Art as therapy

1. Introduction

Version followed: Edith Kramer's "art as therapy" approach, as set out in Art Therapy in a Children's Community (1958), Art as Therapy with Children (1971; Schocken 1972 printing, 1974 edition cited by some authors), Childhood and Art Therapy (1979), "The art therapist's third hand" (1986) and Art as Therapy: Collected Papers (2000/2001, ed. with foreword by Lani Gerity). No publicly available text of Kramer's books exists, so the content here comes from secondary sources that quote her with page numbers (Morrison 2013; Thompson 2012; Franklin 2010; Franklin & Siemon 2008; Dannecker's 2014 obituary in Art Therapy Online), and each claim is tagged. The five ways of using art materials are checked against two independent sources quoting Art as Therapy with Children pp. 54–55 and 121–122; the US (ATCB) and UK (HCPC, BAAT) credentials are checked on the official pages. [uncertain]: group procedures, session length and frequency, and anything not quoted from Kramer by a cited source.

What it is. Art as therapy is an approach to art therapy, not a manualised protocol. Kramer (Vienna 1916 to Grundlsee, Austria, 2014) studied painting with Friedl Dicker, a Bauhaus-linked teacher. In New York her work with children at the Little Red School House was first called "art therapy". From 1949 she ran an art therapy programme at the Wiltwyck School for Boys for seven years, then set up a second programme at Jacobi Hospital in the Bronx and worked for more than 13 years with blind children at the Jewish Guild for the Blind. From 1971 she taught at Hahnemann University and George Washington University, and from 1973 co-developed the NYU master's programme with Laurie Wilson. [source: Dannecker 2014, pp. 2–4; NYU finding aid MC 215] Margaret Naumburg treated art as a route to verbal, psychoanalytic work ("art in therapy" or art psychotherapy). Kramer argued that making art is itself the therapy, and that verbal analysis of the work is not essential. [source: Aranguren & León 2011; Dannecker 2014, p. 5] She saw art therapy as close to the humanities and as a supplement to psychotherapy, not a replacement for it. [uncertain: secondary, unverified]

How change happens. The core mechanism is sublimation, a Freudian concept. Kramer saw it as a multi-part process of regression, displacement and re-channelling of drive energy, in which an urge that might be acted out becomes a deliberate, symbolic, socially valued equivalent in art. [source: Franklin & Siemon 2008, citing Kramer 2000, pp. 28–39] Artistic quality is read as a sign of successful sublimation, and creative work can turn inner turmoil into an effort at integration. [source: Dannecker 2014, p. 6, citing Kramer 1971 and 1979] Raw discharge of feeling onto materials is displacement, not sublimation. The work becomes therapeutic when the ego organises that charge into formed expression, and the client gains from both the making and the finished product. [source: Franklin 2010; Franklin & Siemon 2008; Psychology Today, Malchiodi 2014]

2. Framework

No staged protocol. No published fixed phase model, session count or criteria for moving between phases exists for this approach. Kramer's own clinical structure, as reported, is listed below. The phase scaffold after it is a [synthesis] built from her concepts, not her own model.

Kramer's reported structure

Setting. Ongoing art studio sessions, individual and group, inside residential, school, hospital-ward or other therapeutic milieus (Art as Therapy with Children has a chapter titled "Art, art therapy, and the therapeutic milieu"). [source: archive.org table of contents; Dannecker 2014, pp. 3–4] Session length and frequency are not specified. [uncertain]
Evaluation session. Kramer and colleagues (Kramer & Fields; Kramer & Schehr 2000) ran a single evaluation session for children aged about 4 to 15 using three media: pencil, then tempera paint, then clay. The child chooses the content. [source: Morrison 2013, citing Kramer & Schehr 2000, pp. 74, 91; psychotherapy.net film description] See 4.9.
Ongoing work. The child makes art with a small set of good-quality basic materials. The therapist acts as artist, teacher and therapist at once, offers "third hand" help, and supports movement from less organised uses of materials towards formed expression. [source: Franklin 2010, citing Kramer 1979, 1986; Morrison 2013]

Working scaffold [synthesis]

Phase	Goal	Typical content	Move on when
A. Engagement and evaluation (about 1–3 sessions)	Learn how the client uses materials, their developmental level and their relationship to the therapist	Three-media evaluation (4.9); studio orientation; safety rules	You can describe the client's usual way of using materials (4.3) and a working alliance exists
B. Working phase (open-ended; Kramer's settings were long-term)	Shift from discharge, defensive or stereotyped work towards pictographs and formed expression; build frustration tolerance and ego functions	Sustained studio work; third-hand help; technical teaching; containing charged themes in form	Formed expression appears more often and the client can tolerate the process when it goes wrong
C. Consolidation and ending	Keep the gains and take ownership of the work	Finishing significant pieces; reviewing the body of work; deciding what happens to the artworks	Treatment goals met; ending worked through

Professional frame. Art as therapy is practised by trained art therapists. US: graduate-level art therapy training, the American Art Therapy Association (AATA), state licensure where it exists (state list: [uncertain: secondary, unverified]; check the relevant state board), and the Art Therapy Credentials Board (ATCB) credentials: ATR-P (provisional, graduate education done or in progress, practising under an approved supervisor), ATR (graduate art therapy programme plus the supervised post-graduate clinical experience required for independent practice), ATR-BC (an ATR who has passed the board certification examination; recertified every five years by 100 continuing-education credits or re-examination) and ATCS (experienced ATR-BC who supervises); holders attest annually to the ATCB Code. [source: ATCB, About the credentials] UK: "art psychotherapist" and "art therapist" are protected titles; only people who have completed an HCPC-approved programme and are on the HCPC Register may use them, and misuse of a protected title is a criminal offence under Article 39(1) of the Health Professions Order 2001. "Arts therapist" (with an s) is not protected. The British Association of Art Therapists (BAAT) is the professional body. [source: HCPC, The professions; Kidson, HCPC, in BAAT InSight, Winter 2024] A psychotherapist without art therapy training can bring in basic art-making and non-interpretive support [synthesis]. Do not call it art therapy or art psychotherapy, and do not use the evaluation session or material-use categories as assessments, without art therapy training and supervision.

3. Guiding principles

Art is the therapy. Making art is the main healing factor, so keep the session centred on making rather than talking. [source: JKP book page; Dannecker 2014, p. 5]
Words are not primary. Kramer warned against letting words take priority over art, so do not turn every image into a verbal interpretation exercise. [source: JKP book page]
Aim for sublimation, not just discharge. Welcome charged feeling, then help the client contain it in form instead of only spilling it. [source: Franklin & Siemon 2008]
Process and product are one. The finished piece matters too. Help clients finish, and keep their work safe. [source: Franklin & Siemon 2008, citing Kramer 2000b, pp. 36–38; Malchiodi 2014]
Quality matters. Kramer treated the quality of the work as "a measure (though not the only measure)" of therapeutic success, and saw artistic quality as a sign of successful sublimation. Offer good materials and real artistic help so the work can become "formed expression". [source: Dannecker 2014, p. 6; Morrison 2013]
Permit disorder on the way. Accept "disordered, partial, or even chaotic" work as part of the process. [source: Franklin & Siemon 2008, quoting Kramer 2000b] Do not demand polish early.
Therapist as artist, teacher and therapist. Teach technique clearly when it serves the client's own intention. [source: Franklin 2010, citing Kramer 1979; Morrison 2013]
The third hand is least intrusive. Help without imposing content, distorting meaning or showing off your skill. [source: Franklin 2010; Franklin & Siemon 2008]
Respect the client's visual "handwriting". Match their style and developmental level, and keep your own style out of their work. [source: Franklin 2010, citing Kramer 1986]
Auxiliary ego. Lend organising capacity, such as planning, sequencing and frustration tolerance, that the client cannot yet supply. (The 1971 book has a section on the therapist's function as an extension of the ego.) [source: archive.org table of contents; Franklin & Siemon 2008]
Simple, basic materials in depth. Pencil, crayon, charcoal, tempera, pastel and clay challenge initiative and inventiveness better than frequent novelty. Kramer cautioned against adding new media before adolescence. [source: Morrison 2013, citing Kramer 1971/1974, pp. 22, 44]
Developmental fit. Choose materials for the client's cognitive and physical development. [source: Morrison 2013, p. 44]
Trust with real tools. Kramer trusted children with adult tools, which built their autonomy and their respect for safety. [source: psychotherapy.net, Art Therapy's Muse Part 3]
Art tells the truth. Treat the work as an honest record of the client's state, without forcing interpretation onto it. [source: Psychology Today, Malchiodi 2014, quoting Kramer]
The therapist keeps making art. Kramer held it vital that the art therapist is an artist; your own art practice keeps your capacity and sensitivity alive. [source: Dannecker 2014, pp. 5–6]
Culture shapes how materials are offered. Notice your own cultural assumptions about art and materials. [source: Morrison 2013, citing Kramer 2002, p. 219]

4. Intervention inventory

Kramer's "interventions" are ways of setting up, observing and taking part in art-making. They are not scripted exercises: she gave no directive themes, and clients chose their own content. [source: Morrison 2013, citing Kramer & Schehr 2000, p. 91] Steps are written for a trained art therapist. Where a step goes beyond what the sources describe, it is tagged [synthesis].

4.1 Setting up a studio with basic, quality materials

Purpose / when: From the first session. Good basic materials make formed expression possible and "elicit specific kinds of behavior". [source: Morrison 2013, quoting Kramer & Schehr 2000, p. 74]
Steps:
1. Stock pencil, crayons, charcoal, tempera paints, pastels, good paper and ceramic clay, plus kiln access for firing sculpture. These are Kramer's recommended basics. [source: Morrison 2013, citing Kramer 1971/1974, p. 44]
2. Keep materials orderly and visible so the client can choose. [synthesis]
3. Give each client a safe storage place for work in progress, such as a folder or a shelf for clay. [synthesis]
4. Set safety rules (see 4.14) before handing out tools.
Example language (illustrative): "These are real artists' materials. You can use any of them. I'll show you how they work if you want."
Watch for: Materials that are too fluid or too many for a disorganised client. Cheap materials that fight the client's intention. Signs it is working: the client returns to the same materials with growing skill and investment.

4.2 Developmentally matched choice of material, worked in depth

Purpose / when: Throughout. Fit the medium to the client's cognitive and physical development, and build depth before novelty. [source: Morrison 2013, citing Kramer 1971/1974, pp. 22, 44]
Steps:
1. Note age, motor control, frustration tolerance and impulse control. [synthesis]
2. Offer the basic media. Hold off on novel or craft materials, which Kramer cautioned against before adolescence, so the child develops initiative and inventiveness within simple media. [source: Morrison 2013, p. 22]
3. If a medium regularly sets off loss of control (for example wet paint or soft clay), offer a more resistant one such as pencil, firmer clay or pastel, and add structure (a smaller surface, fewer colours). Return to the fluid medium when the client can manage it. [synthesis, drawing on the media spectrum in Morrison 2013, p. 91]
Example language (illustrative): "Paint ran away from you last time. Want to try pastels today? They stay where you put them."
Watch for: Boredom (a cue to deepen technique, not to switch media) versus over-stimulation (a cue for more structure).

4.3 Recognising the five ways of using art materials

Kramer described five ways of using art materials that shape "both the artist and the art product": precursory activities, chaotic discharge, art in the service of defence, pictographs and formed expression. [source: Morrison 2013 and Thompson 2012, both citing Art as Therapy with Children, p. 54] Definitions as the sources quote or paraphrase her:

Precursory activities: scribbling, smearing and exploring a material's physical properties, which does not yet lead to symbolic configurations. [source: Thompson 2012, quoting Kramer 1971, p. 54; Morrison 2013]
Chaotic discharge: loss of control over the material, such as spilling, splashing, destroying or pounding. [source: Morrison 2013, citing Kramer 1971/1974]
Art in the service of defence: "bland stereotypes that are dull, repetitious, and conventional"; rigid, stereotyped work. [source: Thompson 2012, quoting Kramer 1971, pp. 121–122]
Pictographs: drawn narratives that replace or accompany words; Kramer notes they "are, as a rule, crudely executed". [source: Morrison 2013; Thompson 2012, quoting Kramer 1971, p. 54]
Formed expression: symbolic configurations that serve both self-expression and communication; the most desired level. [source: Thompson 2012, quoting Kramer 1971, p. 55; Morrison 2013]

Use them to observe and to guide your response, not as a diagnostic scale. Morrison notes the literature has not critically evaluated them. [source: Morrison 2013, p. 58] The responses to each category in 4.4–4.8 are partly [synthesis]: the secondary sources define the categories but give little of Kramer's own step-by-step response.

Steps: After each session, note which way(s) the client used the materials, what came before any shift, and what you did. [synthesis] Track the pattern over sessions rather than judging from one image.

4.4 Responding to precursory activities

Purpose / when: Scribbling, smearing and exploring what a material does, which Kramer regarded as positive exploration. [source: Morrison 2013, p. 35, citing Kramer] Common with young, regressed or newly engaged clients.
Steps:
1. Allow the exploration. Give enough material and space. [synthesis]
2. Name what the material is doing, without judging. [synthesis]
3. When interest appears, offer small technical next steps such as mixing a colour or rolling a coil. [synthesis]
Example language (illustrative): "Look what happens when the blue runs into the yellow."
Watch for: Exploration that turns into escalating mess (see 4.5). Signs it is working: the exploration starts to become intentional shapes or images.

4.5 Responding to chaotic discharge

Purpose / when: Spilling, splashing, destroying and pounding materials that gets out of control. [source: Morrison 2013, citing Kramer 1971/1974] This is displacement of raw affect, which "falls short of sublimation". [source: Franklin & Siemon 2008]
Steps:
1. Keep everyone safe first and stop anything that endangers people or property (see 5). [synthesis]
2. Do not punish the feeling. Acknowledge it. [synthesis]
3. Lend structure: fewer or firmer materials, a defined surface, a suggestion that the feeling could become a picture or a figure. [synthesis, consistent with the auxiliary-ego role in Franklin & Siemon 2008]
4. Help with technique so the client can give the impulse a form, for example making a clay figure strong enough to be hit without collapsing, or a painting of the storm instead of throwing paint. [synthesis]
Example language (illustrative): "You're really furious. Let's make that fury into something that can stand up, so it doesn't just splash everywhere."
Watch for: Escalation, shame afterwards, peers joining in. Signs it is working: aggressive themes appear inside an organised image rather than as mess.

4.6 Responding to art in the service of defence (stereotyped use)

Purpose / when: Kramer's term for "bland stereotypes that are dull, repetitious, and conventional": rigid, stereotyped work that keeps feeling at a distance. [source: Thompson 2012, quoting Kramer 1971, pp. 121–122] The 1971 book has a section titled "Various stereotyped ways of using art materials". [source: archive.org table of contents] Particular forms such as copying, tracing or a repeated formula are examples you may meet; they are not confirmed as Kramer's own list. [uncertain] In Thompson's case report of an adult client stuck at the pictograph and defence levels, empathic support alone did not shift the repetitive cycle; a later change of medium (collage) and slow development of an artist identity did. This is one case, not a Kramer procedure. [source: Thompson 2012]
Steps [synthesis]:
1. Respect the defence. Do not tear it away, since it may be protecting a fragile client.
2. Look for small openings within the stereotype, such as a new colour, a change of setting or a personal detail.
3. Teach technique so that real observation or invention feels achievable.
4. If the cycle persists over many sessions, consider offering a different basic medium. [synthesis, informed by Thompson 2012]
5. Move at the client's pace. Return to safe formats when needed.
Example language (illustrative): "You draw that car really well. What kind of road is it on today?"
Watch for: Anxiety when the routine is disrupted. Signs it is working: personal content appears without loss of control.

4.7 Responding to pictographs

Purpose / when: Drawn narratives that stand in for words or add to them. [source: Morrison 2013, p. 50, citing Kramer] The client communicates through the image but has not yet made a fully formed work.
Steps:
1. Receive the communication and let the client tell you what is there if they wish. [synthesis]
2. Do not over-interpret. Kramer kept words secondary to art. [source: JKP book page]
3. Where the client wants it, help the pictograph develop into a more complete picture with setting, scale, colour and expression (4.8, 4.10). [synthesis]
Example language (illustrative): "So this shows what happened in the yard. Do you want to make it so someone else could really feel it?"
Watch for: Disclosures of harm (see 5, safeguarding). Signs it is working: the image becomes richer and more invested.

4.8 Supporting formed expression and sublimation

Purpose / when: The goal state. Art that serves self-expression and communication, reached through committed work with basic materials. [source: Morrison 2013, p. 56, citing Kramer] Formed expressions are honest, unified compositions that carry feeling to a viewer. [source: Franklin & Siemon 2008; Franklin 2010]
Steps:
1. Help the client hold a charged theme long enough to work on it, by staying with it over sessions. [source: Franklin & Siemon 2008]
2. Offer technical and compositional help when the work stalls (4.10, 4.11).
3. Support finishing and appreciation of the product (4.12).
4. Expect some regression. Kramer saw regression in formed expression as a way of staying connected to the charged material. [source: Franklin 2010, citing Kramer 1971]
Example language (illustrative): "This picture really holds how alone he feels. What does it still need to be finished?"
Watch for: Perfectionism that blocks finishing. Signs it is working: the client is absorbed, more coherent, more invested, and proud of the work.

4.9 Three-media evaluation session (pencil, paint, clay)

Purpose / when: At intake, to see how a child aged about 4 to 15 uses different media and relates to the therapist. Kramer contrasted this with formulaic rating-scale tools. [source: Morrison 2013, citing Kramer & Schehr 2000, pp. 74, 91–92; psychotherapy.net, Art Therapy's Muse Part 3]
Steps:
1. Offer pencil first, then tempera paint, then clay, in one session. The child chooses what to make each time. [source: Morrison 2013, p. 91]
2. Notice what each medium tends to bring out. Pencil is linked to narrative imagery and to signs of perceptual problems or thought disorder. Paint invites emotional expression. Clay shows playfulness and sustained effort, or regression. [source: Morrison 2013, citing Kramer & Schehr 2000, p. 91]
3. Observe artistic skill relative to age; engagement, from play through to concern with formal qualities; attitude towards the therapist and the materials; and the capacity to learn something new in the session. [source: Morrison 2013, pp. 91–92]
4. Write up your observations as hypotheses for treatment planning. [synthesis]
Example language (illustrative): "Today you'll get to try three things: pencil, paint and clay. You decide what to make with each."
Watch for: Kramer and Schehr reported that evaluation artwork was more invested and complex than work made for standardised tests. [source: Morrison 2013, p. 77] No published validity or reliability data are cited for this session. [uncertain] It is a clinical observation method, not a validated diagnostic test. Never treat its images as evidence of abuse or of a specific disorder.

4.10 Clear technical instruction (therapist as teacher)

Purpose / when: When lack of skill blocks the client's intention, or when the client asks. Kramer gave clear art instruction in support of the client's own process. [source: Morrison 2013, p. 22; Franklin 2010, citing Kramer 1979]
Steps:
1. Find out what the client is trying to achieve. [synthesis]
2. Demonstrate briefly, on scrap or on your own piece, never on the client's work unless asked (see 4.11). [synthesis]
3. Let the client try, then step back. [synthesis]
Example language (illustrative): "If you want the arm to stay on, score both pieces and add slip. I'll show you on this scrap."
Watch for: Teaching turning into your agenda. Signs it is working: the client uses the skill on their own later.

4.11 Third-hand intervention

Purpose / when: When the client's art process breaks down at a key moment and some help would keep their intention alive. Kramer described the third hand as a hand that helps the creative process along without being intrusive, and without distorting meaning or imposing ideas alien to the client. [source: Dannecker 2014, p. 6, quoting Kramer 1986; Franklin 2010] The therapist uses artistic competence "in the least intrusive" way. [source: Franklin & Siemon 2008, quoting Kramer]
Steps:
1. Watch, from a stance of visual dialogue, for where the process falters. [source: Franklin 2010]
2. Offer a specific, limited help at a critical moment, such as mixing a colour the client wants [source: Malchiodi 2014]. Other examples, such as steadying a clay form, suggesting a way to fix a mistake or preparing a surface, are illustrative [synthesis].
3. Match the client's style and developmental level. Keep your own style and technical virtuosity out. [source: Franklin 2010, citing Kramer 1986]
4. Never add content or change meaning, and always ask before touching the client's work. [source: Franklin 2010; the asking step is synthesis]
Example language (illustrative): "You want a darker green for the shadow. Shall I mix it while you hold the brush?"
Watch for: Merging with the client, sympathy instead of empathy, or acting on countertransference. Becoming too intimate too fast with clients whose sense of self is chaotic. [source: Franklin 2010] Signs it is working: the client keeps ownership and carries on more confidently.

4.12 Valuing, finishing and keeping the product

Purpose / when: Throughout and at ending. Kramer held that the client gains from gratification in the finished product, not only from the process. [source: Malchiodi 2014; Franklin & Siemon 2008] That withholding the product deprives the client is a secondary reading. [uncertain: secondary, unverified]
Steps:
1. Support finishing (4.8). [source: as above]
2. Store work carefully, and fire clay where possible. [source: Morrison 2013, kiln, p. 44; storage is synthesis]
3. Look at the work together. Respond to it as art (what it shows, how it is made) rather than with interpretation. [synthesis, consistent with "words not primary", JKP]
4. Agree with the client and setting policy what happens to the work: kept in the record, taken home or exhibited with consent. [synthesis]
Example language (illustrative): "This is finished and strong. Do you want to take it home or keep it here safe for now?"
Watch for: Destroying work in shame or anger. Talk about it, and protect the work if the client agrees. [synthesis] Exhibition without consent.

4.13 Lending ego functions (auxiliary ego)

Purpose / when: With clients whose impulse control, planning or frustration tolerance cannot yet support formed work. The 1971 book discusses the therapist's function "as an extension of the ego". [source: archive.org table of contents; Franklin & Siemon 2008; Franklin 2010]
Steps [synthesis]:
1. Break the task into steps, such as sketch, block in, then detail.
2. Keep time and set boundaries.
3. Hold the plan when the client loses it.
4. Step back as the client takes over these functions.
Example language (illustrative): "Let's plan it first: what goes in the middle, what goes in the background?"
Watch for: Dependency. Fade your support over time.

4.14 Real tools, real safety

Purpose / when: Kramer trusted children with adult tools, which built autonomy and respect for safety. [source: psychotherapy.net, Art Therapy's Muse Part 3]
Steps [synthesis]:
1. Teach correct, safe use before handing over carving tools, scissors or wire.
2. Count sharp tools out and back in, and supervise closely.
3. Use non-toxic, child-safe (AP-labelled or equivalent) paints and pastels. Avoid solvents.
4. Clean clay wet to keep dust down, and do not sand dry clay or fire bisque indoors without ventilation.
5. Only trained staff run the kiln, out of reach of clients.
6. Assess risk individually: no sharp tools for a client at current risk of self-harm or violence.
Example language (illustrative): "This is a real carving tool. I'll show you how to cut away from your hand."
Watch for: Tools going missing, horseplay, an agitated client.

4.15 Group studio and milieu work

Purpose / when: Kramer worked in children's communities (Wiltwyck), in a hospital (Jacobi) and with blind children, and the 1971 book addresses art therapy within the therapeutic milieu. [source: archive.org table of contents; NYU finding aid; Dannecker 2014, pp. 3–4] She led group sessions, including with blind children at the Jewish Guild for the Blind. [source: psychotherapy.net] Group procedure details (how sessions were run, size, length) are not documented in the secondary literature cited here; Morrison 2013 describes no Kramer group work. [uncertain]
Steps [synthesis]:
1. Each member works on their own piece in a shared studio.
2. The therapist moves between members, offering 4.10 and 4.11.
3. Manage peer contagion of chaotic discharge.
4. Share information with the care team without interpreting the art as diagnosis.
Example language (illustrative): "Everyone's working on their own piece today. I'll come round if you need a hand."
Watch for: Comparison and shaming between members, and splitting within staff teams.

4.16 The therapist's own art practice

Purpose / when: Ongoing. Kramer held it vital that the art therapist is an artist, and she remained a painter and sculptor throughout her career. [source: Dannecker 2014, pp. 5–6; Psychology Today, Malchiodi 2014] That own art-making helps the therapist cope with demanding clinical work is a secondary reading. [uncertain: secondary, unverified]
Steps: Keep a regular personal studio practice outside sessions. Use supervision for countertransference. [synthesis]
Watch for: Your aesthetic preferences shaping what you help clients make.

4.17 Later development: empathic "third-hand" response art (Franklin, not Kramer)

Purpose / when: Michael Franklin (2010) extended the third hand into therapist-made images that reflect a group's or client's themes. This is a derived application, not Kramer's own procedure. [source: Franklin 2010]
Steps (as Franklin describes): Identify the group's core theme. Make an image that holds it, for example a fortress for group resistance or a figure behind bars for isolation. Show it and describe it in words. Invite members to speak for it. Use their responses to shape the next image, including clay versions. [source: Franklin 2010]
Example language (illustrative): "I drew what I've been sensing in here. What would this figure say if it could talk?"
Watch for: Your image overriding the clients' own images, and the timing of the intimacy it invites. [source: Franklin 2010]

5. Handling problems

The secondary sources give little explicit problem-handling guidance. Unless a source is cited, everything in this section is [synthesis] built on Kramer's principles.

Stuck client / blank page. Go back to precursory exploration of one basic material (4.4). Offer a technical starting point, such as a ground colour or a lump of clay to wedge, rather than a theme. Kramer let clients choose content. [source for choice of content: Morrison 2013, p. 91] [synthesis]
Stuck in stereotyped work. Treat it as a defence (4.6). Introduce small variations and teach skills. Do not ridicule copying or force "original" work. [synthesis] [uncertain: category definition]
Chaotic discharge or overwhelm. Pause and put safety first. Narrow the materials to firmer, more resistant ones. Use auxiliary-ego structuring (4.13). If needed, end the art task and regulate first with breathing, a walk, or containment elsewhere in the milieu, then return to form-making later (4.5). Kramer distinguished raw discharge from sublimation. [source: Franklin & Siemon 2008] Do not push a client to stay with a flooding traumatic image.
Destroying work. Stop harm to others' work at once. With the client's own work, slow the action down and offer to store the piece instead. If destruction happens, treat it as communication, not a moral failure. Offer to rebuild, or to make an image of the destruction. [synthesis]
Resistance or refusal. Respect it. Kramer's model relies on the client's own initiative. Keep the studio available, work alongside on your own piece (4.16) without pressure, and offer choice of material. Franklin's response-art approach also shows the therapist respectfully naming a group's resistance in an image. [source: Franklin 2010]
Therapist over-helping (third-hand drift). Signs: the work looks like yours, or the client stops trying. Response: return the tools, apologise if you overstepped, and take it to supervision. [source: Franklin 2010 on least intrusive help and countertransference] [synthesis for the response]
Ruptures. Name and repair them directly, for example after a third-hand mistake, a damaged artwork, or a perceived criticism of the work. Take responsibility for your part. [synthesis]
Perfectionism and "I can't draw". Teach one concrete skill (4.10). Permit unfinished and messy stages, since Kramer accepted disordered, partial or chaotic work. [source: Franklin & Siemon 2008] [synthesis for the response]
Non-attendance or low engagement. Check that the materials suit the client's developmental level (4.2). Make sure the client's work is kept safe between sessions (4.12). Liaise with the milieu team. [synthesis]
Over-interpretation pressure (staff, parents or the client asking "what does it mean?"). Kramer kept words secondary to art. [source: JKP] In her view the value of art lies in the making, not in "diagnostic assessment of an image". [source: Dannecker 2014, p. 5] Explain that the image is not proof of anything. Share process observations instead. [synthesis]
Disclosure of harm in images (children). An image alone is never evidence of abuse. If a child discloses, or you have a concern, follow your local safeguarding or mandatory-reporting procedure without delay. Record the child's own words and keep the artwork as part of the record. Do not interview or lead the child. [synthesis, standard safeguarding practice]
Consent and assent (children). Get carer consent and the child's assent for treatment, for keeping artwork, and for any photography, exhibition or teaching use. Involve carers in planning without breaking the child's reasonable confidentiality. [synthesis]
Self-harm or suicide themes. Assess risk using your setting's standard procedure. Remove sharp tools while risk is current (4.14). Do not explore method content in the art. Make a safety plan and arrange lethal-means counselling (safe storage and removal) as indicated. [synthesis]
Physical and material safety. Watch for clay dust, solvents and other toxic materials, sharp tools, kiln heat, spills that cause falls, and allergies. See 4.14. [synthesis]
Blind or disabled clients. Kramer worked for many years with blind children and saw body image appear in their art. [source: psychotherapy.net] Adapt with tactile media such as clay, textured papers and raised lines, with orientation to the workspace and with adapted tools. [synthesis]
Cultural mismatch. Kramer noted that how we offer materials is shaped by our cultural environment. [source: Morrison 2013, citing Kramer 2002, p. 219] Ask what art-making means in the client's culture, and include materials and subjects that are familiar to them. [synthesis]
Scope limits. If the problem needs verbal psychotherapy, medication review or crisis care, refer or co-work. [synthesis] Kramer is reported to have seen art therapy as a supplement to psychotherapy. [uncertain: secondary, unverified]

Sources

Web sources

Books and papers cited (through the secondary sources above)

Kramer, E. (1958). Art Therapy in a Children's Community. Springfield, IL: Charles C. Thomas.
Kramer, E. (1971). Art as Therapy with Children. New York: Schocken (1972 printing; 1974 edition cited by Morrison).
Kramer, E. (1979). Childhood and Art Therapy. New York: Schocken.
Kramer, E. (1986). The art therapist's third hand: Reflections on art, art therapy, and society at large. American Journal of Art Therapy, 24, 71–86.
Kramer, E. (2000/2001). Art as Therapy: Collected Papers (L. A. Gerity, ed./foreword). London: Jessica Kingsley.
Kramer, E. & Schehr, J. (2000). An art therapy evaluation session for children. In Art as Therapy: Collected Papers.
Gerity, L. & Anand, S. A. (eds.) (2017). The Legacy of Edith Kramer: A Multifaceted View. Routledge.

[uncertain]: Kramer's own books are known here only through quotation; the five categories rest on quotations in Morrison 2013 and Thompson 2012; particular forms of art in the service of defence (copying, tracing); session length, frequency and phase criteria; group procedure details; validity data for the evaluation session.

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