With respect to treating depression, the creative therapies provide a viable alternative to the

traditional talk therapies and as McGlasson (2012) asserted, the creative approaches can be less
intimidating, particularly when working with children and adolescents. Additionally, the creative
therapies lend themselves well to fostering support and trust. The first section of the book will
focus on the use of art as an approach to working with depressed clients. Psychologists have long
explored the link between depression and cre-ativity (Verhaeghen, Joormann & Allman, 2014).
"Creativity is a multifac-eted construct with many determinants and correlates situated both
inside and outside the individual" (Verhaeghen et al., 2014, p. 211). Major depres-sion has
afflicted many creative individualsfamous artists, musicians, and writers alike, such as
William Blake, Edgar Allen Poe, Sylvia Plath, Robed Schumann, Ludwig van Beethoven, and
Charles Mingus to name a few (Verhaeghen et al., 2014). Dark Side of Creativity briefly explores
the art of famous painters plagued with bouts of depression and mental illness, such as Munch,
van Gogh, Gauguin, Picasso, O'Keeffe, and more (CNN, 2014). Based on research and these
famous case examples, creative behavior is associated with a higher risk of depression
(Verhaeghen et al., 2014). Even famous psy-chologists such as Freud and Jung suffered
depressive episodes. Jung was noted for working through his dark periods by painting. Jung
wrote, "The biographies of great artists make it abundantly clear that the creative urge is often so
imperious that it battens onto their humanity and yokes everything to the service of the work,
even at the cost of ordinary health and human happiness" (as cited on HighExistence.com, 2014,
paragraph 9).
Depression in Women According to the National Institute of Mental Health (n.d.), women
are 70 percent more likely to experience depression than are men, with one in eight women
struggling with at least one major depression in their life. The onset of depression occurs around
age 32. There are many factors that can contribute to a woman's developing depression. These
factors include genet-ics, biology, the life cycle, hormones, interpersonal factors, certain psychological and personality characteristics, and abuse and oppression (National Alliance of Mental
Health, 2009; National Institute of Mental Health, n.d.). Biologically, hormones can trigger
depressive symptoms that occur in the premenstrual, postpartum, and perimenopausal periods
(Payne, 2003). Premenstrual dysphoric disorder (PMDD) can predispose some women to
developing a mood disorder, like depression. Yonkers (1997) explained that women with PMDD
have a lifetime history of other mood disorders, with rates ranging from 30 to 70 percent
simultaneously. Women are vulnerable to postpartum depression after giving birth, with 10 to 15
percent experienc-ing this type of depression. Hormonal and physical changes occur and a
woman may become overwhelmed with the new responsibility of caring for a newborn. Women
can develop depression when experiencing menopause because of hormonal fluctuations. In
addition to these types of depression, women may experience depres-sion from additional social
roles causing them stress, such as work, home and family responsibilities, aging parents, and
relationship strains. Kendler and Gardner (2014) found that neuroticism, divorce, marital
satisfaction, lack of social support, and lack of parental warmth or love were risk factors causing
women to experience depression. Further, Nolen-Hoeksema (2001) identi-fied social inducing
factors that increase the likelihood that a woman will develop depression. She explained that
women are more likely to be victims of sexual abuse than are men, and they become trapped as a
continuous caregiver because they are caring for their children and aging parents, feel-ing

sandwiched. Furthermore, Nolen-Hoeksema (2011) argued that women could experience

depression because they have a greater chance of not being equal in a heterosexual relationship
because the male will make the life-changing decisions. The social roles women encounter may
not always cause a woman to experience depression. It is important to understand that researchers are unclear why some women who face enormous challenges do not develop
depression while others facing the same challenges do develop depression (National Institute of
Mental Health, n.d.).
Depression in Men Because men have a lower chance of experiencing depression, this disorder is usually associated with women. Addis and Mahalik (2003) attribute this to men denying
the illness or avoiding personal health care providers to maintain their masculinity. However, the
National Institute of Mental Health (n.d.) noted that six million American men have depression
yearly. Risk fac-tors causing men to experience depression can include childhood sexual abuse,
drug abuse, past history of major depression, conduct disorder, finan-cial trouble, stress at work,
and legal issues (Kendler & Gardner, 2014). Men rarely talk about feeling depressed but rather
talk about their emo-tional problems as stress. From a young age, males are taught to be independent, competitive, and patient and to have self-control. Therefore, men do not show the
typical signs of depression, such as crying or feeling sad (Ogrodniczuk & Oliffe, 2011). Signs of
depression in men can include irri-tability; anger; hostility; abusive behavior; risk taking;
aggression; substance abuse; and escaping behavior, such as spending more time at work than
with the family. Another escaping behavior is when a man becomes overly semi-ally active by
having an extramarital affair or brief emotionless sexual en-counters (Brownhill, Wilhelm,
Barclay & Schmied, 2005). A man may be-have this way to avoid intimacy in relationships that
may reveal his vulner-ability. Therefore, men use acting-out symptoms as a mask to avoid
dealing with feelings of depression.
INTRODUCTION
Reflecting our inner images of self and others, metaphors are like mirrors (Kopp, 1995).
Metaphoric imagery may be a key that unlocks new pos-sibilities for self-created insight and
change (Ronen & Rosenbaum, 1998). The title of this work stems from a power metaphor for
depressionthe black dog. "Metaphors give us a new way of looking at things, and they deal
with those 'unconscious' processes of association, image, emotion, memory, and analytical
thought" (Mays, 1990, p. 427). The information about this metaphor and history came from Paul
Foley (2014) of the Black Dog Institute. It is said that Winston Churchill and Abraham Lincoln
referred to their depression as "the black dog." Samuel Johnson became famous for the use of
this phrase that he shared in a letter to a friend: "What will you do to keep away the black dog
that worries you at home" (as cited in Foley, 2014, p. 7). Going back further, the black dog
metaphor and its association with depression were found in the works of Horace and Apollonius.
For instance, I-Iorace describes this metaphor as fol-lows: "No company's more hateful than your
own / You dodge and give yourself the slip; you seek / In bed or in your cups from care to sneak /
In vain: the black dog follows you and hangs / Close on your flying skirts with hungry fangs"
(Horace, as cited in Foley, 2014, p. 3). The "dark hound" is an archetypal object of fear: "an ever
present com-panion, lurking in the shadows just out of sight, growling, vaguely menacing,

always on the alert; sinister and unpredictable, capable of overwhelming you at any moment"
(Foley, 2014, p. 1). Although there are many negative con-notations for the metaphor of black
dog, Foley notes that black dogs were highly prized by the Romans as guard dogs that had
healing power. "In this sense, it is a metaphor of hope: the 'black dog' may be to some extent a
friend, but he is a bad friend; and as with anyone who renders life miserable and restricts
interactions and possibilities, he needs to be left behind, no mat-ter how persistent his pursuit"
(Foley, 2014, p. 14). In this chapter, we will dis-cuss the relationship of creativity to depression.
Although there is a link between the two, creative art therapists can use their traditions to help
clients face the black dog and emerge from depression. The International Encyclopedia of
Depression (Ingram, 2009) provides an overview about the history of depression. In the 1800s,
mental afflictions were known as mania (furious madness), melancholia (partial madness),
dementia (weakened psychological resources and behavioral incapacities), and phren-sy leading
to mental disorganization in the brain. During the first half of the nineteenth century, alienists
wanted to know if mental afflictions existed that are a primary disorder of intellectual, emotional,
or willingness functions. Esquirol, a French psychiatrist, developed the term lypemania that he
be-lieved was a primary disorder of mood (Ingram, 2009). By the middle of the nineteenth
century, the term lypemania was replaced with the word depres-sion. Depression was first called
mental depression but the word mental was removed by the 1880s when the term was removed
from being used in heart physiology. The terms depression and melancholia were used during
this cen-tury, with depression being a more severe disorder. A German psychiatrist, Kraepelin,
associated depression with mania (Ingram, 2009). Depression was viewed as a form of madness
(psychosis) by the early twentieth century (Ingram, 2009). However, clinical experts did not
believe depression meant the patient was mad. European alienists, Gillespie and McCurdy
constructed minor, neurotic, or reactive depression. The debate began a decade later between
those who believed depression was unimodal and bimodal. Although the debate was never
resolved, the unimodal per-spective was identified as more convenient because of the biological
model of depression (Ingram, 2009). Mental health professionals have a better understanding
about what depression is. "Depressionliterally, the state of being pushed downis com-monly
used
to
refer
to
emotional
states
of
sadness,
despair,
numbness/
emptiness/deadness/hopelessness, and related "down" or "blue" moods that often involve a
depletion of normal levels of energy, interest, mental focus, pleasure, social engagement, and
appetite" (Ingram, 2009, 112). Each person has experienced sadness, but this sadness is often
short-lived. Depression impacts people differently because it interferes with daily life and can
last for a long period of time. Depression can occur when a person experiences be-reavement,
loses a job, is experiencing a divorce or breakup, or has been diagnosed with a serious illness.
Further, Ingram (2009) notes that depression can also occur when a person did not meet a major
life goal. The way depres-sion manifests will depend on the person's age and perhaps, gender.

ETC
Kinesthetic/Sensory Level The kinesthetic/sensory level of the ETC corresponds to the
most basic ways in which information is taken in and processed. Infants and toddlers learn

through motor and sensory channels; conscious higher-level cortical functioning is not necessary
for effective intake and use of this type of infor-mation (Lusebrink, 1990). At this level of the
ETC, art media frequently are used as passive facilitators of action and sensation. The final art
product often is not as important as the process involved in making movement and stimu-lating
the senses. Therapeutic use of the kinesthetic component can involve helping patients use
movement to release pent-up energy or become more in tune with the healing rhythms of their
lives. The sensory component can be used to heighten awareness and memory for external
sensation or to create healing inner sensations. What can emerge from therapeutic work on this
level is patient movement to the perceptual/affective level, with more open access to emotions
and use of formal elements of visual expression to under-stand life challenges and advantages.
Patients suffering from depression can benefit from therapeutic work on the kinesthetic/sensory
level of the ETC. Fenton (2008) demonstrated how patients with depression accompanying
chronic illness could use forger paint in a kinesthetic manner to express the emotional turmoil
associated with life-threatening illness. Patients might also benefit from the release of pent-up
muscular tension and reintegration of healing bodily rhythms that can occur when using resistive
media such as clay (Sholt & Gavron, 2006). Hannemann (2006) discussed the use of art therapy
in a sensory manner with elderly de-pressed patients. Additionally, Hannemann hypothesized
that exciting the senses stirred emotional responding that in turn ignited cognitive processes, all
of which had been dampened during the course of depression. This de-scription of reintegration
sounds very much like moving up the develop-mental hierarchy of the ETC and was echoed by
Hass-Cohen (2008), who stated that the use of art media and processes in a sensory fashion could
encourage "vertical integration of brain functioning" (p. 35). Jensen (1997) and Stewart (2006)
suggested that patients in assisted-living facilities suffer from sensory deprivation that can
exacerbate depression and that the many sensory aspects of art therapy not only help to alleviate
sensory deprivation, but also help to decrease patient depression.
Perceptual/Affective Level The use of formal elements of visual expression to organize,
elucidate, and integrate information is emphasized on the perceptual pole of the perceptual/affective level of the ETC. With guidance from the art therapist, patients can be helped to
explore their images visually from an objective viewpoint and an emphasis on the formal
elements, such as line, shape, color, and space. Work with the perceptual component helps
patients inte-grate new images of themselves and their worlds perceptually in a non-threatening
manner (Riley [1979] as cited in Lusebrink, 1990). On the oppo-site pole of this level, learning
about and integrating emotion is central to work with the affective component of the ETC.
Therapeutic work can focus on helping patients identify emotions, discriminate among them,
express emotions appropriately, and soothe emotions when necessary (Hinz, 2009). Aiding
patients in developing an emotional vocabulary that can be easily accessed and readily employed
is carried out through work on the affective component of the ETC. Therapeutic work with the
perceptual/affective level can lead to a new view of the self, which prompts integration of this
new information on the cognitive/symbolic level. Researchers have noted that depressed patients
commonly use dark col-on to express negative mood states (Gantt & Talbone, 1998; Hanes,
2008; Malchiodi, 2007). Patients have described the experience of art therapy-assisted recovery
from depression as "a sense of emerging from darkness" (Fenton, 2008, p. 139). Indeed, the
prescription and manipulation of color and light in painting can aid emotional flow and

expression when patients become mired in darkness and sadness (Bar-Sela et al., 2007). Patients
suffering from depression often are overwhelmed by emotion: feeling sadness, experiencing
crying spells, and judging themselves guilty and worthless. When emotions are experienced as
unmanageable, the art therapist can suggest a focus on the formal elements of visual expression
and move away from the affective side toward the perceptual pole. Fenton (2008) mentioned that
one depressed patient used attention to the formal elements of landscape paintings as a method of
containing her distress. Muri (2007) discussed the merits of self-portraiture as a means of selfexploration and self-growth from depression. Muri warned, however, that this sort of work was
not helpful with patients who obsessed about their physical faults and char-acter flaws.
Malchiodi (2007) stated that mandala drawings, due to their cir-cular structure, can help contain
the sometimes overpowering sadness expe-rienced in depression. Malchiodi hypothesized that
the circular form of the drawing helped provide focus, structure, and stability to otherwise
chaotical-ly experienced emotions.
Cognitive/Symbolic Level The most complex forms of information processing and image
formation occur on the cognitive/symbolic level of the ETC. The cognitive component
encompasses brain functioning that has been referred to as "executive func-tioning" and includes
visual spatial sequencing and ordering, planning abili-ties, concept formation, abstraction, word
inclusion, and problem solving (Hinz, 2009; Lusebrink, 1990). The symbolic pole of this level
emphasizes universal and personal processing of information to form meaningful sym-bolic
expressions. The healing function of work with the cognitive compo-nent involves helping
patients generalize from their experiences, develop problem-solving skills, and integrate
meaningful representations of their experiences. Healing work with the symbolic component
encompasses the formation and mastery of personal symbols that frequently involves the integration of disowned or split off parts of the self. What can emerge from work on the
cognitive/symbolic level is the ability to embrace and integrate all parts of the self in meaningful
ways, perhaps leading to self-actualization through creative activity (Hinz, 2009). Depression is
a disorder characterized by constricted thinking reflected in the impoverished images often
produced by patients suffering from de-pression (Hanieh & Walker, 2007; Thorne, 2011;
Wadeson, 1980). Depres-sion constricts self-perception and robs patients of the ability to see the
world or their futures in a positive light. Work on the cognitive/symbolic level can be an essential
part of the treatment of depression, emphasizing the integra-tion of new and more positive views
of the self, the world, and the future. Hanes (2008) discussed how the symbolism contained in
road drawings can provide support in current circumstances as well as hope for the future to suicidal prison inmates. Holmes, Lang, and Shah (2009) demonstrated that imagery plays a more
important role than do verbal descriptions in chang-ing cognitive distortions leading to and
maintaining depressive states. Al-though the authors focused on mental images, their findings
might general-ize to concrete images produced by patients in art therapy.
Creative Level
As was mentioned previously, the creative level of the ETC is conceived of as an
overarching phenomenon. Creativity can characterize an experience involving one component of
the ETC, or it can involve the integration of functioning on many levels. As described by

Lusebrink (1990), creative activ-ity is characterized by feelings of closure, satisfaction, and joy.
Through cre-ative activity, patients gain insight into themselves and are spurred toward
psychological growth and self-actualization. Many authors have discussed ways that creative
activity aids depressed patients. Creative activity gives a renewed sense of purpose or meaning
(Fenton, 2008), aids in spiritual recon-nection (Lloyd, Wong & Petchkovsky, 2007), increases
connectedness and hope (Drapeau & Kronish, 2007; Hannemann, 2006), lifts the "darkness" and
increase the quality of life (Drapeau & Kronish, 2007), and introduces new and positive life
themes (Hanieh & Walker, 2007). In her work with de-pressed elderly patients, Kates (2008)
noted that involvement in art therapy changed patient concentration on lower level needs, such as
food and safety matters, to a focus on higher-level needs such as belonging and love. She
concluded that art therapy was an effective treatment for depression because it facilitated the
rewarding integration of emotion about both past and pre-sent in the expression and satisfaction
of higher level needs. Viewing patient participation in art therapy within framework of the ETC
encourages understanding of the therapeutic processes from a holistic point of view that includes
functioning on diverse levels. Assessment within the structure of the ETC involves discovering
preferred, overused, under-used, and blocked functions that may be augmented or controlled to
balance functioning and relieve depressive symptoms. As was mentioned earlier, wellfunctioning individuals are able to access input and process information with all components of
the ETC.
The ETC can provide a comprehensive theoretical and practical struc-ture for approaching
the assessment and treatment of depressive disorders. Assessment following the structure of the
ETC can take into account the myriad presentations and underlying issues associated with
depression and suggest an individualized therapeutic approach for each patient (Hinz, 2009).
Given the different and sometimes confusing ways that patients can present with depression, the
ETC assists art therapists in making decisions about entry points for therapeutic involvement and
provides rationales for how to intervene. In addition, patients can be actively involved in making
treatment decisions, understanding not only the general rationale behind art therapy, but also why
particular art media and processes are used. Thus, using the structure of the ETC, art therapists
and patients can participate together in formulating powerful, individualized treatments for the
diverse and varied array of symptoms that is called depression.
ASSESSMENT AND TREATMENT PLANNING WITH THE ETC
Assessment within the context of the ETC requires that patients be al-lowed free access to
art media to perform at least three free art tasks. These art tasks can be done in a single session or
over the course of at least three images. Freedom of choice is necessary to allow patients to
demonstrate their familiarity and comfort with a range of materials. Table 3-1 contains a list of
elements to be attended to in art assessment that provide information about preferred, overused,
neglected, or blocked ETC processes. Media prefer-ence, including strength of that preference,
media properties, and risk taking all can point to an ETC component. Consistent choice of freely
flowing media like watercolor paint or chalk pastels likely indicates a preference for functioning
with the affective component of the ETC. Repeated selection of resistive media such as collage
materials or pencil is associated with a pref-erence for the cognitive component and perhaps

resistance to affective func-tioning (Hinz, 2009; Lusebrink, 1990). Patients' manner of

interaction with the chosen media also provides clues as to their preferred component(s). In
assessing manner of interaction, the art therapist carefully notes responses to boundaries and
limits, commitment and frustration tolerance, level of energy, and coping skills demonstrated
during the art activities. Persons suffering from depression are likely to show constricted themes
(Hanieh & Walker, 2007; Thorne, 2011; Wadeson, 1980) and small images placed well within the
boundaries of the paper (Gantt & Talbone, 1998). In addition, one would expect to see low levels
of energy and commitment to the art-making process (Gantt & Talbone, 1998; Hinz, 2009;
Wadeson, 1980). Stylistic elements from the final art product also provide information about
patients' overused or blocked components. Research has indicated that the images of persons
suffering from depression can demon-strate dark colors or the absence of color.
The stigma in seeking treatment altogether is often addressed by creative therapies,
because creative therapies do not carry the associations of psychi-atry or medical model as
strongly as some other treatments do. In one com-munity-based study, it was found that
accessing information and referrals for depression via a community arts program was effective
(Chung et al., 2009). Depressed patients generally have a negative view of themselves and their
art capabilities. "In the initial difficulties in working with severely depressed patients, usually the
objection to art production embodies a projective expec-tationthat my judgment of the patient
will be as harsh as the patient's judg-ment of him or herself" (Wadeson, 1980, p. 49). In reporting
a positive out-come of dance with clients exhibiting geriatric depression, the authors ob-serve
that the use of dance therapy and dancing "does not have the stigma of a mental health
intervention and could appeal to many who would other-wise not seek treatment for their
depression" (Habousch, Floyd, Caron, LaSota & Alvarez, 2006, p. 96). Maintaining gains after
treatment of depression is also an issue. In a study of this by Ellison, Greenberg, Goldman, and
Angus (2009), the use of experiential techniques was key in maintaining gains; thus, creative
therapies can be postulated as essential given the experiential nature of all the creative therapies.
Similarly, media, such as in this case collage, are used in a wide variety of applications, so the
goal is to connect the specific aspects that make it heal-ing for depression, not simply using these
techniques as a one size fits all but to tailor the creative choices the therapist makes and use them
to benefit the clients. Helen Landgarten's work (1993) with collage forms the backdrop and
foundation for much of the use of collage by therapists. Her work is a neces-sary precursor to
any use of collage and provides good parameters that ther-apists continue to reference in current
literature. For example, collage imag-ery, although specifically suited to use with diverse groups,
still carries a man-date to consider the types of images being offered and to provide a broad
range of, as well as culturally appropriate, images that clients can connect to (Garrison, 2006). A
review of the use of collage pointed to some inconsis-tencies of interpretation (Aoki, 2000) and
Sumizawa (2003) provides a case example of collage helping with overall sociality and positive
feelings in a long-term case that included feelings of depression.
Generally, however, in the professional therapeutic literature, collage is not specifically
identified in relation to depression. Ziller's discussion of the use of photo-self-narratives is not
pure collage using found magazine images, but the approach mirrors magazine photo collage
directly and essentially focuses it further. This is de-monstrated in the second case I will discuss

below. "By recording individual adaptation processes, it helps us to become more aware of the
individual's life struggles and the genius of their personal approaches which wondrously reestablish control over a field of multifarious life forces" (Ziller, 2000, p. 276).