Open Access
Published: June 2025
Licence: CC BY-NC-4.0
Issue: Vol.20, No.1
Word count: 5,054
About the authors
Creating space for meaning: Exploring emotional integration through psychodynamic art therapy in forensic mental health
Abigail Reisner, Theresa Van Lith, Danielle Ashley and Lorrae Mynard
Abstract
This case study explores the role of psychodynamic art therapy within a high-security forensic mental health hospital in Australia, focusing on its potential to support emotional integration, relational safety, and self-understanding for individuals living with complex mental health needs. The paper follows the therapeutic journey of Sebastian, a man in his 40s diagnosed with schizophrenia, who participated in weekly art therapy over an 18-month period. Within a setting often shaped by mistrust, surveillance, and the challenges of psychosis, art therapy offered a non-verbal, symbolic space where Sebastian could engage with themes of identity, guilt, spirituality, and trauma. Grounded in Johnson’s psychodynamic model of internalisation, re-collection, and moral constraint (1998), the work evolved through symbolic imagery, collaborative art making, and attuned relational presence. Key therapeutic processes, such as transference, countertransference, and the dynamic relationship between client, therapist, and artwork are explored to illustrate the subtle interplay of containment, expression, and insight. Outcomes highlight increases in emotional literacy, symbolic communication, and relational trust. Reflections consider the importance of sustained supervision, therapist reflexivity, and ethical sensitivity in forensic practice. This study offers insight into how creative, relational approaches can gently support psychological integration within trauma-informed models of forensic rehabilitation.
Keywords
Psychodynamic, forensic, symbolic, relational, integration
Cite this practice paperReisner, A., Van Lith, T., Ashley, D., & Mynard, L. (2025). Creating space for meaning: Exploring emotional integration through psychodynamic art therapy in forensic mental health. JoCAT, 20(1). https://www.jocat-online.org/pp-25-reisner
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.
Figure 1. Sebastian, Magneto, mixed media, dimensions unknown.
This shift in tone was not seen as a rupture, but as an authentic way of moving between affective states. Liddell (2012) argues that humour in therapy can function as a reparative force offering relief, reframing trauma, and asserting agency over overwhelming emotion. In Sebastian’s case, humour became a tool for resilience and regulation, one that bridged sorrow with creativity. The role of humour continued to be a feature within the work together. In a later session, Sebastian’s beliefs about his birth mother were explored. He reflected that he didn’t believe his mother was his birth mother. Sebastian described her appearance, and the therapist drew an image of her (Figure 2). Sebastian laughed at the depiction of his mother. This collaborative process used the artwork as a tool for connection and understanding, showing “visual empathy” (Nash & Zentner, 2023, p.85) towards the client. Laughter played a significant role in this encounter, creating an opportunity for relief and reframing of an otherwise challenging topic.
Figure 2. Art Therapist, Therapist’s image of Sebastian’s mother, charcoal and pencil on paper, 297 × 420mm.
Sebastian often described his experience in art therapy as “peeling back the scab”, a strikingly visceral metaphor that became a shared touchstone throughout the work with the art therapist. For him, this phrase captured the paradoxical nature of the therapeutic process: the discomfort of exposing old wounds, coupled with the relief of allowing them to breathe. It was not a phrase offered once in passing, but a recurring articulation of how therapy felt sometimes painful, sometimes necessary, always revealing. In many ways, his language mirrored a core psychodynamic principle: that therapeutic change often arises through the slow, supported surfacing of unconscious or defended material, which can then be held, processed, and integrated within the safety of the therapeutic frame (Gilroy & McNeilly, 2000).
In the final months of the work, Sebastian expressed that he enjoyed the sessions because they gave him someone to talk to about art, and in that moment, he felt transported away from the unit. He explained that creating helped with getting out of his head and into the picture. His words encapsulated a deepening awareness of the relationship between internal experience and external expression. His growing engagement with the process revealed key signs of therapeutic progress such as the capacity to reflect, to name experiences, to symbolise emotions, and to share them with others. Within the constraints of a secure forensic environment, art therapy had become a space not only of expression, but of transformation.
Relational tailoring in art therapy practice
Tailoring in art therapy is best understood not as a procedural adaptation but as a dynamic, relational act, one that unfolds in response to the client’s shifting internal world. Johnson (1998) conceptualised the therapeutic action of the creative arts as arising through a psychodynamic interplay of opposing forces such as structure and spontaneity, or containment and freedom. Within this view, tailoring becomes an ongoing negotiation shaped by affective rhythm, sensory readiness, and the level of relational closeness the client can tolerate. In Sebastian’s case, whose inner world was deeply impacted by schizophrenia and the isolating routines of institutional life, tailoring involved continuous attunement to his verbal and non-verbal cues, emotional states, and the often-ambiguous symbols that emerged through his artwork.
Rather than implementing predefined strategies, each session was developed with an awareness of Sebastian’s evolving needs. Trauma-informed care principles (Department of Health, Victoria, 2022) underpinned this work, emphasising consistency, transparency, and choice. Each decision around art materials, seating arrangements, or thematic invitations was approached with care. These were not minor logistical details, but opportunities to co-create safety and autonomy. When Sebastian expressed feeling watched while working, for instance, the art therapist gently repositioned the chairs so they could sit side-by-side. This subtle shift eased the pressure of direct observation and supported a more equal, companionable dynamic, reinforcing a sense of trust and emotional safety.
The choice of materials became another essential way of responding to Sebastian’s momentary needs. On days when he described himself as feeling twitchy or not right in the head, the therapist offered fluid and tactile materials such as marbling inks. These materials were not only calming to observe and manipulate but also acted as sensory anchors. They helped Sebastian remain engaged without overwhelming his cognitive capacity.
Johnson’s theory (1998) reminds us that art can act as a symbolic container for feelings too difficult to express in words. In one session, after experimenting with watercolours, Sebastian remarked that the colours reminded him of a “comfortable place” (Figure 3). Though he did not name this place directly, the sensory and symbolic experience seemed to connect him with a moment of calm, bypassing conscious memory and providing a form of implicit regulation.
Figure 3. Sebastian, Untitled, watercolour on paper, 297 × 210mm.
Tailoring also took the form of metaphor and imaginative prompts, which provided access to aspects of Sebastian’s identity that might have otherwise remained out of reach. When invited to imagine himself as a type of tree, Sebastian initially said he would be a shrub. After a moment of reflection, however, he changed his mind, saying he would like to be a large, 200-year-old oak tree quietly watching the world from a distance. This shift in imagery suggested not only a yearning for resilience and stability, but also revealed a capacity for playfulness and insight. The artwork he created that day, a bright, eccentric “alien tree” (Figure 4), spoke to both his sense of otherness and his creative inner life. In this space, metaphor became a language through which contradictory self-states could be expressed without judgment.
Figure 4. Sebastian, Alien Tree, watercolour and pencil, 297 × 420mm.
Sebastian’s unique system of symbolism soon became a compass for relational pacing. Recurring numbers, colours, and phrases formed a shared visual language between him and the therapist. Rather than interpreting these elements in a clinical sense, the therapist chose to mirror them in conversation and artwork, allowing Sebastian to lead the meaning-making process. This approach honoured his internal logic and emotional timing. Johnson (1998) emphasises the importance of working within the client’s symbolic frame, allowing therapeutic meaning to arise gradually, rather than being imposed. In Sebastian’s case, this meant resisting the urge to decode his repeated mathematical equations and instead treating them as stabilising anchors amid psychological uncertainty.
Adaptation extended to the structure of therapeutic activities. When a timeline activity elicited anxiety due to gaps in memory and the disorientation of institutionalisation, the therapist proposed a comic-strip format. The structured panels created a sense of sequence and containment, making it easier for Sebastian to revisit difficult experiences without becoming emotionally overwhelmed. This method, often used in trauma-informed graphic storytelling (Hagert, 2017), allowed him to engage with autobiographical material at a safe distance. One resulting comic (Figure 5) featured a surreal narrative involving magic mushrooms, a tennis star, and a wedding in the Swiss Alps. While fantastical, the imagery offered rich insight into his longings, coping strategies, and fractured yet resilient sense of self.
Figure 5. Sebastian, Untitled, marker pen and stickers on paper, 297 × 420mm.
The relational quality of tailoring was also evident in the evolving therapeutic alliance. In the early sessions, the art therapist made art alongside Sebastian (Figure 6). This collaborative stance helped level the perceived power imbalance and modelled emotional risk-taking. Known as “working alongside” (Nash & Zentner, 2023), this practice fostered a sense of creative synchrony and relational safety. As trust grew, Sebastian began inviting the therapist to co-create elements of his artwork, offering brushes, suggesting colours, or asking for feedback. These gestures reflected a growing sense of mutuality and shared investment in the creative process.
Figure 6. Sebastian and Art Therapist, Untitled, oil pastel on paper, 297 × 420mm.
As the work progressed, Sebastian began using language from the sessions in everyday contexts. Phrases such as “it’s time for a holiday” or “if it ain’t broke, don’t fix it” took on new meanings and functioned as internalised mantras. The therapist intentionally wove these phrases back into conversation, helping Sebastian hear his own wisdom reflected to him. This kind of echoing reinforced his sense of authorship and self-recognition within the therapeutic space.
Each session held a different emotional tone. Some days, humour and lightness were essential, offering needed relief from the weight of traumatic memory. On other days, the studio held space for sorrow, uncertainty, or existential reflection. Being attuned to these emotional shifts required not just theoretical understanding but a willingness to respond with presence, warmth, and flexibility. Johnson (1980) refers to this capacity as the holding function of the creative process, where the therapist provides enough structure for emotional material to emerge without fear of collapse.
Even routine boundaries became opportunities for relational depth. When Sebastian once asked if a session could be extended, the therapist did not offer a simple yes or no. Instead, they invited a conversation about what the ending felt like for him that day. This dialogue revealed deeper fears of abandonment and feelings of incompleteness. Although the session time remained unchanged, its emotional meaning was acknowledged and explored with care. This moment reinforced the idea that therapeutic structure can hold meaning even when it cannot be altered.
In its fullest sense, tailoring in art therapy was a process of relational choreography. It required the therapist to move with, rather than ahead of, the client. It invited moments of silence and bursts of humour, allowed metaphor to do quiet but powerful work, and gave space for uncertainty to be held rather than resolved. Johnson’s psychodynamic model (1998) reminds us that being known and not known can coexist in therapeutic relationships. In a forensic setting characterised by control and surveillance, this kind of adaptive, responsive presence created a space where Sebastian’s identity could be explored and expressed through image, symbol, and the rhythms of shared attention.
Implications for future applied research in forensic art therapy
This case study suggests further applied research in forensic art therapy, particularly through a psychodynamic lens, would be meaningful. Sebastian’s engagement with symbolic imagery invites deeper exploration into how metaphor and visual narrative can facilitate processes such as desistance, empathy, and moral repair. These are delicate, often non-linear movements that unfold uniquely within each therapeutic relationship and deserve thoughtful, context-sensitive inquiry.
Equally important is research that centres the therapist’s experience. Working in high-risk, emotionally charged environments demands a capacity to sit with ambiguity, manage complex transference dynamics, and remain grounded in ethical practice. Practice-based research can illuminate the role of supervision, reflective processes, and systemic support structures that sustain the art therapist’s presence and effectiveness in forensic work.
This case study also invites a broader interrogation of recovery itself. In settings where autonomy is constrained and detention may be indefinite, recovery cannot be defined solely by symptom reduction or behavioural compliance. Future research should consider how art therapy supports existential dimensions of recovery, reconnection with meaning, agency, identity, and relational belonging. Narrative and postmodern paradigms offer rich theoretical frameworks for this work, particularly when integrated with client-led, arts-based methodologies.
Applied research in forensic art therapy must reflect the inherent complexity of the field. While individual cases may not be statistically generalisable, they offer profound insights into processes that are often invisible to standardised outcome measures. Longitudinal, participatory, and practice-informed approaches are especially suited to capturing the layered nature of therapeutic change and relational depth.
Finally, advocacy must walk alongside research. As systems shift toward trauma-informed and recovery-oriented models, art therapy must be recognised not as ancillary, but as central to humane, ethical care in forensic mental health. Research that honours this complexity can help embed art therapy more fully within these evolving frameworks.
Conclusion
This case study has explored the role of psychodynamic art therapy in supporting a forensic in-patient with schizophrenia to symbolically access, explore, and integrate fragmented aspects of his inner world. Within the relational container of the therapeutic triangle between client, artwork, and therapist, Sebastian was able to engage with complex themes of identity, trauma, spirituality, and moral reflection in ways that bypassed the barriers imposed by psychosis, institutionalisation, and mistrust. Through image, metaphor, and the co-regulated presence of the art therapist, the therapeutic space became a rare site of both safety and symbolic freedom, a place where contradictions could be held, and meaning could slowly emerge.
This work contributes to the growing body of knowledge advocating for art therapy as a vital component of forensic mental health care. It underscores the need for relational, trauma-informed approaches that make space for ambiguity, depth, and non-verbal expression. While individual in its scope, this case study invites broader reflection on how creative therapies can support emotional integration, symbolic communication, and narrative repair in contexts where conventional interventions may falter.
In keeping with the ethical principles of transparency, collaboration, and respect for client agency, the development of this article included a client review process. A draft was shared with Sebastian, who was given the opportunity to reflect on how his experience had been represented. His feedback was engaged with thoughtfully and, where appropriate, integrated into the final manuscript. This process was not simply a procedural step, but an extension of the therapeutic alliance, one that honoured his authorship of the therapeutic journey and reinforced the collaborative spirit of psychodynamic art therapy.
Acknowledgement
Thank you to the Victorian Institute of Forensic Mental Health (Forensicare), Melbourne, Victoria, Australia.
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Authors
Abigail Reisner
MAT, BA(Fine Arts), AThR
Abigail is a licensed art therapist who specialises in forensic and trauma informed care. A sole clinician at Thomas Embling Hospital, she draws on art to aid reflection and healing in a high-security forensic mental health facility. Her practice is informed by an interdisciplinary approach that is patient-centered and draws on understandings of trauma-informed care. She enjoys collaborating with other clinicians to provide holistic care, and sees art as a path to self-expression for those who struggle to otherwise express their inner world. Abigail’s research is driven by her experiences in sensitive settings and aims at improving outcomes for society’s most vulnerable.
Theresa Van Lith
PhD, MA, AThR, ATR-BC
Theresa is an Associate Professor of Art Therapy at La Trobe University, internationally recognised for her contributions to mental health recovery, mindfulness-based art therapy, and research strategy development. She serves on editorial boards, collaborates globally, and has received prestigious grants including the NEA Research Award. Her practice-led, community-focused research bridges therapeutic insight and scholarly rigour, advancing the field of art therapy through innovation, evidence, and advocacy. Along with Dr Nancy Gerber, she helped to establish the Art Therapy Research Community Network – www.artthxresearch.com. Theresa is also a registered art therapist and passionate educator.
Danielle Ashley
BOccTher, MAOT, GradCertHlthProfEd
Danielle is an occupational therapy educator with significant experience of working as an occupational therapist in the forensic mental health field, including working with youth offenders, and those with cognitive impairment as well as working in prison-based mental health services. Danielle has a Master of Advanced Occupational Therapy and is passionate about building practice-based evidence.
Lorrae Mynard
BOccTher(Hons)/BBSc, GradCertHM, Member OTA, Member WFOT
Lorrae is an occupational therapist and doctoral researcher who has worked in adult mental health settings in Australia, Canada, and the UK. Passionate about engaging consumers in occupations that they find meaningful, she is a keen advocate for the expansion of creative art therapies in forensic mental health services.