2 Can School-Based Art Therapy Programs Improve Access to Counselling for Young People?

Michelle Kotzas


Living through a global pandemic has identified an increase in mental health vulnerabilities and associated social, cultural, and economic concerns. Whilst there have been some recent positive changes in the way people view mental health support and wellbeing, young people are even more less likely to seek support through counselling services, and when they do, express dissatisfaction with the process. The World Health Organisation and other organisations like the Australian Bureau of Statistics and Mission Australia all report several barriers to young people, especially, seeking professional support for their mental health. Whether it is due to limited verbal access to emotional expression, access to resources, trust in the services, isolation or stigmatisation, a lack of early intervention or mental health diagnosis can have long term effects on a person. School-based Art Therapy programs may offer a solution to promoting access and a form of communication that engages young people in therapeutic support. This chronological review examines the foundational work in schools providing art therapy to students in the mid-twentieth century, through to current investigations into the efficacy of expressive arts therapy in helping alleviate aggressive behaviours, trauma, depression, and anxiety, as an accredited allied health service. As such, this review aims to identify if school-based arts therapy programs could be implemented to overcome barriers for young people accessing counselling services.

Keywords: mental health disorders, art therapy, interdisciplinary, collaborative, efficacy


Since the COVID pandemic, the last three years has seen an increase in people, young and old, struggling to maintain their mental health. Over the period 2020 to 2021, the Australian Bureau of Statistics reports, “Over two in five Australians aged 16-85 years experienced a mental disorder at some time in their life.” (ABS, 2022), noting that anxiety was the most identified mental disorder for young people. Furthermore, the ABS (2022) reports that two in five people between the ages of 16 and 24, had a mental disorder. However, the 2020-2021 report goes on to show that not even half of these people between the ages of 16-34 saw a health professional. Mission Australia’s Youth Survey for 2021 further reports that only 21.9 % of young people aged between 15-19 years of age would access a school counsellor (Mission Australia, 2022). Youth show the greatest increase in reporting anxious and depressive conditions, yet they appear to be the most resistant to seeking support from free and accessible school counselling services. Researchers have investigated the barriers adolescents encounter accessing counselling services in more recent years, noting difficulty with accessing the language to speak about their emotions, as well as the stigmas associated with speaking to a stranger about their problems (Liu et al., 2022). These barriers warrant investigation into effective alternative therapeutic experiences for young people that promote and encourage increased counselling access in a school setting.

Current Barriers and Burdens

The World Health Organisation Mental Health Report (2022) determined that approximately one in eight people in the world live with a mental disorder (p. xv). Despite this, there remain barriers that prevent people from accessing mental health support, indicating: poor quality of services, low levels of health literacy in mental health, and stigma and discrimination. In many places, formal mental health services do not exist. Even when they are available, they are often inaccessible or unaffordable. People will often choose to suffer mental distress without relief rather than risk the discrimination and ostracisation that comes with accessing mental health servicesPeople will often choose to suffer mental distress without relief rather than risk the discrimination and ostracisation that comes with accessing mental health services. (p. xv).

This suggests that despite the reinforcing media spotlighting mental health awareness and seeking support following the global impact of COVID lockdowns, people still stigmatise psychotherapy and mental illness. In their research into public and self-stigma and help-seeking attitudes, Yu et al., (2022) identified that there is a perception that the public view people seeking psychological help as, “flawed and socially unacceptable” (p. 2). Pfiffer and In-Albon (2022), also reviewed similar barriers to counselling in their study, emphasising that there still exists negative social attitudes towards people with mental disorders (2022, p. 2571). Hintzpeter (2014, in Pfiffer and In-Albom, 2022), highlighted that adolescents who suffer from poor mental health are not accessing long term services or treatment (p. 2571). In their study, Pfiffer and In-Albom (2022), also note several barriers including self-stigma, accessibility, health insurance access, shame, fears around confidentiality, and for adolescents, a lack of trust in the therapist, citing a preference to solve their own problems in the ‘pursuit of autonomy’, and instead seeking help from friends (p. 2572). A lack of trust and fears about discrimination through counselling are also reinforced with the LGBTQ+ community. In their investigation of young LGBTQ+ experiences in managing their mental health, Town et al. (2022), found sexual minority youth were more likely to experience ‘hostile social environments, prejudice, discrimination and stigma, and more likely than their heterosexual peers to experience depression, self-harm, and lower self-esteem’ (2022, p. 1442). Furthermore, their investigation also found that LGBTQ+ adolescents perceived more discrimination from mental health services than any other health service, consequently, making them a more vulnerable minority. In their national data, Mission Australia’s 2021 Youth Survey Report highlighted that gender diverse groups identified health services, school counselling and community services as the lowest in their options for help and support.

In the North Queensland region, the 2019-2022 Northern Queensland Primary Health Network Health Needs Assessment, recently reported the following barriers to support services, including, limited availability in rural and remote areas, challenges with establishing cost-effective services, inefficient access to assessments, limited relief in accessing e-mental health services, especially in remote areas (2022, p. 22). This is despite the Report’s review of the increase in homelessness, unemployment, domestic violence and self-harm in the North Queensland region. Some services can have waiting lists for counselling of up to 5–9 months. For young people, this delay can be detrimental to their academic, social and emotional development. Berberian, in her research into School-Based Art Therapy (2019), highlights the emergence of schools and educators over the last decade as the primary responders for young people with identified mental health issues, especially when considering the majority of diagnoses for mental health disorders occur once children are of school age.

Fear, insecurity, insufficient emotive vocabulary, insufficient resources and access, a lack of trust, and peer and self-scrutiny; With such barriers to young people accessing mental health support, schools and educators are in the situation where they need to be more equipped to alleviate this burden, whilst also using alternative therapeutic practices that foster acceptance and non-judgement for young people. One such solution is through Arts Therapy.

Emergence of the Alternative Therapy – Mid to late 20th Century

Creative Arts therapies in schools have provided an alternative to talking therapies since the early 20th century when the Walden School was established by Margaret Naumburg in New York in 1915 and continued through to the 1940s when Edith Kramer commenced work at the Wiltwyk School for Boys, developing an art therapy program for emotionally troubled boys (Malchiodi, 2014). Since their foundational research, Arts Therapy has continued to be investigated for its efficacy in therapeutic treatment for young people with trauma, anxiety, depression, behavioral issues and aggression, attention deficit disorders, among other conditions, and where clients find it difficult to communicate verbally about their emotions. Despite this, there appears to be under-resourced opportunities in school settings equipped to provide art therapy through counselling services. In their 2010 article on creative arts programs assisting students with special needs in Jersey City Public schools, Nelson suggests that these programs face several challenges due to factors including the availability of staff trained to facilitate the therapy, funding for resources, and timetable constraints to release students during their school day. However, studies over the last 20 years provide encouraging reports on the academic, psychological, and economic benefits of school-based Art Therapy in improving the mental health of young people through early intervention and supportStudies over the last 20 years provide encouraging reports on the academic, psychological, and economic benefits of school-based Art Therapy in improving the mental health of young people through early intervention and support..

In 1915, Margaret Naumburg founded and directed the Walden School for children in affluent New York, where the program focused on achievement through a balance of mental and physical wellbeing. Naumburg, an educator and art therapist, employed creative free association to diagnose and support the mental health of children. She used this research in the 1960s to train art educators in art therapy practices, obtaining family history, interviewing techniques, and completing reviews to support students through their conditions using creative arts. Naumburg stated in her 1964 address at the Syracuse University Summer Session Symposium that “symbolic visual power is universal and [through it] we are able to encourage the release of spontaneous expression in ways in order to develop fresh forms of human adjustment” (p. 46). There were some limitations with Naumburg’s training at the time, for instance, the imperativeness of the established teacher/pupil versus therapist/ patient relationship for any therapy. Furthermore, the need for the teacher’s role to shift from being ‘active imparters of information on passive students, to drawing the pupil out’ (Naumburg, p.48), and subsequently taking a child / client-centred approach to understanding their creative motivations. As a result, Naumburg’s educator feedback noted the limitations with psychology training and inability to acknowledge understanding the client and their unconscious motivations, as well as the scope of this new educational approach. However, Naumburg’s case studies during the 1960s, record the impact of teachers’ success in working with children with depressive symptoms during this time. The studies indicated the teachers were able to provide help beyond the typical competence and role of a teacher, by utilising their knowledge of and relationship with their students and families, their developed level of trust, and psychological insight.

Edith Kramer pursued this further with her work at the Wiltwyck School for Boys but is reported to believe the role of the art therapist should consist of, ‘skilled artist, teacher and therapist [using these roles] and knowledge to not directly interpret unconscious meaning, but help the child produce artwork that contains and expresses emotionally loaded material’ (Kramer, 1971, as cited in Nguyen, 2015, p.31).

Natalie Rogers’ work in the 1980s through the establishment of the Person-centered Expressive Therapy Institute, explored the merging of expressive arts and psychotherapy, to engage clients to open up more freely to new experiences; thus enabling them to lead the therapist through their own process of healing (Sommers-Flanagan, 2007).

Early Trial Programs – 2000 – 2015

A consequence of this early work by Naumburg and Kramer, has continued with evidence-based research that art therapy can help young people with trauma, depression, anxiety, and aggressive behaviours, amongst other mental health disorders. Furthermore, in the field of art education and pedagogical practice, more researchers are exploring the implementation of art therapy programs in schools to manage behaviour disorders, especially since 2000. Dunn-Snow and D’Amelio (2000) acknowledge the foundational work of Kramer and Naumburg in addressing the valuable relationship between art therapy and art education. Dunn-Snow and D’Amelio go on to discuss problems with the increasing demand on schools to complement the increase in school children presenting with aggressive behaviours, stating that a lack of access to treatment and insurance has seen many children with emotional and behavioural disorders attending school without ‘support of therapeutic resources and alternatives for themselves or their families’ (Carter & Simpson, 1993, as cited in Dunn-Snow & D’Amelio, 2000, p. 47). Subsequently, the spotlight is on teachers’ lack of training in mental health counselling. Their research explores how art teachers can provide an effective therapeutic experience in their art classes. Their proposed solution is for art teachers to work in collaboration with school counsellors to develop alternative ways young people can explore their specific issues, emotions, hopes and concerns, in a safe and accepting space. However, they do suggest the success of art therapy in school programs relies on interdisciplinary teams of teachers, various specialists, school leadership and parents working together to support the training of teachers to provide therapeutic support, counselling practices, ethical standards, and confidentiality agreements across systems. Their investigation further considers the benefits of such programs helping to build resilience in children, provide extended support for children with special needs, and with proposed additional training, teachers will gain the skills required to support the increase of children in their classes with mental health needs.

Similar to Dunn-Snow and D’Amelio (2000), Kay and Wolf (2017) also posit collaboration is the key in their research project, Resilience and Girl Power – Adolescent Girls Make Art. Their project was a collaborative approach that involved the working efforts of an art therapist, researcher, and art teachers, with the aim to improve self-awareness and the inner strength of adolescent girls through creative arts. The project addressed adolescent girls with various social, emotional, behavioural, and academic needs. It responded to previous research and gathered evidence on the effective responses subjects had to art therapy when coming from backgrounds in trauma, and the ever-emerging focus on wellbeing and the positive self-image young people should be developing throughout adolescents to improve resilience. Like researchers before them, Kay and Wolf are responding to the concerning increase in reported mental health issues for young people and the need to provide accessible and safe counselling services to meet their needs. Almost a decade after Dunn-Snow and D’Amelio’s research, The Resilience and Girl Power project applied the therapeutic process of obtaining informed consent of the participants’ guardians, addressing appropriate use of space and risk assessments, mandatory reporting training, permission to display artworks and resourcing of activities. Overall, Kay and Wolfe (2017), reviewed The Resilience and Girl Power project as a model of a successful collaborative approach, fostering positive adult relationships in a positive professional work environment, and providing students with the creative arts skills to communicate and unpack their understanding of self and others.

Research by Wallin & Durr (2002), indicates that Arts Therapy trials in schools are showing evidence that this form of creative expression breaks down cultural, racial and gender barriers, whilst also focusing on the client when developing activities that are person-centered, thus reinforcing the earlier work of Natalie Rogers. Whilst some criticism of art therapy suggests that to clinify artwork may contradict the purpose and process of art making (Franklin, 1996, as cited in Potash et al., 2016), consideration should be given to the purpose of art therapy as not focused on the end piece, but the journey the client takes; that is, art as a means and process that restores and mental health. More researched studies are being applied to arts therapy, especially when working with adolescents to improve their mental health.

The Jersey City Public School Department introduced an expressive arts therapy program specially aligned to students with special needs. Utilising the collaborative arts and specialists from supporting fields, the program continues to support children who are also from disadvantaged homes and trauma backgrounds (Nelson, 2010). Their implementation has involved sourcing grants to fund the materials and staff training, collaborating with parents and general staff across schools, along with special needs specialists and other multidisciplinary professionals to develop the program and provide ongoing therapeutic support for the student participants. This is an example of how creative arts is assisting with the emergence of therapy programs in a school setting, to improve academic performance and child health and wellbeing, providing a form of communication that is accessible. (Nelson, 2010).

Applying Alternate Art Therapy Practices with Adolescents – Future Focused: 2015 onward

Researched studies over the last ten years highlight the benefits of art therapy, as the global statistics continue to show a rise in diagnosed mental health disorders in adolescents, combined with the social and economic factors of hunger, poverty, unemployment, and homelessness, along with the domestic violence, substance abuse and trauma (WHO, 2022).

Constance Chung’s (2020) Literature Review on the Effectiveness of Expressive Therapies with Spirituality to Hong Kong Traumatized Protesters, reviewed how to combine expressive therapy with spirituality as an intervention for young protesters in Hong Kong, traumatized by the 2019 riots against Chinese authorities. From their review, Chung concluded that expressive arts therapy would provide effective support through non-verbal expression and a group dynamics model of collective stories (p. 31).

In their study, Alavinezhad et al. (2014) trialled an art therapy intervention program with 30 children aged between 7-11 years, identified with aggression and experiencing difficulty with verbal communication. Their study looked at how art therapy could be used as an intervention with children identified with anger and aggression. Therapy sessions involved integrating a cognitive behavioural approach with narrative therapy and using visual arts. The aim was to reduce anger through group interaction in painting and drawing and observe changes in self-awareness and self-esteem. Alavinezhad et al. (2014) ran a series of comparative tests including the Coppersmith Self-esteem Inventory to track possible improvements. Their research found that art therapy does reduce aggression, anger, stress and other cognitive disorders, stating that ‘artwork can help transform destructive aggression into constructive strength” (Alavinezhad et al., p. 115).

Similarly, U-Seman and Chethiyar’s (2021) study of the efficacy of intervention based art therapy on adolescents with aggressive behaviours, was a response to the increase in youth delinquency in Malaysia. Their intervention involved 30 children, mixed sex, aged 13 – 18 years of age, and investigated empirical evidence that art therapy was effective in achieving cognitive behavioural change in aggressive behaviours for children, through the promotion of self-esteem and self-awareness. The findings revealed improvement in the mental health of the participants and most specifically noted the sense of belonging young people found with one another through group sessions, highlighting that the non-threatening setting allowed participants to creatively connect.

Martin and Colp’s (2022 ), study looking into ways arts practices are promoting mental health in Canadian schools, addresses the mental health crisis in Canada calling for new thinking and changes in approach. Their tested solution is schools, citing Kessler et al (2007), that it is in the early teenage years that half of all mental health conditions emerge. Berberian (2019) reinforces this in her study, entitled, School-Based Art Therapy, that most mental disorders are diagnosed when children reach school age, and that art therapy can help young people manage emotional stressors. The findings of Martin and Colp’s (2022) study suggest that art therapy exercises can lead to a healthier mental state and that evidence-based solutions should be urgently sought for the mental health crisis, with controlled studies extending into schools.

Lui et al., (2022), completed a 75 year bibliometric analysis into art therapy aided health and well-being research, investigating the future direction of art therapy and reviewing how it improves health and well-being. The investigation found that over the last 75 years, art therapy has been found to improve the wellbeing and mental health of adolescents, particularly group therapy for improving resilience and other conditions including anxietyArt therapy has been found to improve the wellbeing and mental health of adolescents, particularly group therapy for improving resilience and other conditions including anxiety..


A chronological review of the literature indicates that art therapy is an effective intervention for improving adolescent mental health with behavioural, emotional and academic challenges. Case studies over the years have shown that it reduces aggressive behaviours in children and improves self-esteem and self-image, (Alavinezhad, 2015; Kay & Wolf, 2017; U-Seman & Chethiyar’s, 2021). Art therapy is also found to be an effective non-verbal method for expressing emotions where children may have limited access to the language (Naumburg, 1964; Dunn-Snow, 2000; Nelson, 2010; Alavinezhad, 2015; Chung, 2020). Expressive arts provide an avenue for children to explore creative communication. Furthermore, one component of Goal 2 of the Alice Springs (Mparntwe) Education Declaration (2019) is that all Australians, as individuals, achieve creativity and confidence.

This research also suggests that Art Therapy in schools can provide a solution to overcoming barriers to children accessing counselling services due to the non-judgmental, safe, familiar, and supported setting for fostering academic achievement (Harpazi, 2020, p.2). Berberan’s 2019 study, proposed that easy access and early intervention with art therapy is necessary to address acute and chronic stress that impact child development, whilst also providing an alternative therapeutic approach for children that accommodates non-verbal communication. As it is on-site and in the typical setting of a school, these programs have the benefit of not requiring additional travel for participants, provide children with a safe space in the school environment, and can foster feeling connected with their community, thus improving confidence. The on-site Art Therapist and arts educators, present positive and accessible role models in the school setting and can be a support network for at-risk students. Thus, breaking down barriers to counselling services, overcoming stigmas, and improving trust for children. Additionally, Harpazi’s (2020) research reviewed participant feedback, which suggested most participants did not feel self-conscious about attending the program, although did suggest not naming it therapy and trusting in the art therapist’s privacy processes to protect confidentiality.

Therefore, the search for alternative ways to support the mental health of young people is important and, as the reviewed case studies indicate, a collaborative and interdisciplinary approach is recommended to reach young people and engage them in therapeutic support. In addressing this problem, consideration must be given to how challenges can be met in establishing school-based art therapy programs in local schools. Bosgraaf et al. (2020) found that materials and techniques for art therapy are dependent on the needs of the client and are adaptive and flexible. Staff training in schools and buy-in through education about art therapy and support from school leaders and the community is essential. At a macro level, program implementation, funding, site set up, student referral processes and staff training needs must be addressed. A clear guide on the role of the art therapist in schools and how they collaborate with staff, students and families, also needs to be established.

In their systematic literature review of art therapy from 1983 – 2014, Potash et al. (2016), identify the developments art therapists have made since the late eighties, adapting to new approaches by integrating the studio and the clinic. Their review drew light on how the future role of art therapists can be defined as a profession engaged in health practices. They evaluated the changes that have taken place over the last 30 years in the field and note the introduction of licensing and credentials now required for art therapists and recognition as a health care provider. Thus, acknowledging the impact of increasing numbers of mental health patients on other healthcare systems, which subsequently limits accessibility and availability for potential clients. In Australia, art therapists are now recognised by Allied Health Professions Australia and are funded under the NDIS.  The Art Therapist assigned to develop and oversee the program with the schools will need to run professional development workshops with arts educators. Crane and Baggerley, (2013, as cited in Hannigan et al., 2019), stipulate that teachers need to be equipped through training to be in the therapist/client relationship, ensuring they maintain ethical principles and observe boundaries. The Australian, New Zealand and Asian Creative Arts Therapies Association is engaging with the Victorian Education Department to establish school-based art therapy programs in response to the Victoria Government’s ‘Healthy Kids Healthy Futures’ (2021) five year action plan to support student health and wellbeing, particularly their mental health.  However, for regional North Queensland, where access to services is even more limited, it is time to investigate how schools and interdisciplinary teams can support their most vulnerable. Ideally, by establishing networks of schools working with an assigned art therapist and a team of trained educators.

Notably, school-based art therapist, Janet Bush (1997, as cited in Berberian, 2019) suggests that art therapists can meet the current challenges to assist young people through an upgrade to their school based programs, acknowledging the foundational work of Margaret Naumburg and Edith Kramer.


Young people need access to mental health services where they feel supported, safe, non-judged or stigmatized, where they can communicate easily and feel a connection to others, reinforcing they are not alone in their struggles. The challenges of social, emotional and academic conflict will continue to increase for youth, and schools and their staff are at the frontline in responding to these growing needs. With these changes, schools need to consider how they can change to support their students, beyond the curriculum. Children cannot fully engage with their learning until they are mentally healthyChildren cannot fully engage with their learning until they are mentally healthy.. Educators and therapists, like Naumburg and Kramer, were aware of this in the mid-20th century and worked with troubled children through the expressive arts to better understand their disturbances, and pioneered art therapy practices with young people. Their approach in these early years was to utilise the setting of the school and the collaboration of educators, who best know their children, to unlock their emotive language. Since then, educators and therapists have investigated the efficacy of expressive arts activities as therapeutic practice. Their results over the years have indicated that arts therapy can improve the mental health of young people with aggression, depression, anxiety, trauma, and other disorders. This non-verbal, person-centred approach to therapy can be the solution to encouraging more young people to access counselling services at school, with the support of a peer group and art therapist. Art therapy as an intervention, is being utilised more in health service settings and the credentials for art therapy as a profession have improved in the last ten years. Over more recent years, art therapeutic activities have been used to promote positive mindfulness and wellbeing. Schools are in an ideal situation to implement school supported art therapy programs with a network of trained professionals in Townsville regional schools, improving accessibility to counselling services as a regional centre, whilst also providing safe and alternative therapies that engage and connect with young people. A review of some programs trailed over the last twenty years provides opportunities to plan forward to how art therapy can be integrated into the school system. Thus, complementing the arising 21st century needs of young people and improving their school-based access to counselling services.


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New Directions in Guidance and Counselling Research: 2022 Edition Copyright © 2023 by Michelle Kotzas is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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