Original title: Zur aktuellen Situation der Kunsttherapien. Merkurstab 1995; 48: 346-51. English by J.Collis.

Art therapies are developing and changing although within the range of modern medicine as a whole they are relatively old and established compared to the variety of new drugs and surgical procedures now appearing on the scene. Hardly any of the drugs now available existed in the 1920's or 1930's, precisely the time when a modest beginning in art therapy was being made.

Introducing art therapy into the medical practice of the 20th Century was a pioneering achievement of anthroposophical medicine. The use of color, painting or sculpting, music or speech, and of the qualities of movement in therapy goes back to Rudolf Steiner's research and suggestions. His pupils, physicians, curative teachers and artists (Ita Wegman, Margarethe Hauschka and many others) took up his ideas and put them to clinical use, gathering experience and developing them further.

Independently from the anthroposophic situation in Europe, work with art therapies also began in the United States during the 1930's, first with children and later also with adults. The pioneers of American art therapy were Margaret Naumburg, Edith Kraemer and Elenor Ulman. The National Institute of Mental Health in the USA has cataloged a vast literature on the fundamentals and application of art therapy methods. The profession of art therapist has been recognized in the USA since 1960.

At that time, new developments were also brought about in connection with non-anthroposophic medicine in Europe by psychiatrists and psychotherapists interested in art. Courses or further study seminars in art or music therapy are now available at a number of universities or academies in Germany.

Art, music and movement therapies are mainly used in psychiatry, psychotherapy and for psychosomatic conditions. They are also applied, though much more rarely, in oncology or for a few other chronic physical conditions. However, the range of clinical use has widened considerably over the last few years, so that it is now almost impossible to catalog all the possibilities. Numerous suggestions have been made to differentiate among the various approaches, and the anthroposophical approach is always included among several others. The literature distinguishes among:

1. the anthroposophical approach,

2. the expressive and experiential approach,

3. the analytical and depth psychology approach.(1)

More pragmatically: "The psychiatric approach, the art education approach, the special education approach, the psychotherapeutic approach, the anthroposophical approach, the receptive approach and the integrative approach" in art therapy."(2)

Although a vast amount of literature on art therapy already exists (the Salzburg catalog alone lists over 1000 titles in German) there are, so far as we know, hardly any convincing studies on the effectiveness of art therapies(3) nor scientific accounts of their efficacy. The reasons for this lie in the situation itself, i.e. use of art or artistic methods in conjunction with conventional medicine and its scientific methods which go in the opposite direction to the individual nature of art therapy.

The current situation for art therapy and therapists is as follows: Experience has been gained for decades with art therapy in psychiatry, psychotherapy, for psychosomatic and also some physical conditions. A tremendous range exists of publications, basic descriptions, theoretical reasoning, and clinical reports. In every field of art therapy increasing numbers of practitioners with varying backgrounds have trained in art, psychology, psychotherapy, art education, anthroposophical and other special education, as well as the medical, social or caring professions. The number of training opportunities and courses at private establishments, specialist colleges, universities and academies is growing all the time. There are insufficient, though growing, numbers of openings for art therapy work at clinics (especially psychiatric, psychosomatic and psychotherapeutic clinics), in rehabilitation units, nursing homes and sanatoria, in old age homes, in curative and special homes as well as prisons and detention centers.

With a situation as dynamic as this it is perhaps surprising that the profession of art therapist is neither protected nor officially recognized in Germany. In Germany, training as an art therapist in private or public courses does not lead to any recognized therapy or medical diploma. There are no regulations governing the use of the designation 'art therapist'; on the other hand, it is not forbidden to call oneself an art therapist.

The fact that art therapists are not recognized under federal law does not mean that their work cannot be paid for by the statutory medical insurance companies. It is the job of those who represent the interests of art therapists, i.e. their professional associations, to negotiate payment by the insurance companies. The German Anthroposophical Medical Association has joined forces with the Association of Anthroposophical Art Therapists and the Association of Eurythmy Therapists to work on getting the profession of anthroposophical art therapist officially recognized.

The legal situation in Germany As described above, the legal situation in which art therapists find themselves in Germany has not yet been fully clarified. There are positive as well as negative aspects to this.

On the negative side, the profession is not recognized, the code of practice is not standardized, and above all payment by the statutory medical insurance companies is not guaranteed. On the positive side, the lack of regulations or laws means that, although there is a lack of protection, there is also a great deal of freedom for committed art therapists to develop their own personal methods, to make their own arrangements, and to engage in creating their own organizations.

This applies to all art therapists whatever training they have undergone. For those working in hospitals or similar institutions the legal and financial situation is very much better than for those running their own practices.

Although there is no country-wide recognition of art therapy as a profession or medical specialty and therefore no legal security for the therapist's work, i.e. the art therapist does not have official permission to practice, nevertheless there appears to be no plan to curtail or outlaw the activities of art therapists in hospitals or in their own practices. On the contrary, the number of art therapists seems to be increasing all the time while the good reputation of art therapy and the therapists themselves continues to grow. This is surely due to the committed, convincing and successful therapeutic activities of the art therapists themselves. Nevertheless the question remains: to what extent should therapists be allowed to work independently with patients and to what extent should physicians refer patients to them on the basis of their medical diagnosis and therefore take a share in the responsibility?

The fundamental question behind this is: should it be possible at all for art therapists to work with patients independently and on their own responsibility on the basis of the training they have received and the legal precautions they have entered into? Or, because of their training and the legal precautions, should they work only work with patients referred to them by a physician who has made the diagnosis and given indications and who therefore bears the responsibility? The latter would place the therapists in the category of auxiliary medical specialists like physiotherapists, speech therapists and, as the law now stands, also psychotherapists. At present there are only two legally-recognized healing professions in Germany that can work independently: the physician and the Heilpraktiker, a non-medically qualified practitioner.

Legally, the situation is quite clear: apart from physicians and Heilpraktiker no one is allowed to practice a healing profession, i.e. treat patients, independently. Others wishing to work therapeutically with patients may only do so as "instruments" of physicians, following their indications or prescriptions. The physician has supervisory responsibility and must see that the patient comes to no harm as a result of the therapy. The degree of medical "supervision" exercised by the physician depends on the seriousness of the condition and the intensity of the prescribed therapy.

The supervisory obligation applies equally in connection with all the auxiliary medical specialists. Only non-medical psychotherapists (psychologists), to whom patients are referred by a physician, enjoy a greater degree of freedom and, thus, a greater responsibility over against the referring physician. All others (art therapists, masseurs, physiotherapists, speech therapists etc.) are responsible only for carrying out their work correctly, while the referring physician is responsible for seeing that the prescribed treatment is clinically relevant and not harmful or contraindicated. If necessary, the physician must take steps to ensure that the therapy prescribed is carried out in a suitable manner. This applies equally to recognized auxiliary medical specialists and to unrecognized art therapists.

The legal regulations apply to the protection of the detailed description of the profession and of the professional title, not the protection of the sole (conditional) permission to practice a particular activity. Conditional (sole) permission to practice a healing profession applies only to physicians, Heilpraktiker (non-medically qualified practitioners), and in obstetrics to midwives and physicians.

Unscrambled, this means: at present, anyone can call him- or herself an art therapist because the detailed description of the profession is unprotected, and anyone can practice art therapy so long as this is done in accordance with a physician's directions. There is some guarantee that the therapy is being carried out in accordance with recognized rules if the art therapist has had appropriate training or belongs to a professional association for which membership is conditional upon having undergone such training.

Markus Treichler MD

Dept. of Psychosomatic Medicine

Art Therapy and Eurythmy Therapy

Filderklinik

D-70794 Filderstadt

Germany

References 1 Handwoerterbuch der Psychatrie, Stuttgart 1992, p.295.

2 Aktuelle Tendenzen in der Kunsttherapie, Stuttgart 1993.

3 Ute Hallaschka Zur Entwicklung ernes Studiendesigns fuer anthroposophische Kunsftherapie, Stuttgart 1994.