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How Natalie Carlton Sees Art Therapy

March 28, 2017

By Roberta Perry

Natalie Carlton, PhD is the new director of the MA Art therapy and Counseling program and clinical associate professor in the Creative Arts Therapies (CAT) Department. This Temple University undergraduate studied fine art and visual anthropology, and while she identified herself as an artist, she wasn’t one who sought solo shows or exhibits of her work. She was more drawn to collaboration with people in visual arts, theater and music. This was a perfect entry into art therapy.

Early on, Carlton developed an appreciation for folk art, multi-media use, and artists that “were considered visionary or ‘outsider’ artists producing outside the fine art academy.” She was drawn to and identified with persons and ideas that created spaces and truths outside established norms. “I found that art can be exciting, very enlivening to the person who was making it within a greater community or cause,” said Carlton. Art therapy afforded her exposure to people who were creating art with tools and media that proved very versatile, whether children working with weaving materials in outdoor spaces, people with mental illnesses working with found materials, adults with intellectual disabilities developing artistic practices and careers, and families and communities who may face challenges but evidence empowerment and creativity through self-representational photography or videos. Carlton found creative processes and products helped develop an interesting exchange of immediacy or longer sustained conversation between the makers and the viewers.

To help CNHP and all its constituents get to know Carlton, the following questions and answers are from a recent interview with her.

RP: What is art therapy?

NC: It’s hard to unpack quickly and without context. Art therapy seems so simple, but once you get into its theories and methods, clinical applications and assessments, and research, it’s complex. It is also delivered, conceived of and described in a variety of ways by art therapists. For me, art therapy is more than clients simply expressing emotions or thoughts through visual imagery. It’s also more than art therapists being able to “interpret images” and in turn, come to know things about people to help them. It’s a phenomenon beyond words but also steeped in them. It’s about collaboration. It’s about cultural intersections and holding different perspectives between client and therapists, or coming together into treatment communities and holding purposeful intention and communication.

I’ve done a lot of work with youth coming out of incarceration, youth and families of mixed racial and socioeconomic identifications, and it’s been very powerful work. Using art therapy media and methods as tools of “healing” are not finite vehicles to how each particular therapeutic relationship or process can work. The structure, improvisation or play of creativity can be vital movement and pathways of the body and mind, display concrete to abstract thinking and communication, hold both flow and resistance — and being a creative person has made me more able to interact with large varieties of people and to have a certain authenticity and realness. Being an art therapist has reinforced values of give and take, respect and humility for others and myself. Being a creative person with an open mind has brought me very powerful experiences within the different situations we call therapy.

RP: I believe I have a misconception of how art therapy works. Is it more than drawing a picture? How does it work?

NC: Part of the complication is that both art and therapy work at multiple levels and they work in combination differently for diverse people. It is hard to answer that direct question simply and give an example that’s applicable to everyone. I’ve worked a lot with children and parents. Let me just give you an example of that.

Let us say a parent and child came to my private practice seeking art therapy services. I would sign them in through an informed consent process; explain confidentiality, how Medicaid or insurance works for subsidizing or paying outright for sessions, and answer any questions about therapy and how it may work for their situation or needs. Some families would know that I’m an art therapist and others would not, they just knew that I took insurance and I had a good reputation in our community, so those may be some the primary reasons why they were coming to me. I would describe my training, and then show them a little about what art therapy can be by leading them through an experience with art media, either together or separate. If a young person and a parent come in to focus on the child’s behaviors at school, I would actively listen, evaluate stress levels in the family, and how the family is absorbing the stress and interrelated behaviors and/or deflecting or mirroring them into additional situations. We would try to identify together what was creating the behaviors and when to track the frequency they occurred. To build rapport and get to know them a bit I would ask each of them to do a personal symbol drawing. Depending on the age of the child, theirs might be on multiple pieces of paper or maybe something spontaneous they wished to draw. With the parent, the activity I facilitated might have communicated, “Hey I want to get to know you.” For the young person, it may be about starting a conversation with them about art materials, their experiences with them and what is on their mind. Self-identified symbols can be concrete and immediate and they also go into deeper levels of what we carry in our bodies and psyches, what we represent to ourselves and others, what we hold valuable within our belief systems. I sometimes asked many questions that first session and had multi-level exchanges if they could tolerate it well, if they could not, I would titrate the exchange and build in stages. But basically, I would be trying to get to “this is the situation, this is your system around it, and where do you see the therapy intervening?”  That was a typical introductory session in my way of applying art therapy.

Medicaid and other insurances typically require clinicians to diagnose the child and increase or decrease positive or maladaptive behaviors, but art therapy, my version of art therapy, we look at relationships, or the resources and strengths of each client while doing a differential diagnosis ascertaining if the issue of concern is rising from an organic problem (learning issue for example) or situational stressor (trauma response or unsafe family dynamics). I would be trying to diagnose, as my clinical roles and responsibilities required me often to do, but also critically build a relationship and where I would let people know directly, “your life, values, and symbols have meaning and we are finding solutions together.” An older adult or teenager may draw a mountainside and its rivers of snowmelt in Northern New Mexico and then tell me memories in that landscape and all the cultural truth of those experiences. At the end of 50 minutes, I would know that person in a way that would be very different than had we just talked. I guarantee you.

The art becomes a vehicle of bringing that visual or symbolic expression, thinking and sharing forward. If I had time, or at the next session, I might have those same family members do a drawing together. I might have the child initiate the drawing, and then the parent initiate the next one to see how they collaborate, cooperate, or if one tends to dominate the other. We’re typically finding answers and insights to problems indirectly and through “back doors” often by strengthening relationships.

RP: How do you get kids to open up?

NC: A child might be shut down emotionally for many reasons and as creative arts therapists, we are trained in how to conceptualize and safely handle difficult affect or behaviors. The first rule is to not take anything personal and be curious as to why something is presenting within an individual or a group. The “shut-down” behaviors may be due to how words get the child all tied up or angry inside because adults may not be listening carefully to what they are saying. I’ll never ask anybody to “draw your feelings” outright because emotions are very complicated, abstract notions. Feelings get expressed through exchanges and behaviors, and then maybe through carefully chosen words when we are much older. I worked with a child who was a perfectionist, and really creative. He had a lot of grief because his parents were going through a conflictual divorce. His grief was often expressed by trying to fix objects and to render carefully drawn lines, but he seemed to be really trying to fix his world that was falling apart. Those needs not being met by circumstances drove and triggered his larger emotional grief and need for protection. I remember him doing a drawing with a pencil and eraser, and through his dissatisfaction with elements of the drawing he would get so frustrated and angry. I evaluated I could safely let him go there because we had worked together to establish rapport, or trust. He collapsed after a few minutes of drawing and erasing, and he cried while I sat beside him quietly. By a therapeutic presence, you create a waiting and holding space with people that you are attending to and in that listening and “not doing,” you essentially validate their experiences. I eventually asked what was happening for him and he was able to say, “I get really sad.” We worked together for months while I simultaneously coached his mother in how she could increase his emotional support, defuse conflict in his immediate surroundings, and grow her insight regarding his triggers to frustration and sadness. The mother had acknowledged that he often expressed anger and perfectionism at home, but maybe he had never claimed “the why” until that moment when he really told a hard truth to a family outsider like me.  It started to change for him after that period, but not instantaneously.

Art therapy can help with communication because young people do not developmentally have direct emotional language — like the dimensions of what sad means. They aren’t hiding anything and they’re not dumb. They actually feel emotions deeply and embody them, and they struggle to communicate it all with words, so they often act it out or act in. When you’re doing something that’s action-oriented with young people like art therapy, you see their patterns of behaviors, thoughts, and feelings emerge in metaverbal ways. They may get frustrated easily but you may ask as an art therapist, “does this happen at school or at home too?”  So, the therapy space and interactions become an approximate of their lives, and an “as if” space to be themselves and begin to try out new ways of being through both the creativity and unique relationship with an art therapist. As art therapists, we are discerning and tracking the patterned behaviors with our clients and introducing new solutions or new versions so maybe they can begin to shift thoughts, feelings, and behaviors — and their other relationships too.

RP: Do people often worry that they don’t know how to draw when they go to art therapy?

NC: Yes, we definitely hear some of our clients say, ‘I’m not an artist.’ We introduce materials and directives that may inspire basic visual expression and art forms and then apply “scaffolded” techniques, including less and less structure in materials and directives, to see how clients may begin exploring more on their own. Art therapy is not about drawing well or teaching clients to draw well. It can be as simple as having them diagram out what happens in their thoughts and behaviors, or a situation with others. For people who don’t draw or create every day (which are most people besides children and non-artists), art therapists consciously structure media use and explorations for our clients and ask ourselves — what is creativity to this individual, what are art materials they wish to use and that suit or push their limits, what’s the impact of the materials like fabric versus ink versus clay versus drawing?

As an art therapist, I am sometimes actively teaching clients and family members about art material choices and their impacts, identifying if they’re relaxing, creating anxiety or making them push through things that frustrate. I am also simply providing a ritual of time and space. Young people so often do not have a solid hour with somebody where the door is shut and all cell phones are off or quiet. That sanctuary of time and space, and the consistency of a weekly appointment, is in and of itself, incredibly supportive and healing. When the parent takes the child to counseling or therapy, it places them also in role of support. The parent or caregiver is bringing and picking up the child, and they are essentially collaborating with the therapist and the child with that provision of access and communication exchange. That can shake up a family dynamic of discord and it helps build a new frame around the relationships by enhancing their trust in the short term, that they can resolve something harder in the long term. Nine times out of ten, the family is going through something challenging — that’s why the child is struggling.

Art therapy can be detective work and is extremely relational. I have seen people use art materials to do incredible things, but I really do think that most of the power lies in therapeutic relationship and the lessons clients learn about finding solutions and having more creative, flexible minds and perspectives. Sometimes, when youth are graduating or ending a term of art therapy, I ask them to take a pledge of creativity — I say ‘hold up your hand and repeat, when I am faced with a struggle or a hard thing, I will think creatively. I will be flexible. I will be patient with myself and others.’ Art therapy is not as much about taking away someone’s pain as it is about helping them look at it unapologetically and work with it, in ways that are empowering and increasing to their own sense of agency. 

RP: That sounds similar to the point of meditation and mindfulness — you’re not trying to run away, you’re trying to recognize and be aware that this is exactly where I am right now.

NC: Yes, you are actually embracing the truth rather than denying it. Therapy can be like that — dropping some “stop gaps” into the family dynamic or teaching them to slow down emotional reactions together. Maybe no one ever said the word divorce or they haven’t talked about the mother that died several years ago from a drug addiction. They have talked about her without talking about it. The avoidance causes great pain and when people finally tell their own truths and perspectives, then the avoided thing can start to lose power over them.

RP: It seems like what you do is more difficult than being a talk-only therapist. How do you blend that? Do you wear a therapist’s hat and an art therapist’s hat or is it all combined or how do you know what the proper course is for an individual?

NC: You take a lot of signals from clients — what do they need, what are their preferences, interests, boundaries — what are the fluctuating needs at the moment. I also know how to find my way to work with some people based somewhat on predictable behavioral patterns and cues I have learned having worked previously with similar situations. Again, the truth is often very contextual, but there are patterns to be discerned  —  and questioned. For instance, if I have a young person coming in with a lot of hyperactivity and unfocused behavior, I’m going to make sure my studio is put away and not too distracting. I am going to try to de-stimulate that child and create a lot of structure versus for another child who is more shut down, and maybe experiencing an emotional trauma, I might tempt his senses to draw him out. I might leave out a pile of fabric and see what he does with that. I am also going to question any generalizations I may make or patterns of thinking and behaving I show, and test out new possibilities all the time.

The Drexel University degree title is Art Therapy and Counseling and that hybrid of identity has added value to the mix of “art” and “therapy.”  Historically we had a bit of a preoccupation amongst creative arts therapists asking — are we therapists or artists? Now with the added counseling in the degree title, we are asking about dualities again, are we art therapists or counselors? We are discerning more and more what both, and a true integration, can mean for students’ careers and clinical skills. For me, the professional integrations happen over time, with work experience and collaborations with other therapists. In Taos, New Mexico where I worked for 20 years, there was only one other art therapist, no music or dance/movement therapists, so addictions and recovery counselors, professional counselors, social workers, and couple and family counselors were my immediate colleagues. We all share ethical principles and protocols, then we have distinct to similar expertise that help us help our clients. And that variety and choice of art therapist, counselor or social worker, is what people really appreciate when they seek out therapy, and they benefit when a professional is a hybrid of two or more professions, specialties or perspectives. I have had a few clients who really did not want to do art therapy. They wanted to talk and that’s fine, but I would always share with them how my power to help them truly resided in my knowledge base from art therapy, and the action-orientation of creativity and materials use. Eventually all clients I have worked with have used art therapy materials and techniques to minimal or maximized capacities.

RP: Where do you see creative arts therapies going in the future?

NC: Personally, I feel there is a lot of potential for expansion. There has always been waxing and waning public funding available for medical and psychiatric treatment, however, there’s been a gradual defunding now being accelerated in the current political climate. Traditionally, creative arts therapists have many jobs in medical and other settings, but I have vision for us continually expanding beyond strict or narrow models of therapy. It has already started, but I see even more opportunity in juvenile justice advocacy, nonprofit work, community engagement projects, college counseling and school-based creative arts therapy. Schools are a complicated mixture of systems, but there are more and more art therapists collaborating with special education teachers in integrated classrooms. Ideas of what therapy is are continually expanding into private and public spheres.

RP: I think people are stressed out, having trouble and struggling and they don’t understand why.

NC: There are huge stigmas around mental health issues, so people think they should be ashamed of vulnerabilities and deal with them on their own. Stigmas can prevent individuals, families and communities from seeking support, and they can exist within mental health communities and be perpetuated by mental health practitioners. Stigmas against seeking support can often generate from adults and not young people. For example, youth would walk up to me in my small community and often introduce me to a family member or friend as their art therapist. Three youth reportedly had a full on compare and contrast conversation about me as their art therapist in a middle school choral class.

Back to where I see emerging edges forming in art therapy. One of my areas of interest is digital media use in art therapy and that is something I would like to bring more of to Drexel. I envision bringing more new materials use to class projects and learning, but also have specialty classes on how to use digital media more in-depth with clients. Historically those of us interested in using technology in therapy learned the techniques on our own and from each other. There are a few programs just beginning to teach digital media skills as expanded media choices. Digital media applications will not take over the other fine art and craft materials applications, but will simply keep expanding the palate of what’s available for clients. I imagine this as exciting interdisciplinary work between our department and College, and with other programs within Drexel. Healthcare and digital media have a huge future as does education and digital literacy and media use. Drexel certainly has the resources and the ability to both research and educate in these expanding areas. I just wrote a chapter for a book edited by Ricky Garner titled, Digital Art Therapy, where I talk about the current developments in digital media and what that could mean for art therapy and humanity. I would love to see discussions and interdisciplinary work of that nature at Drexel University.

RP: I can’t even wrap my head around what that is.

NC: A simple example would be how a teenager might lose a friend to unexpected death and does a R.I.P music video as a remembrance or to share with others. They might record a rap or poem they write and set it to music, add visual imagery and all done with the computer in a session or series of sessions. The imagery and music can be created by the youth, made collaboratively with others, or containing mixed and ‘sampled’ materials from the Internet.

RP: So, digital media use could be combined elements of music, video, and visual art resources and creativity?

Yes. Digital media are hardware such as computers and digital devices, they are tools within creative mediums and specific software, and then they are also platforms or social media streams and communication options. There are many digital media techniques and applications that art therapists are beginning to use in sessions and contained within the boundaries of client and therapist work, while some projects and materials use are beginning to go out of traditional therapy bounds. For instance, there’s a photo site where adults with intellectual disabilities have started amassing photographs and self-stories to represent themselves rather than the world talking about them in the third person. They are saying, ‘this is us. This is me. This is me looking through my camera lens and my identity.’ They are reclaiming their own imagery production and dissemination, their thoughts, group to individual drives, and a “culture” of belonging. They have not done this work necessarily in therapy sessions but such projects represent beautifully the bigger truths I have been taught by similar types of people in therapy and caring communities. Self-representation is often where people reveal their inner brilliance and community drives, besides what others may see as “disability” from the outside. Building creative products in digital media is one element to conceive of in art therapy use, but how greater communications and advocacy may be shared with purpose and intention is another area still developing.

RP: What are your specific plans besides introducing a digital art therapy track, program or class?

NC: It wouldn’t be a track, just more learning about its benefits and challenges in our current and expanding course. There is not a lot infused in current class content, but we are developing ideas for the near future. We need additional hardware and software choices for students to experiment with and more ability and opportunities to integrate it into clinical skills.

RP: How do you want to expand the program beyond that?

NC: A digital art therapy specialties course is a future goal as well as yearly digital media symposia that bring together international and interdisciplinary work between creative arts therapies, film makers, video gamers, educators, and digital media engineers, programmers and designers. Additionally, my attention is on how the Art therapy and Counseling program will implement and sustain immediate content growth. Educational competencies and outcomes are being standardized across all US programs accredited by our national American Art Therapy Association (AATA). The content growth is a potent mixture of art therapy standards raising expectations on teaching inclusion skills and diversity awareness and social justice and advocacy, and our larger departmental implementation of PAR recommendations. Our current “dual degree” of the Masters of Art therapy and Counseling requires us to carefully track counseling requirements and related core competencies, as well as those articulated for art therapy national board certification. Right now, myself and many faculty are rewriting the CAT curriculum and I’m getting to know better my faculty teams, creating collaborative ideas about what’s working and what’s not, implementing some of the changes now in the short term and definitely redesigning for an improved overall program in a couple years. It’s a huge collage puzzle I’m working on and with the positive collaboration I am experiencing here, I feel suited to do it.

I am also discovering that what makes our CAT program distinct and what makes us special is the depth and breadth of this integrated department. That critically includes our counseling faculty and integrated creative arts therapies programs.

RP: What else do you think is really special about what you see at Drexel?

NC: The immediate exposure to practicum and internship clinical work for our incoming cohorts. When students first come here, they start their practicum right away so they’re both taking classes full-time and experiencing clinical work simultaneously, and there’s some variety in that practicum and internship experiences. Also, as I mentioned before, the parallel trainings and advancing integrations of dance/movement, music, art and counseling professions make this a distinct program. Some programs add counseling by name, but they’re not necessarily hiring people that are experts in their fields or adding quality counseling methods, literature and research to their course content. How I see our program, especially in the future, is much better integrated to suit the professional needs of our students who are competing for and fulfilling a variety of jobs. We’re really trying to prepare people for a swath of different job possibilities. I think another distinct quality for this program is its foundations in counseling, psychology and multi-professional clinical language — so our burgeoning students can present at grand rounds, to psychiatrists, doctors, social workers and nurses and be coherent in what they’re saying about their work with clients. We have our own distinct languages in creative arts therapies, but we also know how to speak the professional languages of others.