gms | German Medical Science

GMS Psycho-Social-Medicine

Corporate journal of German scientific societies in psychosocial medicine

ISSN 1860-5214

Using artwork to understand the experience of mental illness: Mainstream artists and Outsider artists

Die Verwendung von Kunst zum besseren Verständnis von psychischen Erkrankungen: Mainstream- und Außenseiter-Künstler

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  • corresponding author Terry A. Rustin - School of Nursing, University of Texas at Houston Health Science Center, Houston, Texas, USA

GMS Psychosoc Med 2008;5:Doc07

The electronic version of this article is the complete one and can be found online at:

Published: July 8, 2008

© 2008 Rustin.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Objective: Artwork and psychiatric disorders are often linked. Accomplished artists with psychiatric disorders express themselves and their emotional distress through their works, and art therapists use the visual arts to help clients understand their problems and cope with them. There have been a number of psychiatric patients with no previous art training who produced artwork that many consider museum-worthy (Art Brut, or Outsider Art.) For the past two years, I have used artwork in another way: to better understand my clients and their psychiatric disorders.

Methods: Presented here are paintings I have made about the mental illness experience of some of my clients, all well known to me through their therapy. It is a form of visual psychodrama, in which I reverse roles with the client through the paintings. My goal has been to experience the stresses felt by my clients so that I can understand them better.

Results: The paintings have served as a point of embarkation for therapy sessions, as a means of clarifying a client’s experience, and as a way to show clients that their therapist is attending to what they say. Countertransference undoubtedly plays a role in my choice of clients and their portrayals, but the intent is to help me better understand the clients’ experiences.

Included here are images of some of these paintings with a short psychiatric history of the client about whom they were made. Accompanying each one are responses from the clients upon viewing “their” paintings, and a discussion of the client’s psychiatric disorder.

Conclusions: Making these paintings has helped me understand better the feelings of isolation, rejection, loss, and alienation that many of my clients experience every day. In turn, they tell me that viewing the paintings is an intense experience for them as well. As an outsider artist, I must leave it to the viewer to determine whether or not these paintings qualify as “art.”

Keywords: art, Art Brut, Outsider Art, psychotherapy, painting, mental illness


Ziel: Bildende Kunst und psychische Erkrankungen sind häufig miteinander verknüpft. Erfahrene Künstler mit psychischen Erkrankungen äußern oft sich selbst und ihre emotionale Notlage durch ihre Werke, und Kunsttherapeuten verwenden die bildende Kunst, um Patienten zu helfen, ihre Probleme zu verstehen und mit ihnen besser umzugehen. Es gab eine Reihe von psychiatrischen Patienten ohne vorherige Ausbildung, die Kunst produzierten, die man als museumswürdig betrachten kann (Art Brut, Außenseiter-Kunst). In den letzten zwei Jahren habe ich die Kunst in einer anderen Art und Weise verwendet: nämlich, um meine Patienten und ihre psychischen Erkrankungen besser zu verstehen.

Methoden: Die hier vorgestellten Gemälde habe ich über die Erfahrungen mit der psychischen Krankheit einiger meiner Patienten gemalt, die ich aus ihren Therapien gut kenne. Ich sehe das als eine Form des visuellen Psychodramas, indem ich durch die Bilder meine Rolle mit den Patienten tausche. Mein Ziel ist es, meine Patienten dadurch besser verstehen zu können.

Ergebnisse: Die Bilder dienten als Ausgangspunkt für die Therapie, als ein Mittel zur Klärung des Erlebens des Patienten und als ein Weg, Patienten zu zeigen, dass ihre Therapeuten an dem, was sie sagen, auch wirklich Anteil nehmen. Gegenübertragung spielt eine wichtige Rolle bei meiner Wahl der Patienten und ihrer Beschreibungen, aber die wichtigste Absicht ist es, mir zu helfen, sie besser zu verstehen.

Dargestellt sind einige dieser Bilder mit einer kurzen Geschichte der psychiatrischen Patienten. Daneben sind dann jeweils die Reaktionen der Patienten auf "ihre" Bilder, und eine Diskussion über die psychische Störung der jeweiligen Patienten.

Schlussfolgerungen: Das Malen dieser Bilder hat mir geholfen, die Gefühle der Isolation, der Ablehnung, des Verlust und der Entfremdung, die viele meiner Patienten jeden Tag erleben, besser zu verstehen. Dazu kommt noch, sagen mir viele der Patienten, dass das Betrachten der Bilder eine intensive Erfahrung für sie ist. Als Außenseiter-Künstler muss ich es dem Betrachter überlassen, ob diese Bilder als "Kunst" angesehen werden.

Schlüsselwörter: Kunst, Art Brut, Außenseiter-Kunst, Psychotherapie, Malerei, psychische Erkrankungen


The thoughts, beliefs, values, and emotions of artists are inescapably represented in their work – and on some occasions, intentionally depicted. Three of the more familiar connections between art and the functions of the mind are the ways in which artists express their own thoughts, feelings, and mental distress in their paintings; the use of art to help individuals with mental disorders; and the occasional emergence of a person with mental illness, untrained as an artist, who proves to have a unique artistic vision.

Several notable artists with psychiatric disorders have expressed their thoughts and moods in their artwork. Mark Rothko, Edvard Munch, and Bernard Buffet stated that their artwork reflected their depressed mood. Art historians and writers have interpreted the paintings of some artists (including Paul Cézanne, Vincent van Gogh, and Jackson Pollock) as showing evidence of a psychiatric disorder [1].

Psychotherapy clients are often at a loss to describe how they feel. The discipline of art therapy is devoted to helping individuals express themselves without the need for language or logic; their lack of artistic skill or training is no barrier to self-expression [2].

A few individuals with mental disorders have produced works that have gained the attention of artists, art dealers, art historians, collectors, and curators. Jean Dubuffet called their work “Art Brut,” (“rough art,” or “coarse art”) [3]. Roger Cardinal later defined a category he called “Outsider Art,” which included Art Brut and also the work of folk artists, primitive artists, and untrained artists without mental illness who were indifferent to the prevailing culture. Outsider artists, as defined by Cardinal, are not influenced by the art establishment, and are free of the restraining conventions of traditional art [4].

I have found another intersection of art and the mind: artwork produced by the psychotherapist with the emotional experience of the client as the subject. For the last two years, I have been making paintings depicting the depression, mania, psychosis, and compulsions of my clients. The paintings have become part of the bond between us, and are integrated into our psychotherapy. My initial purpose was to enter into the clients’ world of mental illness to help me understand it better. The paintings have done that, and more – they have helped the clients by making tangible their intangible experiences.

This paper explores the intersection of art and the functions of the mind, and concludes with a discussion of the paintings I have made.

Artists with mental illness

In 1792, Francisco Goya (1746-1828) fell desperately ill with a fever and mental confusion; he may have had encephalitis. Upon physical recovery, he still suffered with episodes of hallucinosis, depressed mood, and emotional outbursts. Goya then set about depicting mental illness and those who suffer with it in a series of etchings (“Los Proverbios” or “Los Disparates,” 1815 through 1824, Link 1). He never exhibited these etchings, and they were not published until 40 years after his death.

Paul Cézanne (1839-1906), who had repeated bouts of depression, revealed his depressed mood in a number of canvases. These include:

  • “Pyramid of skulls” (Link 2)
  • “The murder” (Link 3)
  • “Three skulls on an Oriental rug” (Link 4)
  • “Young man with a skull” (Link 5)
  • “Self portrait, depressed and brooding” (Link 6)
  • “Self portrait” (Link 7)
  • “Self portrait” (Link 8)
  • “Self portrait” (Link 9)

Vincent van Gogh (1853-1890), had episodes of depression, episodes of expansive and frenetic mood, and episodes of hallucinations; he died by his own hand. His physicians blamed absinthe and a seizure disorder for his mental illness; he has been posthumously diagnosed with a variety of disorders, including bipolar disorder [5]. His mood swings, his recurring obsession with death, and his psychotic perceptions can be seen in many of his works.

Paintings and drawings describing his psychiatric hospitalizations include:

  • “Barred window (sketch)” (Link 10)
  • “Stone steps in the garden of St. Paul's Hospital at Saint-Rémy” (Link 11)
  • “Vestibule of St. Paul's Hospital at Saint-Rémy” (Link 12)
  • “Window of Vincent’s studio in St. Paul’s Hospital at Saint-Rémy” (Link 13)

Evidence for depressed mood and obsession with death is found in the following works:

  • “Cemetery in the rain” (Link 14)
  • “Hanging skeleton with cat” (Link 15)
  • “Wheatfield with crows” (Link 16)
  • “Cypresses” (Link 17)

Evidence for hallucinations and delusions can be seen in these paintings:

Evidence for mania and mixed mania is seen in:

  • “Rain” (Link 23)
  • “Poppies with butterflies” (Link 24)
  • “Village street (in Auvers)” (Link 25)
  • “The raising of Lazarus” (Link 26)

Several Post-Impressionists are known for expressing their mood disorders in their work. The best known single work is “The Scream” by the Norwegian Edvard Munch (1863-1944), of which there are a number of versions (Link 27). “The Scream” shows a desperate man, shrieking in his despair. Many of Munch’s other paintings also express the depressed and hopeless mood that tormented him throughout his life, his obsession with death, and his overwhelming fears. These include:

Mark Rothko (1903-1970) struggled with depression his entire adult life, eventually killing himself. His color field paintings evoke profound feelings of depression in many viewers, as they did in the artist. A few of many include “Untitled no. 4” (Link 35), “Untitled”, painted in 1968 (Link 36), and the fourteen large canvases in the Rothko Chapel, part of The Menil Collection, Houston Texas (Link 37).

The frenzied images of Jackson Pollock (1912-1956) appear to reflect his inner turmoil. Alcohol dependent and never able to stay sober for long, constantly depressed and frequently suicidal, he died in a one-car crash. A film of him painting shows him working at a hectic pace; he appears to be expressing his internal chaos on the canvas before him (Link 38). Examples include:

Bernard Buffet (1928-1999) suffered with depression, and often depicted himself in a depressed state in his paintings, including “Self portrait in the bathroom” (Link 44); “Self portrait #4 1981” (Link 45); and “La mort (Death)” (Link 46; Link 47).

Bryan Charnley (1949-1991) lived with schizophrenia; his medication controlled most of his symptoms but limited his creativity. He deliberately stopped and started medication in order to fully experience his illness and to record it in his paintings (Link 48). As with van Gogh, Charnley’s self-portraits show his progression through psychosis (Link 49), and like van Gogh, he died by his own hand.

Cézanne, Buffet, and Rothko suffered with depression, van Gogh with depression and mood swings, Munch and Pollock with depression and alcohol dependence, Charnley with schizophrenia. This raises the question of whether or not artists are more likely to be mentally ill than other people.

Artists, psychologists, and sociologists have weighed in on this topic for more than 200 years, without a resolution. Benjamin Rush (1745-1813), the “Father of American Psychiatry”, thought a connection between mental illness and artistic creativity was likely [6]. The Italian criminologist and psychiatrist Cesare Lombroso (1836-1909), theorized that artistic genius was also a form of mental illness, publishing these ideas in his book “Genio e Follia” (Genius and Madness), in 1894 [7]. Arnold Ludwig has reported that highly creative individuals are twice as likely to have significant psychopathology as noncreative ones [8], although a connection with alcohol dependence was not apparent [9]. Ludwig has asserted that being mentally ill contributes to the creativity of the artist [10]. Kay Jamison has written extensively that the core elements of the “artistic temperament” as identical with the core elements of bipolar disorder [1].

While a number of artists have committed suicide (Link 50), whether or not their rate of suicide is higher than that of the general population is an open question. Preti and Miotto found that artists have a lower suicide rate than creative writers; those who do suicide appeared to be despondent over the rejection of their work, rather than from internal psychiatric distress [11]. Burch et al. reported a study of artists showing high degrees of schizotypy [12], but not serious mental illness. Given the enormous number of people who put brush to canvas, as students, hobbyists, and professionals, there is no way to know for certain the degree to which artistic creativity and mental illness are linked.

There is even disagreement over the advisability of treating creative individuals with mental illness. Rothenberg asserted that individual with bipolar disorder are more creative than others, and advised caution in the use of treatments that could inhibit their creativity [13].

Artists depicting mental illness in their work

Charles Louis Lucien Muller (1815-1892) documented one of the seminal events in psychiatry, Philippe Pinel ordering the chains of the mentally ill inmates at the Bicêtre Asylum in Paris removed (Link 51). A few years later, Pinel did the same for the inmates of La Salpêtrière, shown in an equally well-known painting by Tony Robert-Fleury (1838-1912) (Link 52).

Jean-Etienne Dominique Esquirol (1772-1840), who succeeded Philippe Pinel at La Salpêtrière, illustrated his 1838 text Traité des maladies mentales considérées sous le rapport médical, hygiénique et médico-légal (A treatise on mental disorders with consideration of their medical, health and forensic aspects) with dramatic etchings of mentally ill patients by the artist Ambroise Tardieu (1818-1879) (Link 53, Link 54).

Charles Bell (1774-1842), born in Scotland, used his skill as an anatomist and an artist to make some of the finest surgical atlases of the day; he described the VIIth cranial nerve palsy that carries his name. Bell sympathized with the condition of mentally ill patients, and made a number of etchings showing the degrading conditions in which they were kept in England (Link 55).

Picasso drew a remarkable picture of a schizophrenic man (The Madman, Link 56) in 1904. George Cruikshank, son of an alcoholic and an ardent advocate for temperance, made a series of etchings and paintings showing that the ultimate effect of drinking was violence, dissolution and death (Link 57) [14].

Suicide has been depicted in many paintings, usually with a historical or literary perspective. The Biblical story of the suicide of Saul, who killed himself rather than suffer humiliation, was painted by Pieter Breughel the Elder (1525-1569) (Link 58; Link 59). Botticelli (1445-1510) depicted the legend of Lucretia, who killed herself after having been raped by the king’s son (Link 60). Titian, Rembrandt, Veronese, and Raphael have also made paintings showing Lucretia’s rape, her suicide, or the overthrow of the king that followed. Cleopatra’s suicide using an asp has been painted by Giovanni Francesco Barbieri (1591-1666) (Link 61), and by Jean André Rixens, Guido Reni, and Reginald Arthur. The suicides of Romeo and Juliet in Shakespeare’s play have been painted by Joseph Wright (1734-1797) (Link 62), and by Frederic Leighton and Johann Heinrich Füssli. The suicide of Socrates was the subject of a great painting by Jacques-Louis David (1748-1825), painted during the French Revolution, that acclaimed Socrates’ choice of death with honor (Link 63) – one of the themes of the Revolution. Edouard Manet (1832-1883) painted an unusual picture of a man in evening dress who has just shot himself in the abdomen and fallen onto his bed (Link 64). Manet may have been despondent over the suicide of a friend and fellow painter [15].

Ric Hall and Ron Schmitt collaborate in pastels and have many works that reflect serious mental illness, including major depressive disorder (“Depression”, 2001; Link 65); delusions (“Inner demons", 2002; Link 66), alcohol dependence and depression (“Awaiting Tomorrow”, 2002; Link 66), opioid dependence (“Fascination with the Pill", 2003; Link 67), and imminent death (“When Sickness And Health Are Too Much”, 2007; Link 68).

Art therapy

The first documentation of art as therapy was in the mid-19th century, in Scotland [16], when asylum inmates were given art materials and encouraged to draw and paint. Since then, art therapy has evolved into a professional discipline with study at the Masters level leading to certification.

Shaun McNiff, an art therapist, university professor, and prolific author [17], [18], elaborated on the value of art for healing: “… the core process of healing through art involves the cultivation and release of the creative spirit. If we can liberate the creative process in our lives, it will always find a way to whatever needs attention and transformation. The challenge, then, is first to free our creativity and then to sustain it as a disciplined practice” ([17], p. 5).

Art therapy is used with hospitalized patients with severe and persistent mental illness, inpatients with depression and anxiety disorders, and outpatients with any emotional disorder. Some addiction recovery programs use art therapy, as do programs for autistic children, incarcerated prisoners, and multi-lingual programs where verbal exchange between clients is limited (Link 69).

Art therapy is also used with individuals without mental illness as a way to express their thoughts and feelings (Link 70; Link 71). As with other psychological and expressive therapies, modality is an instrument in the relationship between the client and the art therapist. Catherine Moon described her work as an art therapist as “responding to clients through the poetry of their lives” [19].

Art brut and Outsider Art

The concept that the paintings, drawings, and constructions of individuals under treatment for mental illness might have artistic merit dates from the late 19th century. Cesare Lombroso (cited above for his controversial theories on creativity and mental illness) collected the artwork of patients at the mental hospital he directed, and published a treatise on his collection, L’Arte Nei Pazzi (The Art of the Insane), in 1880. Emil Kraepelin (1856-1926), one of the fathers of biological psychiatry, began a collection of drawings and paintings done by psychotic patients at the hospital of the University of Heidelberg, Germany, beginning around the turn of the 20th century. When Hans Prinzhorn (1886-1933) became the superintendent of the hospital, he expanded the collection, and in 1922 he published an account of it, Bildnerei der Geisteskranken (Artistry of the Mentally Ill) [20]; the collection eventually contained 5000 items. At about the same time, in Switzerland, Walter Morgenthaler published Ein Geisteskranker als Künstler (A Psychiatric Patient as Artist), describing the drawings of one of his patients, Adolf Wölfli.

Jean Dubuffet (1901-1985), a talented but inconsistent painter (Link 72) and sculptor (Link 73), became intrigued with the concept of art produced by individuals with mental illness. After the end of World War II, Dubuffet sought out these untrained, socially marginalized, and emotionally troubled artists and began collecting and showing their work. Critics maintained that the works produced by these psychiatric patients were not art at all, but only technical productions; Dubuffet argued that the artwork spoke for itself, and was as fully “Art” as any work produced by trained artists, and especially notable because it was unaffected by the traditions of Western art, the influence of society, or any commercial interest. He named this genre “Art Brut,” and organized the first public exhibition of it, “L’Art Brut Préféré aux Arts Culturels/Raw Art is Preferred to Cultural Art,” in Paris in 1949 (Link 74) [3]. (The collection is now housed in its own museum in Lausanne, Switzerland (Link 75)).

Dubuffet’s museum defines Art Brut as follows:

Les auteurs d’Art Brut sont des marginaux réfractaires au dressage éducatif et au conditionnement culturel, retranchés dans une position d’esprit rebelle à toute norme et à toute valeur collective. Ils ne veulent rien recevoir de la culture et ils ne veulent rien lui donner. Ils n’aspirent pas à communiquer, en tout cas pas selon les procédures marchandes et publicitaires propres au système de diffusion de l’art [21].
The creators of Art Brut are marginalized individuals who are resistant to the normative educational and cultural structure, who maintain an independent attitude in spite of societal norms and values. They want nothing from mainstream culture and have no interest in engaging in it. They do not wish to discuss their works, seek no publicity, and want nothing to do with the commercial aspects of art. (translation: TR)

In 1970, Roger Cardinal described as “Outsider Art” a category of artistic expression that included the work of individuals untrained in art, whose creations were spontaneous expressions of their thoughts, feelings, and beliefs – but who were not necessarily mental patients [4]. Outsider Art included Art Brut, folk art, primitive art, and other artwork outside of the cultural establishment. His book was viewed with skepticism by many, as in this book review by John Milner published in the art journal Leonardo: “If the author points out a land where original marvels await discovery, then he may have achieved a great deal. But he does not begin to show us how to go there or how to leave behind the culture that we know” [22].

Brut artists with mental illness include Adolf Wölfli, Martin Ramirez, Henry Darger, and Madge Gill.

Adolf Wölfli (1864-1930) (Link 76), spent his entire adult life in psychiatric institutions in Switzerland, diagnosed with paranoid schizophrenia. He produced some 25,000 sketches, drawings, collages, and other images exploring his delusions and fantasies, and sometimes gave them to visitors in exchange for cigarettes or small amounts of money. In his narrative, Wölfli re-created an imaginary autobiography beginning at birth and continuing far into the future [23].

Martin Ramirez (1895-1963) (Link 77), spent most of his life in a psychiatric hospital in California, and was also diagnosed with schizophrenia; he used any available scrap of paper and any available implement that would make a mark for his pictures of trains, animals, and Madonnas [24].

Henry Darger (1892-1973) (Link 78) received psychiatric treatment only briefly. He lived an isolated life, without friends or family, venturing out of his apartment only to go to work. After his death, his landlord opened his apartment, and discovered a massive quantity of drawings, paintings, songs, epistles, and a novel of more than 15,000 pages, which Darger had never shown to anyone [25].

Madge Gill (1882-1961) (Link 79) was never treated as a psychiatric patient, but her behavior suggests both a thought disorder and a mood disorder, and in her later years, alcohol dependence. She made complex pen-and-ink drawings of herself and her daughter in ornate gowns, in response to guidance from a spirit she called “Myrninerest,” ranging in size from post cards to 30 feet long (drawn on a piece of fabric.) She rarely sold any of them, maintaining that they belonged not to her, but to her spirit guide. After her death, thousands of them were found in her home, stacked in cupboards, and piled under the bed.

The work of Wölfli, Ramirez, Darger, and Gill have been the subject of many scholarly books and papers, and numerous exhibits have focused on them [26], [27]. A Foundation at the Museum of Fine Arts in Bern, Switzerland is devoted to Wölfli’s work (Link 80). The Milwaukee Museum of Art recently mounted an exhibition of Ramirez work (Link 81), and the American Folk Museum has established the Henry Darger Study Center (Link 82). Nearly all of Madge Gill’s drawings are owned by the Borough of Newham, London, but are not being displayed; a few are in the Art Brut museum in Lausanne.

A good example of an Outsider artist with no apparent mental illness is the French postman, Ferdinand Cheval (1836-1924). He picked up a stone on his postal route one day and brought it home. Each day he picked up more stones, and, intrigued by them, he began building a structure with them. Over the next 33 years, this became a passion (or an obsession); eventually, he brought along a wheelbarrow to carry his stones home. The flamboyant castle he created by cementing the stones together is now a French national landmark (Link 83).

In 1976, at the age of 60, Howard Finster (1916-2001) (Link 84), an ordained minister, received a vision commanding him to produce sacred art. He was not a mental patient; he had worked as a minister, engaged in his community, and raised a family. He had no training in art, and had never painted in his life. He said he received a a command to complete 5000 paintings glorifying the Word of God. He responded with over 16,000 works (and once completed 67 paintings in a single day). Most of these works are now on display at the museum he established for them in Summerville, Georgia (Link 85). Although he accepted commissions (he painted album covers for the rock groups REM and Talking Heads), he remained focused on his spiritual calling – all his paintings are filled with religious images and Bible verses. He considered his commissioned album covers as part of his mission, since every person who purchased the band’s album would also be exposed to his spiritual message.

Gaston Chaissac (1910-1964) (Link 86), had a few drawing lessons in his youth, but was otherwise untrained; however, he was exposed to the work of contemporary artwork through several artists that he met, who encouraged him. He never received psychiatric treatment, although he had episodes of depression, and lived on the outskirts of society most of his life. His work clearly reflects the influence of Picasso, Kandinsky, Paul Klee, and Georges Braque, yet, he sought no professional recognition and painted strictly for himself.

The work of Franco Magnani (1934- ), the “memory artist,” can also be considered Outsider Art. Magnani left his home village of Portito, Italy, when just a boy; he worked as a cook and a baker, eventually settling in San Francisco. Although he had no artistic training, he started painting scenes recalled from boyhood, which are remarkably accurate (Link 87).

Grandma Moses (Anna Mary Robertson Moses, 1860-1961) (Link 88), began painting in her 70s, without art instruction, and became famous for her scenes of rural life. She was called a “folk artist” in her time, indicating the coarse, plain style of her work; she can also be considered an Outsider artist.

John the Painter, a long-term patient in an Irish mental hospital, (his date of birth and last name have been withheld by the hospital for reasons of confidentiality), was accorded a one-man show in the Irish National Museum in 2003 (Link 87). The Museum describes his work (Link 88) in this way: “Art has given him a means to explore his own feelings and thoughts about that life, surprisingly creating a body of artwork that is exuberantly colourful and celebratory” [28].

James Ure, an untrained artist who lives with schizoaffective disorder, tells the story of his illness in paintings (“The colorful outside represents the dance of mania and the black, purple, center represents the ‘black hole’ of depression,” Link 91), and sells prints over the internet. Ure is an example of an Outsider artist who wants to be noticed – most avoid public attention. The advent of internet publishing has made it much easier for Outsider artists to interact with the world, if they want to (Link 92).

Greg Bottoms has written a fascinating book describing his search for Outsider artists in the American South. He describes Outsider Art in this way: “It is more often fuelled by passion, troubled psychology, extreme ideology, faith, despair, and the desperate need to be heard and seen that comes with cultural marginalization and mental unease ([29], p. 2).” Bottoms quotes David Fecho on Outsider artists: “All these folks lead very peripheral lives in terms of the normative social structures. They are driven by something outside of commercial success or acceptance…. They don’t really care about the long-term viability of their art. Perfection of craft and vocation are not at all what drives then. What they care about is getting up every day and engaging with the materials and speaking through these materials about their lives what they mean in a grander scheme ([29], p. 7).”

Typically, Outsider artists paint for themselves, but not for fame or fortune. The Taiwanese artist, Hung Tung (1920-1987) (Link 93), is an example of this; when the public became interested in buying his paintings, he retreated back to isolation and died in poverty, rather than sell his work. “At one time derided and believed insane for his obsession with painting, Hung was eventually heralded as a master,” writes Victoria Y. Lu in the book, “Vernacular Visionaries.” “Hung’s death caused the market value of his surviving works to skyrocket and elevated his reputation as one of the most important artists of twentieth century Taiwan ([30], p. 93).” Similarly, when a wealthy art collector offered to buy all of Gaston Chaissac’s paintings (he was penniless at the time), Chaissac turned him down, stating that he preferred his independence to wealth, and would rather have his paintings than money.

Outsider artists have become the victims of a perverse irony: their disdain for the world of mainstream of art has made them an object of great interest of the art world. An exhibition of Outsider Art is held annually in New York and elsewhere, and artists with mental illness are being encouraged by professionals to exhibit and sell their work [31]. There is even a national organization that promotes art exhibitions by artists with mental illness (Link 94), and a program in Massachusetts that advises Brut artists how to exhibit and sell their work [32].

Traditional, or establishment artists study technique and method, in order to improve the quality of their work; the value of such study does not occur to Outsider artists. Similarly, trained artists analyze the great art works of the past; Outsider artists generally know very little about the history of art [33], [34]. In formal art training, the student begins with simple forms, exploring line and color, and progresses to more complex designs under supervision; Outsider artists jump right in on whatever subject interests them. Ulbricht asserts that because of their ignorance and their spontaneity, professional artists would do well to study the work of Outsider artists, whose works are direct expressions of their inner world, not productions made for hire that conform to the expectations of the society in which they live [35].

Most authors no longer find value in distinguishing between Brut artists and Outsider artists, generally preferring the latter, more inclusive term as more useful [36]. A more important distinction is that between Outsider Art and mainstream or establishment art. The differences lie primarily in the economics of art and the definition of mental illness in the culture of the artist – not with the art itself. The psychoanalyst Ernst Kris believed that the “artworks” of psychiatric patients were mere mechanical productions, characterized by crowded and repetitive images, psychotic symbols, delusional visions, and primitive technique [37]. It is true that Adolf Wölfli crammed his pictures with figures (“horror vacuui”), but so did Pieter Breughel (Link 95) and Hieronymus Bosch (Link 96). Hung Tung painted imaginary scenes, but so did Watteau (Link 97) and Raphael (Link 98). Howard Finster painted in response to a call from God, but so did Michaelangelo (Link 99) and the anonymous monks who illuminated the Book of Hours (Link 100). The works of John the Painter and James Ure may seem more like the work of preschool children than artists, but so do Matisse’s cutouts (Link 101) and the scribblings of Cy Twombly (Link 102). In the light of these comparisons, Kris’s criticisms appear to be based more on prevailing culture than on artistic merit.

The art of Vincent van Gogh forces us to reconsider how we categorize artists. Van Gogh spent many months in a psychiatric hospital, most likely with bipolar disorder and alcoholism, where he made many paintings with the encouragement of his brother Theo and the staff; perhaps this was an early form of art therapy, a mentally ill patient trying to find himself. He never sold a painting for more than a few sous, but this did not deter him from painting; he completed 900 paintings and 1100 drawings in just over 10 years, most of them in the last two years of his life, and he died a suicide; perhaps he should be considered a Brut artist. His artistic style differed from that of his contemporaries and was considered amateurish and clumsy by art dealers; however, many well-known artists, including Cézanne, Gauguin, and Manet, admired his work, so perhaps he should be considered an Outsider artist. Today, any of his paintings would sell for tens of millions of dollars, and he is considered a “master.” In fact, van Gogh has been accorded the two ultimate accolades of an artist – art forgers have selected van Gogh as worthy of imitation (Link 103), and his paintings have been stolen from prominent museums (Link 104).

My paintings (all client names are pseudonyms)

The paintings I have made follow the tradition of Outsider Art. I have no formal art training nor have I attempted to sell any paintings. As with the Outsider artists discussed in this paper, my paintings are made for personal reasons – in my case, to understand more fully the emotional experiences of my clients. Some paintings depict a specific event in a client’s life: a suicide attempt, a sexual assault, a physical beating, a moment in a therapy session. Some tell a more general story: the insidious creep of traumatic memories into consciousness, the feeling of panic with nowhere to run, the depths of depression, the hectic turmoil of mania. Some seek to evoke an abiding or overwhelming feeling: the uncontrollable mood swings of bipolar disorder, the intensity of depression, the joy of recovery from addiction.

These paintings are a form of role reversal in which the canvas is a stage and the image is a projection of what I feel in the role of the client. As I make the paintings, I place myself in the client’s ego state and represent what I feel on the canvas. As a psychodrama therapist, I utilize role reversal techniques with clients in therapy every day; the paintings are a sort of graphical role reversal, which help me see the world from the point of view of the client. The technique of role reversal was introduced by J.L. Moreno, the creator of psychodrama therapy, which he described in this way:

...A meeting of two
Eye to eye
Face to face
And when you are near
I will tear out your eyes
And place them instead of mine
And you will tear out my eyes
And place them instead of yours
Then I will look at you
With your eyes
And you will look at me
With mine... [38]

I show the paintings to clients as part of their therapy sessions, and then keep the paintings in the office, where the clients can see them again (or not), as they wish. I also show the paintings to other clients, and tell the story behind the paintings (without, of course, revealing the identity of the client about whom they were made.)

Clients have various responses to the images. In general, they express gratitude at having a painting made about them; they know that many hours are required to complete a painting, and they take it as an honor. With the first few paintings, the clients responded immediately with compliments; these statements were made out of politeness, and interfered with therapy. Since then, I show clients their painting for the first time during a session, and I ask them not to say anything at all right away. Their first comments now are about the experience and not about the “art”. A common first statement is, “Yeah, that’s what it’s like,” or “I know that feeling,” or “You made this about me?” or “That’s exactly what I feel like, but how could you know?” This gives us an opportunity to discuss the issues further in that session – and the next one, and the next.

When I first show a painting to a client, I check for accuracy, asking if I have interpreted and shown their story correctly; occasionally, clients want something added or changed. Since this process is about insight and understanding, not art, we discuss the best way to represent how they feel. For example, Talia felt that a bubble surrounding her ought to be added to the painting showing her isolating herself from the chaotic world in which she lives. Edith asked that a .22 caliber bullet be added to the rope, shards of glass, and blades attached to her painting, to more clearly represent her suicide attempts.

I often ask clients to bring their spouse or a family member with them when I first show them their painting, both for support and to build empathy. Significant others often lack a clear understanding of what it is like to have a mental disorder – naturally, they focus on how the mental disorder has affected them. I will ask the client, “Tell your husband what the experience shown here is all about.” Using the painting as an external validation of their internal distress has helped some clients discuss their psychiatric disorders with their spouses and family members.

Clients often ask to “visit” their painting again at the end of a session, or bring their spouse or a family member to see it. I email a JPG of the picture to the client as well. They often ask to see the paintings made for other clients; they tend to make non-committal responses to paintings depicting issues not familiar to them (“uh-huh”) and spend more time on those they understand; at times, they have strong reactions to stories that are much like their own. Hannah, who was sexually abused as a child, drew back on seeing and hearing about Benjy’s painting (“How long would I have to spend in jail for molesting a child?”). At the subsequent visit four weeks later, she had no recollection of having seen the painting. Some clients react so strongly to their painting that they would rather not see it again. Karen said, “It’s burned into my mind; I don’t have to see it again.” Larry said, “I want to burn that painting.” On three occasions, I have had a client express a great deal of interest in a particular painting with a topic that is similar to their own story. Later, I introduced the two clients to each other client, and asked them to share the meanings of their paintings with each other. This has led to several supportive friendships between clients with similar stories.

Many of the images are frightening or depressing; after all, they express what I hear in therapy sessions, and clients do not often come to a therapist to talk about their joy and runs of good luck. Some pictures show dramatic moments, such as the moment when Larry, as a baby, was violently shaken by his abusive father. Some depict pervasive feelings, such as Carol’s grief over the death of her children.

I do not imagine that I am the first therapist to use artwork in this way, but after an extensive literature search, I have been unable to find any papers discussing this use of artwork, in the medical literature, in the psychotherapy literature, or in popular literature. Surely, there have been many psychotherapists and psychiatrists who were also skilled painters, and there have certainly been many budding young artists who decided to become therapists or psychiatrists instead of professional artists – but I have been unable to find accounts of them painting with the purposes described here. The closest I have found are the paintings made by Jack Kevorkian (1928- ), the Michigan physician who advocates voluntary euthanasia; and the computer-generated art by the psychologist Don Tatro (1934-2004), drawn from his years as evaluating clients, victims, and perpetrators.

Kevorkian, who has never considered himself an artist, made a series of 18 paintings two decades ago, depicting the distress of some of his “patients.” These paintings were reportedly lost in shipment and have never reappeared. Kevorkian subsequently painted another eight paintings; the originals are not on display, but reproductions of six of them are available for purchase, and can be seen at Link 105. They are quite striking, and are strongly influenced by the surrealists. One of his paintings was featured as the cover art for an album by the rock group Paegan Terrorism Tactics (Link 106).

Tatro did not consider himself an artist, either; he was a forensic psychologist with a gift for graphic art. He created a series of computer-generated images, on view at Link 107, that describe mental illness, but without reference to particular clients. In Tatro’s words: “Each is meant to depict one of the main mental disorders or, in their lesser manifestations, personality types. I have attached a little explanatory text to each image, briefly describing the kind of problem being depicted and how the image is intended to symbolize it” [31].

The following are images of a few of my paintings, each accompanied by a short clinical history and a DSM-IV diagnosis; I have completed 45 as of this writing. More can be found at Link 108.

Olivia: I feel like running away, but there’s no place to run to (2006)

Acrylic and oil on canvas
56.5” x 54” (143.5 cm x 137 cm)
Figure 1 [Fig. 1]

Olivia has severe panic attacks, and is terrified by things that most people take in stride – talking to cashiers, driving in traffic, talking on the telephone. She often goes weeks without leaving the house, because of her fears. Therapy has focused on her current stresses (marital conflict, problems with a blended family); problems in the past (raised by a domineering father, leaving home in her teens, abused in her first marriage); and managing her psychiatric issues (mood swings from mania to depression, obsessive-compulsive features, panic attacks, agoraphobia.)

This was one of my first paintings. It shows a complex background of hectic reds, oranges, yellows and blues, upon which is a running figure in yellow – trying to get away, and never succeeding. The panic experience feels like a life-threatening emergency – yet, there is no danger apparent anywhere nearby. The crisis is entirely internal, and therefore, it is not possible to run away from it.

During her therapy sessions, Olivia sits in a chair facing this painting; one time, she said, “It keeps reminding me that I can never run away from how I feel. It’s either learn to deal with it, or still suffer from it.”

Being confronted with a depiction of her fear-based behavior during each session has encouraged Olivia to confront her fears and take action to improve her life. She filed for divorce from her domineering husband, she has ventured out to meet friends, and she has begun attending her children’s school performances and sports activities. Progress has been slow, but steady.

Olivia’s DSM-IV diagnoses:
- Panic disorder, with agoraphobia 300.21
- Specific phobias 300.29
- Bipolar I disorder, most recent episode depressed 296.53

Edith: The waves of my life, from the highest peaks to the lowest depths (2007)

Acrylic and found objects on canvas
72” x 51.5” (183 cm x 131 cm)
Figure 2 [Fig. 2]

Edith lives with bipolar disorder and a dissociative disorder; she has been in recovery from alcohol and drug dependence for over 20 years. I asked her if she would like me to make a painting for her, and if so, what should it show. She wrote to me:

From the depths of the ocean; whirlpool sucking me down. To the peaks of the mountains where only God stands with you. And back again. That is where my disease takes me…. Crying out to a father with no ears. My tears are of blood, pouring from the cuts on my wrists. Messages carved into my flesh, silenced by simple pieces of clothing, hidden from all that might see.

Edith commented one day that the wisteria was in bloom, and that her birthday was coming up – her mother made the connection every year. “It is beautiful,” she said of the wisteria, “smells good and can kill a large pine tree by wrapping around it and strangling it. No wonder it reminds me of my mother.”

I have placed these symbols into the painting. In the lower right are her suicide attempts. The thick black paint show the intense ones where she intended to die (she has shot herself in the chest with a handgun, hung herself with a rope, taken a drug overdose several times, and has cut herself with a knife, a razor, glass shards, and other sharp objects). Above that are the times she carved on herself in a cry for help. Above that are the times she cut herself in an attempt to spill as much blood as possible, but without much risk of dying. In the lower left is the whirlpool, sucking her down to Hell, the waves reflected in the Colorado mountains at the top of the picture (where she once nearly died in a car wreck in the snow). The eyes peering at her are a part of her recurrent delusions that everyone is watching her, often accompanied by a pathological fear of birds. In the upper left, is the wisteria, choking her. And yet, from the depths of the whirlpool, she has arisen, going back to school and achieving high marks, staying sober and helping other in AA, and enjoying life (represented by the fireworks display).

Edith makes a point of taking a look at the painting each time she is in the office (and she has a photograph of it.). She will at times comment on a symbol, or identify something new she sees there. “That’s my father,” she said once, pointing to the dark face intended to represent the shadow element in her dreams. Another time, she identified it as her mother. However, she is usually drawn to the images of suicide in the lower right. I have the feeling that by seeing the image, she is better able to verbalize what she feels. One day, she emailed this to me:

If I had had a gun today I fear that I would have used it on myself. The impulse, the vision of placing it to my head is still vivid… I thought about going to the police station and trying to get them to shoot me. I contemplated this for a while... The last time I went to the police station it was not a pretty picture and I ended up with charges against me. Hanging did not seem to excite me. If I had some antifreeze, I don't think that is the way to go either. Too slow. Any way I don't have any unless I take the lower radiator hose off on my truck and get it from there. The garage is too big and has too many openings for air intake; if I chose to run my engine. I don't have enough motivation to do any thing destructive at the moment. Not even to cut myself. I will just lay alone, in silence until this passes or I die of natural causes.

Edith’s DSM-IV diagnoses:
- Bipolar I disorder 296.80
- Dissociative identity disorder 300.14
- Alcohol dependence (in remission) 303.90

Larry: Shaken baby (2007)

Acrylic on canvas
42” x 30” (107 cm x 76 cm)
Figure 3 [Fig. 3]

Larry’s father was a brutal, abusive alcoholic who beat his wife and children. When Larry was an infant, his father shook him violently, leading to permanent brain damage and mental retardation. The Court ordered Larry taken away from his father and mother (also an alcoholic); his mother’s sister became his guardian and has raised him. He has had multiple hospitalizations for violent behavior, and was judged too impaired to attend school. He had never learned to read or write.

After seeing Larry for several months, I made the diagnosis of bipolar disorder and put him on mood stabilizers; Larry’s behavior improved considerably. A year later, his father died in a fiery one-car crash. A few months later, Larry began to deal with his mixed feelings of anger, loss, and despair about the injuries dealt to him by his father, and never having had a father or a mother who cared about him.

I offered to make a painting for Larry, at a time when his impulsiveness was under good control, and he appeared to be engaging in psychotherapy. I did not give him a choice of images or an opportunity to contribute to the content. When the painting was completed, I showed it to Larry and his aunt. He stared at it for a long time, and then said, “I want to burn that painting.” Since then, Larry has done even better in therapy. In a recent session, he said:

How do I get rid of the sadness? Is there something wrong with me because I’m sad? People say I should love him because he was my father… but I have this anger and I hate him. How do I get rid of it? I hide it, but they can see the anger in me. I don’t want them to see the sadness in me, because they’ll make fun of me. Why am I crying? You know how angry I was a couple of years ago… I would be yelling and cursing and stuff, and I’d start breaking stuff and tearing stuff up. Now it’s mostly frustration. It’s not fair for me to be angry at [my aunt]; it’s not her fault.

Part of our therapy is working on acceptance of his mental disabilities and striving to maximize his abilities. A part of that is telling his story to others. Whenever Larry is in the office and I have a client who I believe will be supportive, I ask Larry to describe the painting to that person. “Telling the story” in a supportive environment (and in Larry’s case, just one-on-one, as he is not really capable of dealing with group therapy), has been a major effort for Larry, and also a significant avenue for healing. The painting provides a prompt to tell the story and a visual validation of his history. Recently, he described the painting to another person, saying:

That’s me, like 20 years ago; that’s my father, shaking me. He tried to kill me. I was in my baby crib, and I was crying, and he got drunk and decided to hurt me. I do have problems, like I want to kill him. But he’s already dead. But I would kill him if he was alive.

Larry’s DSM-IV diagnosis:
- Bipolar I disorder 296.80
- Impulse control disorder NOS 312.30
- Posttraumatic stress disorder 309.81
- Mental retardation, moderate 318.0
- Traumatic brain injury, severe 854

Benjy: How long would I have to spend in jail? (2007)

Oil and acrylic on wood panel
30” x 34” (76 cm x 86.5 cm)
Figure 4 [Fig. 4]

Benjy is an adult with pervasive developmental disorder and moderate mental retardation. He has begun having sexual fantasies about the young boys he sees walking past the group home. In one session, he asked me, “How long would I have to spend in jail for molesting a child?” The rest of that session focused on: “Benjy, that would be wrong. That would be wrong.” This portrait, which I started that day, shows his response.

On seeing the painting, Benjy said, “I feel angry, I feel betrayed, I feel hurt. You used to be my friend. You used to support me. You tricked me. You betrayed me.” Benjy went on to say that he had expected that I would support him and help keep him out of jail; instead, I told him he could not do what he wanted to do.

Since then, Benjy has not put his fantasies into action, although he may be displacing his urges; he has been eating compulsively and now weighs 135 kg at 170 cm height.

Benjy does not appreciate the painting at all, and would like to get rid of it. His mother, however, wants it for her own; she sees in it the intensity of Benjy’s yearnings to be “normal,” and his ambivalence (doing what he wants to do, or doing what he is told is the right thing to do), which is what she has dealt with in raising him.

Benjy’s DSM-IV diagnoses:
- Pervasive developmental disorder 299.80
- Mild mental retardation 317
- Sexual compulsions, not acted upon 302.9

Talia: This is where I go to hide (2008)

Acrylic on canvas
15” x 41” (38 cm x 104 cm)
Figure 5 [Fig. 5]

Talia hides from the chaos of the world around her in a shell of denial, rejection, and irritability. Alcohol helped her cope for years, but caused innumerable problems. She went to treatment and stayed sober for 15 months; following a relapse on alcohol, she now has 10 months of sobriety. Her depression has not abated, however, and she is overwhelmed with feelings of guilt, anxiety, and self-loathing.

Talia wrote this after seeing the painting:

Lonely alone afraid
Sad that I was shy, couldn’t stand up to my parents
Angry that I’m sitting here
Wishing I could go into this picture and stay…
Sad to hear the truth – that I don’t care about anyone or anything in the world and uncovinced that that will ever change…
I want to cut myself up and find a small secret place to hide and feel my pain
I can’t do that ….

This painting is unusual in that I completed it, showed it to Talia, and hung it on the wall, but was not satisfied. I discussed this feeling with Talia, who told me that the “chaos” depicted was far too little to show what she lived with. I took the painting home and added more “chaos” to the background, and brought it back to the office. Talia then commented that she feels as if her depression is a bubble that protects herself from the chaos of the world around her. I added a piece of plastic for a bubble, but it did not serve, so again I took the painting home and added a representation of Talia’s “bubble.” Finally, Talia told me that the painting was done.

Talia’s DSM-IV diagnoses:
- Major depressive disorder 296.33
- Alcohol dependence, in early remission 303.90


I began painting two years ago with no purpose in mind other than to understand more completely the emotional experiences of my clients. Prior to that time, it had never occurred to me to put paint to canvas. Having had no training in painting or sculpture, I did not consider what I was doing as creating “art”; rather, I was seeking to represent an experience or a feeling. Only later did I begin to wonder what it was that I had created.

I began the study that led to this paper in 2007, and only then did I become aware of Outsider artists. These individuals create art for themselves, not for fame or profit or because their society compels them to. What their work lacks in polish and technique, it makes up for by being genuine and heartfelt. Outsider Art represents an unvarnished, direct representation of the thoughts, feelings, beliefs and experiences of the artist.

On looking around my office at the forty or so paintings displayed there, a client asked how many I had sold. The thought of selling these paintings made me feel uncomfortable, even insulted. I explained to the client that the paintings are part of my relationship with my clients, and to sell one would feel like a violation of the bond between us.

My paintings, therefore, follow in the tradition of Outsider Art such as the work of Howard Finster, Hung Tung, Madge Gill, and Francois Cheval – work created without commercial intent, for personal reasons, using readily available materials, and without professional training. And that, I am proud to say, makes me an Outsider artist.

The insights I have gained into my client’s conditions by representing them on canvas has been invaluable to me as a therapist. I encourage other therapists to become Outsider artists and make a similar exploration. You do not need art lessons or any particular degree of skill; if you don’t know how to paint “the right way,” there will be nothing to block your creativity or undermine your authenticity. Outsider artists blaze their own trail, and since no one has ever taken their exact path, the journey will be unique.



The author is grateful to Mr. Peter Frey of Vienna and New York City, who translated the abstract into German.

Grant support

This paper was written without grant support.

Conflicts of interest

None declared.


International copyright to the images of the author’s paintings, contained herein, is retained by the author.


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