The Arts in Psychotherapy 35 (2008) 341–348

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The Arts in Psychotherapy

A model for art therapy in educational settings with children

who behave aggressively
Edna Nissimov-Nahum, PhD ∗
The David Yellin College of Education, Jerusalem, Israel

a r t i c l e i n f o a b s t r a c t

Keywords: This paper presents a model for improving the effectiveness of individual art therapy with children who
Art therapy behave aggressively. It addresses two major challenges. First, these children often present the therapist
Children with several dilemmas, such as how to respond when faced with symbolic or direct expressions of aggres-
Aggression
sion, and how to establish a treatment relationship when clients arouse strong emotions in the therapist.
Model
Second, when working in educational settings, art therapists often question whether they should strive
Effectiveness
Research to integrate themselves into the school and, if so, what should be their role with teachers and parents?
The model presented here emerged from a phenomenological study that included a survey of a large
sample of Israeli art therapists and in-depth follow-up interviews with two sub-samples of therapists,
who treated aggressive children and whose cases showed the most and least improvement. The study,
which focused on the relation between treatment outcomes and therapists’ practices, perceptions, and
experiences, yielded a conceptual model for effective treatment. The model highlights the dual principal
of conveying acceptance and directing toward change, which is applied on three levels: the child, teachers
and parents, and the therapist. The paper presents the model and suggestions for its implementation.
© 2008 Elsevier Inc. All rights reserved.

The introduction of art therapists into educational settings has
been documented mostly in the past three decades. Art therapy
provides a unique solution for children with special needs, as it
addresses many aspects of the child, including cognitive, emotional,
and social. When schools provide art therapy, they take respon-
sibility for helping children to learn by removing emotional and
behavioral barriers to learning and offer access to services for fam-
ilies who cannot afford to purchase them privately (Anderson, 1994;
Bush, 1997; Dalley, 1990). Kramer (1971) suggests that art therapy
is ideal for working with aggressive children1 as aggression is an
abundant source of energy for creative activity. The creative process
both utilizes and neutralizes the client’s pent-up aggression.
However, despite the importance of the creative process for
expressing aggression, it arouses unique difficulties and pro-
fessional dilemmas in treating this population, which may be
implicated in treatment effectiveness. Moreover, there is a lack of
research in this area and the little research that exists suggests that
∗ Correspondence address: 22/7 Erlich Street, Holon 58680, Israel.
Tel.: +972 3 5546644.
E-mail address: ednana@netvision.net.il.
1
In this article, I use the term äggressive childrenf̈or reasons of brevity, but the
more correct term would be “children who behave aggressively”, as it highlights
the child’s problem behaviour, which can be changed, and does not imply a fixed
personality trait.
art therapy may not always be effective with this population. A
recent review of all the published studies conducted on the effec-
tiveness of art therapy (Reynolds, Nabors, & Quinlan, 2000) revealed
a total of only 17 studies, covering a wide range of age groups
and referral problems and only two of them examined behavior
change in children (Rosal, 1993; Tibbets & Stone, 1990). They found
improvement in indicators of emotional well-being but only one
found improvement in behavior. This paper explains the challenges
that art therapists face in working with aggressive children and
offers a conceptual model for effective treatment.
Aggressive behavior in children
Childhood aggression is a widespread problem that is gaining
increasing attention throughout the world and the search for effec-
tive solutions poses a challenge to practitioners and policy makers
(Astor, Wallace, Behere, & Fravile, 1997). The scope of aggres-
sive behavior in children may be understood in light of the fact
that many factors contribute to the problem, both external (soci-
ety, environment, family, and education) and internal (personality,
emotional, cognitive, and neuro-biological).
Most children will occasionally exhibit aggressive outbursts, but
this behavior becomes problematic when persistent. Children with
frequent disruptive behavior are usually classified as experienc-
ing “emotional and behavioral difficulties” (EBD; Joughin, 2003),

0197-4556/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2008.07.003
342 E. Nissimov-Nahum / The Arts in Psychotherapy 35 (2008) 341–348
such as Oppositional Defiant Disorder, Conduct Disorder, Attention
Deficit Hyperactivity Disorder, or various learning disabilities.
Aggressive behavior bears a high cost for the child and is often
associated with poor academic achievement, low self-esteem, low
frustration tolerance, poor social skills, and depressive symptoms
(Sanders, Gooley, & Nicholson, 2000). Aggressive children are more
likely to truant from school and more likely to be in trouble with
the police. Children who show behavior indicative of EBDs may
suffer damage to relationships with family, peers and teachers.
This paper focuses on the treatment of children with various types
of EBDs, who are referred due to aggressive behavior. The posi-
tion presented here is similar to that of Cohen (1994; p. 91),
who states that “aggression as a symptom crosses diagnostic cat-
egories and confronts the treatment staff with severe challenges
for coping; we often refer to these children as ‘aggressive chil-
dren’ no matter to which category they ‘belong’.” Furthermore, in
most cases, multiple causes may be involved that are often diffi-
cult to separate. It is suggested that aggressive behavior requires
treatment in its own right, as it poses an immediate threat to
the child and others, and inevitably creates a cycle of rejection.
As such, there is a distinct advantage to having understandings
about effective treatment that may be applied to various diagnostic
groups.
The study
The model presented here emerged from a phenomenologi-
cal study of therapists’ experiences, perceptions, and practices in
the treatment of aggressive children in educational settings and
their relationship to perceived treatment effectiveness (Nissimov-
Nahum, 2007). Its goals were to describe, understand, and explain
how art therapists work with this population and, in particular, to
understand the difficulties involved and to learn from their suc-
cesses.
The study included three stages of data collection. First, 113 art
therapists who work in the Israeli educational system completed
a questionnaire. They were asked to report on their general expe-
rience with this population and also to focus on a single case of
individual treatment with a child, from kindergarten through junior
high school, referred because of aggressive behavior. In the sec-
ond stage, follow-up in-depth interviews were conducted with 11
therapists, focused on elucidating the factors that may be associ-
ated with effective treatment. Interviewees were selected on the
basis of their questionnaire responses, as belonging to one of two
groups: therapists who reported cases that showed the most and
the least improvement. These two groups were compared and con-
trasted to identify the characteristics of effective treatment. Finally,
six clinical supervisors of art therapists were also interviewed.
Their perspective was important as it is based on their own clinical
experience, their work with many therapists, and their extended
involvement with the educational system. Analysis and synthesis
of the findings from therapists and supervisors yielded a conceptual
model that presents the principles of effective treatment.
One of the study’s main findings was that relatively few thera-
pists (24%) reported major improvement that could be considered
clinically significant. Mild improvement was reported in 49% of
cases, and no change or worsening in 27% of cases. Moreover, when
asked to provide reasons for any improvement, most therapists
pointed to external factors and appeared to be largely unaware
of the connections between their own activities and treatment
outcomes. Finally, findings showed that most of the therapists
(86%) reported a strong need for knowledge and skills for treating
aggressive children. These findings, together with the above stud-
ies, suggest that when art therapy is applied with this population,
therapists may often be faced with unique challenges and results
may be unsatisfactory.
Challenges in art therapy with aggressive children in
educational settings
The study identified challenges in three main areas: in treat-
ing the child, in working with wider systems, and with therapists’
personal experiences.
Challenges in treating the child
Many therapists reported that, while they desire to provide a
safe environment and encourage free expression, it is often unclear
to them how they should respond to symbolic or direct expressions
of aggression in the treatment room or even to aggression that is
expressed only outside. These situations are associated with several
challenges.
How to safely encourage free creative expression?
Creative expression is considered to be an ideal therapeutic
strategy as it encourages sublimation of drives and promotes ego
development (Rubin, 1978). However, with aggressive children,
there is a risk of their losing control during the creative process and
they may become overwhelmed with anxiety. When venting can
lead to distress in the child, some experts suggest that the therapist
should consider the possibility of structuring the creative process
by limiting the materials that are offered or directing the child
to specific materials, in order to encourage self-control (Hagood,
2000; Kramer, 1971). The challenge for therapists is to determine
when to allow free expression and when and how to limit it, so that
they do not provide too much freedom or, conversely, set limits that
are too rigid.
How to process the symbolic contents of artwork?
The images displayed in the child’s artwork may reflect aggres-
sion and painful issues. McMurray and Schwartz-Mirman (1998)
explain that the creative process transforms aggression into exter-
nal images and this relieves clients’ stress and allows them to reflect
on their inner world. There is debate among therapists, however,
whether and to what degree metaphoric expressions should be
discussed with the child, especially keeping in mind the fact that
aggressive behavior often appears alongside difficulties in verbal
expression (Ripley & Yuill, 2005). Discussion of the artwork can
help children feel that they have been understood, to obtain insight
into the meaning of their symbolic expressions, and to experience
relief (Malchiodi, 1998). Inappropriate interpretations, however,
may lead to premature uncovering of threatening material, loss of
control, and an increase in anxiety and symptoms that may, in turn,
lead to resistance to treatment.
The current study found that most therapists reported that
they respond to aggressive symbolic contents in the artwork with
encouragement, but refrain from discussing or interpreting the
issues. They explained that they were concerned for the child’s
capacity to contain a verbal intervention, due to the stress, anxiety,
or pain that this could arouse. They also described their concern for
jeopardizing the therapeutic relationship and arousing resistance.
As such, therapists are faced with the challenge of whether, when,
and how to process symbolic aggression in the child’s artwork.
How to respond when therapists are faced with direct expressions
of aggression?
Although in general practice, aggressive outbursts may be a rare
occurrence, they are to be expected when treating children who
are referred for aggressive behavior. In the current study, therapists
 E. Nissimov-Nahum / The Arts in Psychotherapy 35 (2008) 341–348
reported aggressive behavior in the treatment room in more than
half (55%) of their cases, including aggression toward the therapist
and property. This often occurs when the child feels threatened,
endangered, hurt, or frustrated, leading to a sense of helplessness,
which can impair the child’s capacity for rational thinking. On the
other hand, this may also be seen as an opportunity in which the
client brings the presenting problem into the treatment room and
the therapist has a chance to address it directly.
This situation is extremely challenging for many therapists,
however, as it poses a danger to their personal safety and may
also jeopardize their ability to fulfill their professional responsi-
bility to safeguard the welfare of clients and prevent destruction
of property. Some experts, such as Moustakas (1975), believe that
therapists should allow the child’s rage, as this will eventually
enable them to discover the possibilities for positive relatedness, for
self-examination and self-growth. Others, such as Hagood (2000)
suggest that it is important for art therapists to strengthen the
client’s self-control and their mutual respect and trust for each
other. Waller (2006) points to the need “to maintain very strong
boundaries and to focus the child’s violent feelings onto the art
rather than his or her own person, or onto others. Change takes
place as a result of the child learning that it is possible to have
angry feelings but to express them ‘safely’ through the art, and in
the knowledge that the therapist will not retaliate” (p. 279). Tenne
(2000) suggests that inexperienced therapists may fall into a trap
when they allow clients to break the rules, as they fail to under-
stand their clients’ needs and are afraid to enter into confrontation
with them or to be seen as “bad.”
Interestingly, in the current study, many therapists addressed
an additional dilemma – they desired to be nurturing caregivers,
but their clients’ aggressive behavior elicited in them a sense of
threat and fear, and at times also feelings of rejection and anger.
They reported that they often became increasingly vigilant and
tense at a time when they should have been presenting a confident
and assertive response. Consequently, therapists ask, how should
they respond when faced with aggressive behavior in the treatment
room?
How to respond when children refrain from bringing their
problem behavior into the treatment room?
In almost half of the cases reported by therapists in this study
(45%), clients did not ever act aggressively inside the treatment
room. They presented only their functional, “good” behavior, yet
their aggression continued on the outside. It is likely that, in such
cases, the treatment relationship provided the kind of structure,
safety, and attention that the child needed in order to maintain
control. On the one hand, this split could be regarded as desir-
able, since the therapist has succeeded in establishing a positive
therapeutic relationship with the child. In time, it is hoped that
this positive behavior will generalize to situations outside of the
treatment room. However, one may suggest that any therapeutic
relationship in which there is no expression of the child’s external
reality is based on an illusion: it is an idealized relationship that
has been neutralized of all anger, tension, and resistance, that can-
not serve as a place for working through the child’s real problems.
Arazi (1994) suggests that such a relationship will eventually jeop-
ardize the treatment, lead to worsening in the child’s symptoms
and prevent behavior change.
This situation poses a complex challenge for therapists, as one
may ask whether and how it is possible to treat behavior that is not
displayed or even reported in the treatment room. Some therapists
believe that issues discussed in treatment should be raised by the
client and, therefore, therapists should wait for clients to report
their aggressive behavior (Axline, 1969). However, this approach
runs the risk that the client may never broach the subject. Other
343
experts maintain that it is the therapist’s responsibility to initiate
gradual discussion of the subject when clients are unable to do so.
The study findings indicate that the answer is not simple. While
many therapists chose to initiate discussion of external events,
some were concerned that introducing such information could lead
to confrontation and to clients feeling criticized and rejected, pos-
sibly even destroying the therapeutic alliance. The challenge for
therapists is to determine whether and how to address aggressive
behavior that is not presented in the treatment room.
Challenges in working with the system
Therapists, who usually meet with their clients only once a
week, can expand their range of influence by working also with
teachers and parents, who have daily contact with children and
often interact with their aggressive behavior. Teachers and parents
have many opportunities to respond and, as such, it would appear
to be beneficial to include them in the process. Research has shown
that work with teachers and parents can contribute significantly
to the effectiveness of school-based programs for children with
behavioral problems (Benbenishty, Astor, & Marchi, 2003).
When therapists collaborate with teachers and parents, they
help to reduce their loneliness and isolation in dealing with the
aggressive child and promote development of a united front, such
that the child receives a consistent approach from all involved,
thereby increasing the potential impact of therapy (Bush, 1997;
Nissimov-Nahum, 1999; Omer, 1999). In contrast, when therapists
exclude teachers and parents from the treatment, they may create
a “split” in the child’s life that makes it hard to generalize new per-
ceptions and behaviors from the treatment room to other settings.
In this study, several dilemmas and challenges were reported.
Should therapists strive to integrate themselves into the school, or
should they limit their interaction with school staff?
While art therapists may work within the schools, they are not
of the schools. They are a “minority culture” and, as such, they often
come face to face with issues of professional affiliation and iden-
tity (Bush, 1997; Wengrower, 2001). Some therapists believe that
they should strive to maintain their separate professional identi-
ties within the school system, so as to ensure that children do not
identify them as authority figures. As such, they may wish to base
their therapeutic alliance with the child on their separateness from
the system. In this study, however, the vast majority of therapists
reported that they believe in the importance of working together
with teachers and parents. In practice, however, it appears that
many therapists experience hardship in working with teachers and
even greater difficulty in working with parents.
This dilemma may be intensified in situations where there is a
lack of clear guidelines for collaboration. Therapists reported that
they were often limited by the fact that they were allocated hours
only for direct work with children and, as such, had to find “creative”
solutions to allow for meetings with teachers and parents. We may
ask, is it the therapist’s responsibility to find ways to incorporate
work with the wider systems, or should they limit themselves to
treating the child?
How to work with teachers and parents who may be unmotivated?
Due to the amount of disruption caused by a child’s aggres-
sive behavior and the potential dangers to others, teachers and
parents cannot avoid reacting in some manner. Research has con-
sistently demonstrated that aggressive children may be exposed to
negative reactions from their teachers (Henricsson & Rydell, 2004),
who often reject children with disturbing behavior and respond to
them with less support and more criticism and punishment than
other children receive (Ladd & Burgess, 1999; Little & Hudson, 1998;
344 E. Nissimov-Nahum / The Arts in Psychotherapy 35 (2008) 341–348
Pianta & Niemitz, 1991). In the current study, therapists reported
that they often encountered teachers and parents who lacked the
willingness, knowledge, and skills for helping children overcome
their problems and who often expressed anger, rejection, helpless-
ness, and despair in relation to the aggressive child.
While there are undoubtedly many teachers and parents who
maintain positive relationships and cope successfully with aggres-
sive children, it is clear that working with them may often pose a
significant challenge for the therapist. Therapists thus ask how to
recruit the cooperation of teachers and parents, how to help them
overcome their negative attitudes toward the child, and how to
guide them toward more effective coping with the child’s aggres-
sive behavior.
Challenges in working with therapists’ personal experiences
Work with aggressive clients may arouse substantial negative
affect also in the therapist. The general literature on psychotherapy
has highlighted the significance and impact of therapists’ conscious
and unconscious feelings and reactions toward the client, often
termed counter-transference. This may be especially relevant in
the treatment of aggressive clients, as therapists may fear that they
will be personally harmed or injured. When a child acts aggres-
sively, the therapist may feel rejected and may react by rejecting
the client themselves. They may feel angry when clients defy them,
enter into power struggles, or damage equipment. When their
attempts to help the child are unsuccessful, or when clients are
resistant and non-compliant, therapists may also sense helpless-
ness. They may also become angry with parents or teachers out
of identification with their clients’ anger at the adults in their
environment.
There is much clinical evidence suggesting that counter-
transference reactions that are not managed well may have a
negative impact on both the process and outcome of therapy
(Rosenberger & Hayes, 2002; Winnicott, 1975, pp. 194–203). The
emotions that are aroused by aggressive clients, especially when
these interact with unresolved personal issues in the therapist’s
life, may cause therapists to lose their professional distance and
react in ways that are not based on the needs of the client. For
instance, therapists may over-identify with clients and may conse-
quently be unable to address their real needs. “Frequently clinicians
are tempted to counterattack, which can result in rejection, pun-
ishment, or hostile demands for compliance” (Riley, 1999; p. 220).
The therapist’s values, feelings, and beliefs may have an effect on
their clients, even when they are silent or outwardly maintain a
calm appearance: “Something as simple as an unconscious sigh may
be experienced by the child as a further rejection, as further evi-
dence of his/her hopelessness” (Greenhalgh, 1994; p. 90). As such,
the main challenge for therapists in this area is how to establish
and maintain a warm treatment relationship and help clients to
change, when children, teachers, or parents arouse strong negative
emotions.
Analysis of the study findings revealed that therapists’ ways of
coping with these challenges may be associated with treatment
outcomes. When faced with children’s aggression, therapists may
adopt dichotomous strategies. For example, therapists may accept
clients, teachers, and parents, but avoid directing them toward
change or, alternatively, may become unable to truly accept the
child or the teachers and parents and focus solely on limiting and
controlling the aggressive behavior. It seems as if therapists felt that
they must choose either to convey acceptance or to direct toward
change. The model to be presented here, which is based on com-
parison of most and least improved cases, suggests that effective
treatment involves a dialectic approach that combines acceptance
and change.
Fig. 1. A conceptual model of the therapist’s role in effective treatment.
The conceptual model
This section presents an integrated conceptual model for effec-
tive treatment of aggressive children in educational settings. The
model provides a framework for understanding and choosing
appropriate interventions that will help children to adjust and cope
better with both their internal and external environments. The
model, illustrated diagrammatically in Fig. 1, highlights the ther-
apist’s role in two dimensions: levels of intervention (circles) and
focus of interventions (arrows). The main understanding here is
that treatment effectiveness is increased when therapists address
three levels: the child, teachers and parents, and themselves. Fur-
thermore, on each level, the therapist’s work should reflect the
dialectical approach of “conveying acceptance and directing toward
change.”
With regard to the first level – treating the child – in effective
treatments, therapists convey acceptance to their clients by estab-
lishing a positive relationship based on empathy and validation and
encouraging free creative expression, while at the same time direct-
ing them to change via creative and verbal interventions to help
develop self-control. On the second level – work with the wider
systems – therapists accept teachers’ and parents’ difficulties and
establish positive relationships with them based on empathy, while
providing them with skills for accepting the child and coping with
the problem behavior. Finally, with regard to the third level – ther-
apists examine and address their own feelings, experiences, and
perceptions. They recognize and accept their own aggression and
also access internal and external resources (e.g., clinical supervi-
sion) for coping with it.
Implementation of the model
This model has wide-reaching implications and the potential
to generate many different types of interventions. It presents the
main features of effective practice that emerged from the study,
commencing with preparation for treatment, followed by each of
the three levels of intervention. These features are summarized in
Appendix A.
Preparation for treatment
At the start of treatment, after therapists obtain information
on the child from a variety of sources in order to understand the
problem and expectations for treatment, they should meet with all
involved—parents, teacher, and child. They thereby set the stage for
positive outcomes by starting to implement the dialectic approach:
 E. Nissimov-Nahum / The Arts in Psychotherapy 35 (2008) 341–348
to convey a sense of acceptance to all involved and to then use this
as a basis from which to direct interventions at changing both the
child’s behavior and the perceptions and responses of teachers and
parents.
An emphasis on establishing a positive relationship, without
judgment or criticism, provides all involved with the sense that
they have been heard and understood, which may contribute to
their motivation for treatment. In addition, parents or teachers have
referred the child because of aggressive behavior and, as such, they
tend to expect that the goal of treatment will reflect the reason
for referral. Therapists thus further engage all those involved when
they clearly convey that the desired ultimate outcome of the treat-
ment is a reduction in the child’s hurtful behavior, in order to reduce
the risks to the child and others. This further conveys to the child
that all the adults are aware of the difficulties and that they intend
to work together to help the child develop better capacity for self-
control, coping with frustration, and consideration of others. In this
way, the therapist also demonstrates that treatment is connected
with the child’s world, that it does not occur in secret or in isolation,
and that it will address the issues openly and honestly.
Interventions with the child
The treatment room and the therapeutic relationship provide
many opportunities for therapists to address aggressive behavior,
whether it is expressed symbolically in the artwork or directly
toward the therapist or the room, and even when manifested only
outside.
Interventions in relation to artwork
The dialectical approach of “conveying acceptance and directing
toward change” may be applied in relation to the child’s creative
expression. A sense of acceptance is conveyed when therapists
encourage free expression by offering a wide variety of materials
and activities. They thereby enable emotional issues to surface from
the inner world and take on external visual form, while the child
is expressing strong emotions and experiencing success, mastery,
and pleasure. In the current study, therapists reported that children
expressed aggression in their artwork via aggressive images (such
as weapons, volcanoes, cops and robbers, monsters), aggressive sto-
ries (involving violence, destruction, suicide, theft, or murder), or
stressful thoughts and emotions (e.g., anger, fear, pain, danger, lone-
liness, punishment, blaming, revenge, helplessness, or distrust). In
addition, children may attempt to destroy their own artwork or may
display extreme aggression in working with materials.
The “change” part of the dialectical approach is expressed when
therapists, at times, become directive in helping clients focus on
specific issues. For example, when clients become overly expansive
and exceed the boundaries of the artwork, therapists may consider
whether to encourage organization and control of materials. In this
way, therapists show their clients how they may express intense
emotions, while maintaining control and consideration for realistic
boundaries. This process also provides therapists themselves with
a greater sense of control inside the room, which will, in turn, be
transmitted to clients.
He enjoyed lighting fires in the treatment room and they repre-
sented the aggression that he could not control. But he accepted
the fact that I supervised. I always made sure that the fire would
burn inside a tin, in a safe place. [Art Therapist]
When clients attempt to destroy their artwork, therapists may
consider whether this is likely to be productive or detrimental.
When therapists consider a client’s artwork to be a representation
of the self, it is their role to help the child accept and integrate
the different parts of themselves, including the parts that they
345
are reluctant to acknowledge. Thus, they may wish to prevent the
destruction and offer clients different ways to cope with and accept
“unsuccessful” creative expressions, so as to help clients discover
new ways of dealing with conflict, disappointment and frustration.
I told him that it’s a pity that he destroys things that he created,
that in the end all that will remain is the destruction. I suggested
that he let the piece rest and next week try and see if he can find
another solution. [Art Therapist]
Apart from interventions before or during the artwork, thera-
pists often reflect on the artwork with clients, after it is completed.
In the current study, the most prevalent therapist response to
symbolic expression of aggression in artwork was acceptance as
expressed in enthusiasm for the creative artwork.
He brought a metaphor: “if the volcano doesn’t explode, then it’s
dead”. I understood that he only feels noticed when he explodes.
His life depended on it, and if nobody looks at him and he’s left
alone, he’ll “die”. He built underground weapon bunkers and an
airplane with dangerous toxic materials that could explode and
he had to see how it could be disarmed. . . I said to him, “Wow!
A ticking bomb that has to be dismantled.” [Art Therapist]
In addition, therapists may wish to discuss the contents of the
artwork, as these children often find it difficult to express their
feelings verbally and, therefore, choose to act them out. Discus-
sion of these deeper issues is an additional way for therapists to
convey acceptance of the child’s inner world and to empathically
convey to them that they are understood. This discussion may also
be important as it provides an opportunity to promote change, by
bringing unconscious issues to the surface, processing them and
correcting distorted cognitions. Surprisingly, when therapists were
asked to describe their responses to aggression in their clients’ art-
work, they rarely mentioned having discussed the aggressive or
painful themes with the child. Supervisors, however, highlighted
the importance of this:
I don’t believe that there can be any therapy without words. To
work only via art and to think that art alone will do the job is an
illusion, in my opinion. . . This is a topic that is frequently dis-
cussed in supervision. I believe in combining the two. Creative
work needs to be followed by words. You need to talk about the
aggression, to give it meaning, to ask whether you come across
aggression in other places, and what happens to you in these
situations. [Supervisor]
Content can be discussed in art therapy on two levels: metaphor-
ically (where discussion is limited to the images and themes in
the artwork) or directly (where therapists point to connections
between the symbolic representations and the client’s own life).
The following example of metaphoric discussion was provided by
a supervisor:
I had a client who created a volcano and said, “It happens all
of a sudden, I have no control, I erupt, I destroy”. We discussed
it metaphorically. We talked about how hard it is for the vol-
cano, that people are afraid to get too close. We pretended to
be miners at the volcano. We gave it a questionnaire to fill out,
asking whether there are any signs before it erupts. He looked
in the mirror and saw how red he was in the face. . . We gave
the volcano suggestions on ways to control itself. [Supervisor]
Interventions following client aggression in the room
To respond effectively in this situation, therapists should have a
clear strategy in advance. A number of interventions may be applied
in a graduated manner, based on the child’s response. The main aim
of these interventions is to help clients understand the relationship
346 E. Nissimov-Nahum / The Arts in Psychotherapy 35 (2008) 341–348
between feelings, thoughts, and behaviors, while, at the same time,
conveying the message that aggressive behavior is not allowed. By
understanding the roots of the behavior, therapists can validate
the child’s motives and feelings. Therapists reported four stages of
verbal intervention for coping with aggression. First, reflecting the
child’s feelings:
I reflected his anger, in order to show him that I understand and
know the place that he is coming from, and I thereby attained
his cooperation. [Art Therapist]
Second, by interpreting the child’s behavior:
I said to him: “I can see that you want to give me a bad feel-
ing. You’d like to hurt me. Maybe you’re testing whether I can
withstand your attack.” [Art Therapist]
Third, therapists share their own feelings about the aggressive
behavior, in order to help the child develop empathy with victims:
I explained the feeling that it elicited in me. I tried to connect
him to feelings he experienced when he had felt attacked. [Art
Therapist]
Fourth, therapists suggest alternate solutions to the problem
that led to the aggression.
I brought up the incident, in order to talk about it together, to
examine his feelings and motives, and convey that there are
always other possibilities. [Art Therapist]
Apart from the above verbal interventions, the art therapists also
has a powerful tool for helping children to sublimate aggression,
via directing them to artwork, focusing on either the content of the
artwork or the art materials:
I suggested that we return to the creative activity, and continue
expressing his aggression toward me in the artwork. [Art Ther-
apist]
He received my permission to “destroy” other things, such as
dried up clay. [Art Therapist]
Finally, there are situations where the child is so upset that the
above interventions may not suffice. In such cases, therapists may
invoke their professional authority. A gradual set of responses may
begin with use of an authoritative tone of voice (“I responded in a
very assertive and clear-cut manner, that he cannot continue the ses-
sion this way, as I cannot allow him to hurt me or to destroy other
children’s artwork”), followed by reminding the child of the rules of
treatment according to the treatment contract (“I said, again, that in
the room we don’t ruin other children’s artwork”), and if these have
not been effective, then active responses, such as stopping an activ-
ity or even ending the session (“When she destroyed equipment, I
stopped her and sent her back to the classroom. When she tried to hurt
me physically, I told her that it is forbidden and I will not agree to it.”).
The above interventions reflect the application of the dialecti-
cal approach. Acceptance is conveyed when the therapist validates
the child’s underlying feelings and thoughts, and helps to under-
stand them rather than act them out. Change is facilitated when
the therapist helps the child to stop the aggressive behavior, pro-
cess thoughts and feelings, regain self-control, and find normative
ways of expressing frustration, anger, or helplessness.
Interventions for client aggression outside the treatment room
The dialectical approach of “conveying acceptance and direct-
ing toward change” may also be applied in this situation and may
be implicated in treatment effectiveness. In such cases, therapists
may wish to encourage clients to share the events that occur out-
side of treatment, in order to demonstrate their interest in all
aspects of their lives. When clients refrain from doing so, therapists
may need to become active and initiate the discussion, in order
for clients to see treatment as a place where they can both feel
truly accepted and also receive help in finding better ways to cope
with their difficulties. Although many therapists may be concerned
that such an intervention could arouse resistance on the part of
their clients, findings of the current study showed that in the most
improved cases, therapists did introduce this information and their
clients cooperated with them. Such interventions can enhance the
client’s sense of acceptance, as they demonstrate the therapist’s
unwillingness to continue a superficial relationship that is based
on concealment, as well as the therapist’s concern, openness, and
responsibility for helping the client to achieve change.
Introducing the external information can be done in a number
of ways. Therapists may organize a formal meeting with the client,
the teacher, and/or parents. Such meetings can be conducted on an
ongoing basis from the start of treatment, so that introduction of
external information becomes a routine and natural part of the pro-
cess. If such meetings are unfeasible, it may be possible to have brief
informal meetings with the child and the teacher, before or after the
child’s session, or to invite parents to the child’s session from time to
time. When such meetings are not possible, it may be inevitable that
therapists themselves will need to introduce information received
from a third party.
Regardless of the format of the meeting, therapists can seek
information about the aggressive incidents and provide clients with
an opportunity to present their point of view. Acceptance is con-
veyed when the adults express empathy for the child’s difficulties
and refrain from any form of blaming or criticism. In addition,
therapists may use this situation as a lever for promoting change,
via discussions that reflect clients’ feelings, help them to develop
empathy for the victim, and explore alternative solutions. Apart
from discussing the situation, therapists may also wish to direct the
child to various types of artwork. These activities convey acceptance
of the child’s feelings and also encourage change.
Interventions with the wider systems
Treatment effectiveness may be significantly enhanced when
therapists include teachers and parents in the process. These chil-
dren often push adults into one of two extreme responses: either
extreme caring and support or extreme emphasis on rules and
boundaries. This model supports Omer’s (1999) contention that
it is the therapist’s role to help parents and teachers strengthen
their authority and to develop a balanced approach that includes
both love and firmness. He also emphasizes, however, that it is not
enough to focus on attitudes and emotions. Therapists should also
provide teachers and parents with practical skills for managing the
child’s behavior, in order to create lasting change.
In this area, the dialectical approach is applied on two paral-
lel levels: the therapist applies it with teachers and parents, and
thereby serves as a role model, with the expectation that they, in
turn, will apply it also with the child. How may this be done? In
meetings with teachers and parents, the therapist may routinely
obtain information about the child’s behavior and their responses to
it, while at the same time validating their feelings and empathizing
with the difficulties that they encounter with the child.
Ever since I learned to stand by their side, and I understood
the pain that they had experienced over the years, my work
with parents of aggressive children has gone smoothly. In the
past, I failed, when I expected parents to accept their child, and
I ignored their pain resulting from his aggression. [Art Therapist]
Once a positive relationship has been established with teachers
and parents, therapists may also wish to share their own expe-
 E. Nissimov-Nahum / The Arts in Psychotherapy 35 (2008) 341–348
riences with the child, in order to highlight the child’s strengths,
difficulties, and inner world. Therapists may consider which infor-
mation is most likely to help them understand the child and change
their perceptions, so that they become more empathic toward the
child, without betraying the child’s confidentiality.
I helped the teacher to see him in a different light. She felt
that it helped her understand him in the most difficult times,
when he was smelly and filthy and drove the other children
crazy. . . It helped her to see him and be empathic toward him.
[Art Therapist]
Therapists should also provide teachers and parents with practi-
cal recommendations for creating change. These may include ways
to cope with emotional responses to the child in order to promote
their own self-control, ways to accept the child by encouraging
pleasurable activities, reinforcing positive behaviors, and validat-
ing the child’s feelings and difficulties. Therapists may also offer
practical advice on ways to modify the child’s behavior, such as
activities for releasing aggression and ways to talk to children and
help them to find alternative solutions to aggressive behavior.
Therapists’ coping with personal experiences
In this challenging area, too, applying the dialectical approach
may be associated with positive treatment outcomes. The study
found that when therapists could identify and connect with their
own aggression, they were likely to be less intimidated by their
clients’ aggression and more able to accept them and to maintain
their sense of professional competency. In addition, when thera-
pists were able to identify personal life experiences in which they
coped with aggressive impulses, they were better equipped to help
others who were struggling with similar issues. That is, when ther-
apists learn to recognize (accept) and control (change) their own
aggression, they appear to be better able to help clients do the same.
I can connect to the feeling that “I’ll ruin everything and I don’t
care what happens.” The only thing that helped me to stop
destroying things was my own therapy. It was as if I didn’t care,
but I really did. I could identify with the moment of eruption,
how good it feels when you release the anger. I could also see
the price you pay. What happens to you as a result of what you
do to others. [Art Therapist]
Poor outcomes, however, may be associated with difficulties
that therapists have in dealing with their personal experiences.
When therapists have not worked through and accepted their
own aggression, they may be unable to identify, understand, and
empathize with their clients’ aggression. Consequently, they may
perceive the child’s aggression as a major threat that can lead to role
confusion: they may feel small or victimized in relation to the client,
which can weaken their professional authority and competence.
Alternatively, they could go to the opposite extreme and respond
to the child with great rigidity and even aggressively. Just as they
have not been able to accept these parts in themselves, they find it
difficult to help their clients accept them and change their behavior.
Based on the understandings that have emerged in this study,
supervisors too may help to promote acceptance and change in
therapists and also help them to examine whether they are pro-
viding a suitable balance of acceptance and change to their clients,
teachers, and parents. They can convey acceptance by helping ther-
apists to become aware of their feelings toward the client and to
identify their own experiences of aggression. Supervisors can also
direct therapists toward change. First, they can help therapists to
understand how their feelings and behavior are connected to the
client’s aggressiveness and to separate their own personal issues
from those of the client. Second, they may provide critical insight
347
into important client dynamics, leading to more empathy for clients
as well as better understanding and empathy for the experiences
and reactions of others in the child’s life. Third, supervisors also
often help therapists to examine how their own experiences with
handling aggression and developing self-control may serve as a
resource in working with aggressive clients. Finally, professional
supervision may help therapists to acquire more specific knowl-
edge and skills so as to become more effective with aggressive
clients.
Discussion
The model presented here offers a dialectic approach to treat-
ment of a population that art therapists have found difficult to treat.
Therapists’ reports indicate that they lack knowledge and skills for
treating aggressive children in educational settings, that they do
not fully understand the connection between their interventions
and treatment outcomes, and that treatment is often only partially
effective. The significance of this model relates to the fact that it
emerged from the experience of therapists in the field via a com-
parison of their most and least improved cases.
Although the therapists did not generally present themselves
as following any particular therapeutic approach, examination of
their interventions reveals elements that may be found in sev-
eral approaches. The dialectical approach of “conveying acceptance
and directing toward change” may be found in Dialectical Behavior
Therapy (DBT; Linehan, 1993), which is a structured approach that
explicitly emphasizes “radical acceptance” and focused change.
Strategies that focus on the importance of the treatment rela-
tionship, free expression, and processing of the therapist’s own
experiences stem primarily from the psychodynamic approach.
Interventions that focus on changing cognitions and behavior have
been developed within the framework of cognitive-behavioral ther-
apy (CBT), while systems approaches offer ways to view problems
and intervene within the context of the family and the educational
system. Since childhood aggression has multiple causes, it makes
sense that treatment should utilize a multi-dimensional approach.
This paper presents a broad conceptual model that deepens
our understanding of effective therapeutic processes. This model,
which emerged from the analysis of therapists’ practices and expe-
riences, has been extremely useful in reflecting on this author’s own
cases, in supervision of other therapists, and in training new thera-
pists. It provides a lens through which to reflect on treatment pro-
cesses and helps to understand the source of difficulties and areas
that may need to be strengthened. The model proposes broad treat-
ment principles which may be applied in many creative ways in var-
ious settings. There is need, however, for further research to exam-
ine the model’s relevance to other contexts and to study whether
all the elements of the model need to be applied for treatment to
succeed or whether it may be enough to apply only some of them.
Acknowledgements
I would like to thank all of the art therapists and supervisors
that participated in the study, who generously shared with me their
experiences and professional knowledge, without which I could not
have conducted the study and arrived at the understandings that
resulted from it. I would also like to thank my supervisor Dr. Angela
Jacklin at the University of Sussex for her patience, guidance, and
support that were crucial in helping me to conduct the study and
develop the model. Many thanks also to Dr. Mark Waysman, for his
patience and creativity in assisting me with editing and translation.
Finally, I would like to thank the Mofet Institute for its support in
the preparation of this manuscript.
348 E. Nissimov-Nahum / The Arts in Psychotherapy 35 (2008) 341–348

Appendix A. Clinical implications of the conceptual model

Conveying acceptance Directing to change

Treating the child - Establishment of a positive relationship based - Focusing goals of treatment on behavior
on empathy and validation change
- Encouraging free creative expression in - Use of professional authority to set limits on
artwork aggressive behavior
- Expressing enthusiasm and appreciation for - Intervening in the creative process to help
artwork develop self-control
Discussion of the aggressive behavior inside or
outside of the room
- Helping child to explore alternative behaviors

Work with the wider systems - Conveying a sense of belonging to the school
system
- Establishment of a positive relationship based
on validating and empathizing with teachers’
and parents’ difficulties with the child
- Explanation of the child’s inner world
- Demonstrating the child’s strengths and
difficulties
Coping with personal experiences - Recognition and acceptance of own
aggression
- Fostering a shared sense of responsibility for
solving the problem
- Helping to understand and accept the child
and providing skills for coping with the
problem behavior
- Separation of personal issues from the child’s
needs
- Accessing personal resources for coping with
aggression
- Acquisition of new skills for treating
aggressive clients

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