Introduction

Art therapy provides an alternative and integrative strategy for accessing and expressing psychological material that may be inaccessible through language, particularly for individuals whose capacity for verbal articulation is compromised. This is especially salient in forensic mental health contexts, where interpersonal trust is often tenuous and strict hierarchies exist between staff and inmates/patients, and a culture where showing vulnerability or intense emotion can feel unsafe. Under such conditions, individuals tend to guard themselves; prisoners may cope through emotional suppression and disengagement as a means of survival. Within these environments, the creative process offers a symbolic and relational conduit for self-exploration, enabling clients to engage with dissociated or overwhelming internal experiences within a contained and supportive therapeutic space (Abbing et al., 2023).

Australian forensic mental health hospitals typically serve individuals found not guilty by reason of mental impairment (NGMI), many of whom have committed serious offences while experiencing psychosis. These secure settings are primarily populated by individuals with chronic psychotic illnesses, most commonly schizophrenia, who present with enduring disturbances in thought, affect, perception, and interpersonal functioning. While pharmacological treatment remains foundational, many individuals continue to experience residual symptoms such as paranoid ideation, disorganised cognition, flattened affect, and profound emotional isolation (Killick, 2017; Ruddy et al., 2005). Moreover, forensic inpatients often have complex trauma histories, are subject to the long-term effects of institutionalisation, and must contend with the social stigma associated with both mental illness and criminality. These contextual and clinical complexities necessitate therapeutic approaches that are both psychologically robust and relationally sensitive.

Within this framework, psychodynamic art therapy emerges as a modality uniquely positioned to address the multilayered needs of this population. Informed by psychological principles, this approach does not aim merely at symptom reduction but instead facilitates the symbolic expression and integration of unconscious material, emotional insight, and relational repair. Art-making provides a multisensory, embodied form of communication, particularly vital for individuals experiencing disturbances in linear thought or verbal coherence as characteristic of psychosis (Chiang et al., 2019; Montag et al., 2014). Symbolic forms serve as both containers and communicators of internal states, allowing the individual to externalise affective material safely while beginning to reflect upon it from a distance. In the transformation phase, the client, often with the therapist’s attuned support, begins to engage reflectively with the imagery. Here, meaning is not imposed but emerges through dialogue with the artwork, allowing for the re-symbolisation of traumatic or chaotic inner experiences. Finally, in the internalisation phase, the insights, emotional shifts, and relational experiences generated within the therapeutic space are gradually integrated into the client’s evolving internal world, supporting a more cohesive and resilient sense of self.

This case study is grounded in Johnson’s (1998) psychodynamic model, which conceptualises therapeutic change through the interrelated processes of internalisation, re-collection, and moral constraint. Within this framework, the client’s artistic expressions are viewed not merely as projections, but as symbolic enactments that enable the re-collection of dissociated or unconscious material. The artistic process functions as a holding environment, akin to Winnicott’s (Caldwell et al., 2017) transitional space, where dissociated or defended material can be expressed safely. As the client engages reflectively with the artwork, often with the therapist’s empathic presence, these images are not interpreted didactically, but explored dialogically. Through this reflective process, new meanings emerge, supporting the internalisation of insight, emotional regulation, and relational understanding. The therapeutic space fosters the gradual development of moral constraint, where the client begins to integrate emerging ethical, relational, and self-regulatory capacities, strengthening a more coherent and resilient sense of self.

Integral to Johnson’s model (1998) is the therapist’s role in maintaining a stance of non-intrusive attunement, facilitating connections between verbal and non-verbal domains without imposing interpretation. This aligns with broader psychodynamic principles of containment (Bion, 2023) and the therapist’s use of self. Drawing on Isserow’s (2008) conceptualisation of the therapeutic triangle, the relationship between client, therapist, and artwork is understood as a triadic structure sustained through joint attention, a shared focus that supports relational attunement and meaning making. In forensic settings, where direct interpersonal engagement may evoke defensiveness or mistrust, the artwork functions not only as a mediating object, but as a shared point of reference that facilitates co-regulation and emotional safety. It enables the client and therapist to engage together in looking and reflecting, allowing affect to be encountered symbolically and relational connection to be established without the perceived threat of direct confrontation or intrusion.

The literature supports the use of psychodynamic art therapy in populations experiencing psychosis, noting that symbolic and non-verbal expression can circumvent some of the cognitive and relational barriers encountered in verbal therapies (Killick, 2017). Symbolic imagery has been shown to facilitate emotional regulation, support narrative coherence, and enable clients to access fragmented or pre-verbal aspects of the self (Montag et al., 2014). In forensic contexts specifically, art therapy has demonstrated utility in addressing key rehabilitative domains such as aggression management, offence-related reflection, and identity integration (Gussak, 2015; Smeijsters et al., 2006). Through symbolic distancing, clients can explore morally complex or shame-laden material in a way that reduces the risk of retraumatisation or defensive collapse.

Gussak (2015) asserts that art therapy enables incarcerated individuals to indirectly address offence-related content, thereby fostering the development of empathy, moral reasoning, and self-insight. The symbolic nature of art serves as a conduit for clients to explore complex emotions and experiences in a non-threatening manner, facilitating personal growth and rehabilitation. The symbolic nature of the medium facilitates what Hinz (2020) terms “reflective distancing” (p.31), whereby the client can engage with difficult material from a safer vantage point. This distance provides clients with the opportunity to process and reflect upon their experiences without becoming overwhelmed, enhancing the therapeutic process.

Killick (2017) proposes that art therapy can support a cohesive principle within the psyche, offering a means for individuals with psychosis to symbolically bridge fragmented inner experiences and move toward a more integrated sense of self. Through creative expression, clients can externalise and organise their thoughts and feelings, contributing to improved self-understanding and integration. Chiang et al. (2019) highlight the therapeutic efficacy of imagery in art therapy, noting that it enables clients to access and express emotionally charged themes, such as persecution, abandonment, or guilt, which might be difficult to articulate verbally. This non-verbal approach allows for the exploration of complex emotions in a manageable and supportive context.

Despite a growing body of international research, there remains a notable paucity of literature examining the application of art therapy within Australasian forensic mental health settings. Specifically, in-depth, qualitative case studies that elucidate therapeutic process, relational dynamics, and symbolic transformation are underrepresented. As Willemsen et al. (2017) argue, single-case studies provide a vital contribution to clinical knowledge by offering granular insights that broader, outcome-focused methodologies may overlook. These studies illuminate the micro-processes of therapeutic change and foreground the relational and symbolic nuances that define complex clinical work.

This paper addresses this gap by presenting a detailed case study of psychodynamic art therapy provided to a forensic inpatient diagnosed with schizophrenia, highlighting the clinical, ethical, and relational dimensions of the work. Particular attention is given to the role of symbolic expression, therapeutic containment, and image-based meaning-making in fostering psychological integration. Ethical considerations, especially around consent, confidentiality, and institutional surveillance are also critically examined, alongside the art therapist’s reflexive positioning and the necessity of robust clinical supervision. In doing so, this inquiry advocates for the broader integration of psychodynamic art therapy within trauma-informed forensic rehabilitation frameworks, and contributes to the growing recognition of creative, relational modalities as essential components of forensic mental health care.

Therapeutic context and art therapy process

The art therapy sessions were facilitated by the first author, a registered art therapist employed as the sole art therapy clinician across several units within a high-security forensic mental health hospital. Working in this complex setting required the therapist to be attuned not only to individual clinical presentations, but also to the rhythms and demands of institutional life. The second author offered academic supervision, ensuring the case study was articulated rigorously and in alignment with contemporary research frameworks, while also supporting critical reflection on the therapist’s role and positioning. Throughout the 18-month intervention, the art therapist received regular clinical supervision from the third author, an occupational therapy educator with extensive experience in forensic mental health. This supervision provided an essential reflective space, where clinical choices, relational dynamics, symbolic themes, and ethical questions could be explored in depth. The fourth author is an occupational therapy educator and researcher who supported the writing process and ensured the case study adhered to organisational requirements.

As part of the allied health team, the art therapist worked collaboratively with colleagues from other disciplines while maintaining the unique voice and values of the profession. At the time of referral, Sebastian (a pseudonym) was not engaged in any other psychological therapies. He had previously declined psychological support, and art therapy was offered as an optional space free from diagnostic scrutiny and therapeutic demand where creative expression could unfold on his own terms. Participation was entirely voluntary, and all sessions were documented in his clinical record. Prior to inclusion in this case study, Sebastian gave written consent for his experience to be shared in a de-identified format, following a collaborative and transparent consent process.

Approval for the project was obtained from hospital management and the relevant forensic research committee. Informed consent was secured in accordance with organisational and journal requirements, with a signed physical consent form provided by the participant. To protect confidentiality, all identifying information was removed and a pseudonym (“Sebastian”) was assigned.

Sebastian is a white man in his early 40s, with a long-standing diagnosis of schizophrenia and an extended history of inpatient care. Sebastian was found not guilty due to mental impairment of committing homicide. He has been receiving treatment within the service for approximately five years. At the time of referral, he had transitioned from an acute to a rehabilitation unit. He was described by his treating team as socially withdrawn, cautious with new relationships, and reluctant to engage in verbal therapeutic formats. While he occasionally attended recreational art groups, he had not previously engaged in one-to-one art therapy or therapeutic image-making. His team identified art therapy as a potentially accessible way for him to explore inner experiences without the pressure of verbal articulation.

Sessions took place in a dedicated art therapy room within the hospital’s rehabilitation unit. This space had been intentionally designed to feel distinct from clinical environments, with warm natural light, colourful murals, and a patient-curated gallery wall that subtly disrupted institutional norms and invited agency. The room was adjacent to the main lounge, offering both accessibility and psychological separation from daily unit routines. Its layout and atmosphere supported therapeutic safety and creativity, qualities often difficult to sustain in carceral spaces.

Sebastian attended weekly one-hour individual art therapy sessions over an uninterrupted 18-month period. The consistency of time, space, and relational presence was crucial, especially given Sebastian’s experiences of paranoia, cognitive fragmentation, and sensitivity to rupture. Sessions followed a semi-structured rhythm, typically including a settling period, time for art-making, and space for shared reflection, while remaining responsive to the client’s needs in the moment. Despite his earlier reluctance to engage with therapy, Sebastian attended 95% of scheduled sessions, a significant indicator of relational trust and therapeutic alliance.

A wide range of materials was available, introduced gradually and in collaboration with Sebastian. These included oil pastels, coloured pencils, graphite, watercolours, acrylics, collage materials, clay, marbling inks, and fine-line markers. Materials were selected not only for their expressive potential but also for their sensory qualities and capacity to support regulation. For example, oil pastels provided rich texture and immediacy, while marbling inks offered calming, fluid movement, often used when Sebastian felt emotionally distant (Hinz, 2020). Observations of how Sebastian engaged with different materials informed therapeutic choices, always with an emphasis on offering, not imposing, possibility. Supporting Sebastian’s autonomy in material selection fostered a sense of agency within the structured holding of the session.

The therapist adopted a stance of respectful curiosity, inviting exploration without interpretation. Simple prompts such as “What kind of tree would you be today?” often opened space for metaphorical dialogue that bypassed more defended cognitive processes.

Sessions flowed between verbal and non-verbal modes of engagement. At times, silence was held gently as part of the creative rhythm. Religious imagery, which frequently appeared in Sebastian’s work, was approached with sensitivity and care, acknowledging its personal meaning and the role it played in his worldview. Clinical supervision was instrumental in supporting the therapist’s navigation of transference, countertransference, and the emotional impact of working with complex content in a high-security setting.

Reflections on the art therapy relationship

Sebastian did not enter art therapy with ease or enthusiasm. His prior experiences with mental health services had left him wary, questioning, and understandably cautious. Within the forensic setting, where surveillance and documentation are ever present, relational mistrust is not merely a clinical symptom, it is often a rational response to the environment. Early in the sessions, he asked pointed questions: “Do you write everything down?” and “Will this go in my file?” These moments revealed not only his apprehension but also the vigilance required to navigate systems that often conflate care with control. For many clients in forensic contexts, trust is not assumed, it is carefully tested, and slowly, sometimes painfully, earned.

As time passed, subtle shifts in Sebastian’s language reflected an emerging sense of safety and belonging. He began to differentiate the art therapy space from the broader institutional environment. He would say that it felt quieter compared to the rest of the unit. This comment spoke not only to the physical qualities of the room but also to the psychological container co-created with the therapist. The studio became, in Winnicottian terms, a potential space, a transitional realm in which play, imagination, and authenticity could emerge without the fear of surveillance or judgment (Caldwell et al., 2017). It was in this space that Sebastian began to speak, through image, gesture, and colour about parts of himself that had long remained hidden.

Over time, Sebastian developed a symbolic language through art that enabled emotional expression and self-reflection. He began assigning colour to mood. For example, on one occasion he said he “felt like using purple today”, linking the hue with spiritual introspection. “Green and blue calm me down”, he noted during another session. These associations reflected an intuitive connection between colour and emotion, one that resonates with the sensory-affective level of Hinz’s (2020) Expressive Therapies Continuum. As he built this internal palette, Sebastian found a way to name feelings that previously eluded language. His capacity for emotional literacy grew, not through instruction, but through the invitation to notice and make meaning from within.

Themes of guilt, shame, and moral injury gradually surfaced in the sessions, as they often do with forensic clients. These themes emerged not through confession, but through imagery. In one session, after looking at Picasso’s Weeping Woman, Sebastian remarked, “That could be me. Or them. Maybe both.” His comment reflected an ambiguous identification with both victim and perpetrator, a dialectic that many clients in forensic settings grapple with but rarely articulate. As Carolan and Backos (2017) observe, art can be ambiguous, allowing multiple, even conflicting, self-states to coexist within a single image. In that moment, the artwork provided a safe place to feel something otherwise unspoken – grief, remorse, confusion – without the need for resolution or defence.

This image became a point of return in later sessions, a visual touchstone to which Sebastian came back when words failed. When the therapist asked him how it felt to revisit it, he spoke about it like it was scratching an itch he didn’t know he had. Again, his language offered profound insight into the affective reality of the therapeutic process. There was a need to reach beneath the surface, but also a cost. This reflects the psychoanalytic notion of working through, the repeated, emotionally invested revisiting of painful material that, over time, allows for its gradual metabolisation (Hock & Scarfone, 2024).

What stood out across the sessions was Sebastian’s appreciation for the freedom art therapy offered, commenting that he could create what he wanted. In contrast to the structured programs and assessment-driven interventions that often characterise forensic rehabilitation, the open-ended, client-led nature of art therapy provided a welcome reprieve. His experience aligns with the person-centred foundation of art therapy, in which the client’s subjective world is held as central, and their innate potential for healing is both trusted and respected (Rubin, 2016).

Sebastian’s sense of humour also emerged as a meaningful part of the therapeutic process. Following a particularly heavy session exploring the death of his mother, he created a sculpture of a comic book villain and burst into laughter (Figure 1). Sebastian’s sculpture was made out of toilet rolls that he painted red, blue and yellow. He named his sculpture Magneto, referencing the comic book character from X-Men. Magneto is a mutant who has the ability to manoeuvre magnetic fields. Magneto is super powerful and is able to control his surroundings.