The importance of Image in the Creative Arts Therapies

by Claire Colreavy Donnelly


Through this article I hope to discuss some clinical work which I believe gives evidence to the importance of image in the effectiveness of the creative arts therapies. I would like to show how therapeutic attunement is achieved through the therapist’s openness to the world of imagery in a session and also to explain how when a client is encouraged to engage authentically in creative spontaneous image making they are afforded the opportunity to engage in deeper dialogue with self. I will share my own simplistic understanding of current relevant research into neuroscience to help explain why these approaches to image are useful.


Wiser (1996) in the research in A Comparison of Change Processes in Psychodynamic therapies say “ There is mounting evidence that ‘facilitating client’s’ affective or emotional experience of their issues can lead to positive shifts for them…a move away from “talking about” their affective experience, to an in-the-moment “experiencing of” affecting experience is critical.

I believe as Creative arts therapists, we are continually working with this “in the moment experiencing of affecting experience”. When clients work with and through image in a session, significant psychic shifts can take place because they engage in experiences which make connections between psyche and soma, between their mind and body. This bridging and integrative effect also takes place between left and right hemispheres of the brain when clients engage in the creative process through the use of metaphor and symbol. As Cox explains, “The symbolic image is generated by the dual processes of the mind. It depends upon dynamic synergism between left and right hemisphere. It is the optimal balancing of imagery, emotion and thought which facilitates the creative process” (Cox,1997:137). As creative arts therapists the creative process is core to our work.

In our sessions, images may come into being as real images made by a client within a session through art work, dramatic enactment or forms of movement. I assume also that within a music therapy session, as with the other arts therapies, the therapist is receptive too to the image which the client brings through their very presence within the space, their body language and the process they engage in through music and sound making. Images may emerge in our work as felt images in response to a client’s material or presence, sometimes termed ‘somatic counter-transference’.We may also as therapists be left with residual or internal symbolic or metaphorical images following the session when we have identified consciously or unconsciously with a clients projection. I believe that being receptive to the whole range of images available to us and our clients in a session allows us to become more empathic and not only attune to the pattern of the therapeutic journey but also to the internal rhythms of the client. This approach also enables us to provide for the client more opportunities for mind body experiences which in turn can offer healing and integration. Rogers has talked about spontaneity and trust in the self as significant factors to mental health and well being. “The individual has within themselves vast resources for self-understanding” (Rogers, 1974). Through a client’s therapeutic involvement in mind body experiences whilst engaged in the creative process these ‘vast resources’ can also be accessed through the ‘dynamic synergism’ which takes place neuropsychologically between the “ikonic mode of the right hemisphere and the linguistic mode of the left” (Cox, 1987). When this synergism takes place there is more opportunity for repressed memories to emerge through imagery in order to be acknowledged, understood and integrated. When these personal resources are harnessed, there is an increase in the potential for the effectiveness of therapy.

Recent developments in neuroscience provide explanations for why the creative arts therapies can be so effective as therapy. Bannister, cites the neurologist and philosopher Damasio as having made a huge contribution to this area when she describes his belief in the importance of body – mind connections to his theory of consciousness. He suggests that life- regulating devices in the brain regulate the body, creating body maps and that the presence of both the brain devices and the body maps are indispensable for the mechanisms that achieve core consciousness (Bannister, 2003:134). She goes on to say that when clients work through trauma in therapy “it seems likely that in recreating the events, in symbolic or metaphoric ways and within safe boundaries, fresh neural patterns are registered as the brain responds to the trigger emotions”. This notion that engaging in creative metaphor therapeutically in order to work through symptoms of dissociation for victims of trauma is not a new concept for creative arts therapists but the neuroscientific research now lends weight to the existing clinical body of work. When we as creative arts therapists provide opportunities for our clients to express internal conflict from trauma or damaging past experience  through metaphor and symbolism, we help them as Wiser says to  “move away from ‘talking about’  their affective experience, [and to engage in]  in-the-moment ‘experiencing of’  affecting experience”.

Sometimes in creative arts therapy the client is enabled to understand the underlying meanings which may belie their symptoms or behaviour. When we explore together their  spontaneous image making in response to the therapist’s question, ‘where is the pain/difficulty, show me what it feels/sounds/moves  like?’, we help clients to connect with the messages that their bodies may be trying to communicate. If as Case explains, “repressed emotional disturbances will often manifest somatically if they are not attended to” (Case, 2004:95), then in the client’s creative engagement with this task, they can be presented with an external expression of their internal world. It is in the bodies’ communication of this, for as Bates quotes Malidoma Patrice Soma, “The person in pain is communicated to by a part of themselves that has no other way of speaking” (Bates, 2009), that clues as to the future direction of therapy can be found.

The client’s creative and spontaneous projections  within a session show a development from Freud’s theory of Free Association, which can be defined as  “letting thoughts emerge into one’s mind without censoring them in any way and describing these out loud” (Lemma on Freud, 2002). It moves to a physical manifestation of emerging inner thoughts and feelings; a concrete record of mind body experience. These images can act as a bridge between unconscious processes and external reality. If client’s can experience a state of reverie and reflection, a kind of “dreaming with open eyes”, as Jung describes his theory of active imagination (Jung, 1912), not only can we both enter into experiences which forge body-mind connections but as clients enter into dialogue with aspects of themselves previously unknown, the therapist is also afforded the opportunity to better attune to their clients experience.

This concept of therapeutic attunement or ‘intersubjective attunement’ has also been explored through new developments into brain research. Kossak in his article Therapeutic  attunement: A transpersonal view of expressive arts therapy, cites research by Gallese, which “pinpoints certain mirror neurons in the brain that activate when any kind of interactive play is engaged” (Gallese, 2001). Kossak goes on to explain “When a person hears a sound or sees an action or an image, the mirror neurons in that person begin to fire off, creating a sympathetic response in the other person” (Kossak, 2009:16). As creative therapists, this sympathetic response is key to helping a client feel understood, affirmed and not alone.

I would like to now describe some of my clinical work which I feel helps to illustrate some of these concepts. Pseudonyms have been used for the following clients and all identifying features have been changed to protect client confidentiality.

Clinical Material: Client 1

David was a young boy of 8 with Crohns disease. Because of the illness, David had been admitted to hospital on a number of occasions. He also had regular checkups, where he had intrusive examinations and bloods were taken. He presented with severe emotional and behavioural difficulties in school. He presented in class with violent outbursts sometimes throwing chairs and screaming at the top of his voice, on other occasions he would be withdrawn and collapse into violent sobbing, hiding in the toilet and refusing to come out until his mother arrived. David also exhibited worrying behaviour where he would talk to himself in class and assume different voices in reply. He was clearly showing serious signs of distress.

Through our art therapy sessions, David used a variety of media and also engaged in movement and role play. Repeatedly, it seemed that he would become consumed with an insatiable need to create visceral messes of red paint and glue. During these occasions, I would feel overwhelmed by strong countertransference responses which resided in my body as well as my mind. If anyone had entered the space they would have seen David, clothed in a splattered apron, hands and arms covered with red paint, and surrounded by images of red mess on the table and floor. He presented this curious image, looking like a child butcher yet without any visible signs of distress.

However, the feelings of panic and helplessness residing in me because of the distressing associations I had made between the red paint and blood stains, made it almost

unbearable to stay therapeutically present whilst witnessing this activity. It later became evident that David was role playing a surgeon ‘fixing’ patients, only for them to return to sickness and need new surgery again. He called himself ‘Dr D’ and would ask for my assistance with the various medical procedures which would take place. It appeared that David was working through some unconscious material relating to the distress he may have experienced in relation to the hospital admissions his illness. My role seemed to be one where I attempted to stay therapeutically open and present whilst not becoming damaged by his projections. Although similarities may have existed through his memory with the sensory connections to red paint, mess and blood, David assumed a very different role to the familiar one of vulnerable patient. He was now in control and had the power to repair damage.

It is not unusual for traumatised clients to engage in reparative work creatively within sessions. We regularly as creative arts therapists have and do witness this as having a healing effect on our client’s experience of past damage. What is interesting now is how developments into neuroscience and consciousness can help us explain why this may be so.

To my understanding, I believe that as David engaged in these experiences simultaneously through mind and body, connecting sensory stimulus, perception and memory with feelings of power and control in the here and now of the session, I am suggesting that new neural patterns were formed in order to counter balance the previous paths that the traumatic experiences had left imprinted. Memory and image are interconnected, “recalled images, present images, body changes and feelings are all interconnected in a process of thinking” (Case, 2007:99). Space does not permit me to describe in more detail David’s therapeutic journey, but slowly over time he began to progress and feel happier in himself.

I have talked about how therapeutic effect takes place through the mind body connections which a client may experience interpersonally when they engage in creative activity which produces images of one kind or another. I believe that the open witnessing by the therapist of these images, embodiments or movements, through their receptivity to fully experience them in turn through their own psyche and soma, helps therapeutic attunement to take place. I believe this ‘vicarious introspection’ which Kohut describes as “two people in relationship experiencing an embodied, psychological and emotional interpersonal relationship” (Kohut,1971), helps client and therapist embark on a journey of meaning making together where the ‘to-ing and fro-ing of meaning becomes a fertile creative relational space. In addition, I believe this relational experience between internal and external phenomena, where internal processes are made visible through creative imagery, also gives the client the opportunity to develop a deeper awareness of self because new ways to dialogue intrapersonally are initiated. In the following cases I would like to illustrate this point.

Client 2

In a 5 day workshop of intensive group art therapy, I began by offering words that have associations with archetypal psychic sites and asked participants, through free association to create art work in response to whatever image emerged for them. My thinking behind this is expressed in Jung’s theories around image which he describes as how the psychic aspect of the self declares itself (Jung, 1967).

Phyliss introduced herself to the group as “a busy housewife, with two beautiful children, a husband who is a successful professional. I have a new car and everything I need.” However, there seemed to be a deep sadness about Phyliss, as if all was not as it appeared and as if she had an inner emptiness. This seemed to be communicated through the mental image which emerged for me in response to her presence, in her body language and the physical movements she made in the space. “The forms it [the body] adopts in movement and repose express social pressures in manifold ways” (Douglas, 1996:69). Phyliss created the image below in response to my offering of ‘Door’.

This painting appeared to contain a profound message for Phyliss, through the glowing golden light which emanated from behind the door. The personal meaning and insight contained within the image (and door) seemed to be just within her grasp, but she

appeared unable to make it real for herself. I invited her to engage with the painting and asked her if she would like me to capture this movement through photography. She agreed. I asked her what she would like to do with the door, to which she replied, “I want to open it and see what is inside.” I encouraged her to do this, but as she did her demeanour changed as she looked to the camera and the rest of the group, forcing a smile as if on stage. I reflected that perhaps if she focused on looking at us looking at her, she might never find out what was inside the door. At this there seemed to be a shift in her consciousness and her body language changed. She then faced the door and opened it as if with a sense of reverence and subsequent stillness. This sequence of interaction with her own image appeared to have a deep resonance with her and she became very reflective.

Although this workshop offered only a brief contact with art psychotherapy, it appeared that Phyllis had begun to make some deep connections. It seemed that she was able to

begin listening and dialoguing with her self through her own image making and authentic interaction with her images. When she gained access to unconscious processes which emerged through her embodiment of her relationship to self and her concrete image, it appeared that she could begin to make real choices around her needs, doubts and fears in life. It was as if she could observe and explore the meaning which belied her body language and external presence with the world. She appeared to become more aware of her pre occupation with trying to live up to (or down to) others expectations of her and how this might distract her from a deeper relationship with her self.

Client 4

Rachel was a client who had separated from an abusive relationship. She had been diagnosed with Fibromyalgia and was being treated for depression. She suffered from insomnia and seemed continually to be in pain. She talked about her “need always to keep things under control and box things away, tidying the house incessantly in order to stave off feelings of chaos”. Rachel explained that she had been the victim of a particularly violent incident perpetrated by her partner. He had captured this violence by creating a photographic image of her abused body. She had later found and destroyed this photograph but it seemed that she could not rid herself of this image psychically.

As I have explained before, the images, sensations, perceptions and memories of this traumatic experience must have left an indelible pattern on her mind and body which could presumably be re triggered by memory or associations to felt or perceived body images. During our work together Rachel tapped into feelings of anger, rage and grief. She expressed these through the use of art materials. The issue of self care was one that we worked on consciously in the sessions.

As Rachel’s therapy was coming to an end, I asked her if she would like to create an ending ritual which might hold some personal meaning for her and to which I would assist. I suggested that she may like to have a photograph of the ritual in order for her to keep as a concrete record of her journey through therapy. She agreed to this and created a simple ritual which contained concrete elements of self care, love and protection. I believe that this photographic image co-created by us served as a therapeutic tool almost like a talisman, symbolising some spiritual healing for Rachel to hold onto. This as a concrete object within the real world but also as a connection to the psychic pain she felt in relation to a deeply damaging experience in the past. The main visual element in the image, like the previous photograph contains an image of her torso, but this time, her body is surrounded by symbols of love and protection. I suggest that this powerful image may create new associations for her which will not dispel or negate the previous toxic image but may create new neurological pathways, which might act as a counterbalance to remind her to listen protectively and engage authentically with her self on a deep and spiritual level.



If our role as therapists is to help clients initiate dialogue with their ‘true’ selves, to find alternate ways to safely express their difficulties, to help them gain some sense of control in their lives by exploring possible meanings for their symptoms and distress, and to strengthen their inner resources and self belief in their own creative problem solving capacities, then I suggest engaging meaningfully with image enriches this role. I believe that working therapeutically with and through image is an effective approach which helps the client to ultimately reframe their experience in order to help the mind and body regenerative process of integration and healing to take place. When we in turn as therapists open our selves to our clients by our willingness to bring our minds and bodies to the therapeutic situation we attune to their needs and can then truly offer ourselves as a resource to them. As Cox says “Metaphor can serve as a container for feelings which are too overwhelming to be tolerated…a vehicle for carrying, mobilizing, expressing and integrating affect and cognition in furthering the therapeutic process.” (Cox, 1997:99).

Claire Colreavy Donnelly is a qualified art psychotherapist. She works within adult psychiatry, child and adolescent mental health, the area of disability and in private practice as a supervisor. She is a member of IACAT.

References                                                                                                                          Bannister, A. (2003) Creative Therapies with traumatized Children, London: JKP

Bates, T. (2005) quoting Malidoma Patrice Some in Conversations with Dr Tony Bates, Interview with Therese Gaynor for Inside Out the Journal for the Irish Association of Humanistic and Integrative Psychotherapy, Winter, 2005.                                                   

Case, A. (2002) Psychodynamic Therapy: The Jungian Approach in Handbook of Individual Therapy, (ed. Dryden) London: Sage.

Case, C. (2007) in Supervision of Art Psychotherapy: A Theoretical and Practical Handbook, Ed. Schaverien J. and Case, C. UK: Routledge.

Cox, M. and Theilgaard, A. (1997) Mutative Metaphors in Psychotherapy: The Aeolian Mode. JKP.

Damasio, A. (2000) The Feeling of What Happens: Body, Emotion and the Making of Consciousness, London:Vintage.

Douglas, M. (1996) Natural Symbols Exploration in Cosmology, UK: Routledge

Freud, S. (1923) The Ego and the Id. Standard Edition Vol. 19. London: Hogarth Press and the Institute of Psychoanalysis.

Gallese, V. (2001) The Shared Manifold Hypothesis: From Mirror Neurons to Empathy, Journal of Consciousness Studies 8(5), quoted in Kossak, M. Therapeutic Attunement: A Transpersonal View of Expressive Arts Therapy, The Arts in Psychotherapy, 36(2009).

Jung, C. (1912) The Psychology  of the Unconscious: Symbols of Transformation.

Jung, C. (1967) Memories, Dreams, Reflections, Collins, New York: Routledge                 Lemma, Alessandra.(2002) The Freudian Approach, Chapter in Handbook of Individual Therapy, Ed. Dryden,  London: Sage.

Kohut, H. (1971) The Analysis of the Self, London: International Universities Press.

Kossak, M. (2009) Therapeutic Attunement: A Transpersonal View of Expressive Arts Therapy, The Arts in Psychotherapy, 36(2009).

Rogers, C. (1967) On Becoming a Person: A Therapist’s View of Psychotherapy, UK: Constable

Wiser, G. (1996) Cognitive Behavioural and Psychodynamic therapies: A Comparison of Change Processes in Dryden, W. (Ed), Research in Counselling and Psychotherapy, London: Sage, quoted in Jones, P. Creative Arts Therapies: A Revolution in Healthcare, London: Routledge

Wood, M. (1984) The Child and Art Therapy: A Psychodynamic Viewpoint, chapter in Art as Therapy, (ed. Dalley, T) London: Tavistock


Excerpts’ from this paper were presented at the Transforming Healthcare 10th International Trinity Nursing Conference 2009.

I wish to thank my clients for their kind permission to use their work and for entrusting me to witness their unique therapeutic journeys.