Adam Blatner, M.D.

(First posted in 2002; Re-posted, November 18, 2004)

Abstract: There are a number of dimensions of healing involved in the creative arts therapies, but one that I want to emphasize is the power of improvisation and how that generates a receptivity to and increased sense of connection with the creative subconscious mind.

Over the past half century, the creative arts have gradually become recognized as vehicles for healing in psychiatric treatment. Creative arts therapists of various kinds have developed their own organizations, so there are now national associations of art, music, dance, poetry, and drama therapists. At present, most hospitals, day treatment centers, and outpatient clinics have one or more creative arts or "expressive" therapists. (Expressive therapists tend to use two or more creative arts media in synergy.) They offer an experiential approach that can involving clients individually, in families, or in groups, and this approach in turn may be part of a multi-modal, integrative treatment plan.

Historic Perspective

The creative arts have been used as vehicles for healing throughout history. Early Greek and Roman physicians wrote about the healing effects of music. Before that, and even today in many cultures, dances, ritual dramas, and/or the creation and use of sacred diagrams were intrinsic to the medical traditions of non-technological cultures. It would be conceited to dismiss such practices as merely "primitive" because their use of suggestion entails principles which, though unrecognized by modern "science," may be more effective in treating some illnesses than what our modern medical system has to offer.

In the nineteenth century in Europe and America, more humane forms of hospital treatment for the mentally ill used the arts and crafts when possible. The idea was to structure the patients' time, divert their attention, and for some, even to acquire a few leisure or vocational skills. Achievement in painting, making music, or putting on small plays offered opportunities for the patients to develop a sense of competence in at least one aspect of their lives.

In the early twentieth century, the development of psychoanalysis helped psychiatrists to go beyond the use of medication and other physical treatments and to work with what patients thought and felt. By the 1920s, several professionals noted that the art of patients could be used as the subject of analysis, for the symbolic productions offered clues to the hidden feelings.

By the mid-1940s, other approaches were being explored. J.L. Moreno (1889-1974), a psychiatrist who immigrated from Vienna twenty years earlier, was promoting his method of psychodrama. He was able to influence the superintendent of Washington D.C.'s St. Elizabeth's Hospital to build a special stage and begin a program for training and treatment using this powerful and multi-dimensional treatment modality. Anti-psychotic medicines had not yet been introduced, and so the field was more open to original approaches which might be able to reach into the inner world of the chronically mentally ill. In this setting, then, Marian Chace introduced dance and movement therapy, and in so doing found she could mobilize patients who had been withdrawn and resistant to other types of treatment. Soon, music therapists, "biblio-therapists" (using recommended readings as stimuli for discussion), and other expressive media were added.

In the 1960s, drama and poetry therapy were developed. At first, drama therapy was more theatrical, entailing the production of rehearsed and scripted plays. By the 1970s, however, techniques from improvisational theater games, psychodrama, and encounter group action techniques were used so much that the field became far more dynamic and capable of addressing the specific problems of patients.

The creative arts and especially psychodrama influenced many of the new therapies which were being developed, including family therapy, Gestalt therapy,  Transactional Analysis, and others. Many of the basic ideas of the encounter group had been originated by Moreno fifty years earlier. Moreno was a fascinating character who pioneered the field of group psychotherapy, improvisational theater, role playing in education, techniques of applied sociology, and a philosophy of therapy which emphasized the importance of people discovering and utilizing their capacity for creativity.

Psychodrama is a method of psychotherapy in which patients are helped to enact key issues in their lives, role playing those situations, bringing out the unspoken feelings, and exploring alternative solutions. This approach is based on the principle that spontaneous action can generate creativity and insight even more effectively than the free association technique in psychoanalysis. (Psychodramatists are primarily psychotherapists who utilize this group of principles and techniques, while drama therapists are primarily creative arts therapists with backgrounds in the field of theatre.)

The other arts therapies dealt with the artistic activities of patients in several ways. Edith Kramer, an eminent art therapist, believed that making the imagery artistic would "sublimate" the feelings and heal the inner world by helping the patient transform personal experiences into a beautiful or poignant expression of the human condition. Margaret Naumberg, perhaps the major pioneer in the field of art therapy, had a different approach: she allowed the patients' spontaneous expressions to become the objects of self-reflection, which would lead to self-understanding. Others combined both approaches. There has been a similar diversity of emphasis in the other arts therapists. Some dance therapists emphasize self-expression and movement apart from any need to orchestrate what might be called a "dance." One poetry therapist might emphasize the reading and interpretation of poetry written by selected poets, while others encourage patients to write their own poetry and share it with others in the group.

Although arts therapies can be of value in the healing process in many ways, one of the most promising recent approaches involves using the creative arts as vehicles for cultivating the experience of spontaneity itself, and from this, discovering the depths and richness of the unconscious.

Evolving Concepts of the Unconscious

Concepts regarding the nature of the unconscious have evolved. The earlier, classically psychoanalytic view was that the unconscious consisted of thoughts or feelings which were essentially unacceptable to the conscious mind, and so buried (or "repressed"). Yet as knowledge of psychology expanded, it became clear that the unconscious mind included far more than what was merely repressed. The human mind has extremely subtle and powerful instinctual patterning tendencies (called "archetypes" by the psychiatrist Carl G. Jung), and these have potentials which go far beyond the Freudian ideas of sex and aggression, including spiritual inclinations, a desire for meaning, and a tendency to seek balance among different aspects of the mind.

In other words, the unconscious is not merely a repository of unpleasant psychic material, but also, and far more importantly, a source of tremendous potentials for creativity and inspiration. Ideas spontaneously arise from the unconscious, not only in the form of visual images, but also in voices, melodies, gestures and postures, and whole complexes of scenes. Many great dramatists, writers, and poets claim that some of their best work was written as if someone else had dictated it, or as if the material wrote itself. They are describing the power of spontaneity when it is expressed through a highly disciplined, yet receptive mind.

From this viewpoint, a well-rounded life involves an integration of this natural background of temperamental inclinations, talents, strengths, weaknesses, interests, and imagery. Such variables reflect the figurative "hand of cards" each person is "dealt" in life, and the process of individuation consists of creatively synthesizing these qualities with the realities of the environment. I think of the unconscious as a temperamental, inarticulate, artistic genius and the conscious mind as the agent whose challenge is helping this artist to express his or her vision fully and to find the most appreciative audience. The artist and the agent must be friends and collaborators, but neither should dominate the other.

Applied to psychotherapy, this principle refers to the task of increasing communication between the conscious and unconscious dimensions of being. The arts offer various channels for this communication, different vehicles for accessing those subtle intuitions, images, associations, and feelings which are easily suppressed and over-ridden by conscious attitudes and familial or cultural conditioning. The arts help people to find their more authentic preferences and forms of expression. Creative arts therapies facilitate healing in at least four ways: (1) through self-expression, (2) by exercising the mind, (3) by deepening patients' self-concept, and (4) by establishing a collaborative relationship with the unconscious.

The Value of Self-Expression

One of the tasks of psychotherapy is to reduce confusion. When ideas and feelings swirl through the mind, they tend to blur, overlap, and be contaminated by doubts, fears, and the ongoing desire to avoid having to think about any of it. The result is a varying degree of confusion. It's as if several different parts of the self are arguing with each other, yet they interrupt each other and raise their voices emotionally while another part of the self covers the ears and screams "I can't--and don't want to--hear a word you're saying!!" By bringing this "mess" out into the light, putting it on the table where others can look at it, self-expression enables the patient to discriminate their useful ideas from the less rational and self-deceiving beliefs and patterns of thinking (Blatner, 2000, Chapter 10).

Yet some feelings are so covered over by defenses and rationalizations that they can't be expressed clearly in mere words. The arts use other, less familiar dimensions of experience, circumventing some of those defenses by making a symbolic compromise: The unconscious will express itself and allow itself to be perceived by the conscious, if it doesn't have to make explicit the shameful or uncomfortable ideas, but rather can express them in metaphoric form, such as in art, music, song, dance, poetry, or in a role of an imaginary character.

It's only partly true that the mind tends to disguise the inner feelings which it cannot permit itself to face; it's also true that some of the things that the unconscious needs to communicate to the conscious mind are paradoxical, many-dimensional, and are better communicated in the poetic, dream-like forms of art; indeed, they couldn't be expressed fully in mere words. Dreams are often strikingly direct demonstrations of the present state of some aspect of the unconscious, and require only a little poetic elaboration and a receptive attitude to understand their messages.

However, the symbols which emerge in dreams or fantasies can also become sources of ongoing guidance and creativity. A particularly vivid figure, whether it be in the form of a person, animal, or plant, can be "personified," that is, treated as if it were a real person with feelings and purposes of its own. Discovering what this character has to say is achieved through engaging in an imagined dialogue. This interaction may be explored using what Jung called "active imagination," or the encounter can be made even more concrete and vivid using the psychodramatic technique of playing both roles--the external conscious self interviews the imagined figure sitting opposite in a chair. Once the person has become sensitive to the ongoing messages from that internal source, the unconscious becomes a guide who will warn, remind, encourage, or reflect, depending on what is needed in the moment.

A profound psychological dynamic is operating here: People can discover that there are aspects of what they imagine which seem not to be part of their "self" at all, but rather seem to be coming from something "other than" or "outside" themselves. Such aspects often carry a sense of vivid reality and spiritual power, and may be experienced as God, Jesus, one of the saints. This potential for experiencing the inner source of guidance as if it were from "elsewhere" has always been part of the human psyche; in other cultures, these "archetypal images" came in forms of totem animals, Greek gods, ancestors, or angelic figures. The modern Alcoholics Anonymous Twelve Step tradition emphasizes the need to surrender to this otherness, specifically as one's higher power or God as the individual understands Him. The point here is that through creative productions in various arts media, people can be helped to discover certain symbols which can serve as ongoing reminders of one's personal "higher self."

Another value of the symbols expressed in the course of the creative arts therapies is that they offer a vehicle for expressing one's individual differences. The goal of helping each person to be creatively expressive changes the nature of the group process. What might be considered "weird" or eccentric in a purely verbal form of group therapy becomes reframed as "original" or "interesting." Thus, in terms of group dynamics, the norms which tend to enforce conformity are neutralized, and a new set of norms emerge which validate individuality, reduces the group member's sense of personal isolation and develops group cohesion.

Strengthening the Mind

Utilizing the arts media requires an exercise of the imagination and intuition in conjunction with the rational mental functions. Two types of skill are especially notable: "role distance" and shifting points of view. Both of these activities in turn support a host of other "ego functions."

Role distance is the term used to describe the way an actor can mentally "step back" and re-evaluate how effectively the part is being played; in other words, it describes the "distance" between the person and the performance. Such a behavior requires a prior assumption that one's performance may be improved. Too many people live their lives with an implicit attitude that there are no alternatives. It is as if they are immersed in their roles, they lack role distance, and so they cannot perceive the errors implicit in their position. On stage, characters who pursue a line of behavior which the audience can see to be self-deceptive or self-defeating are considered fools. Yet the nature of the arts is such that an implied value is that the artist continues to reflect on and improve an artistic skill. This attitude should also be applied to one's everyday life.

In analytically-oriented psychotherapy, the equivalent term for role distance is the "observing ego." One of the goals is to develop this capacity to examine one's own behaviors and the underlying assumptions which influence it. The arts are particularly helpful because they remind the patient that many aspects of one's feelings are symbolic, and that learning to think in this more poetic fashion allows one a greater depth of vision.

In addition to shifting points of view between the literal and the symbolic, patients are helped to shift between attention to the contents of one's consciousness, the thoughts and concrete expressions of feelings on paper, in music, dance, or action; and the process of thinking, noticing or reflecting on how one was able to access or block his or her creative potential. Shifting roles between a high degree of involvement and a more reflective position--exercising role distance, in other words-- is an exercise in mental flexibility.

Another type of shifting roles occurs in role playing when clients are asked to put themselves in the situation of another person in their lives--a spouse, employer, child, co-worker, etc. This technique of "role-reversal" operationalizes the Golden Rule; instead of simply intellectually thinking of what might be nice for another person, the client learns to engage the imagination and intuition more fully in the process of role taking. This technique is a good way to build empathic skills and to reduce egocentricity.

A third shift which employs the vehicles of the creative arts is that of utilizing the imaginal realm, the reality of wishes, hopes, fears, dreams--a reality which in many ways is more "real" to the actual life experience of most people than the facts in external, "objective" reality. There is a great deal of mind expansion associated with the conscious use of symbolic activities. Many conflicts are partly based on subtle limitations of pride, status, and other meanings ascribed to different situations; these then can be resolved by altering the meanings through viewing those experiences from a different perspective.

For example, the experience of grief offers no "reasonable" resolution. A loss is a loss, and there is nothing to be done. Yet, using the arts, loss can be transformed into one of the burdens of life, something that one shares with the rest of humanity, an occasion for receiving support, for being thought of as courageous and feeling, and, in short, for consolidating one's bonds with others yet living. Poetry, dance, art, music, and drama are channels for making the universal drama of death more a part of life.

One technique derived from psychodrama can at times be used to help a person "work through" the grief of a major loss. The bereaved role plays an encounter with an imagined presence of the person who has died or moved away. Feelings are helped to be expressed directly, and, through changing parts and taking the role of the one who has died, the bereaved may engage in a dialogue that in actuality may never have--or perhaps never even could have occurred. This exercise becomes a source of rich imagery which functions as an anchor for taking into the depths of mind the healing significance of what memories were shared and the meanings of those shared experiences for both parties.

The kind of playing referred to in the course of role playing involves not frivolousness but rather a wider range of creative possibility. People with problems tend to become overly serious not only in the sense of experiencing genuine distress, but also in becoming more fixated in their own habitual ways of thinking, behaving, and feeling. They intensify whatever tendencies they have towards intellectualization and defensiveness, and thus become more resistant to the mind-expanding task of psychotherapy. The arts offer vehicles which are relatively novel in requiring participants to express themselves non-verbally, and this then circumvents some of those subconscious habits of defensiveness. Furthermore, the challenge associated with this novelty also serves as an intrinsic motivation, an element of playful pleasure mixed in with the sometimes painful struggle towards self-awareness.


In summary, the arts therapies, especially if utilized with an emphasis on spontaneity, offer a number of avenues to insight and healing. They offer structured activities that allow for creative expression within a realistic setting, they allow for symbolic expression of emotions which serve as a form of catharsis, and they help the individual develop a greater connection with his or her subconscious mind. With guidance, this connection can be turned to a more positive process of integration and self-acceptance.


Blatner, A. (2000). Foundations of Psychodrama (4th ed., updated and revised). New York: Springer.

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