Professor Reference GreenGreen (2009) encourages us to think beyond the structured interview and symptom checklist and to allow our patients to express their experiences and distress in the ways, words and modalities most appropriate to them. This always has been and remains at the heart of our profession, even if prevailing ideologies encourage us to depart from it. However, pictures, more than words, rely for meaning not just on the originator but also on the perceiver – how a picture is perceived may bear little or no relationship to the thoughts and intent of its originator (Reference BergerBerger 1972). The same words or images can have radically different meaning or significance to different individuals or in different cultures. Sensitive exploration of meaning and an awareness of one's own cultural heritage and biases are essential parts of the use of art as a means of therapeutic communication.

Imbuing of mental state from the interpretation of a painting is fraught with danger. Green cites his own study (Reference Cohen, Samson and ShakespeareCohen 2001) in support of his contention that abnormal mental states can be recognised from art, at least in children, although scarce detail is available from this conference abstract. There is little convincing evidence either from psychiatry (Reference Rao and KeshavanRao 2006) or from art history (Reference Dubuffet, Harrison and WoodDubuffet 1948) that it is possible to recognise individuals with mental illness by their art alone. Indeed Dubuffet, one of the fathers of ‘art brut’ or ‘outsider art’, writes: ‘Our point of view is that art is the same in all cases, and there is no more an art of the mad than there is an art of the dyspeptic, or an art for those with bad knees’ (Reference Dubuffet, Harrison and WoodDubuffet 1948: p. 608). Art brut's emphasis was on encompassing the vitality and spontaneity of artists traditionally ignored or regarded as unschooled into the cathedra of the established art world and not on some intrinsic differentness that their art possessed.

Green writes: ‘I am suggesting two processes: the first, a sustained sense of not knowing, linked with free-floating attention; the second, a gradual piecing together of local connections between elements of another's communication, which build up gradually into a more coherent overall image. This image is suddenly meaningful, “makes sense” and is accompanied by an intuition of the other person's mental state’ (2009: p. 142). This has reflexive echoes of Hilton's writing in 1961 about the production of art: ‘Painting is feeling. Just as much as a sentence describes, so a sequence of colours describes … All art is an attempt to exteriorise one's sensations and feelings, to give them form … Words and painting don't go together. The more words that are written about a painting the less people will see the painting.’ (Hilton 2003 reprint: pp. 772–773).

Images are created through a process. In art therapy in particular it is the process and the relationship that develops between client, therapist and image and the shared understanding that develops from this that is of importance rather than an end product taken out of context and then layered with the viewer's own interpretations.