kinds of problems, or with
no problems at all. So any picture will be just one of a group. We do not just want 'special'
pictures or particularly good pictures. It is more important to have a variety, so we would
like a picture from anyone willing to do one. It does not matter if anyone cannot draw as
well as they would wish as this is not an artistic project.
You will be asked to paint a picture in a group. The picture will be numbered. Your name
will not appear on it. No-one will see the picture but the people doing research. We have
no connection with any treatment or ward.
You will not be asked to discuss the pictures with anyone. The pictures will be taken
away and used as a group study. We will keep a list of pictures for the time of the study
and then the list will be destroyed.
If you do not wish to help, it will not affect any treatment or care. I you want to do a
picture, and then decide not to after all, or take your picture out of the study once it is
done, this is your choice.
Thank you for your help and co-operation.
415
Psychiatry Dept., School P.G. M edicine.
Researcher Sue Hacking.
Research Project - DRAW A PICTURE. Study 1.

PROTOCOL.
If something goes wrong, or there is some alteration to the procedure, would you please
write on the back of this paper what it was - and return it with the completed pictures.
Allow about one hour for the session.
Obtain consent from individuals before the series, using the information sheets and consent
forms provided, if someone refuses, they may still attend their usual sessions with the
group.
On the reverse of this paper write ward no. and group leader. Give every participant a
number beginning ______ so the first one would be ___1. Write the number and their
names on the back of this paper, so they can be identified.
Note the refusers like this: <so many people> male/female who chose not to take part, no
names.
1. M ake sure that each person has access to the following materials on their table:
RED YELLOW ORANGE PURPLE GREEN BLUE BROWN WHITE BLACK, available
for use, i.e. red and yellow do not provide orange, orange must be mixed and available.
2. Facilities to make thick and thin lines, preferably with different colours.
3. One piece of paper, A3 size - as big as 2 sheets of photocopy paper.
Themed Sessions, one theme per session.

1. Draw yourself as you usually are.
2. Draw yourself as you might look if you were an animal.
3. Draw a picture of yourself doing something you like to do.
4. Draw a picture of your life with the past and the future on it.
5. Draw a picture of yourself as you are feeling now.
Other instructions to the group:

You can put anything in the picture and you can use any colours that you want to use.
You will not have to show it to anyone, or talk about it, you have up to one hour to finish
the picture.
Function of the researcher as helper to the group leader. To ensure that the participants
make as free a choice as possible as to what colours they should use, and what kind of
picture they should draw. To encourage participants and discourage dropout if possible.
Participants who finish early may do something else.
416
Psychiatry Dept., School P.G. M edicine.
Researcher Sue Hacking.
Research Project - DRAW A PICTURE - PROTOCOL. Study 2.

KEEP THIS PAPER
Instructions for group leader. Please save the paintings from your themed or recreational
sessions with patients. So that we can identify patients please follow these instructions.
If something goes wrong, or there is some alteration to the procedure, would you please
write on the back of this paper what it was - and return it with the completed pictures.
Allow about one hour for the session.
Obtain consent from individuals before the series, using the information sheets and consent
forms provided, if someone refuses, they may still attend their usual sessions with the
group.
On the reverse of this paper write ward no. and group leader and the date. Give every
participant, including staff who provide a picture, a number beginning ______ so the first
one would be ___1. Write the number and their names on the back of this paper, so they
can be identified.
Note the refusers like this: <so many people> male/female who chose not to take part, no
names.
Try to provide these materials on every table:

RED YELLOW ORANGE PURPLE GREEN BLUE BROWN WHITE BLACK, available
for use, i.e. red and yellow do not provide orange, orange must be mixed and available.
2. There should be facilities to make thick and thin lines, in colour, best achieved with
paint and preferable for this research.
3. One piece of paper, A3 size - as big as 2 sheets of photocopy paper, placed so that the
top (furthest away from the artist) is the longer side (landscape format).
If there are limitations, please note them on the back of this paper.
You can use any type of sessions for this research, themed or free sessions or personal
work. Self portraits are particularly useful. Do not direct the participants as to colours
used, or suggest a type of picture they should draw for the research. Participants should
not do anything different than they usually do in their art session (i.e. talk about their
pictures or show them to anyone else if they usually do not). Be encouraging and
supportive and discourage dropout if possible.
Write on the back of the picture, the numbers and not the names of all participants
including staff. Keep for collection. Thankyou for your co-operation.
417
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418
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The psychopathology of everyday art:

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

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

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

and controlled interactions between variables.

indications that combinations of variables could further isolate groups.

placed the DAPA far ahead of the field.

Chapter Two: Literature Review

Chapter Three: Positive Thinking: What are the common

Chapter Four: The Descriptive Assessment for Psychiatric Art

2. Reliability Study 193

Chapter Five: Results Section

Chapter Six: Discussion 245

Chapter Seven: Conclusion 293

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

Table 8: Reliability statistics and discriminating variables for category of

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

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

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

Specific Differences for each variable

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

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

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

Chapter One: Introduction

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

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

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

validity for new instruments.

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

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

The Argument for Another Art Assessment

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

psychiatric art2. These two sources alone provide a comprehensive historical

describing the product.

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

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

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

specific reactions, as with a conversation.

are based on theoretical assumptions which do not concern this study7.

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

categorisations. Institutionalisation may have accounted for much of the previous

in operational definitions of specific categories.

The need for more research in art assessment

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

the contribution of the artwork to psychopathology8.

Investigation into the psychopathology of art: the background

proposed by Lombroso, Italian psychiatrist and criminologist, in 18919, has survived in

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

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

so diagnosed today. By the turn of the century, psychiatry14 acknowledged the

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

length16. Speculative attempts to relate psychiatric symptoms to images were mostly

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

patients were demonstrated to influence raters' judgement of normality in the 1970s17,

Art Therapy and Psychoanalytic Interpretation

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

scope because of the enormous complexity of the understanding of psychoanalytic

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

in their clinical practice.

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

interpretations and assumptions concerning archetypes25 and universal symbols26 on a

Psychoanalytic interpretation of content has thrown the only major light on

analysis techniques with theoretical excerpts from Jung.