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Prejudice and discrimination against people with disabilities started far back in history. A lot of this discrimination originated because societies lacked knowledge of the human body and technologies to assist those with disabilities. Because people with disabilities often had “abnormal” bodies and “could not function correctly in society”, they became outcasts. These outcasts are talked about in multiple encounters and miracles in the Bible and disabilities have even been a form of punishment such as in the “Code of Hammurabi”. Other well-known thinkers and leaders have proposed laws against raising children with deformities or disabilities. Throughout history, disabilities have been a social construct based not on things of reality but of prejudice and assumptions.

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Training guidelines for rehabilitation disciplines are generally based on medical models that focus on acquisition of knowledge (eg, anatomy, diagnoses, policies) and skills (eg, discipline-specific interventions) related to different disability diagnoses. However, there are mounting calls to expand the sensitivity of rehabilitation professionals to the personal experiences of, and social biases toward, individuals with disabilities (ie, issues of 'attitude'). It is argued that the review of artistic depictions of disability in their respective historical contexts offers an excellent vehicle by which to sensitize rehabilitation professionals to these issues. This article reviews the manner in which different western societies throughout history have depicted individuals with physical, mental, and sensory disabilities in the visual arts, ranging from primarily negative (eg, reflection of divine punishment for deserved transgressions, objects to be ridiculed for entertainment, etc.) to more recent positive perceptions (eg, heroes in contemporary films). Suggestions are offered regarding the use of the visual arts to educate rehabilitation professionals regarding individual and societal biases of disability, and to reduce the perpetuation of the stigma, misrepresentation, and mistreatment of individuals with disabilities.

Introduction

Since the passage of the Americans with Disabilities Act (ADA, 1990) there has been increased interest in promoting a better understanding and acceptance of persons with disabilities, as well as improving the societal discrimination they face. The Disability Rights Movement developed primarily in the last quarter of the 20 th century with considerable growth in advocacy efforts over the past three decades (eg, see Lives Worth Living). Of primary importance, the ADA prohibits discrimination and ensures equal opportunity for persons with disabilities in: employment; state and local government programs and services; access to places of public accommodation such as business, transportation, and non-profit service providers; and telecommunications. Although the ADA has provided greater opportunities and access for persons with disabilities, in order for them to attain complete inclusion into society, it is essential to change the negative attitudes and misperceptions regarding them commonly held by the general public-as well as by many rehabilitation professionals.

The manner in which individuals with disabilities were perceived, treated, and integrated into societies throughout history is complex and related to multiple issues involving economic, scientific, and religious factors. ¹ In the past, individuals with disabilities were frequently viewed as objects to be ridiculed and for the most part they have been perceived as a burden to others and considered to be of limited value to society. 2,3 This was due in large part to the limited understanding of human anatomy and physiology, as well as the lack of methods to treat disease and injuries, minimize impairments, or develop assistive devices (eg, prosthetic devices, assistive technologies, environmental accommodations). As such, they were often socially ostracized and driven to live on the margins of society. In contrast, there have also been various cultures and religious sects throughout history that have tended to care for and be empathetic toward individuals with disabilities.

Imagery From Ancient Times to the Present Day

Ancient writings and images reveal a wide variety of messages about how individuals with disabilities were treated and perceived in early historical times, including the portrayal of disability as a source of punishment in the Code of Hammurabi (ca. 1780 BCE), as predictors of good or bad events in The Omen Series Summa Izbu (ca. 1300 BCE), as individuals capable of community leadership in Homeric writings (The Iliad, 750 BCE), or even as a mark of beneficence in ancient Egypt. 2,4 However, few know that Aristotle proposed a law to prevent parents from raising deformed children, ⁵ that Spartan laws obliged parents to abandon deformed children, ⁶ or that Cicero claimed that the body determined the 'shape' of the soul. ⁷ Even numerous biblical passages demonstrate how individuals with various physical disabilities (eg, leprosy and paralysis) were perceived and treated negatively. 2,8 In fact, numerous laws/policies throughout history legalized or encouraged discrimination against individuals with disabilities and such negative representations further reinforced public perception of disability as 'abnormal,' along with the social division between the disabled and nondisabled. ⁹ These negative perceptions of disability generally persisted until the second half of the 20 th century when advances in medicine and innovative treatments/technologies allowed for the approach to disabilities to be improved.

Training in Disability Issues Across Rehabilitation Professions

With the development of the profession of physical medicine and rehabilitation following World War II, society began to view more consistently individuals with disabilities as worthy of treatment, and to assist them in recovering as fully as possible and returning to productive, independent lives. ¹⁰ Since then, rehabilitation disciplines have developed training guidelines to improve the health and functioning of individuals with disabilities (Table 1). In general, these professional organizations call for training based on medical models that emphasize knowledge and skills, often leading to the treatment of individuals as 'disorders' (eg, a spinal cord injury, a traumatic brain injury, a stroke) or 'impairments' (eg, forgetfulness, irritability, spasticity), rather than individuals with disabilities. As such, rehabilitation 'success' could be over-simplistically evaluated in terms of improvements in range of motion, memory scores, or increased psychological traits, without consideration of the need for full inclusion of individuals with disabilities into society. Because of these factors, it has been concluded that rehabilitation professionals "are often negative about disability, seeing inability before ability and frustrated by the lack of a prospect of cure and ill-informed about simple accommodations." 11(p462)

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Table 1: Rehabilitation Discipline Training Guidelines
American Board of Internal Medicine (2013). Internal medicine/physical medicine and rehab policies. Accessed online on 7/20/2020 at: http://www.abim.org/certification/policies/combinedim/comrehab.aspx

Accreditation Content for Occupational Therapy Education (2018). Standards of practice for occupational therapy. Accessed online on 7/20/2020 at: https://acoteonline.org/wp-content/uploads/2020/07/2018-ACOTE-Standards.pdf

American Physical Therapy Association (2018). Standards of practice for physical therapy. Accessed online on 7/20/20 at: http://www.apta.org/uploadedFiles/APTAorg/AboutUs/Policies/HOD/Practice/standards.pdf.

American Speech-Language-Hearing Association. (2020). Scope of practice in speech

language pathology [Scope of Practice]. Accessed online on 7/20/20 at: https://www.asha.org/certification/2020-slp-certification-standards/.

American Psychological Association Rehabilitation Psychology Division (2012). Guidelines for postdoctoral training in rehabilitation psychology. Accessed online on 7/20/20 at: https://www.apa.org/pubs/journals/features/rep-a0030774.pdf.

American Therapeutic Recreation Association Standards of Practice. Accessed online on 7/20/20 at: https://www.atra-online.com/page/SOP.

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More recently, there has been increased recognition of the need for training in the ability to understand the personal experiences of persons with disabilities and the societal biases experienced by these individuals (sometimes referred to as training in issues of attitude). It is relatively easy to teach knowledge (eg, facts, diagnostic criteria) and skills (eg, procedures, tests, discipline-specific therapies), as these are generally fact-based and able to be memorized. However, it is much more difficult to mold individual and societal attitudes (ie, conscious and unconscious biases and beliefs) about disabilities. Changing attitudes and beliefs, however, is central to improving the lives of people with disabilities given that prejudicial and exclusionary social practices are believed to be greater barriers to social participation than specific mental, physical, or sensory impairments. ¹² It is important for healthcare professionals to examine their own beliefs about disability and awareness of how persons with disabilities are perceived, portrayed, and treated today, and particularly for those rehabilitation professionals who work with these populations on a daily basis.

Rehabilitation Psychology Training Guidelines: An Example

Although all rehabilitation training guidelines generally focus on the medical model, initial post-doctoral training guidelines for rehabilitation psychology provide an example of training methods to address issues of attitude. This specifically involves the need to be educated about the manner by which disability is a socially-constructed phenomenon, as well as the manner by which our own biases affect our treatment, interactions with, and expectations for, individuals with disabilities. For example, one of the most notable rehabilitation psychology guidelines calls for training in "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them." ¹³ This suggestion is truly unique among the various rehabilitation disciplines in that it acknowledges the significant role that societal expectations and misperceptions have in the manner by which individuals with disabilities are treated. Although this suggestion is noteworthy, there are no specific methods to suggest how to train rehabilitation professionals regarding the societal perceptions that impact persons with disabilities. This article suggests that studying images of disability in art history is an important and impactful method for teaching rehabilitation professionals about the experiences and biases experienced by those patients they serve.

Art as a Means to Better Understand the Experience of Disability

Human beings have made art to communicate and connect with each other since prehistoric times. Art has the powerful ability to help viewers relate to the individuals depicted in the image on a human, empathetic level, which, in turn enhances the goal of understanding and acceptance on a new level. Artists have used various mediums (eg, paintings, poetry, narratives, sculpture, film, etc.) to express emotional turmoil, tragedy, social isolation, and psychological disturbance as a means to relate and share personal experiences. The medical, legal, and social zeitgeist of an era is often reflected by the artwork created of that time. Alternatively, societal perceptions have long been influenced by how individuals with disability are represented to the public visually and politically. There are few primary sources from ancient and medieval times regarding people with disabilities, ³ and as a result, researchers have relied on the arts to determine the social context of disability at various times throughout history. In fact, a historian of disability states that, "Studying the representation of disability in literature and art is an important and relatively unexplored research frontier in disability studies." 14(p 54)

The arts have been used in rehabilitation for people with disabilities primarily through recreational therapies in which individuals engage in the visual arts, music, dance, and expressive writing to adjust to their disabilities. However, a review of artistic representations of disability throughout history also offers an excellent method by which to improve the training of rehabilitation professionals. There is increased recognition that studying the humanities helps health professionals gain a better understanding of the human side of chronic disabilities.

People with disabilities are depicted throughout art history, and these images provide a context for the manner by which they were perceived at that time (eg, worthy of derision or sympathy, objects of ridicule, deserving of divine punishment, etc.). For example, prior to the advent of the printing press, when much of the population was illiterate, paintings were often used to tell stories, depict historical events, and provided examples of how people were treated. ³ As such, many individuals learned social expectations for how to treat the disabled by viewing paintings in churches or watching plays during community festivals. It is from these works of art that we can understand the culture of the times and become sensitized to the relevant social issues of the day as they pertain to disability. By comparing past and current art forms (eg, paintings, drawing, and sculptures from the past to movies, films, and literature from the present) it is possible to better understand how societal perceptions have a major influence on the way individuals with disabilities are treated. Subsequently, training methods can be developed to counter "social myths of disabilities" (see APA Division 22 training guidelines), and educate rehabilitation professionals to become better providers for individuals with disabilities.

PART 1: The Representation of Physical Disability in Art History

Throughout history, individuals with physical disabilities have primarily been perceived and represented as 'misfits, fools, oddities, and marvels,' present in the world for purposes of entertainment, ridicule, and experimentation. ² This relates in part to the lack of understanding of the causes of physical disability, as well as the lack of resources, knowledge, or will to develop accommodations during various historical times. As such, individuals with disabilities often had little support from their families and communities and needed to fend for themselves in creative ways; this was generally the case until the last half of the 20 th century.

As an example, Greuze's The Paralytic (1763; Fig. 1) is one of the few depictions of an individual with paralysis, likely due to the fact that the survival rates for such individuals were extremely low.

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Historically, depictions of physical disability in western civilizations have largely focused on 'abnormalities' and the negative manner by which individuals with disabilities were perceived and treated. In fact, a frequently-cited theory from the late 18 th century related to physiognomy concluded that the disabled were, "[t]he morally worst, the most deformed." ¹⁵ However, it is noteworthy that ancient Egyptian and Greek cultures at various times were generally accepting of individuals with physical disabilities, as illustrated in several of their works of art. 4,16,17 For example, a stone carving from approximately 1300 BCE shows a realistic depiction of an Egyptian leader with a withered leg, apparently from polio (Fig. 2). Greek vases show similar representations of dwarves who were valued as assistants within the medical field, and even portrayed as deities. 16,17 However, throughout history, such positive depictions of physical disabilities were the exception rather than the rule.

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By the Middle Ages, societies began to extend to people with impairments "an acceptance at times awkward, at times brutal, at times compassionate, a kind of indifferent, fatalistic integrations" to people with impairments. 8(p15) However, in general, individuals with disabilities were represented as abnormal, with early portrayals exploiting these abnormalities for amusement. Paintings from this time indicate that individuals with disabilities were viewed in terms of a religious model of disability, in that individuals were believed to be disabled secondary to spiritual transgressions and were thus treated with religious interventions, if they were even treated. Metzler 2(p89) reports "anecdotal evidence suggests that there was a very strong feeling that malformed babies indicated sin on the part of their parents." Spiritual interventions for disabilities were depicted in a painting by di Benvenuto (15 th Century), titled St. Catherine of Siena Exorcising a Possessed Woman (Fig. 3), in which individuals with both physical (ie, characters with crutches) and mental illnesses (central figure) caused by demonic possession were treated with religious interventions within a church setting.

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By the 16 th century, the Renaissance began to focus on classical forms of beauty, which did not typically include the disabled or deformed. However, art from the northern Renaissance depicted individuals with physical disabilities in a realistic manner, providing insight into the way they were treated and socially perceived at that time. Hieronymous Bosch painted a series of 31 'cripples' in 1500, illustrating the various disabling conditions and prosthetic devices used by these individuals. ¹⁹ Similarly, Bruegel's The Cripples (1568; Fig. 4) shows individuals with various prosthetics gathered together in a town square. However, historical context indicates that these individuals were forced to wear fox tails attached to their clothes as indicators that they were objects to be ridiculed at community festivals. 19,20 Similarly, Bruegel's Battle Between Carnival and Lent (1559; Fig. 5) shows the relative isolation faced by individuals with disabilities within their communities. Compared to the so-called 'normal' citizens participating in either carnival or lent, details from the painting show two groups of individuals with disabilities (ie, 'cripples' in middle scene, blind individuals by church entrance) as socially-isolated beggars. These community spectacles are precursors to the freak shows that gained popularity in the mid-16 th century and lasted to the mid-20 th century, which displayed physically unusual or deformed humans for a source of entertainment ²¹ (Fig. 6). By the 19th century, individuals with impairments were even criminalized through public policy (ie, 'ugly laws' involving social restrictions placed on those with physical appearances that might offend 'normal' people) ⁹.

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Paintings such as Wyeth's Christina's World (1948) provide an example of the social isolation and handicaps faced by many individuals with physical disability even in the middle of the 20 th century. This painting appears to show its subject, Christina Olson, admiring a homestead in a windswept field. However, an article in the Journal of Child Neurology ²² indicates that Wyeth was portraying a young woman suffering from a progressive neurological disorder that he observed crawling crab-like up to her farmhouse. This knowledge challenges the initial perception of the scene and shifts our position from viewer to Christina's own perspective. This is the power of studying art history: to guide the viewer by facilitating close looking, deeper contextual understanding, and empathy. An article by J.O. Ballard in JHR is an excellent resource for those who would like to use this painting to increase clinical observation and diagnostic skills regarding disability in health sciences education. ²³

Even within the past quarter century, controversy surrounding the Franklin D. Roosevelt (FDR) Memorial in Washington, DC illustrates the current difficulties society has in accepting individuals with physical disabilities. FDR's Splendid Deception ²⁴ recounts how the original statue of FDR to be placed at the front of his memorial in Washington, DC was designed to depict him in his wheelchair (he could not walk after contracting polio at age 39). However, when the original sculpture was finished, his cape covered his wheelchair completely, in effect hiding his disability (Fig. 7). A second statue, depicting FDR using his actual wheelchair and placed at the other end of the memorial, was completed only after significant advocacy efforts by disability rights groups. It is important to note that ancient Egyptian society could realistically portray important figures with disabilities with compensatory devices over 3,000 years ago (Fig. 2), but the FDR Memorial planners of the 20 th century had problems acknowledging his disability, despite the fact that he was one of the most important and powerful leaders in the world during his lifetime.

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PART 2: The Representation of Mental and Intellectual Disability in Art History

Up until the 19 th century, individuals with physiologically-based mental disorders were conceptualized in terms of 'madness' primarily related to spiritual disorders that needed to be treated through spiritual interventions (although these beliefs persist in some communities even today). For example, di Benvenuto's St. Catherine Exorcising a Possessed Woman, shows a demon being exorcised from a woman's head in the 1300s (Fig. 3). Similarly, Droeschout's To this Grave Doctor Millions do Resort from the 17 th century (Fig. 8) shows a scene in which demons were exorcised from an individual's head in a fancy contraption (figure on right), as well as from their bowels by the apparent use of an elixir to dispel demons (figure on left).

Similarly, a 16 th-century painting by Hieronymus Bosch titled The Extraction of the Stone of Madness (Stones of Folly) illustrates the belief at that time that 'madness' was due to the presence of a stone within the skull that required extraction in order for the person to be cured (Fig. 9). By 1514, mental illness was believed to be related to an imbalance of the four humors of the body (black bile, yellow bile, blood, phlegm) that led to the four primary human temperaments (melancholic, phlegmatic, choleric, and sanguine) ²⁵ as represented in Durer's Melancholia I (Fig. 10). Frans Hal's Malle Babbe (1633-1635) illustrates how mental illness (eg, insanity, alcoholism) was conceptualized in northern Europe during the 17 th century as being caused by the visitation of the bird of lunacy (Fig. 11).

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Art from the 19 th century demonstrates how mental (ie, lunacy) and developmental disabilities (ie, 'idiocy') started to be conceptualized in a different manner in some cultures, in that such disorders were transformed from being conceptualized as 'madness' to 'mental illness' (ie, a medical abnormality) ²⁶. For example, in the 1800s, health professionals attempted to distinguish between different types of mental disorders through the identification of unique facial features, similar to the field of physiognomy.

Theodore Gericault painted a series of 10 'portraits of the insane' ( The Madwoman, 1819-1822; Fig. 12) depicting physical attributes that were thought to be associated with specific psychological disorders-five of the paintings which still exist (Woman Addicted to Gambling, A Child Snatcher, Woman Suffering from Obsessive Envy, Kleptomaniac, Man Suffering from Delusions of Military Command). Although it is difficult to determine how physical features could reveal a 'child snatcher' or someone with 'military delusions,' it is noteworthy that mental illnesses were starting to be categorized in terms of specific abnormalities (ie, physical and psychological).

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Art from other historical periods also offers insight into the manner by which individuals with mental disabilities were segregated and isolated from their communities. Bosch's Ship of Fools (1490-1500; Fig. 13) depicts the practice during the 15 th century and beyond of rounding up the disabled and unwanted and placing them in a wagon with promises of goods, in order to remove them from society. ²⁷ This practice changed in the beginning of the 18 th century when individuals with mental and sensory disabilities began to be institutionalized in hospitals or asylums, but without prescribed care or interventions. 2,3 Goya illustrated such a lunatic asylum in the 1700s (Fig. 14), but incredibly, this representation differs little from the demeaning conditions depicted in the infamous 1970s documentary about the Willowbrook Mental Institution in New Jersey (Fig. 15). These works of art show how individuals with mental illnesses from the Middle Ages until the 1970s were removed from society and deemed unworthy of treatment, which differs considerably from current societal understanding and increasing acceptance of mental illness.

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Although artists throughout history have generally depicted individuals with intellectual disabilities in a negative manner (eg, village idiots, fools), several works of art illustrate how some societies had positive and accepting views of individuals with intellectual disabilities. For example, The Adoration of the Christ Child (circa 1515) offers a powerful message about the acceptance of individuals with developmental disabilities in Northern Europe in the 16th century (Fig. 16). In this painting, medical professionals have suggested that two of the angels surrounding the manger have Down's syndrome (although the syndrome was not known as such at that time). 28,29 This painting likely reflects the longstanding and continued willingness of communities in northern Europe to be inclusive of individuals with intellectual disabilities.

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PART 3: The Representation of Sensory Disability in Art History

Misperceptions and prevailing attitudes of individuals with sensory disorders date back to the biblical era. In its most dramatic fashion, select scriptures led many to believe that God used deafness and blindness as retribution for sin: "Who gave man his mouth? Who makes him deaf or mute? Who gives him sight or makes him blind? Is it not I, the Lord?" (Exodus 4:11); "...if you do not carefully follow His commands and decrees...all these curses will come upon you and overtake you: the Lord will afflict you with madness, blindness, and confusion of the mind. At midday, you will grope around like a blind man in the dark." (Deuteronomy 28:15). This demonization of the blind carried on through the Middle Ages and into the Renaissance.

For example, a manuscript from the 14 th century, The Romance of Alexander, ³⁰ includes illustrations, in the margins, of the daily customs, work, dress, leisure activities, and social norms that existed in Medieval Europe at that time. Of interest, one border illustration shows how individuals with visual impairments were paraded before communities as a form of entertainment at times of festival (Fig. 17), similar to Bruegel's The Cripples (Fig. 4). Writings from 1425 describe a similar event:

"Note, the last Sunday of the month of August there took place an amusement at the residence called d'Arminac in the Rue Saint Honore, in which four blind people, all armed, each with a stick, were put in a park, and in that location there was a strong pig that they could have if they killed it....and there was a very strange battle, because they gave themselves so many great blows with those sticks that it went worse for them, because when the stronger ones believed that they hit the pig, they hit each other, and if they had really been armed, they would have killed each other. Note, the Saturday evening before the aforementioned Sunday, the said blind people were led through Paris all armed, a large banner in front, where there was a pig portrayed, and in front of them a man playing a bass drum" (as cited in Wheatley 26( p1)).

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Throughout history, images of the blind beggar have rendered public perception of blind individuals as helpless, useless, and passively dependent. Given the social, vocational, and financial difficulties associated with blindness and marginalization, some blind individuals have succumbed to accepting this role. For example, Millais (1856) portrayed a young blind girl relegated to beg for money by playing her concertina while wearing a sign on her neck displaying the words, "Pity the Blind" (Fig. 18). This was also depicted in a notorious photograph by Strand in 1916 of an impoverished blind woman in New York City, identifying her disability with a sign around her neck saying "Blind," below the metallic license she needed to obtain to legally beg ³¹ (Fig. 19).

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Beginning in the 17 th century, the perception of individuals with visual disabilities as defective, expendable, and intellectually disabled led to the social control movement of institutionalization for the disabled. In fact, one of the first institutions for disabled individuals was intended for the deaf and the blind, as depicted in Goya's Yard with Madmen (1794; Fig. 14), which represented scenes of institutions he personally witnessed, and was said to be painted at a time when he feared similar consequences from his own mental illness and deafness. The emotional toll of the blind and deaf, due to marginalization and social stigma, can also be seen in Goya's Two Old Men (from his Black Painting series; Fig. 20), capturing the darkness and isolation felt during his years plagued with deafness and physical ailment. Similar sentiments are aroused in Degas' Madame René de Gas (1872/1873; https://www.nga.gov/collection/art-object-page.46599.html), a portrait of his blind sister-in-law's vacant gaze representing her solitude and isolation, and Picasso's The Old Guitarist (1903), both depicting tones of sorrow and loneliness. The sorrow and frustration were a product of living in a society that deemed them incapable and blemished, therefore discounting their intact capabilities that could benefit from accommodation.

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During the mid-20 th century, Americans with visual impairments described the impact of the beliefs, superstitions, and the social/physical environment as the primary obstacle to the emotional and physical adjustment to their disability, as cited in The War Blind in American Social Structure:

"All too frequently the great tragedy of a blind person's life is not primarily his blindness, but the reactions of the family and social group toward him as a non-typical member." ³²

Today, while ambiguous perceptions of those with sensory impairment still exist, knowledge, technological innovation and accommodations leading to expansive and ready access of support helps afford these individuals education and greater independence. Interpreters are more readily available in health care and educational facilities, along with the transcription of texts to Braille or auditory recordings. With these supports and greater public knowledge, individuals with sensory disabilities have disproved past perceptions of being passive, dependent, helpless, unproductive, or intellectually disadvantaged.

PART 4: Modern Artistic Representations of Disability

Although beyond the scope of this article, it is noteworthy how primary art forms of today (ie, movies, TV) have played a substantial role throughout the 20 th and 21 st centuries in shaping societal attitudes toward disability. Thus, it is not surprising that the manner by which disability is represented in media art today has also led to greater acceptance of disability. Such realistic and positive representations of disability will continue to teach people who are secure in their beliefs and perceptions of 'normalcy' that individuals with disabilities are not subjects to be gawked at or marginalized.

For example, children today are exposed to positive images of disability and representations of characters with disability as leaders, such as those portrayed in the Disney movie Finding Nemo (2003). X-Men is a popular comic magazine that has been made into a series of movies (2000-2019). Of note, Charles Xavier, the leader of this band of individuals with superhuman powers, is confined to a wheelchair. Similarly, the critically acclaimed Murderball (2005) is a documentary film that shows individuals with various forms of paralysis engaging in full-contact rugby in the Paralympic Games in Athens, Greece.

The depiction of mental illness in film has also improved over the past 50 years, with individuals with mental illnesses and sensory disabilities portrayed more realistically and empathetically ( One Flew over the Cuckoo's Nest (1975); Rain Man (1988); Children of a Lesser God (1986)). Rehabilitation trainees and professionals can watch these and other movies that show the human experience of disability with subsequent discussion at scheduled training opportunities (Table 2). These movies offer opportunities to discuss differences in how individuals with disabilities have been portrayed and treated in the past and currently, and how more positive portrayals can lead to the development of better skills for rehabilitation professionals-and ultimately greater understanding and acceptance of the personal experience of disability.

PART 5: Disability Training Through the Arts

It is suggested that rehabilitation training guidelines promote opportunities for both students and professionals to become aware of the "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them" (see APA Division 22 training guidelines) through the study of disability in the visual arts. It is recommended that rehabilitation students and professionals review and discuss the visual arts (and literature) relating to the personal experiences of, and societal perceptions of, disability in existing didactics, grand rounds, and journal clubs. Students and professionals can easily review paintings and articles presented in this article for discussion, and particularly those presented in articles from traditional medical journals and art history journals and textbooks (see References below).

Training directors can also find appropriate topics and offerings on art and disability through many websites and organizations (Appendix 1). Review of the representation of disability in the visual arts can also be discussed based on academic sources that provide contextually-relevant cultural information related to specific eras, as well as autobiographies, novels, and collections of short stories that provide examples that relate the personal experiences of persons with disabilities, the challenges they have faced, and the successes they have had in becoming full members of society (Appendix 2).

Conclusion

In conclusion, this article reflects the benefits and necessity of training in the health humanities (versus medical humanities) for both rehabilitation professionals and those individuals with disabilities they serve. Specifically, the health humanities apply transdisciplinary practices that draw on the humanities, fine arts, and social sciences to bring meaning to human experiences of health and illness, to increase social justice for individuals with illness and disabilities. ³⁴ Training in the health humanities can complement training in the medical humanities-which focus on the use of the humanities in service to medicine-to help practitioners learn attributes such as empathy, communication, and compassion.

The authors wish to acknowledge the assistance of Josiah Scott in editing and formatting this article.

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25 Bartrum G. (ed.) Albrecht Dürer and His legacy. London: The British Museum Press; 2002.

26 Wheatley E. Stumbling Blocks Before The Blind: Medieval Constructions of a Disability. Ann Arbor: The University of Michigan Press; 2010.

27 Maher WB, Maher B. The ship of fools: Stultifera Navis or Ignis Fatuus? Am Psychol. 1982;37(7):756-761.

28 Levitas AS, Reid CS. An angel with Down syndrome in a sixteenth century Flemish nativity painting. Am J Med Gen. 2003;116A:399-405.

29 Robotham J. Nativity scene paints different picture of Down syndrome; 2003. Available at: https://www.smh.com.au/national/nativity-scene-paints-different-picture-of-down-syndrome-20030127-gdg67d.html. Accessed 8/15/2013

30 Romance of Alexander (Bodleian Library, Oxford, England); Hasenohr G, Zink M, eds. Dictionnaire des lettres françaises: Le Moyen Age. Collection: La Pochothèque. Paris: Fayard, 1992. ISBN 2-253-05662-6.

31 Chouard G. A Weltian rhapsody: Paul Strand, "Blind" (1917) and Eudora Welty, "Blind Weaver on the WPA, Oktibbeha County, 1930s." Transatlantica 2009;2:27. Available at: https://journals.openedition.org/transatlantica/4696. Accessed 7/24/2020.

32 Gowman AG. The war blind in American social structure. New York: The American Foundation for the Blind; 1957.

33 Wedding D, Boyd MA. Movies & Mental Illness: Using Films To Understand Psychopathology. Boston: McGraw-Hill College; 1999.

34 Klugman CM, Lamb EG. Research methods in the health humanities. New York: Oxford University Press; 2019.

Appendix 1: Art and Disability-related Organizations, Bibliographies, and Training Websites

Disability Studies programs

Appendix 2: Disability-relevant Art and Medicine Books
Albrecht GL. The Encyclopedia of Disability. London, UK: Sage Publications; 2006.

Barth M, Siegel A. Step Right This Way: The Photographs of Edward J. Kelty. New York, NY: Barnes and Noble; 2002.

Bettman OL. A Pictorial History of Medicine. Springfield, IL: Charles C. Thomas Publisher; 1972.

Carmichael AG, Ratzan RM. Medicine: A Treasury of Art and Literature. New York, NY: Hugh Lauter Levin Associates; 1991.

Greenspan RE. Medicine: Perspectives in History and Art. Alexandria, VA: Ponteverde Press; 2006.

Lyons AS, Petrucelli RJ III. Medicine: An Illustrated History. New York, NY: Harry N. Abrams; 1987.

Porter R (ed.). The Cambridge Illustrated History of Medicine. Cambridge, UK: Cambridge University; 1996.

Scull A. Madness in Civilization: A Cultural History of Insanity. Princeton, NJ: Princeton University Press; 2015.

Figures

Figure 1: Jean-Baptiste Grueze's The Paralytic, 1763, Hermitage Museum, St. Petersburg, Russia. ( File:Jean-Baptiste Greuze - Filial Piety - WGA10664.jpg - Wikimedia Commons).

Figure 2: The Polio Stele, Egypt 18 th Dynasty, 1403-1365 B.C., Deutsches Grunes Kreug, Copenhagen, Denmark. ( File:Polio Egyptian Stele.jpg - Wikimedia Commons).

Figure 3: Girolamo di Benvenuto's St. Catherine of Siena Exorcising a Possessed Woman, c. 1500, Denver Art Museum, Denver, Colorado. ( File:'St. Catherine of Siena Exorcising a Possessed Woman', painting by Girolamo di Benvenuto.jpg - Wikimedia Commons).

Figure 4: Pieter Bruegel the Elder's The Cripples, 1568, Louvre, Paris, France. ( File:Pieter Bruegel the Elder - The Cripples - WGA3518.jpg - Wikimedia Commons).

Figure 5: Details from Pieter Bruegel the Elder's Battle Between Carnival and Lent, 1559, Kunsthistorches Museum, Vienna, Austria. ( File:The battle between Carnival and Lent, by Pieter Bruegel (I).jpg - Wikimedia Commons).

Figure 6: Edward J. Kelty, photograph from Madison Square Garden, 1933. Published in Barth M., Siegel AM. Step Right This Way: The Photographs of Edward Kelty (p. 107). New York, NY: Barnes and Noble Books. 2002

Figure 7: Franklin Delano Roosevelt Memorial, Washington, D.C. (https://www.nps.gov/frde/learn/photosmultimedia/index.htm).

Figure 8: Martin Droeschout's To this Grave Doctors Millions do Resort, c. 1620 - 1630, British Museum, London, England. ( File:To this grave doctor millions do resort (BM 1854,1113.154).jpg - Wikimedia Commons).

Figure 9: Hieronymous Bosch's The Extraction of the Stone of Madness (Stones of Folly), c. 1501 - 1505, Prado, Madrid, Spain. ( File:Cutting the Stone (Bosch).jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/the-extraction-of-the-stone-of-madness/313db7a0-f9bf-49ad-a242-67e95b14c5a2).

Figure 10: Albrecht Durer's Melancholia I, 1514, Stadl Museum, Frankfurt, Germany. ( File:Dürer Melancholia I.jpg - Wikimedia Commons).

Figure 11: Frans Hal's Malle Babbe, 1633-1635, Gemaodegalerie, Berlin, Germany. ( File:Frans Hals 021.jpg - Wikimedia Commons).

Figure 12: Theodore Gericault's The Madwoman, 1819-1822, Museum of Fine Art, Lyon, France. ( File:The mad woman-Theodore Gericault-MBA Lyon B825-IMG 0477.jpg - Wikimedia Commons).

Figure 13: Hieronymous Bosch's Ship of Fools, 1494 - 1510, Louvre, Paris, France. ( https://collections.louvre.fr/en/ark:/53355/cl010062860; https://commons.wikimedia.org/wiki/File:Jheronimus_Bosch_011.jpg).

Figure 14: Francisco de Goya y Lucientes's Yard with Madmen, 1794, Meadows Museum, Dallas, Texas. (https://meadowsmuseumdallas.org/collections/pages/objects-1/info/?query=Artist_Maker%3D%2239%22&page=7).

Figure 15: Willowbrook Asylum. Photograph by William Bronston, 1979, from unpublished book (Public Hostage: Public Ransom - Inside Institutional America; online Archive of California: Finding Aid to the William Bronston Papers, 1961-2008 (cdlib.org)).

Figure 16: School of Jan Joest, The Adoration of the Christ Child, 16 th century, Museum of Modern Art, New York, New York. ( File:The Adoration of the Christ Child MET DT8852.jpg - Wikimedia Commons).

Figure 17: Illustration from The Romance of Alexander (artist Jehan de Grise), Flanders, Belgium, 1338-1344 (permission from the Bodleian Library).

Figure 18: John Everett Millais' Blind Girl, 1856, Birmingham Museum and Art Gallery, Birmingham, England. ( File:Millais-Blind Girl.jpg - Wikimedia Commons).

Figure 19: Paul Strand's The Blind Woman, 1916. ( https://commons.wikimedia.org/wiki/File:Blind_Woman.jpg).

Figure 20: Francisco de Goya y Lucentes' Two Old Men, 1821-1823, Prado, Madrid, Spain. ( File:2 alte Männer, um 1821-23.jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/two-old-men/cde9bf01-7535-4a62-8f73-a22d6a68d9a5?searchid=433a4981-4175-39e4-581f-0cc97a3dd2ad).

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Training guidelines for rehabilitation disciplines are generally based on medical models that focus on acquisition of knowledge (eg, anatomy, diagnoses, policies) and skills (eg, discipline-specific interventions) related to different disability diagnoses. However, there are mounting calls to expand the sensitivity of rehabilitation professionals to the personal experiences of, and social biases toward, individuals with disabilities (ie, issues of 'attitude'). It is argued that the review of artistic depictions of disability in their respective historical contexts offers an excellent vehicle by which to sensitize rehabilitation professionals to these issues. This article reviews the manner in which different western societies throughout history have depicted individuals with physical, mental, and sensory disabilities in the visual arts, ranging from primarily negative (eg, reflection of divine punishment for deserved transgressions, objects to be ridiculed for entertainment, etc.) to more recent positive perceptions (eg, heroes in contemporary films). Suggestions are offered regarding the use of the visual arts to educate rehabilitation professionals regarding individual and societal biases of disability, and to reduce the perpetuation of the stigma, misrepresentation, and mistreatment of individuals with disabilities.

Introduction

Since the passage of the Americans with Disabilities Act (ADA, 1990) there has been increased interest in promoting a better understanding and acceptance of persons with disabilities, as well as improving the societal discrimination they face. The Disability Rights Movement developed primarily in the last quarter of the 20 th century with considerable growth in advocacy efforts over the past three decades (eg, see Lives Worth Living). Of primary importance, the ADA prohibits discrimination and ensures equal opportunity for persons with disabilities in: employment; state and local government programs and services; access to places of public accommodation such as business, transportation, and non-profit service providers; and telecommunications. Although the ADA has provided greater opportunities and access for persons with disabilities, in order for them to attain complete inclusion into society, it is essential to change the negative attitudes and misperceptions regarding them commonly held by the general public-as well as by many rehabilitation professionals.

The manner in which individuals with disabilities were perceived, treated, and integrated into societies throughout history is complex and related to multiple issues involving economic, scientific, and religious factors. ¹ In the past, individuals with disabilities were frequently viewed as objects to be ridiculed and for the most part they have been perceived as a burden to others and considered to be of limited value to society. 2,3 This was due in large part to the limited understanding of human anatomy and physiology, as well as the lack of methods to treat disease and injuries, minimize impairments, or develop assistive devices (eg, prosthetic devices, assistive technologies, environmental accommodations). As such, they were often socially ostracized and driven to live on the margins of society. In contrast, there have also been various cultures and religious sects throughout history that have tended to care for and be empathetic toward individuals with disabilities.

Imagery From Ancient Times to the Present Day

Ancient writings and images reveal a wide variety of messages about how individuals with disabilities were treated and perceived in early historical times, including the portrayal of disability as a source of punishment in the Code of Hammurabi (ca. 1780 BCE), as predictors of good or bad events in The Omen Series Summa Izbu (ca. 1300 BCE), as individuals capable of community leadership in Homeric writings (The Iliad, 750 BCE), or even as a mark of beneficence in ancient Egypt. 2,4 However, few know that Aristotle proposed a law to prevent parents from raising deformed children, ⁵ that Spartan laws obliged parents to abandon deformed children, ⁶ or that Cicero claimed that the body determined the 'shape' of the soul. ⁷ Even numerous biblical passages demonstrate how individuals with various physical disabilities (eg, leprosy and paralysis) were perceived and treated negatively. 2,8 In fact, numerous laws/policies throughout history legalized or encouraged discrimination against individuals with disabilities and such negative representations further reinforced public perception of disability as 'abnormal,' along with the social division between the disabled and nondisabled. ⁹ These negative perceptions of disability generally persisted until the second half of the 20 th century when advances in medicine and innovative treatments/technologies allowed for the approach to disabilities to be improved.

Training in Disability Issues Across Rehabilitation Professions

With the development of the profession of physical medicine and rehabilitation following World War II, society began to view more consistently individuals with disabilities as worthy of treatment, and to assist them in recovering as fully as possible and returning to productive, independent lives. ¹⁰ Since then, rehabilitation disciplines have developed training guidelines to improve the health and functioning of individuals with disabilities (Table 1). In general, these professional organizations call for training based on medical models that emphasize knowledge and skills, often leading to the treatment of individuals as 'disorders' (eg, a spinal cord injury, a traumatic brain injury, a stroke) or 'impairments' (eg, forgetfulness, irritability, spasticity), rather than individuals with disabilities. As such, rehabilitation 'success' could be over-simplistically evaluated in terms of improvements in range of motion, memory scores, or increased psychological traits, without consideration of the need for full inclusion of individuals with disabilities into society. Because of these factors, it has been concluded that rehabilitation professionals "are often negative about disability, seeing inability before ability and frustrated by the lack of a prospect of cure and ill-informed about simple accommodations." 11(p462)

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Table 1: Rehabilitation Discipline Training Guidelines
American Board of Internal Medicine (2013). Internal medicine/physical medicine and rehab policies. Accessed online on 7/20/2020 at: http://www.abim.org/certification/policies/combinedim/comrehab.aspx

Accreditation Content for Occupational Therapy Education (2018). Standards of practice for occupational therapy. Accessed online on 7/20/2020 at: https://acoteonline.org/wp-content/uploads/2020/07/2018-ACOTE-Standards.pdf

American Physical Therapy Association (2018). Standards of practice for physical therapy. Accessed online on 7/20/20 at: http://www.apta.org/uploadedFiles/APTAorg/AboutUs/Policies/HOD/Practice/standards.pdf.

American Speech-Language-Hearing Association. (2020). Scope of practice in speech

language pathology [Scope of Practice]. Accessed online on 7/20/20 at: https://www.asha.org/certification/2020-slp-certification-standards/.

American Psychological Association Rehabilitation Psychology Division (2012). Guidelines for postdoctoral training in rehabilitation psychology. Accessed online on 7/20/20 at: https://www.apa.org/pubs/journals/features/rep-a0030774.pdf.

American Therapeutic Recreation Association Standards of Practice. Accessed online on 7/20/20 at: https://www.atra-online.com/page/SOP.

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More recently, there has been increased recognition of the need for training in the ability to understand the personal experiences of persons with disabilities and the societal biases experienced by these individuals (sometimes referred to as training in issues of attitude). It is relatively easy to teach knowledge (eg, facts, diagnostic criteria) and skills (eg, procedures, tests, discipline-specific therapies), as these are generally fact-based and able to be memorized. However, it is much more difficult to mold individual and societal attitudes (ie, conscious and unconscious biases and beliefs) about disabilities. Changing attitudes and beliefs, however, is central to improving the lives of people with disabilities given that prejudicial and exclusionary social practices are believed to be greater barriers to social participation than specific mental, physical, or sensory impairments. ¹² It is important for healthcare professionals to examine their own beliefs about disability and awareness of how persons with disabilities are perceived, portrayed, and treated today, and particularly for those rehabilitation professionals who work with these populations on a daily basis.

Rehabilitation Psychology Training Guidelines: An Example

Although all rehabilitation training guidelines generally focus on the medical model, initial post-doctoral training guidelines for rehabilitation psychology provide an example of training methods to address issues of attitude. This specifically involves the need to be educated about the manner by which disability is a socially-constructed phenomenon, as well as the manner by which our own biases affect our treatment, interactions with, and expectations for, individuals with disabilities. For example, one of the most notable rehabilitation psychology guidelines calls for training in "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them." ¹³ This suggestion is truly unique among the various rehabilitation disciplines in that it acknowledges the significant role that societal expectations and misperceptions have in the manner by which individuals with disabilities are treated. Although this suggestion is noteworthy, there are no specific methods to suggest how to train rehabilitation professionals regarding the societal perceptions that impact persons with disabilities. This article suggests that studying images of disability in art history is an important and impactful method for teaching rehabilitation professionals about the experiences and biases experienced by those patients they serve.

Art as a Means to Better Understand the Experience of Disability

Human beings have made art to communicate and connect with each other since prehistoric times. Art has the powerful ability to help viewers relate to the individuals depicted in the image on a human, empathetic level, which, in turn enhances the goal of understanding and acceptance on a new level. Artists have used various mediums (eg, paintings, poetry, narratives, sculpture, film, etc.) to express emotional turmoil, tragedy, social isolation, and psychological disturbance as a means to relate and share personal experiences. The medical, legal, and social zeitgeist of an era is often reflected by the artwork created of that time. Alternatively, societal perceptions have long been influenced by how individuals with disability are represented to the public visually and politically. There are few primary sources from ancient and medieval times regarding people with disabilities, ³ and as a result, researchers have relied on the arts to determine the social context of disability at various times throughout history. In fact, a historian of disability states that, "Studying the representation of disability in literature and art is an important and relatively unexplored research frontier in disability studies." 14(p 54)

The arts have been used in rehabilitation for people with disabilities primarily through recreational therapies in which individuals engage in the visual arts, music, dance, and expressive writing to adjust to their disabilities. However, a review of artistic representations of disability throughout history also offers an excellent method by which to improve the training of rehabilitation professionals. There is increased recognition that studying the humanities helps health professionals gain a better understanding of the human side of chronic disabilities.

People with disabilities are depicted throughout art history, and these images provide a context for the manner by which they were perceived at that time (eg, worthy of derision or sympathy, objects of ridicule, deserving of divine punishment, etc.). For example, prior to the advent of the printing press, when much of the population was illiterate, paintings were often used to tell stories, depict historical events, and provided examples of how people were treated. ³ As such, many individuals learned social expectations for how to treat the disabled by viewing paintings in churches or watching plays during community festivals. It is from these works of art that we can understand the culture of the times and become sensitized to the relevant social issues of the day as they pertain to disability. By comparing past and current art forms (eg, paintings, drawing, and sculptures from the past to movies, films, and literature from the present) it is possible to better understand how societal perceptions have a major influence on the way individuals with disabilities are treated. Subsequently, training methods can be developed to counter "social myths of disabilities" (see APA Division 22 training guidelines), and educate rehabilitation professionals to become better providers for individuals with disabilities.

PART 1: The Representation of Physical Disability in Art History

Throughout history, individuals with physical disabilities have primarily been perceived and represented as 'misfits, fools, oddities, and marvels,' present in the world for purposes of entertainment, ridicule, and experimentation. ² This relates in part to the lack of understanding of the causes of physical disability, as well as the lack of resources, knowledge, or will to develop accommodations during various historical times. As such, individuals with disabilities often had little support from their families and communities and needed to fend for themselves in creative ways; this was generally the case until the last half of the 20 th century.

As an example, Greuze's The Paralytic (1763; Fig. 1) is one of the few depictions of an individual with paralysis, likely due to the fact that the survival rates for such individuals were extremely low.

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Historically, depictions of physical disability in western civilizations have largely focused on 'abnormalities' and the negative manner by which individuals with disabilities were perceived and treated. In fact, a frequently-cited theory from the late 18 th century related to physiognomy concluded that the disabled were, "[t]he morally worst, the most deformed." ¹⁵ However, it is noteworthy that ancient Egyptian and Greek cultures at various times were generally accepting of individuals with physical disabilities, as illustrated in several of their works of art. 4,16,17 For example, a stone carving from approximately 1300 BCE shows a realistic depiction of an Egyptian leader with a withered leg, apparently from polio (Fig. 2). Greek vases show similar representations of dwarves who were valued as assistants within the medical field, and even portrayed as deities. 16,17 However, throughout history, such positive depictions of physical disabilities were the exception rather than the rule.

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By the Middle Ages, societies began to extend to people with impairments "an acceptance at times awkward, at times brutal, at times compassionate, a kind of indifferent, fatalistic integrations" to people with impairments. 8(p15) However, in general, individuals with disabilities were represented as abnormal, with early portrayals exploiting these abnormalities for amusement. Paintings from this time indicate that individuals with disabilities were viewed in terms of a religious model of disability, in that individuals were believed to be disabled secondary to spiritual transgressions and were thus treated with religious interventions, if they were even treated. Metzler 2(p89) reports "anecdotal evidence suggests that there was a very strong feeling that malformed babies indicated sin on the part of their parents." Spiritual interventions for disabilities were depicted in a painting by di Benvenuto (15 th Century), titled St. Catherine of Siena Exorcising a Possessed Woman (Fig. 3), in which individuals with both physical (ie, characters with crutches) and mental illnesses (central figure) caused by demonic possession were treated with religious interventions within a church setting.

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By the 16 th century, the Renaissance began to focus on classical forms of beauty, which did not typically include the disabled or deformed. However, art from the northern Renaissance depicted individuals with physical disabilities in a realistic manner, providing insight into the way they were treated and socially perceived at that time. Hieronymous Bosch painted a series of 31 'cripples' in 1500, illustrating the various disabling conditions and prosthetic devices used by these individuals. ¹⁹ Similarly, Bruegel's The Cripples (1568; Fig. 4) shows individuals with various prosthetics gathered together in a town square. However, historical context indicates that these individuals were forced to wear fox tails attached to their clothes as indicators that they were objects to be ridiculed at community festivals. 19,20 Similarly, Bruegel's Battle Between Carnival and Lent (1559; Fig. 5) shows the relative isolation faced by individuals with disabilities within their communities. Compared to the so-called 'normal' citizens participating in either carnival or lent, details from the painting show two groups of individuals with disabilities (ie, 'cripples' in middle scene, blind individuals by church entrance) as socially-isolated beggars. These community spectacles are precursors to the freak shows that gained popularity in the mid-16 th century and lasted to the mid-20 th century, which displayed physically unusual or deformed humans for a source of entertainment ²¹ (Fig. 6). By the 19th century, individuals with impairments were even criminalized through public policy (ie, 'ugly laws' involving social restrictions placed on those with physical appearances that might offend 'normal' people) ⁹.

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Paintings such as Wyeth's Christina's World (1948) provide an example of the social isolation and handicaps faced by many individuals with physical disability even in the middle of the 20 th century. This painting appears to show its subject, Christina Olson, admiring a homestead in a windswept field. However, an article in the Journal of Child Neurology ²² indicates that Wyeth was portraying a young woman suffering from a progressive neurological disorder that he observed crawling crab-like up to her farmhouse. This knowledge challenges the initial perception of the scene and shifts our position from viewer to Christina's own perspective. This is the power of studying art history: to guide the viewer by facilitating close looking, deeper contextual understanding, and empathy. An article by J.O. Ballard in JHR is an excellent resource for those who would like to use this painting to increase clinical observation and diagnostic skills regarding disability in health sciences education. ²³

Even within the past quarter century, controversy surrounding the Franklin D. Roosevelt (FDR) Memorial in Washington, DC illustrates the current difficulties society has in accepting individuals with physical disabilities. FDR's Splendid Deception ²⁴ recounts how the original statue of FDR to be placed at the front of his memorial in Washington, DC was designed to depict him in his wheelchair (he could not walk after contracting polio at age 39). However, when the original sculpture was finished, his cape covered his wheelchair completely, in effect hiding his disability (Fig. 7). A second statue, depicting FDR using his actual wheelchair and placed at the other end of the memorial, was completed only after significant advocacy efforts by disability rights groups. It is important to note that ancient Egyptian society could realistically portray important figures with disabilities with compensatory devices over 3,000 years ago (Fig. 2), but the FDR Memorial planners of the 20 th century had problems acknowledging his disability, despite the fact that he was one of the most important and powerful leaders in the world during his lifetime.

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PART 2: The Representation of Mental and Intellectual Disability in Art History

Up until the 19 th century, individuals with physiologically-based mental disorders were conceptualized in terms of 'madness' primarily related to spiritual disorders that needed to be treated through spiritual interventions (although these beliefs persist in some communities even today). For example, di Benvenuto's St. Catherine Exorcising a Possessed Woman, shows a demon being exorcised from a woman's head in the 1300s (Fig. 3). Similarly, Droeschout's To this Grave Doctor Millions do Resort from the 17 th century (Fig. 8) shows a scene in which demons were exorcised from an individual's head in a fancy contraption (figure on right), as well as from their bowels by the apparent use of an elixir to dispel demons (figure on left).

Similarly, a 16 th-century painting by Hieronymus Bosch titled The Extraction of the Stone of Madness (Stones of Folly) illustrates the belief at that time that 'madness' was due to the presence of a stone within the skull that required extraction in order for the person to be cured (Fig. 9). By 1514, mental illness was believed to be related to an imbalance of the four humors of the body (black bile, yellow bile, blood, phlegm) that led to the four primary human temperaments (melancholic, phlegmatic, choleric, and sanguine) ²⁵ as represented in Durer's Melancholia I (Fig. 10). Frans Hal's Malle Babbe (1633-1635) illustrates how mental illness (eg, insanity, alcoholism) was conceptualized in northern Europe during the 17 th century as being caused by the visitation of the bird of lunacy (Fig. 11).

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Art from the 19 th century demonstrates how mental (ie, lunacy) and developmental disabilities (ie, 'idiocy') started to be conceptualized in a different manner in some cultures, in that such disorders were transformed from being conceptualized as 'madness' to 'mental illness' (ie, a medical abnormality) ²⁶. For example, in the 1800s, health professionals attempted to distinguish between different types of mental disorders through the identification of unique facial features, similar to the field of physiognomy.

Theodore Gericault painted a series of 10 'portraits of the insane' ( The Madwoman, 1819-1822; Fig. 12) depicting physical attributes that were thought to be associated with specific psychological disorders-five of the paintings which still exist (Woman Addicted to Gambling, A Child Snatcher, Woman Suffering from Obsessive Envy, Kleptomaniac, Man Suffering from Delusions of Military Command). Although it is difficult to determine how physical features could reveal a 'child snatcher' or someone with 'military delusions,' it is noteworthy that mental illnesses were starting to be categorized in terms of specific abnormalities (ie, physical and psychological).

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Art from other historical periods also offers insight into the manner by which individuals with mental disabilities were segregated and isolated from their communities. Bosch's Ship of Fools (1490-1500; Fig. 13) depicts the practice during the 15 th century and beyond of rounding up the disabled and unwanted and placing them in a wagon with promises of goods, in order to remove them from society. ²⁷ This practice changed in the beginning of the 18 th century when individuals with mental and sensory disabilities began to be institutionalized in hospitals or asylums, but without prescribed care or interventions. 2,3 Goya illustrated such a lunatic asylum in the 1700s (Fig. 14), but incredibly, this representation differs little from the demeaning conditions depicted in the infamous 1970s documentary about the Willowbrook Mental Institution in New Jersey (Fig. 15). These works of art show how individuals with mental illnesses from the Middle Ages until the 1970s were removed from society and deemed unworthy of treatment, which differs considerably from current societal understanding and increasing acceptance of mental illness.

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Although artists throughout history have generally depicted individuals with intellectual disabilities in a negative manner (eg, village idiots, fools), several works of art illustrate how some societies had positive and accepting views of individuals with intellectual disabilities. For example, The Adoration of the Christ Child (circa 1515) offers a powerful message about the acceptance of individuals with developmental disabilities in Northern Europe in the 16th century (Fig. 16). In this painting, medical professionals have suggested that two of the angels surrounding the manger have Down's syndrome (although the syndrome was not known as such at that time). 28,29 This painting likely reflects the longstanding and continued willingness of communities in northern Europe to be inclusive of individuals with intellectual disabilities.

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PART 3: The Representation of Sensory Disability in Art History

Misperceptions and prevailing attitudes of individuals with sensory disorders date back to the biblical era. In its most dramatic fashion, select scriptures led many to believe that God used deafness and blindness as retribution for sin: "Who gave man his mouth? Who makes him deaf or mute? Who gives him sight or makes him blind? Is it not I, the Lord?" (Exodus 4:11); "...if you do not carefully follow His commands and decrees...all these curses will come upon you and overtake you: the Lord will afflict you with madness, blindness, and confusion of the mind. At midday, you will grope around like a blind man in the dark." (Deuteronomy 28:15). This demonization of the blind carried on through the Middle Ages and into the Renaissance.

For example, a manuscript from the 14 th century, The Romance of Alexander, ³⁰ includes illustrations, in the margins, of the daily customs, work, dress, leisure activities, and social norms that existed in Medieval Europe at that time. Of interest, one border illustration shows how individuals with visual impairments were paraded before communities as a form of entertainment at times of festival (Fig. 17), similar to Bruegel's The Cripples (Fig. 4). Writings from 1425 describe a similar event:

"Note, the last Sunday of the month of August there took place an amusement at the residence called d'Arminac in the Rue Saint Honore, in which four blind people, all armed, each with a stick, were put in a park, and in that location there was a strong pig that they could have if they killed it....and there was a very strange battle, because they gave themselves so many great blows with those sticks that it went worse for them, because when the stronger ones believed that they hit the pig, they hit each other, and if they had really been armed, they would have killed each other. Note, the Saturday evening before the aforementioned Sunday, the said blind people were led through Paris all armed, a large banner in front, where there was a pig portrayed, and in front of them a man playing a bass drum" (as cited in Wheatley 26( p1)).

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Throughout history, images of the blind beggar have rendered public perception of blind individuals as helpless, useless, and passively dependent. Given the social, vocational, and financial difficulties associated with blindness and marginalization, some blind individuals have succumbed to accepting this role. For example, Millais (1856) portrayed a young blind girl relegated to beg for money by playing her concertina while wearing a sign on her neck displaying the words, "Pity the Blind" (Fig. 18). This was also depicted in a notorious photograph by Strand in 1916 of an impoverished blind woman in New York City, identifying her disability with a sign around her neck saying "Blind," below the metallic license she needed to obtain to legally beg ³¹ (Fig. 19).

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Beginning in the 17 th century, the perception of individuals with visual disabilities as defective, expendable, and intellectually disabled led to the social control movement of institutionalization for the disabled. In fact, one of the first institutions for disabled individuals was intended for the deaf and the blind, as depicted in Goya's Yard with Madmen (1794; Fig. 14), which represented scenes of institutions he personally witnessed, and was said to be painted at a time when he feared similar consequences from his own mental illness and deafness. The emotional toll of the blind and deaf, due to marginalization and social stigma, can also be seen in Goya's Two Old Men (from his Black Painting series; Fig. 20), capturing the darkness and isolation felt during his years plagued with deafness and physical ailment. Similar sentiments are aroused in Degas' Madame René de Gas (1872/1873; https://www.nga.gov/collection/art-object-page.46599.html), a portrait of his blind sister-in-law's vacant gaze representing her solitude and isolation, and Picasso's The Old Guitarist (1903), both depicting tones of sorrow and loneliness. The sorrow and frustration were a product of living in a society that deemed them incapable and blemished, therefore discounting their intact capabilities that could benefit from accommodation.

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During the mid-20 th century, Americans with visual impairments described the impact of the beliefs, superstitions, and the social/physical environment as the primary obstacle to the emotional and physical adjustment to their disability, as cited in The War Blind in American Social Structure:

"All too frequently the great tragedy of a blind person's life is not primarily his blindness, but the reactions of the family and social group toward him as a non-typical member." ³²

Today, while ambiguous perceptions of those with sensory impairment still exist, knowledge, technological innovation and accommodations leading to expansive and ready access of support helps afford these individuals education and greater independence. Interpreters are more readily available in health care and educational facilities, along with the transcription of texts to Braille or auditory recordings. With these supports and greater public knowledge, individuals with sensory disabilities have disproved past perceptions of being passive, dependent, helpless, unproductive, or intellectually disadvantaged.

PART 4: Modern Artistic Representations of Disability

Although beyond the scope of this article, it is noteworthy how primary art forms of today (ie, movies, TV) have played a substantial role throughout the 20 th and 21 st centuries in shaping societal attitudes toward disability. Thus, it is not surprising that the manner by which disability is represented in media art today has also led to greater acceptance of disability. Such realistic and positive representations of disability will continue to teach people who are secure in their beliefs and perceptions of 'normalcy' that individuals with disabilities are not subjects to be gawked at or marginalized.

For example, children today are exposed to positive images of disability and representations of characters with disability as leaders, such as those portrayed in the Disney movie Finding Nemo (2003). X-Men is a popular comic magazine that has been made into a series of movies (2000-2019). Of note, Charles Xavier, the leader of this band of individuals with superhuman powers, is confined to a wheelchair. Similarly, the critically acclaimed Murderball (2005) is a documentary film that shows individuals with various forms of paralysis engaging in full-contact rugby in the Paralympic Games in Athens, Greece.

The depiction of mental illness in film has also improved over the past 50 years, with individuals with mental illnesses and sensory disabilities portrayed more realistically and empathetically ( One Flew over the Cuckoo's Nest (1975); Rain Man (1988); Children of a Lesser God (1986)). Rehabilitation trainees and professionals can watch these and other movies that show the human experience of disability with subsequent discussion at scheduled training opportunities (Table 2). These movies offer opportunities to discuss differences in how individuals with disabilities have been portrayed and treated in the past and currently, and how more positive portrayals can lead to the development of better skills for rehabilitation professionals-and ultimately greater understanding and acceptance of the personal experience of disability.

PART 5: Disability Training Through the Arts

It is suggested that rehabilitation training guidelines promote opportunities for both students and professionals to become aware of the "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them" (see APA Division 22 training guidelines) through the study of disability in the visual arts. It is recommended that rehabilitation students and professionals review and discuss the visual arts (and literature) relating to the personal experiences of, and societal perceptions of, disability in existing didactics, grand rounds, and journal clubs. Students and professionals can easily review paintings and articles presented in this article for discussion, and particularly those presented in articles from traditional medical journals and art history journals and textbooks (see References below).

Training directors can also find appropriate topics and offerings on art and disability through many websites and organizations (Appendix 1). Review of the representation of disability in the visual arts can also be discussed based on academic sources that provide contextually-relevant cultural information related to specific eras, as well as autobiographies, novels, and collections of short stories that provide examples that relate the personal experiences of persons with disabilities, the challenges they have faced, and the successes they have had in becoming full members of society (Appendix 2).

Conclusion

In conclusion, this article reflects the benefits and necessity of training in the health humanities (versus medical humanities) for both rehabilitation professionals and those individuals with disabilities they serve. Specifically, the health humanities apply transdisciplinary practices that draw on the humanities, fine arts, and social sciences to bring meaning to human experiences of health and illness, to increase social justice for individuals with illness and disabilities. ³⁴ Training in the health humanities can complement training in the medical humanities-which focus on the use of the humanities in service to medicine-to help practitioners learn attributes such as empathy, communication, and compassion.

The authors wish to acknowledge the assistance of Josiah Scott in editing and formatting this article.

1 Albrecht GL, Seelman KD, Bury M. Handbook of Disability Studies. London: Sage Productions; 2001.

2 Albrecht GL (ed). Encyclopedia of Disability: A History in Primary Source Documents (Vol. 5). Thousand Oaks: SAGE Publications; 2006.

3 Metzler I. Disability in Medieval Europe: Thinking About Physical Impairment During the High Middle Ages, c. 1100-1400. London: Routledge; 2006.

4 Sullivan R. Deformity - a modern western prejudice with ancient origins. Proc Royal College Phys Edinburgh. 2001;31:262-266.

5 Kraut R. Aristotle. In: Politics. Books VII and VIII (1st ed.). Oxford: Clarendon Press. Book VII: 1335, 19-21. (translator 1997).

6 Dryden J. Plutarch on Lycurgus. In: Clough AH (ed.) Lives of the Noble Grecians and Romans. New York: Modern Library; 1900.

7 Cicero. Tusculan Disputations. English translation by King JE. Marcus Tellius Series: (Loeb Classical Library 141.) William Heinemann: London; GP Putnam's Sons; 1966; III, X.22-23.

8 Greenspan RE. Medicine: Perspectives in History and Art. Virginia: Ponteverde Press; 2006.

9 Henderson G. Ugliness: A Cultural History. London: Reaktion Press; 2015.

10 Rusk H. A World to Care For. New York: Random House; 1972.

11 Basnett I. Health care professionals and their attitudes toward and decisions affecting disabled people. In: Albrecht GL, Seelman KD, Bury M (eds.) Handbook of Disability Studies. Thousand Oaks: SAGE Publications; 2001:450-467.

12 Scotch RK. Politics and policy in the history of the Disability Rights Movement. Milbank Quarterly. 1989;67:380-400.

13 Patterson DR, Hanson SL. Joint Division 22 and ACRM guidelines for postdoctoral training in rehabilitation psychology. Rehab Psych. 1995;40:299-310. Doi.org/10.1037/0090.5550.40.4.299.

14 Braddock DL, Parrish SL. An institutional history of disability (pp. 11-68). In: GL Albrecht GL, KD Seelman KD, Bury M (eds.) Handbook of Disability Studies. Thousand Oaks: SAGE Publications; 2001.

15 Lavater JC. Essays on Physiognomy for the Promotion of the Knowledge and Love of Mankind. 1788-1793. Available at: Essays on Physiognomy: For the Promotion of the Knowledge and the Love of ... - Johann Caspar Lavater - Google Books. Accessed August 31, 2021.

16 Kozma C. Dwarfs in ancient Egypt. Am J Med Gen. 2006;140:303-311.

17 Kozma C. Genetic drift. The ancient Egyptian dwarfs of the Walters Art Museum. Am J Medical Gen. 2010;152A(10):2556-2562.

18 Stiker HJ. A History of Disability. Ann Arbor: University of Michigan Press; 2019.

19 Dequecker J, Fabry G, Vanopdenbosch L. Hieronymous Bosch (1450-1516): Paleopathology of the Medieval disabled and its relation to the bone and joint decade 2000-2010. Int Med Anthro J. 2001;3:864-871.

20 Dequecker J, Rico M. Rheumatoid arthritis-like deformities in an early 16th century painting of the Flanders-Dutch school. JAMA. 1991;268:249-251.

21 Barth M, Siegel A. Step Right This Way: The Photographs of Edward J. Kelty. New York: Barnes & Noble; 2001.

22 Patterson MC, Cole TB, Siegel E, Mackowick PA. A patient as art: Andrew Wyeth's portrayal of Christina Olson's neurologic disorder in Christina's World. J Child Neurol. 2017;32:647-649. doi: 10.1177/0883073817700603.

23 Ballard JO. Inside Christina's World. J Human Rehabil. 2017. Available at: https://www.jhrehab.org/2017/10/17/inside-christinas-world/. Accessed August 31, 2021.

24 Gallagher HS. FDR's Splendid Deception: The Moving Story of Roosevelt's Massive Disability and the Intense Efforts to Conceal It From The Public. Vandemere; 1999.

25 Bartrum G. (ed.) Albrecht Dürer and His legacy. London: The British Museum Press; 2002.

26 Wheatley E. Stumbling Blocks Before The Blind: Medieval Constructions of a Disability. Ann Arbor: The University of Michigan Press; 2010.

27 Maher WB, Maher B. The ship of fools: Stultifera Navis or Ignis Fatuus? Am Psychol. 1982;37(7):756-761.

28 Levitas AS, Reid CS. An angel with Down syndrome in a sixteenth century Flemish nativity painting. Am J Med Gen. 2003;116A:399-405.

29 Robotham J. Nativity scene paints different picture of Down syndrome; 2003. Available at: https://www.smh.com.au/national/nativity-scene-paints-different-picture-of-down-syndrome-20030127-gdg67d.html. Accessed 8/15/2013

30 Romance of Alexander (Bodleian Library, Oxford, England); Hasenohr G, Zink M, eds. Dictionnaire des lettres françaises: Le Moyen Age. Collection: La Pochothèque. Paris: Fayard, 1992. ISBN 2-253-05662-6.

31 Chouard G. A Weltian rhapsody: Paul Strand, "Blind" (1917) and Eudora Welty, "Blind Weaver on the WPA, Oktibbeha County, 1930s." Transatlantica 2009;2:27. Available at: https://journals.openedition.org/transatlantica/4696. Accessed 7/24/2020.

32 Gowman AG. The war blind in American social structure. New York: The American Foundation for the Blind; 1957.

33 Wedding D, Boyd MA. Movies & Mental Illness: Using Films To Understand Psychopathology. Boston: McGraw-Hill College; 1999.

34 Klugman CM, Lamb EG. Research methods in the health humanities. New York: Oxford University Press; 2019.

Appendix 1: Art and Disability-related Organizations, Bibliographies, and Training Websites

Disability Studies programs

Appendix 2: Disability-relevant Art and Medicine Books
Albrecht GL. The Encyclopedia of Disability. London, UK: Sage Publications; 2006.

Barth M, Siegel A. Step Right This Way: The Photographs of Edward J. Kelty. New York, NY: Barnes and Noble; 2002.

Bettman OL. A Pictorial History of Medicine. Springfield, IL: Charles C. Thomas Publisher; 1972.

Carmichael AG, Ratzan RM. Medicine: A Treasury of Art and Literature. New York, NY: Hugh Lauter Levin Associates; 1991.

Greenspan RE. Medicine: Perspectives in History and Art. Alexandria, VA: Ponteverde Press; 2006.

Lyons AS, Petrucelli RJ III. Medicine: An Illustrated History. New York, NY: Harry N. Abrams; 1987.

Porter R (ed.). The Cambridge Illustrated History of Medicine. Cambridge, UK: Cambridge University; 1996.

Scull A. Madness in Civilization: A Cultural History of Insanity. Princeton, NJ: Princeton University Press; 2015.

Figures

Figure 1: Jean-Baptiste Grueze's The Paralytic, 1763, Hermitage Museum, St. Petersburg, Russia. ( File:Jean-Baptiste Greuze - Filial Piety - WGA10664.jpg - Wikimedia Commons).

Figure 2: The Polio Stele, Egypt 18 th Dynasty, 1403-1365 B.C., Deutsches Grunes Kreug, Copenhagen, Denmark. ( File:Polio Egyptian Stele.jpg - Wikimedia Commons).

Figure 3: Girolamo di Benvenuto's St. Catherine of Siena Exorcising a Possessed Woman, c. 1500, Denver Art Museum, Denver, Colorado. ( File:'St. Catherine of Siena Exorcising a Possessed Woman', painting by Girolamo di Benvenuto.jpg - Wikimedia Commons).

Figure 4: Pieter Bruegel the Elder's The Cripples, 1568, Louvre, Paris, France. ( File:Pieter Bruegel the Elder - The Cripples - WGA3518.jpg - Wikimedia Commons).

Figure 5: Details from Pieter Bruegel the Elder's Battle Between Carnival and Lent, 1559, Kunsthistorches Museum, Vienna, Austria. ( File:The battle between Carnival and Lent, by Pieter Bruegel (I).jpg - Wikimedia Commons).

Figure 6: Edward J. Kelty, photograph from Madison Square Garden, 1933. Published in Barth M., Siegel AM. Step Right This Way: The Photographs of Edward Kelty (p. 107). New York, NY: Barnes and Noble Books. 2002

Figure 7: Franklin Delano Roosevelt Memorial, Washington, D.C. (https://www.nps.gov/frde/learn/photosmultimedia/index.htm).

Figure 8: Martin Droeschout's To this Grave Doctors Millions do Resort, c. 1620 - 1630, British Museum, London, England. ( File:To this grave doctor millions do resort (BM 1854,1113.154).jpg - Wikimedia Commons).

Figure 9: Hieronymous Bosch's The Extraction of the Stone of Madness (Stones of Folly), c. 1501 - 1505, Prado, Madrid, Spain. ( File:Cutting the Stone (Bosch).jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/the-extraction-of-the-stone-of-madness/313db7a0-f9bf-49ad-a242-67e95b14c5a2).

Figure 10: Albrecht Durer's Melancholia I, 1514, Stadl Museum, Frankfurt, Germany. ( File:Dürer Melancholia I.jpg - Wikimedia Commons).

Figure 11: Frans Hal's Malle Babbe, 1633-1635, Gemaodegalerie, Berlin, Germany. ( File:Frans Hals 021.jpg - Wikimedia Commons).

Figure 12: Theodore Gericault's The Madwoman, 1819-1822, Museum of Fine Art, Lyon, France. ( File:The mad woman-Theodore Gericault-MBA Lyon B825-IMG 0477.jpg - Wikimedia Commons).

Figure 13: Hieronymous Bosch's Ship of Fools, 1494 - 1510, Louvre, Paris, France. ( https://collections.louvre.fr/en/ark:/53355/cl010062860; https://commons.wikimedia.org/wiki/File:Jheronimus_Bosch_011.jpg).

Figure 14: Francisco de Goya y Lucientes's Yard with Madmen, 1794, Meadows Museum, Dallas, Texas. (https://meadowsmuseumdallas.org/collections/pages/objects-1/info/?query=Artist_Maker%3D%2239%22&page=7).

Figure 15: Willowbrook Asylum. Photograph by William Bronston, 1979, from unpublished book (Public Hostage: Public Ransom - Inside Institutional America; online Archive of California: Finding Aid to the William Bronston Papers, 1961-2008 (cdlib.org)).

Figure 16: School of Jan Joest, The Adoration of the Christ Child, 16 th century, Museum of Modern Art, New York, New York. ( File:The Adoration of the Christ Child MET DT8852.jpg - Wikimedia Commons).

Figure 17: Illustration from The Romance of Alexander (artist Jehan de Grise), Flanders, Belgium, 1338-1344 (permission from the Bodleian Library).

Figure 18: John Everett Millais' Blind Girl, 1856, Birmingham Museum and Art Gallery, Birmingham, England. ( File:Millais-Blind Girl.jpg - Wikimedia Commons).

Figure 19: Paul Strand's The Blind Woman, 1916. ( https://commons.wikimedia.org/wiki/File:Blind_Woman.jpg).

Figure 20: Francisco de Goya y Lucentes' Two Old Men, 1821-1823, Prado, Madrid, Spain. ( File:2 alte Männer, um 1821-23.jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/two-old-men/cde9bf01-7535-4a62-8f73-a22d6a68d9a5?searchid=433a4981-4175-39e4-581f-0cc97a3dd2ad).

# data[].attributes.attachment_link.authors[].name
Brick Johnstone, PhD, ABPP | Gretchen E. Henderson, Ph.D | Aimee Tessar, Psy.D | Stacey Bayan, Psy.D | Alexandra Chukabarah, MS | Pete Anziano | Mark Johnson, M.Ed

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Art History as a Resource for Understanding Social Bias in Disability

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Download the article (pdf) Training guidelines for rehabilitation disciplines are generally based on medical models that focus on acquisition of knowledge (eg, anatomy, diagnoses, policies) and skills (eg, discipline-specific interventions) related to different disability diagnoses. However, there are mounting calls to expand the sensitivity of rehabilitation professionals to the personal experiences of, and social biases toward, individuals with disabilities (ie, issues of 'attitude').

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Introduction

Over the past 30 years, there has been a considerable evolution in the ways that disability is conceptualized as a social phenomenon. The social model of disability, which first emerged in the 1980s, introduced the idea that disability is socially created rather than being rooted in the individual (Hahn, 1993; Oliver, 2000). The idea that disability was created by social oppressive elements rather than by individuals' impairments was revolutionary and empowering to people with disabilities.

More recently, new models have emerged that seek to more fully encompass individuals' experience of impairment (Crow, 1996; Hughes and Patterson, 1997; Swain and French, 2000). For example, Hughes and Patterson (1997), in calling for a sociology of impairment, argue for an expansion of the social model, and propose "an embodied, rather than a disembodied, notion of disability" (p. 326).

Disability and Identity

With this emerging focus on individual experience comes an emphasis on disability identity as central to disability theory. Siebers (2008) states that "to call disability an identity is to recognize that it is not a biological or natural property but an elastic social category both subject to social control and capable of effecting social change" (p. 4).

Identity is also central to the affirmative model of disability proposed by Swain and French (2000). Rather than situating the "problem" of disability in impaired bodies (as in the medical model of disability) or a disabling society (as in the social model of disability), the affirmative model "encompasses positive social identities, both individual and collective, for disabled people grounded in the benefits of life style and life experiences of being impaired and disabled" (Swain and French, 2000, p. 569).

In a similar vein, Gill (1997) describes a process of disability-identity formation that involves a progression from "coming to feel we belong" (assertion of the right to inclusion in society) to "coming out" (developing a proud disability identity).

Darling (2003), however, argues that while some people with disabilities have adopted disability pride or the affirmation model, others "continue to accept the older views and regard themselves as victims of personal misfortune" (p. 884). She proposes a typology of disability identity encompassing seven types:

Normalization (acceptance and achievement of the norms of the larger society, with or without acceptance of disability stigma)

Crusadership (involvement in a disability subculture in an attempt to achieve normalization)

Affirmation (involvement in a disability subculture and viewing disability as a primary identity and source of pride; "coming out")

Situational Identification (adopting multiple identities in different situations, e.g., normalization when with those without disabilities but affirmation when with others with disabilities)

Resignation (unable to achieve normalization but lacking resources to access the disability subculture)

Apathy (completely uninformed)

Isolated Affirmation (affirmation orientation arrived at without exposure to disability subculture)

Darling (2003) goes on to describe a process of identity "careers" involving movement from one identity to another, emphasizing the importance of societal context for such movement. For example, if a person with a disability succeeds in gaining the access he/she seeks through crusadership, that person may cease being a crusader and shift to a normalization identity. Another example is that exposure to the disability community can lead to a change from another type, such as resignation or normalization, to affirmation.

The Role of Disability Arts

The arts can play an important role in the progression of the disability identity over time, or the identity "career" (Darling, 2003). Swain and French (2000) describe the importance of the UK disability arts movement in developing and expressing a positive group identity for people with disabilities:

Through song lyrics, poetry, writing drama and so on, disabled people have celebrated difference and rejected the ideology of normality in which disabled people are devalued as 'abnormal.' They are creating images of strength and pride, the antithesis of dependency and helplessness. (pp. 577-578)

Similarly, in the United States, Gill (1995) notes that

"disability culture" has become a popular term among our people whether activist or not, young or old, scholarly or undereducated. I detected an underlying assertion in this embrace of the term that goes something like, Yes, we have learned something important about life from being disabled that makes us unique yet affirms our common humanity. We refuse any longer to hide our differences. Rather, we will explore, develop and celebrate our distinctness and offer its lessons to the world."

Likewise, Walker (1998) describes the importance of the arts in disability culture:

Disability Culture is made up of artists who are not trying to pass, artists who don't buy into societies [sic] rule that we should be ashamed of our disabilities, artists who often show in their art a self-acceptance and a pride about who they are, not in spite of a disability, not because of a disability, but including a disability.

Research on artists has further explicated the positive role of the arts with respect to disability identity and culture. Evaluations of arts-based instruction, for example, have found that arts-based teaching and learning (among other things) enhanced self-esteem and built self-confidence on an individual level for artists (Rooney, 2004) including those with disabilities (Mason, Thormann, and Steedly, 2004; Mason, Steedly, and Thormann, 2005).

Taylor (2005) explored the role that visual-arts education plays in the transition experience of college students with disabilities from school to work or to higher education. Stating that "identity dilemma is at the heart of the transition that all adolescents and young people experience" (p. 764), Taylor highlighted the importance of the arts in helping young people come to terms with typical transition issues (e.g., parental relationships, social class, and maturational issues).

Perhaps more importantly, Taylor found that engaging with the arts could also help with issues of disability and impairment that affect transition and the identity-forming process. Specifically, Taylor found that arts education helped these youth "to engage in a process of self-realization" in which they identify and address "negative and oppressive perceptions of disability via their artwork" (p. 763). As a result, the young artists adopted a more "positive, inclusive and potentially multi-identity perspective" (p. 763).

The VSA arts / Volkswagen Program

This paper reports on expressions about identity, in both artwork and reflective words, of 47 young artists with disabilities. These 47 artists were finalists in the VSA arts/Volkswagen of America, Inc. (Volkswagen) Program for program years 2002-2005.

VSA arts is an international nonprofit organization, established in 1974, that develops programs to increase access to the arts and educational inclusion with and for individuals with disabilities. The primary goal of the organization is to create opportunities and events that allow artists of all ages to share their voice and message through the arts. Locally and internationally, VSA arts provides educators, parents, family members, and artists with the resources and tools they need to support literacy, school readiness, career development, and arts programming in different school systems and communities. In particular, the program creates opportunities for artists in the United States and in other areas of the world to showcase their work by promoting increased access to the mainstream arts community.

In 2002, VSA arts and Volkswagen of America, Inc. partnered to create the yearly juried VSA arts/Volkswagen competition for young visual artists with disabilities. The overarching goal of the competition has been to recognize and encourage young artists with disabilities at an important time in their lives. The program is intended to boost the participants' professional development so that more people with disabilities will enter art professions.

The program targets artists ages 16 to 25 for two reasons. First, this is a critical time period during which young people are making the transition from school to college and/or careers, so providing both recognition and financial awards is seen as a way to help them choose a career path in the arts at this juncture. Second, most previously existing VSA arts programs were focused on either adults or younger children, with few opportunities for teenagers or youth. The exclusive focus on artists with disabilities is intended to address the general under-representation of people with disabilities in the arts.

Each year the program selects a theme that reflects its corporate sponsorship. It then uses the theme to announce the arts competition and to invite applications from visual artists with disabilities. Artists are requested to submit up to five pieces of artwork and a personal statement that includes a brief description of each piece of artwork. Applicants are also encouraged to submit artwork that reflects the program theme for that year.

The winning artists are chosen each year by a panel of distinguished jurors. Program finalists are awarded cash awards of between $2,000 and $20,000; attend a reception on Capitol Hill; and are included in an art exhibit at the Smithsonian Institution and an exhibit that travels across the country for two years.

The authors were contracted by VSA arts in 2005 to conduct an evaluation of the program to determine its impact on the finalists' personal and professional development. The overall findings of the evaluation are reported in a previous article (Boeltzig, Sulewski, and Hasnain, 2009). The present article relies on the same data but examines those data through a different lens, focusing on the young artists' sense of and development of their identities both as artists and as people with disabilities.

Methods

The purpose of the original evaluation was to determine the VSA arts/Volkswagen program's impact on the program finalists' personal and professional lives, and to recommend program improvements. Three research questions guided this evaluation:

What impact did the VSA arts/Volkswagen program have on finalists' personal development?

What impact did the VSA arts/Volkswagen program have on finalists' educational, work, and artistic pathways?

What are the implications of the evaluation findings, and what recommendations can be made to further improve the program?

Research staff used a multi-method design to conduct the evaluation. This included a review of relevant source material and documents (described in further detail below), a survey of program finalists who won awards between 2002 and 2005, and in-depth case studies of five of those finalists.

While the original intent of the study was to evaluate the program, some interesting findings emerged from the review of the participants' application materials regarding how they formed identities both as people with disabilities and as artists. The present paper explores those emerging themes in greater detail than our previous publication. Since the paper is focused only on findings from the source-material review, this method section addresses only that component of the data collection.

Description of the Data

Between 2002 and 2005, the program gave awards to 47 emerging artists. We reviewed the application information for each of the 47 finalists, which was provided to us by VSA arts. Each application packet included:

a competition entry form including (a) contact information, (b) date of birth, (c) disability type, (d) prior involvement with VSA arts, (e) academic background, and (f) the name of an art teacher or instructor instrumental to the artist's artistic development;

a 400-word artist statement describing (a) the artist's motivation to begin creating artwork, (b) techniques and media used, (c) the relationship between the artist's disability and his/her art, and (d) the role of art in the artist's education;

a personal statement reflecting on how the artist's artwork related to that year's theme;

images of up to five pieces of artwork; and

a written description of each piece of artwork and how it related to the theme.

The 47 finalists had diverse disabilities including physical disabilities, learning disabilities, sensory disabilities, mental illnesses, and chronic illnesses. They came from 26 states across the country, were evenly split by gender (24 women and 23 men), and had an average age of 21. Most finalists had been making art since they were young children. At the time they applied for the competition, more than half of the young artists (at least 28) were attending or had completed college or university; almost all were pursuing a degree in the arts. Finalists were pursuing their studies in a range of fields including painting and drawing, photography, graphic arts, and digital imaging. Before they applied for the VSA arts/Volkswagen program, many had gained some experience in the arts (apart from the academic study of art), although only a few finalists (three or four) were working as artists or in an arts profession.

Data Analysis

The textual and visual data were imported into ATLAS.ti Version 5.2 for PC, a qualitative data-analysis software package, in preparation for analysis. To analyze the data, we used two techniques: coding (attaching meaningful labels that denote concepts, actions, or recurrent themes to data or pieces of data) and memo-writing (systematically writing about the data during the coding process), as described by Miles and Huberman (1994). The research team developed operational definitions or codes for each theme, as those themes emerged, so that we could share meanings of the codes as a team. These definitions described the codes as the themes emerged. Memo-writing further helped to organize themes from the data. These themes were further developed as the research staff interpreted and analyzed the results (Creswell, 1998).

The research team met on a regular basis, first to reconcile codes and then to discuss the emerging categories and themes. We simultaneously coded and analyzed the data, continually compared specific incidents, refined our concepts, and explored the relationships between various themes, as recommended by Charmaz (2000). We also discussed findings with colleagues, inviting their alternative explanations. Drafts of the findings were compiled using the themes organized during the memo-writing process. In this way, the memos served as an outline for the results that are presented in this paper.

Findings

This section presents our findings about the participating young artists' sense of identity, both as artists and as people with disabilities. The fact that these young people entered an arts competition for people with disabilities indicates that each of them identified to at least some extent as both an artist and a person with a disability. Our examination of their application materials provided more detailed information on how they developed those identities and how the two identities - disability identity and artist identity - intersected (or not) for these young artists.

First we describe various participants' experiences of identity formation as artists and factors influencing their identification as an artist. We then explore finalists' descriptions of their identities as people with disabilities. Finally, we examine the intersection of art and disability in finalists' lives, including how finalists described this dual identity, how disability affected their art-making and vice versa, and how they expressed their experiences of impairment and disability in their art.

Artist Identity

Exposure to art and art-making, and the circumstances and people that connected finalists with the arts, played an important role in these young people becoming artists. Many of them (35 in total) had been making art since early childhood. Although their pathways varied, we discovered a few common themes in the way they discovered art in their early years.

The role and influence of family. About a third of the young finalists came from families where at least one member was an artist (e.g., a painter, a photographer, a musician). One finalist wrote: "I have always been involved with art. My uncle and my grandfather are professional artists and have taught me a lot throughout my life."

Parents who were artists often exposed their children to art from an early age. Two of the finalists whose mothers were art teachers said that art materials were always around and that it was inevitable for them to explore the arts. Several finalists became interested in the arts by observing those family members. One finalist wrote in her application essay, "Drawing was always something I did just for the fun of it. My older sister is an artist and I always admired her work, but I never thought I could be as good as her and I never had serious thoughts about becoming an artist until recently."

Families often encouraged finalists to pursue the arts beyond high school. For example, one finalist wrote, "My family always has positive and encouraging things to say about my work." Likewise, a finalist who was home-schooled believed that the whole process of home schooling and the artistic talents of her parents and sister were essential to her growth as a painter.

Finalists' mothers often served as mentors. For example, one finalist wrote, "My mother has been the greatest source of motivation. For 20 years, she has encouraged my pursuits and served as a tireless teacher. Her dedication to helping me live with diabetes and her uncompromising faith that I will be able to accomplish anything (artistic or otherwise) in spite of its challenges is most amazing."

A few finalists wrote that their fathers played a significant role in their pursuit of the arts. For example, one wrote, "I am blessed to have innate talent for art, apparently inherited from my father, who always nurtured and supported my family. One of the earliest pieces is a self-portrait I did with my father at age five which still hangs in our den."

The role and influence of educators and other (art) professionals. More than half of the finalists (27 in total) wrote about the role that teachers played in recognizing their artistic talents and helping channel these talents in an artistic way and/or in a pedagogical way. One finalist, for example, had started creating artwork at age five, motivated by his kindergarten special-education teacher. Many teachers recognized the potential of art in helping students, especially those with learning disabilities, overcome barriers to academic achievement.

Five finalists said art professionals (such as painters, illustrators, or curators) were involved in their lives and uncovered their emerging artistic talent. One shared her experiences of being diagnosed with a visual impairment while in college. Her mentor relationship with another artist who also had a visual impairment helped her overcome her fears of no longer being able to draw and paint. Another artist described how various local painters had mentored her.

Other circumstances and life situations. The finalists also shared a variety of environmental influences that helped them cultivate their artistic skills and talent. A few (three) were inspired by famous artists, which influenced the way they approached their own art. One finalist, known for his creativity and imagination in creating his own characters and situations, credited his many hours watching cartoons.

For two artists, one whose parents were immigrants and the other one who was born outside of the United States, the immigrant experience had a strong impact. One of them described her journey in the arts despite her parents' strong resistance to her choosing the arts as a profession. Traveling to different parts of the country or abroad influenced two other young artists to share their experience using art. Gaining practical experiences in the arts (through internships, college jobs, or part-time work) and public exposure of the artists and the artwork (through art exhibitions, competitions, awards, publications) also seemed to have helped finalists progress in their development as emerging artists.

Meanings and purposes of art and art-making. Almost all of the finalists commented on the importance and purposes of art in their lives. A number of them used broad statements such as, "Art is a large part of my life," or, "The arts define who I am," while others were more specific. One wrote, "Art gives me a reason to live. It is an outlet for me to feel good about myself and do something well. It has given me purpose and guidance throughout my life involving education, socialization, and dealing with life's challenges." Another said that photography was "an essential part of me," and still another wrote, "Art was the driving force and the reason to further my education." Others noted specific benefits of their arts involvement related to everything from their academic success to their self-confidence to their financial well-being.

Many finalists were drawn to the arts and art-making by the desire to learn and to pursue arts education. For example, one wrote, "I was motivated most by my very first oil painting class and also from being introduced to the history of art." Academically, finalists said they benefited from arts education in a variety of other ways. These included enhanced reading, writing, and math skills, improved critical and creative thinking, and increased commitment to learning and heightened understanding of worldviews and issues. Others had never thought of art as part of their formal education. As one wrote, "It has always been my favorite thing to do, and my future career, not a subject in school."

Another essential factor for many of these young artists was the ability to develop strong connections with varied audiences. One finalist wrote, "Ever since I was little, I have learned to communicate how I feel by the act of creating. I felt safe to explore and to be who I am, by being able to work on a piece of art without ever feeling like I was doing or saying something wrong." For another artist, art was a way of giving to his community: "My skill allows me to continuously give back to my community - the most rewarding aspect of art." In general, finalists were able to connect with schools and colleges, but also with the arts and disability communities: "Art helps me to get to know people better and make a lot of new friends."

Emerging as a young artist meant different things to the finalists. Some became more cognizant of their artistic talent and skill; others became more aware of their disability and incorporated the body, impairment, and disability more thematically into their artwork. Still others experimented with various art media and techniques. However, almost all of these emerging young artists were dealing in some way with figuring out how to incorporate art into their lives and what role art is supposed to play and should play - a hobby, academic study, and/or a profession.

Disability Identity

Being an artist with a disability was an important part of most finalists' identity. Most of them talked about their impairments and disabilities in their application essays (36 finalists) and the descriptions of their artwork (nine finalists). Several described what it was like for them to live with their impairment. In addition, some described the process of taking on a disability identity, whether through becoming more accepting of a disability they had always had or through acquiring a disability and/or impairment.

Living with impairment. Describing the effect of impairment on her life, one finalist said that a combination of two genetic disorders has "drastically affected my life and caused my disability." An artist with a physical disability described learning to

...separate the disability of my body from the ability of my mind. I prefer to live in the mind, to understand the reality of my world from the inside out...I feel that my physical impairment has attuned my senses not toward what can be physically felt, but instead to what can be intuitively understood.

Finalists with learning disabilities (one of the most common disability types among finalists) particularly noted the challenges their impairments posed in their education. For example, one artist described how having a learning disability affected him in his school years:

During my childhood, it became evident through testing and obvious problems in the classroom that I had short-term memory loss, dyslexia, and processing difficulties. Later in my schooling, especially through high school, the academics became much more laborious.

Another expressed the frustration of living with a learning disability that was not diagnosed until after high school:

I study for hours, I sacrifice my time playing with friends in my childhood just to try to get a passing C-. I never did get that C-. I could never figure out why I could study days for a test and still turn out getting a F. Frustrating as this would be after going through my inter school years with a disability that I didn't even know that I had. Many are not aware of this problem, and I was one of them. To this day I still suffer from a bad low comprehension level and I can't read small books.

Claiming disability identity. Several artists described a process of claiming their identity as people with disabilities and learning to take pride in that identity. One artist wrote, "My disability is a burden I wear with pride." Another said that her disability/impairment is something "I live with... as I do all else that defines me as me: gender, appearance, likes/dislikes, intellect, sexuality, talent and so on." She went on to describe a stage in her life when she took control of her disability experience and stopped being dependent on others:

I abandoned the wheelchair. Got myself a cane and some New Balance [sneakers]. Though I had to depart for classes a lot earlier than those days of being pushed I made the way on my own. My course was not dictated by the whims or wants of others. I abandoned the role of pretty girl in the wheelchair... My body slowly became my own.

An artist with a developmental disability stated that she is "still trying to discover more about who I am and what [my disability] means for me."

A few artists described the somewhat different experience of taking on a disability identity after acquiring an impairment in the teenage or young-adult years. One artist with a visual impairment wrote, "After being diagnosed with histoplasmosis, I felt as though my doors were being closed to the world. However, I've always been told, when one door closes, another door opens." Another finalist talked of the effects of lupus and avascular necrosis on her life as a young adult:

Because of avascular necrosis, which gave me unbearable pain in my hips and below, I would limp some days and be unable to walk others. I had to undergo a total hip replacement. Lupus has affected me in many ways, especially with the chronic fatigue that inhibits me from doing much in one day. I had to learn how to let many of my artistic visions go. But after the hip replacement, I was able to attend school again and take my time to achieve my BFA [Bachelor of Fine Arts degree].

Whether through the acquisition of an impairment or through taking on a disability identity, these young people were incorporating disability and their experiences of living with an impairment into their identities. At the same time they were coming to identify themselves more as artists. The next section addresses the intersection of those two identities and how each affected the other.

Intersecting Identities

Artwork as a way of claiming disability identity. For a couple of artists, making art played a role in their taking on a disability identity. For example, one artist's self portrait reflected on his journey or "road trip" as a person with a disability. He wrote, "This piece [see Figure 1] I believe it is a road trip through my past. Going through my past helps to figure out who I have become." Another finalist found that his art helped him talk more openly about his disability: "I have never worn my prosthetic. Very few people know that I own one. After seeing the image occur in a body of work, people now confront me with questions. This allows my disability to come into more conversations" [Figure 2].

Identifying as an artist first. A few (three) artists emphasized the primacy of their artist identity over their disability identity. In an extension of the "people first" language espoused by many people with disabilities in the United States, these young artists considered themselves "artists first" and people with disabilities second. For example, one young man wrote, "I like people seeing me more as an artist and less as a person with a disability." Another finalist said that participating in an earlier VSA arts/Volkswagen competition "helped me to shift into a new mind set and past the self title I had in my mind, of the 'one handed artist.' Now, confidently I am 'an artist that just happens to be one handed.'" Reflecting a similar sentiment, an artist with a visual impairment wrote, "I really don't look at myself as having a disability. Artistically speaking, it hasn't hindered me in anyway."

Art and disability as mutually beneficial. Nine finalists described disability as a factor in choosing to be an artist and/or as an asset to their artwork. For several artists with mobility or fatigue issues, art provided a substitute for other pursuits. For example, one chose the art profession because after the onset of her disability she could no longer work a 45-hour-per-week job. Teaching art accommodated her needs and interests. Others said that from childhood they compensated for their inability to participate in physical activities such as sports or outdoor play by pursuing art. One finalist wrote, "I was never good at sports; my disability made it difficult. Instead, I developed and proceeded to explore the other areas that were open to me [such as music, writing, and art]." Another said that art "almost completely replaces the fact that I can't walk." A third artist wrote, "I do not dance and I do not run - when I'm driven to express all that is within I pick up a brush and this girl's life force pours out."

Several finalists with learning disabilities or mental illness felt that although these disabilities were barriers in other areas (such as academics) they actually enhanced their artistic ability. One young man with dyslexia and learning disabilities used his "strengths in perceptual organization, and began to incorporate his talent with 'mirroring imaging' into his artwork by including images that weren't usually noted by viewers unless the work was turned upside down." Another finalist said attention deficit disorder enhanced his creativity and Asperger's syndrome drove him to communicate through art. A finalist with obsessive compulsive disorder felt that her "obsessive nature was also my driving force for creating one of my favorite pieces. This made me realize that anxiety can be a positive driving force as well as a negative."

Art as a way of coping with negative aspects of disability. A number of finalists (21 in total) said that art helped them deal with depression, anxiety, fear, pain, and/or stigma associated with their disabilities. An artist who had had cancer used art to manage her fears about death. An artist with a physical disability used art to openly address his fears and discomfort about his disability. An artist with mental illness found art to be the only effective way of escaping her symptoms for a while. She wrote,

Painting is an escape from living with my disabilities. It is the physical release from the bi-polar disorder, allowing my emotions to drain on canvas. It is the mental exercise for multiple sclerosis, making me continually think. I feel a drive to create, to overcome the disability.

Another wrote,

Since I was very young I have found refuge in artistic expression. When I couldn't play like other kids and was terrified by certain situations and places, I could connect with the world through drawings and pictures. When I was hospitalized I drew pictures about my pain. When I felt isolated from others, I painted my loneliness and fear. My art has become my best friend and my sanctuary.

Two artists talked of using art as a way to express their experience of pain by drawing pictures of their pain while in the hospital. For example, one of them (see Figure 3) used distorted and fragmented figures to illustrate the experience of living with pain.

Finally, making art and being an artist often provided an escape from disability-related stigma and its effects on the young people's self-confidence. For several artists with learning disabilities, art provided an opportunity to excel when other school pursuits were challenging, and thereby to gain confidence and a sense of accomplishment. One finalist wrote,

Dealing with a learning disability all my life I have always been cast lower than others, pitied, or done worse than my peers. But in art, I can compete on an equal playing field and excel past those who can read better or faster or even spell all their words correctly. Having success with art gives me confidence that I am just as good as the others. It helps me realize I just have other areas of expertise.

Another artist wrote,

While having dyslexia and a learning disability in reading sets me behind others, my obsession for drawing puts me in front of everyone else at the same time...As my school years progressed my artistic abilities overshadowed my disabilities. My teachers and other students associated me with art. I was the kid who could draw and I earned top awards on the work I created. Teachers would ask me to design special projects and my classmates would ask me to create drawings for them. I was recognized for what I was able to contribute rather than what I was lacking.

This role of art in boosting confidence and managing stigma was also apparent with artists with physical and sensory disabilities. An artist with a visual disability expressed a similar sentiment to those quoted above:

I find that I have more confidence in areas throughout life because of the competence I have gained in art. Feeling accomplished in visual art has helped me live my life, work and enjoy it like everybody else without worrying too much about my disability.

A few artists with obvious impairments spoke of how art enabled them to show what was on the inside and get past the initial impression of inability that others took from their appearance. For example, one young woman wrote,

I want to show off my photography to everyone because I want them to see the real me, not what they see at first. Looks can be deceiving, and it seems my looks deceive everyone into thinking that I can't do anything.

Art as a way of communicating about disability. Several finalists described their artwork as either literally or figuratively depicting their disability or impairment and how they felt about it. For these artists, creating such artwork was a way of processing or understanding the role of disability in their identity.

The artists used disability in their artwork in a range of ways. Not all of them conveyed a message of disability identity; many preferred to leave it up to the viewer to identify a message in the artwork. The messages varied as much as the artists, but some artwork portrayed disability in more literal ways while other pieces portrayed it more symbolically. Symbolic representations of disability were particularly prevalent with nine artists describing their artwork as representing disability in this way. For example, one finalist created an art in which a bird in a cage reflected his culture, which tends to protect people with disabilities rather than to empower them. In another part of the same work he shows the bird flying free, no longer caged; for him this symbolizes being in America and having a new perception of disability that he depicts through his art.

Six artists incorporated literal depictions of their or others' disability in their art. As an example, one finalist created a literal depiction of her experiences with having lupus and undergoing a hip replacement at age 23 [Figure 4]. In her application essay, she wrote, "For six months straight I sat down at a coffeehouse with my pen and ink and worked on a 56-page graphic novel called 'Morning Star' that best expressed my journey so far with lupus."

Some finalists intentionally focused their art on aspects of their body, illness, and disability to get a reaction from the viewer as a way to raise peoples' awareness about these issues. Seven submitted self-portraits that depicted impairment or disability in some way. For example, one finalist depicted herself mixing and pulling medication into a syringe. Another finalist used his self-portrait to represent his struggles with short-term memory loss, dyslexia, and processing difficulties. Another shared a self-portrait with a literal depiction of disability. In a diptych of painted self-portraits, she stands in front of a door. She wrote that she felt as though the doors to the world were being closed when she received her diagnosis. In her submitted artwork a large circle is smeared in the middle of the portrait to represent how she sees with her left eye (Figure 5): "Doctors know what histoplasmosis looks like from behind a scope, looking from outside in, but from my view, it's [a] completely different view from the inside looking out."

Another finalist shared her extreme desire to talk about her illness through images. Diagnosed with Hodgkin's disease, she created a symbolic image of herself as a movie star. Still another was interested in creating a symbolic "normal" image of herself as another person might see her. She feared losing her sight to diabetes, but her two self-portraits dealt with the tension and consequences of appearing unaffected by disease and the fear of no longer being able to see the beauty of places. "Much of my art deals with the challenges of my ambivalence toward being perceived as healthy in spite of having a hidden disability," she wrote in her application essay.

Another artist clearly depicted her impairment in a self-portrait titled "Interstitial Cystitis": the image represented her experience of a painful and incurable bladder disease. The finalist wrote, "Most of the time my bladder feels completely raw (symbolized by the blood) or feels as if there are shards of broken glass inside... and never feels empty."

Other artists' messages were concerned with the beauty of nature, human life and existence, and human frailty, and of "turning a negative into a positive, turning an illness into a beautiful art piece." One wrote, "The artwork is symbolic and literal in that a prosthetic interacts on the surface with other images of nature (leaves, flowers, hands) in this illustration of imperfections."

Discussion

The applications of the 47 VSA Arts/Volkswagen competition finalists provide interesting insights into the role of the arts in the evolving identities of young artists with disabilities. These evolving identities often reflected Darling's (2003) concept of identity careers in which people with disabilities move among the seven types of disability identity (normalization, crusadership, affirmation, situational Identification, resignation, apathy, and isolated affirmation).

For some artists, art helped them move toward more of a normalization identity. For example, some artists with learning disabilities described using art as a way of fitting in or demonstrating their value despite difficulties with other aspects of school, indicating that art helped them achieve normalization. Those who described themselves as "artists first," indicating that disability was a part of, but not the defining aspect of, their identities, also demonstrated a normalization identity. Still others used art to facilitate normalization by coping with the negative aspects of disability, such as pain and stigma. For the most part, these individuals seemed to fit into the category of those who "define themselves in normalized terms [but] do not accept the stigmatized image of disability that typically accompanies this perspective" (Darling, 2003, p. 886).

For other young artists, their own art-making and/or exposure to the world of disability arts and culture helped them move more toward an affirmation identity. Some artists used their artwork to illustrate their disability or to communicate a message about disability. Others used characteristics of their disability as artistic strengths.

In general, the arts seemed to help these young people move toward more positive types of disability identities. Their experiences reflects Walker's (1998) description of disability culture as "made up of artists ... who often show in their art a self-acceptance and a pride about who they are." Moreover, a number of them are, as Swain and French (2000) said of the Disability Arts movement, "creating images of strength and pride, the antithesis of dependency and helplessness" (p. 578).

Limitations and Suggestions for Further Research

These findings are, however, only preliminary. Since this paper is based on secondary analysis of data collected to serve a different purpose (judging in an arts competition, rather than research on identity formation), there are multiple limitations to the findings.

First, the sample studied was not selected to be representative of the population of artists with disabilities. As such, the findings are generalizable only to the specific population studied (finalists in the VSA arts/Volkswagen competition) and not to the larger population of all artists with disabilities.

Second, the artists' application essays were intended to serve the purpose of selecting the competition winners, not specifically to learn about identity and identity formation. Therefore, the topics of identity and identity formation do not appear uniformly across all finalists. Several of the themes related to identity only showed up in a few artists' statements; we still consider those themes important as emerging concepts. The emergence of these ideas, unprompted, among even a few artists points to a need for more research to more deliberately explore those ideas.

Third, the data on which this manuscript is based are now close to six years old. The issues covered in this paper (identity formation and the intersection of disability and the arts), however, are enduring enough, and the words of the young artists quoted herein compelling enough, that it still seems worthwhile to share these findings.

These weaknesses point to a need for further research to examine the intersecting identities of artists with disabilities. Such research would contribute to disability culture and society more broadly by raising awareness of the role of the arts in the evolution of the identities of people with disabilities. Such research would also help to further develop the theoretical concept of identity by highlighting the complexities of identity development that cut across art, disability, and impairment.

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Art and Disability: Intersecting Identities Among Young Artists with Disabilities | Disability Studies Quarterly

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Over the past 30 years, there has been a considerable evolution in the ways that disability is conceptualized as a social phenomenon. The social model of disability, which first emerged in the 1980s, introduced the idea that disability is socially created rather than being rooted in the individual (Hahn, 1993; Oliver, 2000).

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“Peter and John Healing the Cripple at the Gate of the Temple”, Rembrandt van Rijn, 1659

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“The Beggars”, Peter Bruegel, 1568

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“Christ Healing the Blind”, El Greco, 1570

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“The Polio Stele”, 1403-1365 BC

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Franklin Delano Roosevelt Memorial, Washington, D.C.

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Kallio-Tavin_Why do art educators need disability studies 030519_FINAL

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Close was born in 194o and passed away in 2021. He struggled with a learning disability throughout his adolescence and later in 1988, he became paralyzed due to a spinal artery collapse. He was still able to paint even with this injury by using a brush holding device that was strapped to his hand and arm. He explored different styles of portrait painting but he became best known for his photorealistic portraits and his use of a grid system.

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“Self-Portrait”, (Figure 1), 2002, Daguerreotype

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“Chuck Close”, 2020

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“Big Self-Portrait”, 1968, Acrylic on Canvas

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“Phil”, 2014

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“Phil”, 1976

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Introduction

Over the past 30 years, there has been a considerable evolution in the ways that disability is conceptualized as a social phenomenon. The social model of disability, which first emerged in the 1980s, introduced the idea that disability is socially created rather than being rooted in the individual (Hahn, 1993; Oliver, 2000). The idea that disability was created by social oppressive elements rather than by individuals' impairments was revolutionary and empowering to people with disabilities.

More recently, new models have emerged that seek to more fully encompass individuals' experience of impairment (Crow, 1996; Hughes and Patterson, 1997; Swain and French, 2000). For example, Hughes and Patterson (1997), in calling for a sociology of impairment, argue for an expansion of the social model, and propose "an embodied, rather than a disembodied, notion of disability" (p. 326).

Disability and Identity

With this emerging focus on individual experience comes an emphasis on disability identity as central to disability theory. Siebers (2008) states that "to call disability an identity is to recognize that it is not a biological or natural property but an elastic social category both subject to social control and capable of effecting social change" (p. 4).

Identity is also central to the affirmative model of disability proposed by Swain and French (2000). Rather than situating the "problem" of disability in impaired bodies (as in the medical model of disability) or a disabling society (as in the social model of disability), the affirmative model "encompasses positive social identities, both individual and collective, for disabled people grounded in the benefits of life style and life experiences of being impaired and disabled" (Swain and French, 2000, p. 569).

In a similar vein, Gill (1997) describes a process of disability-identity formation that involves a progression from "coming to feel we belong" (assertion of the right to inclusion in society) to "coming out" (developing a proud disability identity).

Darling (2003), however, argues that while some people with disabilities have adopted disability pride or the affirmation model, others "continue to accept the older views and regard themselves as victims of personal misfortune" (p. 884). She proposes a typology of disability identity encompassing seven types:

Normalization (acceptance and achievement of the norms of the larger society, with or without acceptance of disability stigma)

Crusadership (involvement in a disability subculture in an attempt to achieve normalization)

Affirmation (involvement in a disability subculture and viewing disability as a primary identity and source of pride; "coming out")

Situational Identification (adopting multiple identities in different situations, e.g., normalization when with those without disabilities but affirmation when with others with disabilities)

Resignation (unable to achieve normalization but lacking resources to access the disability subculture)

Apathy (completely uninformed)

Isolated Affirmation (affirmation orientation arrived at without exposure to disability subculture)

Darling (2003) goes on to describe a process of identity "careers" involving movement from one identity to another, emphasizing the importance of societal context for such movement. For example, if a person with a disability succeeds in gaining the access he/she seeks through crusadership, that person may cease being a crusader and shift to a normalization identity. Another example is that exposure to the disability community can lead to a change from another type, such as resignation or normalization, to affirmation.

The Role of Disability Arts

The arts can play an important role in the progression of the disability identity over time, or the identity "career" (Darling, 2003). Swain and French (2000) describe the importance of the UK disability arts movement in developing and expressing a positive group identity for people with disabilities:

Through song lyrics, poetry, writing drama and so on, disabled people have celebrated difference and rejected the ideology of normality in which disabled people are devalued as 'abnormal.' They are creating images of strength and pride, the antithesis of dependency and helplessness. (pp. 577-578)

Similarly, in the United States, Gill (1995) notes that

"disability culture" has become a popular term among our people whether activist or not, young or old, scholarly or undereducated. I detected an underlying assertion in this embrace of the term that goes something like, Yes, we have learned something important about life from being disabled that makes us unique yet affirms our common humanity. We refuse any longer to hide our differences. Rather, we will explore, develop and celebrate our distinctness and offer its lessons to the world."

Likewise, Walker (1998) describes the importance of the arts in disability culture:

Disability Culture is made up of artists who are not trying to pass, artists who don't buy into societies [sic] rule that we should be ashamed of our disabilities, artists who often show in their art a self-acceptance and a pride about who they are, not in spite of a disability, not because of a disability, but including a disability.

Research on artists has further explicated the positive role of the arts with respect to disability identity and culture. Evaluations of arts-based instruction, for example, have found that arts-based teaching and learning (among other things) enhanced self-esteem and built self-confidence on an individual level for artists (Rooney, 2004) including those with disabilities (Mason, Thormann, and Steedly, 2004; Mason, Steedly, and Thormann, 2005).

Taylor (2005) explored the role that visual-arts education plays in the transition experience of college students with disabilities from school to work or to higher education. Stating that "identity dilemma is at the heart of the transition that all adolescents and young people experience" (p. 764), Taylor highlighted the importance of the arts in helping young people come to terms with typical transition issues (e.g., parental relationships, social class, and maturational issues).

Perhaps more importantly, Taylor found that engaging with the arts could also help with issues of disability and impairment that affect transition and the identity-forming process. Specifically, Taylor found that arts education helped these youth "to engage in a process of self-realization" in which they identify and address "negative and oppressive perceptions of disability via their artwork" (p. 763). As a result, the young artists adopted a more "positive, inclusive and potentially multi-identity perspective" (p. 763).

The VSA arts / Volkswagen Program

This paper reports on expressions about identity, in both artwork and reflective words, of 47 young artists with disabilities. These 47 artists were finalists in the VSA arts/Volkswagen of America, Inc. (Volkswagen) Program for program years 2002-2005.

VSA arts is an international nonprofit organization, established in 1974, that develops programs to increase access to the arts and educational inclusion with and for individuals with disabilities. The primary goal of the organization is to create opportunities and events that allow artists of all ages to share their voice and message through the arts. Locally and internationally, VSA arts provides educators, parents, family members, and artists with the resources and tools they need to support literacy, school readiness, career development, and arts programming in different school systems and communities. In particular, the program creates opportunities for artists in the United States and in other areas of the world to showcase their work by promoting increased access to the mainstream arts community.

In 2002, VSA arts and Volkswagen of America, Inc. partnered to create the yearly juried VSA arts/Volkswagen competition for young visual artists with disabilities. The overarching goal of the competition has been to recognize and encourage young artists with disabilities at an important time in their lives. The program is intended to boost the participants' professional development so that more people with disabilities will enter art professions.

The program targets artists ages 16 to 25 for two reasons. First, this is a critical time period during which young people are making the transition from school to college and/or careers, so providing both recognition and financial awards is seen as a way to help them choose a career path in the arts at this juncture. Second, most previously existing VSA arts programs were focused on either adults or younger children, with few opportunities for teenagers or youth. The exclusive focus on artists with disabilities is intended to address the general under-representation of people with disabilities in the arts.

Each year the program selects a theme that reflects its corporate sponsorship. It then uses the theme to announce the arts competition and to invite applications from visual artists with disabilities. Artists are requested to submit up to five pieces of artwork and a personal statement that includes a brief description of each piece of artwork. Applicants are also encouraged to submit artwork that reflects the program theme for that year.

The winning artists are chosen each year by a panel of distinguished jurors. Program finalists are awarded cash awards of between $2,000 and $20,000; attend a reception on Capitol Hill; and are included in an art exhibit at the Smithsonian Institution and an exhibit that travels across the country for two years.

The authors were contracted by VSA arts in 2005 to conduct an evaluation of the program to determine its impact on the finalists' personal and professional development. The overall findings of the evaluation are reported in a previous article (Boeltzig, Sulewski, and Hasnain, 2009). The present article relies on the same data but examines those data through a different lens, focusing on the young artists' sense of and development of their identities both as artists and as people with disabilities.

Methods

The purpose of the original evaluation was to determine the VSA arts/Volkswagen program's impact on the program finalists' personal and professional lives, and to recommend program improvements. Three research questions guided this evaluation:

What impact did the VSA arts/Volkswagen program have on finalists' personal development?

What impact did the VSA arts/Volkswagen program have on finalists' educational, work, and artistic pathways?

What are the implications of the evaluation findings, and what recommendations can be made to further improve the program?

Research staff used a multi-method design to conduct the evaluation. This included a review of relevant source material and documents (described in further detail below), a survey of program finalists who won awards between 2002 and 2005, and in-depth case studies of five of those finalists.

While the original intent of the study was to evaluate the program, some interesting findings emerged from the review of the participants' application materials regarding how they formed identities both as people with disabilities and as artists. The present paper explores those emerging themes in greater detail than our previous publication. Since the paper is focused only on findings from the source-material review, this method section addresses only that component of the data collection.

Description of the Data

Between 2002 and 2005, the program gave awards to 47 emerging artists. We reviewed the application information for each of the 47 finalists, which was provided to us by VSA arts. Each application packet included:

a competition entry form including (a) contact information, (b) date of birth, (c) disability type, (d) prior involvement with VSA arts, (e) academic background, and (f) the name of an art teacher or instructor instrumental to the artist's artistic development;

a 400-word artist statement describing (a) the artist's motivation to begin creating artwork, (b) techniques and media used, (c) the relationship between the artist's disability and his/her art, and (d) the role of art in the artist's education;

a personal statement reflecting on how the artist's artwork related to that year's theme;

images of up to five pieces of artwork; and

a written description of each piece of artwork and how it related to the theme.

The 47 finalists had diverse disabilities including physical disabilities, learning disabilities, sensory disabilities, mental illnesses, and chronic illnesses. They came from 26 states across the country, were evenly split by gender (24 women and 23 men), and had an average age of 21. Most finalists had been making art since they were young children. At the time they applied for the competition, more than half of the young artists (at least 28) were attending or had completed college or university; almost all were pursuing a degree in the arts. Finalists were pursuing their studies in a range of fields including painting and drawing, photography, graphic arts, and digital imaging. Before they applied for the VSA arts/Volkswagen program, many had gained some experience in the arts (apart from the academic study of art), although only a few finalists (three or four) were working as artists or in an arts profession.

Data Analysis

The textual and visual data were imported into ATLAS.ti Version 5.2 for PC, a qualitative data-analysis software package, in preparation for analysis. To analyze the data, we used two techniques: coding (attaching meaningful labels that denote concepts, actions, or recurrent themes to data or pieces of data) and memo-writing (systematically writing about the data during the coding process), as described by Miles and Huberman (1994). The research team developed operational definitions or codes for each theme, as those themes emerged, so that we could share meanings of the codes as a team. These definitions described the codes as the themes emerged. Memo-writing further helped to organize themes from the data. These themes were further developed as the research staff interpreted and analyzed the results (Creswell, 1998).

The research team met on a regular basis, first to reconcile codes and then to discuss the emerging categories and themes. We simultaneously coded and analyzed the data, continually compared specific incidents, refined our concepts, and explored the relationships between various themes, as recommended by Charmaz (2000). We also discussed findings with colleagues, inviting their alternative explanations. Drafts of the findings were compiled using the themes organized during the memo-writing process. In this way, the memos served as an outline for the results that are presented in this paper.

Findings

This section presents our findings about the participating young artists' sense of identity, both as artists and as people with disabilities. The fact that these young people entered an arts competition for people with disabilities indicates that each of them identified to at least some extent as both an artist and a person with a disability. Our examination of their application materials provided more detailed information on how they developed those identities and how the two identities - disability identity and artist identity - intersected (or not) for these young artists.

First we describe various participants' experiences of identity formation as artists and factors influencing their identification as an artist. We then explore finalists' descriptions of their identities as people with disabilities. Finally, we examine the intersection of art and disability in finalists' lives, including how finalists described this dual identity, how disability affected their art-making and vice versa, and how they expressed their experiences of impairment and disability in their art.

Artist Identity

Exposure to art and art-making, and the circumstances and people that connected finalists with the arts, played an important role in these young people becoming artists. Many of them (35 in total) had been making art since early childhood. Although their pathways varied, we discovered a few common themes in the way they discovered art in their early years.

The role and influence of family. About a third of the young finalists came from families where at least one member was an artist (e.g., a painter, a photographer, a musician). One finalist wrote: "I have always been involved with art. My uncle and my grandfather are professional artists and have taught me a lot throughout my life."

Parents who were artists often exposed their children to art from an early age. Two of the finalists whose mothers were art teachers said that art materials were always around and that it was inevitable for them to explore the arts. Several finalists became interested in the arts by observing those family members. One finalist wrote in her application essay, "Drawing was always something I did just for the fun of it. My older sister is an artist and I always admired her work, but I never thought I could be as good as her and I never had serious thoughts about becoming an artist until recently."

Families often encouraged finalists to pursue the arts beyond high school. For example, one finalist wrote, "My family always has positive and encouraging things to say about my work." Likewise, a finalist who was home-schooled believed that the whole process of home schooling and the artistic talents of her parents and sister were essential to her growth as a painter.

Finalists' mothers often served as mentors. For example, one finalist wrote, "My mother has been the greatest source of motivation. For 20 years, she has encouraged my pursuits and served as a tireless teacher. Her dedication to helping me live with diabetes and her uncompromising faith that I will be able to accomplish anything (artistic or otherwise) in spite of its challenges is most amazing."

A few finalists wrote that their fathers played a significant role in their pursuit of the arts. For example, one wrote, "I am blessed to have innate talent for art, apparently inherited from my father, who always nurtured and supported my family. One of the earliest pieces is a self-portrait I did with my father at age five which still hangs in our den."

The role and influence of educators and other (art) professionals. More than half of the finalists (27 in total) wrote about the role that teachers played in recognizing their artistic talents and helping channel these talents in an artistic way and/or in a pedagogical way. One finalist, for example, had started creating artwork at age five, motivated by his kindergarten special-education teacher. Many teachers recognized the potential of art in helping students, especially those with learning disabilities, overcome barriers to academic achievement.

Five finalists said art professionals (such as painters, illustrators, or curators) were involved in their lives and uncovered their emerging artistic talent. One shared her experiences of being diagnosed with a visual impairment while in college. Her mentor relationship with another artist who also had a visual impairment helped her overcome her fears of no longer being able to draw and paint. Another artist described how various local painters had mentored her.

Other circumstances and life situations. The finalists also shared a variety of environmental influences that helped them cultivate their artistic skills and talent. A few (three) were inspired by famous artists, which influenced the way they approached their own art. One finalist, known for his creativity and imagination in creating his own characters and situations, credited his many hours watching cartoons.

For two artists, one whose parents were immigrants and the other one who was born outside of the United States, the immigrant experience had a strong impact. One of them described her journey in the arts despite her parents' strong resistance to her choosing the arts as a profession. Traveling to different parts of the country or abroad influenced two other young artists to share their experience using art. Gaining practical experiences in the arts (through internships, college jobs, or part-time work) and public exposure of the artists and the artwork (through art exhibitions, competitions, awards, publications) also seemed to have helped finalists progress in their development as emerging artists.

Meanings and purposes of art and art-making. Almost all of the finalists commented on the importance and purposes of art in their lives. A number of them used broad statements such as, "Art is a large part of my life," or, "The arts define who I am," while others were more specific. One wrote, "Art gives me a reason to live. It is an outlet for me to feel good about myself and do something well. It has given me purpose and guidance throughout my life involving education, socialization, and dealing with life's challenges." Another said that photography was "an essential part of me," and still another wrote, "Art was the driving force and the reason to further my education." Others noted specific benefits of their arts involvement related to everything from their academic success to their self-confidence to their financial well-being.

Many finalists were drawn to the arts and art-making by the desire to learn and to pursue arts education. For example, one wrote, "I was motivated most by my very first oil painting class and also from being introduced to the history of art." Academically, finalists said they benefited from arts education in a variety of other ways. These included enhanced reading, writing, and math skills, improved critical and creative thinking, and increased commitment to learning and heightened understanding of worldviews and issues. Others had never thought of art as part of their formal education. As one wrote, "It has always been my favorite thing to do, and my future career, not a subject in school."

Another essential factor for many of these young artists was the ability to develop strong connections with varied audiences. One finalist wrote, "Ever since I was little, I have learned to communicate how I feel by the act of creating. I felt safe to explore and to be who I am, by being able to work on a piece of art without ever feeling like I was doing or saying something wrong." For another artist, art was a way of giving to his community: "My skill allows me to continuously give back to my community - the most rewarding aspect of art." In general, finalists were able to connect with schools and colleges, but also with the arts and disability communities: "Art helps me to get to know people better and make a lot of new friends."

Emerging as a young artist meant different things to the finalists. Some became more cognizant of their artistic talent and skill; others became more aware of their disability and incorporated the body, impairment, and disability more thematically into their artwork. Still others experimented with various art media and techniques. However, almost all of these emerging young artists were dealing in some way with figuring out how to incorporate art into their lives and what role art is supposed to play and should play - a hobby, academic study, and/or a profession.

Disability Identity

Being an artist with a disability was an important part of most finalists' identity. Most of them talked about their impairments and disabilities in their application essays (36 finalists) and the descriptions of their artwork (nine finalists). Several described what it was like for them to live with their impairment. In addition, some described the process of taking on a disability identity, whether through becoming more accepting of a disability they had always had or through acquiring a disability and/or impairment.

Living with impairment. Describing the effect of impairment on her life, one finalist said that a combination of two genetic disorders has "drastically affected my life and caused my disability." An artist with a physical disability described learning to

...separate the disability of my body from the ability of my mind. I prefer to live in the mind, to understand the reality of my world from the inside out...I feel that my physical impairment has attuned my senses not toward what can be physically felt, but instead to what can be intuitively understood.

Finalists with learning disabilities (one of the most common disability types among finalists) particularly noted the challenges their impairments posed in their education. For example, one artist described how having a learning disability affected him in his school years:

During my childhood, it became evident through testing and obvious problems in the classroom that I had short-term memory loss, dyslexia, and processing difficulties. Later in my schooling, especially through high school, the academics became much more laborious.

Another expressed the frustration of living with a learning disability that was not diagnosed until after high school:

I study for hours, I sacrifice my time playing with friends in my childhood just to try to get a passing C-. I never did get that C-. I could never figure out why I could study days for a test and still turn out getting a F. Frustrating as this would be after going through my inter school years with a disability that I didn't even know that I had. Many are not aware of this problem, and I was one of them. To this day I still suffer from a bad low comprehension level and I can't read small books.

Claiming disability identity. Several artists described a process of claiming their identity as people with disabilities and learning to take pride in that identity. One artist wrote, "My disability is a burden I wear with pride." Another said that her disability/impairment is something "I live with... as I do all else that defines me as me: gender, appearance, likes/dislikes, intellect, sexuality, talent and so on." She went on to describe a stage in her life when she took control of her disability experience and stopped being dependent on others:

I abandoned the wheelchair. Got myself a cane and some New Balance [sneakers]. Though I had to depart for classes a lot earlier than those days of being pushed I made the way on my own. My course was not dictated by the whims or wants of others. I abandoned the role of pretty girl in the wheelchair... My body slowly became my own.

An artist with a developmental disability stated that she is "still trying to discover more about who I am and what [my disability] means for me."

A few artists described the somewhat different experience of taking on a disability identity after acquiring an impairment in the teenage or young-adult years. One artist with a visual impairment wrote, "After being diagnosed with histoplasmosis, I felt as though my doors were being closed to the world. However, I've always been told, when one door closes, another door opens." Another finalist talked of the effects of lupus and avascular necrosis on her life as a young adult:

Because of avascular necrosis, which gave me unbearable pain in my hips and below, I would limp some days and be unable to walk others. I had to undergo a total hip replacement. Lupus has affected me in many ways, especially with the chronic fatigue that inhibits me from doing much in one day. I had to learn how to let many of my artistic visions go. But after the hip replacement, I was able to attend school again and take my time to achieve my BFA [Bachelor of Fine Arts degree].

Whether through the acquisition of an impairment or through taking on a disability identity, these young people were incorporating disability and their experiences of living with an impairment into their identities. At the same time they were coming to identify themselves more as artists. The next section addresses the intersection of those two identities and how each affected the other.

Intersecting Identities

Artwork as a way of claiming disability identity. For a couple of artists, making art played a role in their taking on a disability identity. For example, one artist's self portrait reflected on his journey or "road trip" as a person with a disability. He wrote, "This piece [see Figure 1] I believe it is a road trip through my past. Going through my past helps to figure out who I have become." Another finalist found that his art helped him talk more openly about his disability: "I have never worn my prosthetic. Very few people know that I own one. After seeing the image occur in a body of work, people now confront me with questions. This allows my disability to come into more conversations" [Figure 2].

Identifying as an artist first. A few (three) artists emphasized the primacy of their artist identity over their disability identity. In an extension of the "people first" language espoused by many people with disabilities in the United States, these young artists considered themselves "artists first" and people with disabilities second. For example, one young man wrote, "I like people seeing me more as an artist and less as a person with a disability." Another finalist said that participating in an earlier VSA arts/Volkswagen competition "helped me to shift into a new mind set and past the self title I had in my mind, of the 'one handed artist.' Now, confidently I am 'an artist that just happens to be one handed.'" Reflecting a similar sentiment, an artist with a visual impairment wrote, "I really don't look at myself as having a disability. Artistically speaking, it hasn't hindered me in anyway."

Art and disability as mutually beneficial. Nine finalists described disability as a factor in choosing to be an artist and/or as an asset to their artwork. For several artists with mobility or fatigue issues, art provided a substitute for other pursuits. For example, one chose the art profession because after the onset of her disability she could no longer work a 45-hour-per-week job. Teaching art accommodated her needs and interests. Others said that from childhood they compensated for their inability to participate in physical activities such as sports or outdoor play by pursuing art. One finalist wrote, "I was never good at sports; my disability made it difficult. Instead, I developed and proceeded to explore the other areas that were open to me [such as music, writing, and art]." Another said that art "almost completely replaces the fact that I can't walk." A third artist wrote, "I do not dance and I do not run - when I'm driven to express all that is within I pick up a brush and this girl's life force pours out."

Several finalists with learning disabilities or mental illness felt that although these disabilities were barriers in other areas (such as academics) they actually enhanced their artistic ability. One young man with dyslexia and learning disabilities used his "strengths in perceptual organization, and began to incorporate his talent with 'mirroring imaging' into his artwork by including images that weren't usually noted by viewers unless the work was turned upside down." Another finalist said attention deficit disorder enhanced his creativity and Asperger's syndrome drove him to communicate through art. A finalist with obsessive compulsive disorder felt that her "obsessive nature was also my driving force for creating one of my favorite pieces. This made me realize that anxiety can be a positive driving force as well as a negative."

Art as a way of coping with negative aspects of disability. A number of finalists (21 in total) said that art helped them deal with depression, anxiety, fear, pain, and/or stigma associated with their disabilities. An artist who had had cancer used art to manage her fears about death. An artist with a physical disability used art to openly address his fears and discomfort about his disability. An artist with mental illness found art to be the only effective way of escaping her symptoms for a while. She wrote,

Painting is an escape from living with my disabilities. It is the physical release from the bi-polar disorder, allowing my emotions to drain on canvas. It is the mental exercise for multiple sclerosis, making me continually think. I feel a drive to create, to overcome the disability.

Another wrote,

Since I was very young I have found refuge in artistic expression. When I couldn't play like other kids and was terrified by certain situations and places, I could connect with the world through drawings and pictures. When I was hospitalized I drew pictures about my pain. When I felt isolated from others, I painted my loneliness and fear. My art has become my best friend and my sanctuary.

Two artists talked of using art as a way to express their experience of pain by drawing pictures of their pain while in the hospital. For example, one of them (see Figure 3) used distorted and fragmented figures to illustrate the experience of living with pain.

Finally, making art and being an artist often provided an escape from disability-related stigma and its effects on the young people's self-confidence. For several artists with learning disabilities, art provided an opportunity to excel when other school pursuits were challenging, and thereby to gain confidence and a sense of accomplishment. One finalist wrote,

Dealing with a learning disability all my life I have always been cast lower than others, pitied, or done worse than my peers. But in art, I can compete on an equal playing field and excel past those who can read better or faster or even spell all their words correctly. Having success with art gives me confidence that I am just as good as the others. It helps me realize I just have other areas of expertise.

Another artist wrote,

While having dyslexia and a learning disability in reading sets me behind others, my obsession for drawing puts me in front of everyone else at the same time...As my school years progressed my artistic abilities overshadowed my disabilities. My teachers and other students associated me with art. I was the kid who could draw and I earned top awards on the work I created. Teachers would ask me to design special projects and my classmates would ask me to create drawings for them. I was recognized for what I was able to contribute rather than what I was lacking.

This role of art in boosting confidence and managing stigma was also apparent with artists with physical and sensory disabilities. An artist with a visual disability expressed a similar sentiment to those quoted above:

I find that I have more confidence in areas throughout life because of the competence I have gained in art. Feeling accomplished in visual art has helped me live my life, work and enjoy it like everybody else without worrying too much about my disability.

A few artists with obvious impairments spoke of how art enabled them to show what was on the inside and get past the initial impression of inability that others took from their appearance. For example, one young woman wrote,

I want to show off my photography to everyone because I want them to see the real me, not what they see at first. Looks can be deceiving, and it seems my looks deceive everyone into thinking that I can't do anything.

Art as a way of communicating about disability. Several finalists described their artwork as either literally or figuratively depicting their disability or impairment and how they felt about it. For these artists, creating such artwork was a way of processing or understanding the role of disability in their identity.

The artists used disability in their artwork in a range of ways. Not all of them conveyed a message of disability identity; many preferred to leave it up to the viewer to identify a message in the artwork. The messages varied as much as the artists, but some artwork portrayed disability in more literal ways while other pieces portrayed it more symbolically. Symbolic representations of disability were particularly prevalent with nine artists describing their artwork as representing disability in this way. For example, one finalist created an art in which a bird in a cage reflected his culture, which tends to protect people with disabilities rather than to empower them. In another part of the same work he shows the bird flying free, no longer caged; for him this symbolizes being in America and having a new perception of disability that he depicts through his art.

Six artists incorporated literal depictions of their or others' disability in their art. As an example, one finalist created a literal depiction of her experiences with having lupus and undergoing a hip replacement at age 23 [Figure 4]. In her application essay, she wrote, "For six months straight I sat down at a coffeehouse with my pen and ink and worked on a 56-page graphic novel called 'Morning Star' that best expressed my journey so far with lupus."

Some finalists intentionally focused their art on aspects of their body, illness, and disability to get a reaction from the viewer as a way to raise peoples' awareness about these issues. Seven submitted self-portraits that depicted impairment or disability in some way. For example, one finalist depicted herself mixing and pulling medication into a syringe. Another finalist used his self-portrait to represent his struggles with short-term memory loss, dyslexia, and processing difficulties. Another shared a self-portrait with a literal depiction of disability. In a diptych of painted self-portraits, she stands in front of a door. She wrote that she felt as though the doors to the world were being closed when she received her diagnosis. In her submitted artwork a large circle is smeared in the middle of the portrait to represent how she sees with her left eye (Figure 5): "Doctors know what histoplasmosis looks like from behind a scope, looking from outside in, but from my view, it's [a] completely different view from the inside looking out."

Another finalist shared her extreme desire to talk about her illness through images. Diagnosed with Hodgkin's disease, she created a symbolic image of herself as a movie star. Still another was interested in creating a symbolic "normal" image of herself as another person might see her. She feared losing her sight to diabetes, but her two self-portraits dealt with the tension and consequences of appearing unaffected by disease and the fear of no longer being able to see the beauty of places. "Much of my art deals with the challenges of my ambivalence toward being perceived as healthy in spite of having a hidden disability," she wrote in her application essay.

Another artist clearly depicted her impairment in a self-portrait titled "Interstitial Cystitis": the image represented her experience of a painful and incurable bladder disease. The finalist wrote, "Most of the time my bladder feels completely raw (symbolized by the blood) or feels as if there are shards of broken glass inside... and never feels empty."

Other artists' messages were concerned with the beauty of nature, human life and existence, and human frailty, and of "turning a negative into a positive, turning an illness into a beautiful art piece." One wrote, "The artwork is symbolic and literal in that a prosthetic interacts on the surface with other images of nature (leaves, flowers, hands) in this illustration of imperfections."

Discussion

The applications of the 47 VSA Arts/Volkswagen competition finalists provide interesting insights into the role of the arts in the evolving identities of young artists with disabilities. These evolving identities often reflected Darling's (2003) concept of identity careers in which people with disabilities move among the seven types of disability identity (normalization, crusadership, affirmation, situational Identification, resignation, apathy, and isolated affirmation).

For some artists, art helped them move toward more of a normalization identity. For example, some artists with learning disabilities described using art as a way of fitting in or demonstrating their value despite difficulties with other aspects of school, indicating that art helped them achieve normalization. Those who described themselves as "artists first," indicating that disability was a part of, but not the defining aspect of, their identities, also demonstrated a normalization identity. Still others used art to facilitate normalization by coping with the negative aspects of disability, such as pain and stigma. For the most part, these individuals seemed to fit into the category of those who "define themselves in normalized terms [but] do not accept the stigmatized image of disability that typically accompanies this perspective" (Darling, 2003, p. 886).

For other young artists, their own art-making and/or exposure to the world of disability arts and culture helped them move more toward an affirmation identity. Some artists used their artwork to illustrate their disability or to communicate a message about disability. Others used characteristics of their disability as artistic strengths.

In general, the arts seemed to help these young people move toward more positive types of disability identities. Their experiences reflects Walker's (1998) description of disability culture as "made up of artists ... who often show in their art a self-acceptance and a pride about who they are." Moreover, a number of them are, as Swain and French (2000) said of the Disability Arts movement, "creating images of strength and pride, the antithesis of dependency and helplessness" (p. 578).

Limitations and Suggestions for Further Research

These findings are, however, only preliminary. Since this paper is based on secondary analysis of data collected to serve a different purpose (judging in an arts competition, rather than research on identity formation), there are multiple limitations to the findings.

First, the sample studied was not selected to be representative of the population of artists with disabilities. As such, the findings are generalizable only to the specific population studied (finalists in the VSA arts/Volkswagen competition) and not to the larger population of all artists with disabilities.

Second, the artists' application essays were intended to serve the purpose of selecting the competition winners, not specifically to learn about identity and identity formation. Therefore, the topics of identity and identity formation do not appear uniformly across all finalists. Several of the themes related to identity only showed up in a few artists' statements; we still consider those themes important as emerging concepts. The emergence of these ideas, unprompted, among even a few artists points to a need for more research to more deliberately explore those ideas.

Third, the data on which this manuscript is based are now close to six years old. The issues covered in this paper (identity formation and the intersection of disability and the arts), however, are enduring enough, and the words of the young artists quoted herein compelling enough, that it still seems worthwhile to share these findings.

These weaknesses point to a need for further research to examine the intersecting identities of artists with disabilities. Such research would contribute to disability culture and society more broadly by raising awareness of the role of the arts in the evolution of the identities of people with disabilities. Such research would also help to further develop the theoretical concept of identity by highlighting the complexities of identity development that cut across art, disability, and impairment.

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Art and Disability: Intersecting Identities Among Young Artists with Disabilities | Disability Studies Quarterly

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Over the past 30 years, there has been a considerable evolution in the ways that disability is conceptualized as a social phenomenon. The social model of disability, which first emerged in the 1980s, introduced the idea that disability is socially created rather than being rooted in the individual (Hahn, 1993; Oliver, 2000).

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Training guidelines for rehabilitation disciplines are generally based on medical models that focus on acquisition of knowledge (eg, anatomy, diagnoses, policies) and skills (eg, discipline-specific interventions) related to different disability diagnoses. However, there are mounting calls to expand the sensitivity of rehabilitation professionals to the personal experiences of, and social biases toward, individuals with disabilities (ie, issues of 'attitude'). It is argued that the review of artistic depictions of disability in their respective historical contexts offers an excellent vehicle by which to sensitize rehabilitation professionals to these issues. This article reviews the manner in which different western societies throughout history have depicted individuals with physical, mental, and sensory disabilities in the visual arts, ranging from primarily negative (eg, reflection of divine punishment for deserved transgressions, objects to be ridiculed for entertainment, etc.) to more recent positive perceptions (eg, heroes in contemporary films). Suggestions are offered regarding the use of the visual arts to educate rehabilitation professionals regarding individual and societal biases of disability, and to reduce the perpetuation of the stigma, misrepresentation, and mistreatment of individuals with disabilities.

Introduction

Since the passage of the Americans with Disabilities Act (ADA, 1990) there has been increased interest in promoting a better understanding and acceptance of persons with disabilities, as well as improving the societal discrimination they face. The Disability Rights Movement developed primarily in the last quarter of the 20 th century with considerable growth in advocacy efforts over the past three decades (eg, see Lives Worth Living). Of primary importance, the ADA prohibits discrimination and ensures equal opportunity for persons with disabilities in: employment; state and local government programs and services; access to places of public accommodation such as business, transportation, and non-profit service providers; and telecommunications. Although the ADA has provided greater opportunities and access for persons with disabilities, in order for them to attain complete inclusion into society, it is essential to change the negative attitudes and misperceptions regarding them commonly held by the general public-as well as by many rehabilitation professionals.

The manner in which individuals with disabilities were perceived, treated, and integrated into societies throughout history is complex and related to multiple issues involving economic, scientific, and religious factors. ¹ In the past, individuals with disabilities were frequently viewed as objects to be ridiculed and for the most part they have been perceived as a burden to others and considered to be of limited value to society. 2,3 This was due in large part to the limited understanding of human anatomy and physiology, as well as the lack of methods to treat disease and injuries, minimize impairments, or develop assistive devices (eg, prosthetic devices, assistive technologies, environmental accommodations). As such, they were often socially ostracized and driven to live on the margins of society. In contrast, there have also been various cultures and religious sects throughout history that have tended to care for and be empathetic toward individuals with disabilities.

Imagery From Ancient Times to the Present Day

Ancient writings and images reveal a wide variety of messages about how individuals with disabilities were treated and perceived in early historical times, including the portrayal of disability as a source of punishment in the Code of Hammurabi (ca. 1780 BCE), as predictors of good or bad events in The Omen Series Summa Izbu (ca. 1300 BCE), as individuals capable of community leadership in Homeric writings (The Iliad, 750 BCE), or even as a mark of beneficence in ancient Egypt. 2,4 However, few know that Aristotle proposed a law to prevent parents from raising deformed children, ⁵ that Spartan laws obliged parents to abandon deformed children, ⁶ or that Cicero claimed that the body determined the 'shape' of the soul. ⁷ Even numerous biblical passages demonstrate how individuals with various physical disabilities (eg, leprosy and paralysis) were perceived and treated negatively. 2,8 In fact, numerous laws/policies throughout history legalized or encouraged discrimination against individuals with disabilities and such negative representations further reinforced public perception of disability as 'abnormal,' along with the social division between the disabled and nondisabled. ⁹ These negative perceptions of disability generally persisted until the second half of the 20 th century when advances in medicine and innovative treatments/technologies allowed for the approach to disabilities to be improved.

Training in Disability Issues Across Rehabilitation Professions

With the development of the profession of physical medicine and rehabilitation following World War II, society began to view more consistently individuals with disabilities as worthy of treatment, and to assist them in recovering as fully as possible and returning to productive, independent lives. ¹⁰ Since then, rehabilitation disciplines have developed training guidelines to improve the health and functioning of individuals with disabilities (Table 1). In general, these professional organizations call for training based on medical models that emphasize knowledge and skills, often leading to the treatment of individuals as 'disorders' (eg, a spinal cord injury, a traumatic brain injury, a stroke) or 'impairments' (eg, forgetfulness, irritability, spasticity), rather than individuals with disabilities. As such, rehabilitation 'success' could be over-simplistically evaluated in terms of improvements in range of motion, memory scores, or increased psychological traits, without consideration of the need for full inclusion of individuals with disabilities into society. Because of these factors, it has been concluded that rehabilitation professionals "are often negative about disability, seeing inability before ability and frustrated by the lack of a prospect of cure and ill-informed about simple accommodations." 11(p462)

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Table 1: Rehabilitation Discipline Training Guidelines
American Board of Internal Medicine (2013). Internal medicine/physical medicine and rehab policies. Accessed online on 7/20/2020 at: http://www.abim.org/certification/policies/combinedim/comrehab.aspx

Accreditation Content for Occupational Therapy Education (2018). Standards of practice for occupational therapy. Accessed online on 7/20/2020 at: https://acoteonline.org/wp-content/uploads/2020/07/2018-ACOTE-Standards.pdf

American Physical Therapy Association (2018). Standards of practice for physical therapy. Accessed online on 7/20/20 at: http://www.apta.org/uploadedFiles/APTAorg/AboutUs/Policies/HOD/Practice/standards.pdf.

American Speech-Language-Hearing Association. (2020). Scope of practice in speech

language pathology [Scope of Practice]. Accessed online on 7/20/20 at: https://www.asha.org/certification/2020-slp-certification-standards/.

American Psychological Association Rehabilitation Psychology Division (2012). Guidelines for postdoctoral training in rehabilitation psychology. Accessed online on 7/20/20 at: https://www.apa.org/pubs/journals/features/rep-a0030774.pdf.

American Therapeutic Recreation Association Standards of Practice. Accessed online on 7/20/20 at: https://www.atra-online.com/page/SOP.

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More recently, there has been increased recognition of the need for training in the ability to understand the personal experiences of persons with disabilities and the societal biases experienced by these individuals (sometimes referred to as training in issues of attitude). It is relatively easy to teach knowledge (eg, facts, diagnostic criteria) and skills (eg, procedures, tests, discipline-specific therapies), as these are generally fact-based and able to be memorized. However, it is much more difficult to mold individual and societal attitudes (ie, conscious and unconscious biases and beliefs) about disabilities. Changing attitudes and beliefs, however, is central to improving the lives of people with disabilities given that prejudicial and exclusionary social practices are believed to be greater barriers to social participation than specific mental, physical, or sensory impairments. ¹² It is important for healthcare professionals to examine their own beliefs about disability and awareness of how persons with disabilities are perceived, portrayed, and treated today, and particularly for those rehabilitation professionals who work with these populations on a daily basis.

Rehabilitation Psychology Training Guidelines: An Example

Although all rehabilitation training guidelines generally focus on the medical model, initial post-doctoral training guidelines for rehabilitation psychology provide an example of training methods to address issues of attitude. This specifically involves the need to be educated about the manner by which disability is a socially-constructed phenomenon, as well as the manner by which our own biases affect our treatment, interactions with, and expectations for, individuals with disabilities. For example, one of the most notable rehabilitation psychology guidelines calls for training in "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them." ¹³ This suggestion is truly unique among the various rehabilitation disciplines in that it acknowledges the significant role that societal expectations and misperceptions have in the manner by which individuals with disabilities are treated. Although this suggestion is noteworthy, there are no specific methods to suggest how to train rehabilitation professionals regarding the societal perceptions that impact persons with disabilities. This article suggests that studying images of disability in art history is an important and impactful method for teaching rehabilitation professionals about the experiences and biases experienced by those patients they serve.

Art as a Means to Better Understand the Experience of Disability

Human beings have made art to communicate and connect with each other since prehistoric times. Art has the powerful ability to help viewers relate to the individuals depicted in the image on a human, empathetic level, which, in turn enhances the goal of understanding and acceptance on a new level. Artists have used various mediums (eg, paintings, poetry, narratives, sculpture, film, etc.) to express emotional turmoil, tragedy, social isolation, and psychological disturbance as a means to relate and share personal experiences. The medical, legal, and social zeitgeist of an era is often reflected by the artwork created of that time. Alternatively, societal perceptions have long been influenced by how individuals with disability are represented to the public visually and politically. There are few primary sources from ancient and medieval times regarding people with disabilities, ³ and as a result, researchers have relied on the arts to determine the social context of disability at various times throughout history. In fact, a historian of disability states that, "Studying the representation of disability in literature and art is an important and relatively unexplored research frontier in disability studies." 14(p 54)

The arts have been used in rehabilitation for people with disabilities primarily through recreational therapies in which individuals engage in the visual arts, music, dance, and expressive writing to adjust to their disabilities. However, a review of artistic representations of disability throughout history also offers an excellent method by which to improve the training of rehabilitation professionals. There is increased recognition that studying the humanities helps health professionals gain a better understanding of the human side of chronic disabilities.

People with disabilities are depicted throughout art history, and these images provide a context for the manner by which they were perceived at that time (eg, worthy of derision or sympathy, objects of ridicule, deserving of divine punishment, etc.). For example, prior to the advent of the printing press, when much of the population was illiterate, paintings were often used to tell stories, depict historical events, and provided examples of how people were treated. ³ As such, many individuals learned social expectations for how to treat the disabled by viewing paintings in churches or watching plays during community festivals. It is from these works of art that we can understand the culture of the times and become sensitized to the relevant social issues of the day as they pertain to disability. By comparing past and current art forms (eg, paintings, drawing, and sculptures from the past to movies, films, and literature from the present) it is possible to better understand how societal perceptions have a major influence on the way individuals with disabilities are treated. Subsequently, training methods can be developed to counter "social myths of disabilities" (see APA Division 22 training guidelines), and educate rehabilitation professionals to become better providers for individuals with disabilities.

PART 1: The Representation of Physical Disability in Art History

Throughout history, individuals with physical disabilities have primarily been perceived and represented as 'misfits, fools, oddities, and marvels,' present in the world for purposes of entertainment, ridicule, and experimentation. ² This relates in part to the lack of understanding of the causes of physical disability, as well as the lack of resources, knowledge, or will to develop accommodations during various historical times. As such, individuals with disabilities often had little support from their families and communities and needed to fend for themselves in creative ways; this was generally the case until the last half of the 20 th century.

As an example, Greuze's The Paralytic (1763; Fig. 1) is one of the few depictions of an individual with paralysis, likely due to the fact that the survival rates for such individuals were extremely low.

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Historically, depictions of physical disability in western civilizations have largely focused on 'abnormalities' and the negative manner by which individuals with disabilities were perceived and treated. In fact, a frequently-cited theory from the late 18 th century related to physiognomy concluded that the disabled were, "[t]he morally worst, the most deformed." ¹⁵ However, it is noteworthy that ancient Egyptian and Greek cultures at various times were generally accepting of individuals with physical disabilities, as illustrated in several of their works of art. 4,16,17 For example, a stone carving from approximately 1300 BCE shows a realistic depiction of an Egyptian leader with a withered leg, apparently from polio (Fig. 2). Greek vases show similar representations of dwarves who were valued as assistants within the medical field, and even portrayed as deities. 16,17 However, throughout history, such positive depictions of physical disabilities were the exception rather than the rule.

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By the Middle Ages, societies began to extend to people with impairments "an acceptance at times awkward, at times brutal, at times compassionate, a kind of indifferent, fatalistic integrations" to people with impairments. 8(p15) However, in general, individuals with disabilities were represented as abnormal, with early portrayals exploiting these abnormalities for amusement. Paintings from this time indicate that individuals with disabilities were viewed in terms of a religious model of disability, in that individuals were believed to be disabled secondary to spiritual transgressions and were thus treated with religious interventions, if they were even treated. Metzler 2(p89) reports "anecdotal evidence suggests that there was a very strong feeling that malformed babies indicated sin on the part of their parents." Spiritual interventions for disabilities were depicted in a painting by di Benvenuto (15 th Century), titled St. Catherine of Siena Exorcising a Possessed Woman (Fig. 3), in which individuals with both physical (ie, characters with crutches) and mental illnesses (central figure) caused by demonic possession were treated with religious interventions within a church setting.

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By the 16 th century, the Renaissance began to focus on classical forms of beauty, which did not typically include the disabled or deformed. However, art from the northern Renaissance depicted individuals with physical disabilities in a realistic manner, providing insight into the way they were treated and socially perceived at that time. Hieronymous Bosch painted a series of 31 'cripples' in 1500, illustrating the various disabling conditions and prosthetic devices used by these individuals. ¹⁹ Similarly, Bruegel's The Cripples (1568; Fig. 4) shows individuals with various prosthetics gathered together in a town square. However, historical context indicates that these individuals were forced to wear fox tails attached to their clothes as indicators that they were objects to be ridiculed at community festivals. 19,20 Similarly, Bruegel's Battle Between Carnival and Lent (1559; Fig. 5) shows the relative isolation faced by individuals with disabilities within their communities. Compared to the so-called 'normal' citizens participating in either carnival or lent, details from the painting show two groups of individuals with disabilities (ie, 'cripples' in middle scene, blind individuals by church entrance) as socially-isolated beggars. These community spectacles are precursors to the freak shows that gained popularity in the mid-16 th century and lasted to the mid-20 th century, which displayed physically unusual or deformed humans for a source of entertainment ²¹ (Fig. 6). By the 19th century, individuals with impairments were even criminalized through public policy (ie, 'ugly laws' involving social restrictions placed on those with physical appearances that might offend 'normal' people) ⁹.

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Paintings such as Wyeth's Christina's World (1948) provide an example of the social isolation and handicaps faced by many individuals with physical disability even in the middle of the 20 th century. This painting appears to show its subject, Christina Olson, admiring a homestead in a windswept field. However, an article in the Journal of Child Neurology ²² indicates that Wyeth was portraying a young woman suffering from a progressive neurological disorder that he observed crawling crab-like up to her farmhouse. This knowledge challenges the initial perception of the scene and shifts our position from viewer to Christina's own perspective. This is the power of studying art history: to guide the viewer by facilitating close looking, deeper contextual understanding, and empathy. An article by J.O. Ballard in JHR is an excellent resource for those who would like to use this painting to increase clinical observation and diagnostic skills regarding disability in health sciences education. ²³

Even within the past quarter century, controversy surrounding the Franklin D. Roosevelt (FDR) Memorial in Washington, DC illustrates the current difficulties society has in accepting individuals with physical disabilities. FDR's Splendid Deception ²⁴ recounts how the original statue of FDR to be placed at the front of his memorial in Washington, DC was designed to depict him in his wheelchair (he could not walk after contracting polio at age 39). However, when the original sculpture was finished, his cape covered his wheelchair completely, in effect hiding his disability (Fig. 7). A second statue, depicting FDR using his actual wheelchair and placed at the other end of the memorial, was completed only after significant advocacy efforts by disability rights groups. It is important to note that ancient Egyptian society could realistically portray important figures with disabilities with compensatory devices over 3,000 years ago (Fig. 2), but the FDR Memorial planners of the 20 th century had problems acknowledging his disability, despite the fact that he was one of the most important and powerful leaders in the world during his lifetime.

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PART 2: The Representation of Mental and Intellectual Disability in Art History

Up until the 19 th century, individuals with physiologically-based mental disorders were conceptualized in terms of 'madness' primarily related to spiritual disorders that needed to be treated through spiritual interventions (although these beliefs persist in some communities even today). For example, di Benvenuto's St. Catherine Exorcising a Possessed Woman, shows a demon being exorcised from a woman's head in the 1300s (Fig. 3). Similarly, Droeschout's To this Grave Doctor Millions do Resort from the 17 th century (Fig. 8) shows a scene in which demons were exorcised from an individual's head in a fancy contraption (figure on right), as well as from their bowels by the apparent use of an elixir to dispel demons (figure on left).

Similarly, a 16 th-century painting by Hieronymus Bosch titled The Extraction of the Stone of Madness (Stones of Folly) illustrates the belief at that time that 'madness' was due to the presence of a stone within the skull that required extraction in order for the person to be cured (Fig. 9). By 1514, mental illness was believed to be related to an imbalance of the four humors of the body (black bile, yellow bile, blood, phlegm) that led to the four primary human temperaments (melancholic, phlegmatic, choleric, and sanguine) ²⁵ as represented in Durer's Melancholia I (Fig. 10). Frans Hal's Malle Babbe (1633-1635) illustrates how mental illness (eg, insanity, alcoholism) was conceptualized in northern Europe during the 17 th century as being caused by the visitation of the bird of lunacy (Fig. 11).

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Art from the 19 th century demonstrates how mental (ie, lunacy) and developmental disabilities (ie, 'idiocy') started to be conceptualized in a different manner in some cultures, in that such disorders were transformed from being conceptualized as 'madness' to 'mental illness' (ie, a medical abnormality) ²⁶. For example, in the 1800s, health professionals attempted to distinguish between different types of mental disorders through the identification of unique facial features, similar to the field of physiognomy.

Theodore Gericault painted a series of 10 'portraits of the insane' ( The Madwoman, 1819-1822; Fig. 12) depicting physical attributes that were thought to be associated with specific psychological disorders-five of the paintings which still exist (Woman Addicted to Gambling, A Child Snatcher, Woman Suffering from Obsessive Envy, Kleptomaniac, Man Suffering from Delusions of Military Command). Although it is difficult to determine how physical features could reveal a 'child snatcher' or someone with 'military delusions,' it is noteworthy that mental illnesses were starting to be categorized in terms of specific abnormalities (ie, physical and psychological).

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Art from other historical periods also offers insight into the manner by which individuals with mental disabilities were segregated and isolated from their communities. Bosch's Ship of Fools (1490-1500; Fig. 13) depicts the practice during the 15 th century and beyond of rounding up the disabled and unwanted and placing them in a wagon with promises of goods, in order to remove them from society. ²⁷ This practice changed in the beginning of the 18 th century when individuals with mental and sensory disabilities began to be institutionalized in hospitals or asylums, but without prescribed care or interventions. 2,3 Goya illustrated such a lunatic asylum in the 1700s (Fig. 14), but incredibly, this representation differs little from the demeaning conditions depicted in the infamous 1970s documentary about the Willowbrook Mental Institution in New Jersey (Fig. 15). These works of art show how individuals with mental illnesses from the Middle Ages until the 1970s were removed from society and deemed unworthy of treatment, which differs considerably from current societal understanding and increasing acceptance of mental illness.

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Although artists throughout history have generally depicted individuals with intellectual disabilities in a negative manner (eg, village idiots, fools), several works of art illustrate how some societies had positive and accepting views of individuals with intellectual disabilities. For example, The Adoration of the Christ Child (circa 1515) offers a powerful message about the acceptance of individuals with developmental disabilities in Northern Europe in the 16th century (Fig. 16). In this painting, medical professionals have suggested that two of the angels surrounding the manger have Down's syndrome (although the syndrome was not known as such at that time). 28,29 This painting likely reflects the longstanding and continued willingness of communities in northern Europe to be inclusive of individuals with intellectual disabilities.

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PART 3: The Representation of Sensory Disability in Art History

Misperceptions and prevailing attitudes of individuals with sensory disorders date back to the biblical era. In its most dramatic fashion, select scriptures led many to believe that God used deafness and blindness as retribution for sin: "Who gave man his mouth? Who makes him deaf or mute? Who gives him sight or makes him blind? Is it not I, the Lord?" (Exodus 4:11); "...if you do not carefully follow His commands and decrees...all these curses will come upon you and overtake you: the Lord will afflict you with madness, blindness, and confusion of the mind. At midday, you will grope around like a blind man in the dark." (Deuteronomy 28:15). This demonization of the blind carried on through the Middle Ages and into the Renaissance.

For example, a manuscript from the 14 th century, The Romance of Alexander, ³⁰ includes illustrations, in the margins, of the daily customs, work, dress, leisure activities, and social norms that existed in Medieval Europe at that time. Of interest, one border illustration shows how individuals with visual impairments were paraded before communities as a form of entertainment at times of festival (Fig. 17), similar to Bruegel's The Cripples (Fig. 4). Writings from 1425 describe a similar event:

"Note, the last Sunday of the month of August there took place an amusement at the residence called d'Arminac in the Rue Saint Honore, in which four blind people, all armed, each with a stick, were put in a park, and in that location there was a strong pig that they could have if they killed it....and there was a very strange battle, because they gave themselves so many great blows with those sticks that it went worse for them, because when the stronger ones believed that they hit the pig, they hit each other, and if they had really been armed, they would have killed each other. Note, the Saturday evening before the aforementioned Sunday, the said blind people were led through Paris all armed, a large banner in front, where there was a pig portrayed, and in front of them a man playing a bass drum" (as cited in Wheatley 26( p1)).

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Throughout history, images of the blind beggar have rendered public perception of blind individuals as helpless, useless, and passively dependent. Given the social, vocational, and financial difficulties associated with blindness and marginalization, some blind individuals have succumbed to accepting this role. For example, Millais (1856) portrayed a young blind girl relegated to beg for money by playing her concertina while wearing a sign on her neck displaying the words, "Pity the Blind" (Fig. 18). This was also depicted in a notorious photograph by Strand in 1916 of an impoverished blind woman in New York City, identifying her disability with a sign around her neck saying "Blind," below the metallic license she needed to obtain to legally beg ³¹ (Fig. 19).

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Beginning in the 17 th century, the perception of individuals with visual disabilities as defective, expendable, and intellectually disabled led to the social control movement of institutionalization for the disabled. In fact, one of the first institutions for disabled individuals was intended for the deaf and the blind, as depicted in Goya's Yard with Madmen (1794; Fig. 14), which represented scenes of institutions he personally witnessed, and was said to be painted at a time when he feared similar consequences from his own mental illness and deafness. The emotional toll of the blind and deaf, due to marginalization and social stigma, can also be seen in Goya's Two Old Men (from his Black Painting series; Fig. 20), capturing the darkness and isolation felt during his years plagued with deafness and physical ailment. Similar sentiments are aroused in Degas' Madame René de Gas (1872/1873; https://www.nga.gov/collection/art-object-page.46599.html), a portrait of his blind sister-in-law's vacant gaze representing her solitude and isolation, and Picasso's The Old Guitarist (1903), both depicting tones of sorrow and loneliness. The sorrow and frustration were a product of living in a society that deemed them incapable and blemished, therefore discounting their intact capabilities that could benefit from accommodation.

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During the mid-20 th century, Americans with visual impairments described the impact of the beliefs, superstitions, and the social/physical environment as the primary obstacle to the emotional and physical adjustment to their disability, as cited in The War Blind in American Social Structure:

"All too frequently the great tragedy of a blind person's life is not primarily his blindness, but the reactions of the family and social group toward him as a non-typical member." ³²

Today, while ambiguous perceptions of those with sensory impairment still exist, knowledge, technological innovation and accommodations leading to expansive and ready access of support helps afford these individuals education and greater independence. Interpreters are more readily available in health care and educational facilities, along with the transcription of texts to Braille or auditory recordings. With these supports and greater public knowledge, individuals with sensory disabilities have disproved past perceptions of being passive, dependent, helpless, unproductive, or intellectually disadvantaged.

PART 4: Modern Artistic Representations of Disability

Although beyond the scope of this article, it is noteworthy how primary art forms of today (ie, movies, TV) have played a substantial role throughout the 20 th and 21 st centuries in shaping societal attitudes toward disability. Thus, it is not surprising that the manner by which disability is represented in media art today has also led to greater acceptance of disability. Such realistic and positive representations of disability will continue to teach people who are secure in their beliefs and perceptions of 'normalcy' that individuals with disabilities are not subjects to be gawked at or marginalized.

For example, children today are exposed to positive images of disability and representations of characters with disability as leaders, such as those portrayed in the Disney movie Finding Nemo (2003). X-Men is a popular comic magazine that has been made into a series of movies (2000-2019). Of note, Charles Xavier, the leader of this band of individuals with superhuman powers, is confined to a wheelchair. Similarly, the critically acclaimed Murderball (2005) is a documentary film that shows individuals with various forms of paralysis engaging in full-contact rugby in the Paralympic Games in Athens, Greece.

The depiction of mental illness in film has also improved over the past 50 years, with individuals with mental illnesses and sensory disabilities portrayed more realistically and empathetically ( One Flew over the Cuckoo's Nest (1975); Rain Man (1988); Children of a Lesser God (1986)). Rehabilitation trainees and professionals can watch these and other movies that show the human experience of disability with subsequent discussion at scheduled training opportunities (Table 2). These movies offer opportunities to discuss differences in how individuals with disabilities have been portrayed and treated in the past and currently, and how more positive portrayals can lead to the development of better skills for rehabilitation professionals-and ultimately greater understanding and acceptance of the personal experience of disability.

PART 5: Disability Training Through the Arts

It is suggested that rehabilitation training guidelines promote opportunities for both students and professionals to become aware of the "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them" (see APA Division 22 training guidelines) through the study of disability in the visual arts. It is recommended that rehabilitation students and professionals review and discuss the visual arts (and literature) relating to the personal experiences of, and societal perceptions of, disability in existing didactics, grand rounds, and journal clubs. Students and professionals can easily review paintings and articles presented in this article for discussion, and particularly those presented in articles from traditional medical journals and art history journals and textbooks (see References below).

Training directors can also find appropriate topics and offerings on art and disability through many websites and organizations (Appendix 1). Review of the representation of disability in the visual arts can also be discussed based on academic sources that provide contextually-relevant cultural information related to specific eras, as well as autobiographies, novels, and collections of short stories that provide examples that relate the personal experiences of persons with disabilities, the challenges they have faced, and the successes they have had in becoming full members of society (Appendix 2).

Conclusion

In conclusion, this article reflects the benefits and necessity of training in the health humanities (versus medical humanities) for both rehabilitation professionals and those individuals with disabilities they serve. Specifically, the health humanities apply transdisciplinary practices that draw on the humanities, fine arts, and social sciences to bring meaning to human experiences of health and illness, to increase social justice for individuals with illness and disabilities. ³⁴ Training in the health humanities can complement training in the medical humanities-which focus on the use of the humanities in service to medicine-to help practitioners learn attributes such as empathy, communication, and compassion.

The authors wish to acknowledge the assistance of Josiah Scott in editing and formatting this article.

1 Albrecht GL, Seelman KD, Bury M. Handbook of Disability Studies. London: Sage Productions; 2001.

2 Albrecht GL (ed). Encyclopedia of Disability: A History in Primary Source Documents (Vol. 5). Thousand Oaks: SAGE Publications; 2006.

3 Metzler I. Disability in Medieval Europe: Thinking About Physical Impairment During the High Middle Ages, c. 1100-1400. London: Routledge; 2006.

4 Sullivan R. Deformity - a modern western prejudice with ancient origins. Proc Royal College Phys Edinburgh. 2001;31:262-266.

5 Kraut R. Aristotle. In: Politics. Books VII and VIII (1st ed.). Oxford: Clarendon Press. Book VII: 1335, 19-21. (translator 1997).

6 Dryden J. Plutarch on Lycurgus. In: Clough AH (ed.) Lives of the Noble Grecians and Romans. New York: Modern Library; 1900.

7 Cicero. Tusculan Disputations. English translation by King JE. Marcus Tellius Series: (Loeb Classical Library 141.) William Heinemann: London; GP Putnam's Sons; 1966; III, X.22-23.

8 Greenspan RE. Medicine: Perspectives in History and Art. Virginia: Ponteverde Press; 2006.

9 Henderson G. Ugliness: A Cultural History. London: Reaktion Press; 2015.

10 Rusk H. A World to Care For. New York: Random House; 1972.

11 Basnett I. Health care professionals and their attitudes toward and decisions affecting disabled people. In: Albrecht GL, Seelman KD, Bury M (eds.) Handbook of Disability Studies. Thousand Oaks: SAGE Publications; 2001:450-467.

12 Scotch RK. Politics and policy in the history of the Disability Rights Movement. Milbank Quarterly. 1989;67:380-400.

13 Patterson DR, Hanson SL. Joint Division 22 and ACRM guidelines for postdoctoral training in rehabilitation psychology. Rehab Psych. 1995;40:299-310. Doi.org/10.1037/0090.5550.40.4.299.

14 Braddock DL, Parrish SL. An institutional history of disability (pp. 11-68). In: GL Albrecht GL, KD Seelman KD, Bury M (eds.) Handbook of Disability Studies. Thousand Oaks: SAGE Publications; 2001.

15 Lavater JC. Essays on Physiognomy for the Promotion of the Knowledge and Love of Mankind. 1788-1793. Available at: Essays on Physiognomy: For the Promotion of the Knowledge and the Love of ... - Johann Caspar Lavater - Google Books. Accessed August 31, 2021.

16 Kozma C. Dwarfs in ancient Egypt. Am J Med Gen. 2006;140:303-311.

17 Kozma C. Genetic drift. The ancient Egyptian dwarfs of the Walters Art Museum. Am J Medical Gen. 2010;152A(10):2556-2562.

18 Stiker HJ. A History of Disability. Ann Arbor: University of Michigan Press; 2019.

19 Dequecker J, Fabry G, Vanopdenbosch L. Hieronymous Bosch (1450-1516): Paleopathology of the Medieval disabled and its relation to the bone and joint decade 2000-2010. Int Med Anthro J. 2001;3:864-871.

20 Dequecker J, Rico M. Rheumatoid arthritis-like deformities in an early 16th century painting of the Flanders-Dutch school. JAMA. 1991;268:249-251.

21 Barth M, Siegel A. Step Right This Way: The Photographs of Edward J. Kelty. New York: Barnes & Noble; 2001.

22 Patterson MC, Cole TB, Siegel E, Mackowick PA. A patient as art: Andrew Wyeth's portrayal of Christina Olson's neurologic disorder in Christina's World. J Child Neurol. 2017;32:647-649. doi: 10.1177/0883073817700603.

23 Ballard JO. Inside Christina's World. J Human Rehabil. 2017. Available at: https://www.jhrehab.org/2017/10/17/inside-christinas-world/. Accessed August 31, 2021.

24 Gallagher HS. FDR's Splendid Deception: The Moving Story of Roosevelt's Massive Disability and the Intense Efforts to Conceal It From The Public. Vandemere; 1999.

25 Bartrum G. (ed.) Albrecht Dürer and His legacy. London: The British Museum Press; 2002.

26 Wheatley E. Stumbling Blocks Before The Blind: Medieval Constructions of a Disability. Ann Arbor: The University of Michigan Press; 2010.

27 Maher WB, Maher B. The ship of fools: Stultifera Navis or Ignis Fatuus? Am Psychol. 1982;37(7):756-761.

28 Levitas AS, Reid CS. An angel with Down syndrome in a sixteenth century Flemish nativity painting. Am J Med Gen. 2003;116A:399-405.

29 Robotham J. Nativity scene paints different picture of Down syndrome; 2003. Available at: https://www.smh.com.au/national/nativity-scene-paints-different-picture-of-down-syndrome-20030127-gdg67d.html. Accessed 8/15/2013

30 Romance of Alexander (Bodleian Library, Oxford, England); Hasenohr G, Zink M, eds. Dictionnaire des lettres françaises: Le Moyen Age. Collection: La Pochothèque. Paris: Fayard, 1992. ISBN 2-253-05662-6.

31 Chouard G. A Weltian rhapsody: Paul Strand, "Blind" (1917) and Eudora Welty, "Blind Weaver on the WPA, Oktibbeha County, 1930s." Transatlantica 2009;2:27. Available at: https://journals.openedition.org/transatlantica/4696. Accessed 7/24/2020.

32 Gowman AG. The war blind in American social structure. New York: The American Foundation for the Blind; 1957.

33 Wedding D, Boyd MA. Movies & Mental Illness: Using Films To Understand Psychopathology. Boston: McGraw-Hill College; 1999.

34 Klugman CM, Lamb EG. Research methods in the health humanities. New York: Oxford University Press; 2019.

Appendix 1: Art and Disability-related Organizations, Bibliographies, and Training Websites

Disability Studies programs

Appendix 2: Disability-relevant Art and Medicine Books
Albrecht GL. The Encyclopedia of Disability. London, UK: Sage Publications; 2006.

Barth M, Siegel A. Step Right This Way: The Photographs of Edward J. Kelty. New York, NY: Barnes and Noble; 2002.

Bettman OL. A Pictorial History of Medicine. Springfield, IL: Charles C. Thomas Publisher; 1972.

Carmichael AG, Ratzan RM. Medicine: A Treasury of Art and Literature. New York, NY: Hugh Lauter Levin Associates; 1991.

Greenspan RE. Medicine: Perspectives in History and Art. Alexandria, VA: Ponteverde Press; 2006.

Lyons AS, Petrucelli RJ III. Medicine: An Illustrated History. New York, NY: Harry N. Abrams; 1987.

Porter R (ed.). The Cambridge Illustrated History of Medicine. Cambridge, UK: Cambridge University; 1996.

Scull A. Madness in Civilization: A Cultural History of Insanity. Princeton, NJ: Princeton University Press; 2015.

Figures

Figure 1: Jean-Baptiste Grueze's The Paralytic, 1763, Hermitage Museum, St. Petersburg, Russia. ( File:Jean-Baptiste Greuze - Filial Piety - WGA10664.jpg - Wikimedia Commons).

Figure 2: The Polio Stele, Egypt 18 th Dynasty, 1403-1365 B.C., Deutsches Grunes Kreug, Copenhagen, Denmark. ( File:Polio Egyptian Stele.jpg - Wikimedia Commons).

Figure 3: Girolamo di Benvenuto's St. Catherine of Siena Exorcising a Possessed Woman, c. 1500, Denver Art Museum, Denver, Colorado. ( File:'St. Catherine of Siena Exorcising a Possessed Woman', painting by Girolamo di Benvenuto.jpg - Wikimedia Commons).

Figure 4: Pieter Bruegel the Elder's The Cripples, 1568, Louvre, Paris, France. ( File:Pieter Bruegel the Elder - The Cripples - WGA3518.jpg - Wikimedia Commons).

Figure 5: Details from Pieter Bruegel the Elder's Battle Between Carnival and Lent, 1559, Kunsthistorches Museum, Vienna, Austria. ( File:The battle between Carnival and Lent, by Pieter Bruegel (I).jpg - Wikimedia Commons).

Figure 6: Edward J. Kelty, photograph from Madison Square Garden, 1933. Published in Barth M., Siegel AM. Step Right This Way: The Photographs of Edward Kelty (p. 107). New York, NY: Barnes and Noble Books. 2002

Figure 7: Franklin Delano Roosevelt Memorial, Washington, D.C. (https://www.nps.gov/frde/learn/photosmultimedia/index.htm).

Figure 8: Martin Droeschout's To this Grave Doctors Millions do Resort, c. 1620 - 1630, British Museum, London, England. ( File:To this grave doctor millions do resort (BM 1854,1113.154).jpg - Wikimedia Commons).

Figure 9: Hieronymous Bosch's The Extraction of the Stone of Madness (Stones of Folly), c. 1501 - 1505, Prado, Madrid, Spain. ( File:Cutting the Stone (Bosch).jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/the-extraction-of-the-stone-of-madness/313db7a0-f9bf-49ad-a242-67e95b14c5a2).

Figure 10: Albrecht Durer's Melancholia I, 1514, Stadl Museum, Frankfurt, Germany. ( File:Dürer Melancholia I.jpg - Wikimedia Commons).

Figure 11: Frans Hal's Malle Babbe, 1633-1635, Gemaodegalerie, Berlin, Germany. ( File:Frans Hals 021.jpg - Wikimedia Commons).

Figure 12: Theodore Gericault's The Madwoman, 1819-1822, Museum of Fine Art, Lyon, France. ( File:The mad woman-Theodore Gericault-MBA Lyon B825-IMG 0477.jpg - Wikimedia Commons).

Figure 13: Hieronymous Bosch's Ship of Fools, 1494 - 1510, Louvre, Paris, France. ( https://collections.louvre.fr/en/ark:/53355/cl010062860; https://commons.wikimedia.org/wiki/File:Jheronimus_Bosch_011.jpg).

Figure 14: Francisco de Goya y Lucientes's Yard with Madmen, 1794, Meadows Museum, Dallas, Texas. (https://meadowsmuseumdallas.org/collections/pages/objects-1/info/?query=Artist_Maker%3D%2239%22&page=7).

Figure 15: Willowbrook Asylum. Photograph by William Bronston, 1979, from unpublished book (Public Hostage: Public Ransom - Inside Institutional America; online Archive of California: Finding Aid to the William Bronston Papers, 1961-2008 (cdlib.org)).

Figure 16: School of Jan Joest, The Adoration of the Christ Child, 16 th century, Museum of Modern Art, New York, New York. ( File:The Adoration of the Christ Child MET DT8852.jpg - Wikimedia Commons).

Figure 17: Illustration from The Romance of Alexander (artist Jehan de Grise), Flanders, Belgium, 1338-1344 (permission from the Bodleian Library).

Figure 18: John Everett Millais' Blind Girl, 1856, Birmingham Museum and Art Gallery, Birmingham, England. ( File:Millais-Blind Girl.jpg - Wikimedia Commons).

Figure 19: Paul Strand's The Blind Woman, 1916. ( https://commons.wikimedia.org/wiki/File:Blind_Woman.jpg).

Figure 20: Francisco de Goya y Lucentes' Two Old Men, 1821-1823, Prado, Madrid, Spain. ( File:2 alte Männer, um 1821-23.jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/two-old-men/cde9bf01-7535-4a62-8f73-a22d6a68d9a5?searchid=433a4981-4175-39e4-581f-0cc97a3dd2ad).

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Training guidelines for rehabilitation disciplines are generally based on medical models that focus on acquisition of knowledge (eg, anatomy, diagnoses, policies) and skills (eg, discipline-specific interventions) related to different disability diagnoses. However, there are mounting calls to expand the sensitivity of rehabilitation professionals to the personal experiences of, and social biases toward, individuals with disabilities (ie, issues of 'attitude'). It is argued that the review of artistic depictions of disability in their respective historical contexts offers an excellent vehicle by which to sensitize rehabilitation professionals to these issues. This article reviews the manner in which different western societies throughout history have depicted individuals with physical, mental, and sensory disabilities in the visual arts, ranging from primarily negative (eg, reflection of divine punishment for deserved transgressions, objects to be ridiculed for entertainment, etc.) to more recent positive perceptions (eg, heroes in contemporary films). Suggestions are offered regarding the use of the visual arts to educate rehabilitation professionals regarding individual and societal biases of disability, and to reduce the perpetuation of the stigma, misrepresentation, and mistreatment of individuals with disabilities.

Introduction

Since the passage of the Americans with Disabilities Act (ADA, 1990) there has been increased interest in promoting a better understanding and acceptance of persons with disabilities, as well as improving the societal discrimination they face. The Disability Rights Movement developed primarily in the last quarter of the 20 th century with considerable growth in advocacy efforts over the past three decades (eg, see Lives Worth Living). Of primary importance, the ADA prohibits discrimination and ensures equal opportunity for persons with disabilities in: employment; state and local government programs and services; access to places of public accommodation such as business, transportation, and non-profit service providers; and telecommunications. Although the ADA has provided greater opportunities and access for persons with disabilities, in order for them to attain complete inclusion into society, it is essential to change the negative attitudes and misperceptions regarding them commonly held by the general public-as well as by many rehabilitation professionals.

The manner in which individuals with disabilities were perceived, treated, and integrated into societies throughout history is complex and related to multiple issues involving economic, scientific, and religious factors. ¹ In the past, individuals with disabilities were frequently viewed as objects to be ridiculed and for the most part they have been perceived as a burden to others and considered to be of limited value to society. 2,3 This was due in large part to the limited understanding of human anatomy and physiology, as well as the lack of methods to treat disease and injuries, minimize impairments, or develop assistive devices (eg, prosthetic devices, assistive technologies, environmental accommodations). As such, they were often socially ostracized and driven to live on the margins of society. In contrast, there have also been various cultures and religious sects throughout history that have tended to care for and be empathetic toward individuals with disabilities.

Imagery From Ancient Times to the Present Day

Ancient writings and images reveal a wide variety of messages about how individuals with disabilities were treated and perceived in early historical times, including the portrayal of disability as a source of punishment in the Code of Hammurabi (ca. 1780 BCE), as predictors of good or bad events in The Omen Series Summa Izbu (ca. 1300 BCE), as individuals capable of community leadership in Homeric writings (The Iliad, 750 BCE), or even as a mark of beneficence in ancient Egypt. 2,4 However, few know that Aristotle proposed a law to prevent parents from raising deformed children, ⁵ that Spartan laws obliged parents to abandon deformed children, ⁶ or that Cicero claimed that the body determined the 'shape' of the soul. ⁷ Even numerous biblical passages demonstrate how individuals with various physical disabilities (eg, leprosy and paralysis) were perceived and treated negatively. 2,8 In fact, numerous laws/policies throughout history legalized or encouraged discrimination against individuals with disabilities and such negative representations further reinforced public perception of disability as 'abnormal,' along with the social division between the disabled and nondisabled. ⁹ These negative perceptions of disability generally persisted until the second half of the 20 th century when advances in medicine and innovative treatments/technologies allowed for the approach to disabilities to be improved.

Training in Disability Issues Across Rehabilitation Professions

With the development of the profession of physical medicine and rehabilitation following World War II, society began to view more consistently individuals with disabilities as worthy of treatment, and to assist them in recovering as fully as possible and returning to productive, independent lives. ¹⁰ Since then, rehabilitation disciplines have developed training guidelines to improve the health and functioning of individuals with disabilities (Table 1). In general, these professional organizations call for training based on medical models that emphasize knowledge and skills, often leading to the treatment of individuals as 'disorders' (eg, a spinal cord injury, a traumatic brain injury, a stroke) or 'impairments' (eg, forgetfulness, irritability, spasticity), rather than individuals with disabilities. As such, rehabilitation 'success' could be over-simplistically evaluated in terms of improvements in range of motion, memory scores, or increased psychological traits, without consideration of the need for full inclusion of individuals with disabilities into society. Because of these factors, it has been concluded that rehabilitation professionals "are often negative about disability, seeing inability before ability and frustrated by the lack of a prospect of cure and ill-informed about simple accommodations." 11(p462)

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Table 1: Rehabilitation Discipline Training Guidelines
American Board of Internal Medicine (2013). Internal medicine/physical medicine and rehab policies. Accessed online on 7/20/2020 at: http://www.abim.org/certification/policies/combinedim/comrehab.aspx

Accreditation Content for Occupational Therapy Education (2018). Standards of practice for occupational therapy. Accessed online on 7/20/2020 at: https://acoteonline.org/wp-content/uploads/2020/07/2018-ACOTE-Standards.pdf

American Physical Therapy Association (2018). Standards of practice for physical therapy. Accessed online on 7/20/20 at: http://www.apta.org/uploadedFiles/APTAorg/AboutUs/Policies/HOD/Practice/standards.pdf.

American Speech-Language-Hearing Association. (2020). Scope of practice in speech

language pathology [Scope of Practice]. Accessed online on 7/20/20 at: https://www.asha.org/certification/2020-slp-certification-standards/.

American Psychological Association Rehabilitation Psychology Division (2012). Guidelines for postdoctoral training in rehabilitation psychology. Accessed online on 7/20/20 at: https://www.apa.org/pubs/journals/features/rep-a0030774.pdf.

American Therapeutic Recreation Association Standards of Practice. Accessed online on 7/20/20 at: https://www.atra-online.com/page/SOP.

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More recently, there has been increased recognition of the need for training in the ability to understand the personal experiences of persons with disabilities and the societal biases experienced by these individuals (sometimes referred to as training in issues of attitude). It is relatively easy to teach knowledge (eg, facts, diagnostic criteria) and skills (eg, procedures, tests, discipline-specific therapies), as these are generally fact-based and able to be memorized. However, it is much more difficult to mold individual and societal attitudes (ie, conscious and unconscious biases and beliefs) about disabilities. Changing attitudes and beliefs, however, is central to improving the lives of people with disabilities given that prejudicial and exclusionary social practices are believed to be greater barriers to social participation than specific mental, physical, or sensory impairments. ¹² It is important for healthcare professionals to examine their own beliefs about disability and awareness of how persons with disabilities are perceived, portrayed, and treated today, and particularly for those rehabilitation professionals who work with these populations on a daily basis.

Rehabilitation Psychology Training Guidelines: An Example

Although all rehabilitation training guidelines generally focus on the medical model, initial post-doctoral training guidelines for rehabilitation psychology provide an example of training methods to address issues of attitude. This specifically involves the need to be educated about the manner by which disability is a socially-constructed phenomenon, as well as the manner by which our own biases affect our treatment, interactions with, and expectations for, individuals with disabilities. For example, one of the most notable rehabilitation psychology guidelines calls for training in "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them." ¹³ This suggestion is truly unique among the various rehabilitation disciplines in that it acknowledges the significant role that societal expectations and misperceptions have in the manner by which individuals with disabilities are treated. Although this suggestion is noteworthy, there are no specific methods to suggest how to train rehabilitation professionals regarding the societal perceptions that impact persons with disabilities. This article suggests that studying images of disability in art history is an important and impactful method for teaching rehabilitation professionals about the experiences and biases experienced by those patients they serve.

Art as a Means to Better Understand the Experience of Disability

Human beings have made art to communicate and connect with each other since prehistoric times. Art has the powerful ability to help viewers relate to the individuals depicted in the image on a human, empathetic level, which, in turn enhances the goal of understanding and acceptance on a new level. Artists have used various mediums (eg, paintings, poetry, narratives, sculpture, film, etc.) to express emotional turmoil, tragedy, social isolation, and psychological disturbance as a means to relate and share personal experiences. The medical, legal, and social zeitgeist of an era is often reflected by the artwork created of that time. Alternatively, societal perceptions have long been influenced by how individuals with disability are represented to the public visually and politically. There are few primary sources from ancient and medieval times regarding people with disabilities, ³ and as a result, researchers have relied on the arts to determine the social context of disability at various times throughout history. In fact, a historian of disability states that, "Studying the representation of disability in literature and art is an important and relatively unexplored research frontier in disability studies." 14(p 54)

The arts have been used in rehabilitation for people with disabilities primarily through recreational therapies in which individuals engage in the visual arts, music, dance, and expressive writing to adjust to their disabilities. However, a review of artistic representations of disability throughout history also offers an excellent method by which to improve the training of rehabilitation professionals. There is increased recognition that studying the humanities helps health professionals gain a better understanding of the human side of chronic disabilities.

People with disabilities are depicted throughout art history, and these images provide a context for the manner by which they were perceived at that time (eg, worthy of derision or sympathy, objects of ridicule, deserving of divine punishment, etc.). For example, prior to the advent of the printing press, when much of the population was illiterate, paintings were often used to tell stories, depict historical events, and provided examples of how people were treated. ³ As such, many individuals learned social expectations for how to treat the disabled by viewing paintings in churches or watching plays during community festivals. It is from these works of art that we can understand the culture of the times and become sensitized to the relevant social issues of the day as they pertain to disability. By comparing past and current art forms (eg, paintings, drawing, and sculptures from the past to movies, films, and literature from the present) it is possible to better understand how societal perceptions have a major influence on the way individuals with disabilities are treated. Subsequently, training methods can be developed to counter "social myths of disabilities" (see APA Division 22 training guidelines), and educate rehabilitation professionals to become better providers for individuals with disabilities.

PART 1: The Representation of Physical Disability in Art History

Throughout history, individuals with physical disabilities have primarily been perceived and represented as 'misfits, fools, oddities, and marvels,' present in the world for purposes of entertainment, ridicule, and experimentation. ² This relates in part to the lack of understanding of the causes of physical disability, as well as the lack of resources, knowledge, or will to develop accommodations during various historical times. As such, individuals with disabilities often had little support from their families and communities and needed to fend for themselves in creative ways; this was generally the case until the last half of the 20 th century.

As an example, Greuze's The Paralytic (1763; Fig. 1) is one of the few depictions of an individual with paralysis, likely due to the fact that the survival rates for such individuals were extremely low.

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Historically, depictions of physical disability in western civilizations have largely focused on 'abnormalities' and the negative manner by which individuals with disabilities were perceived and treated. In fact, a frequently-cited theory from the late 18 th century related to physiognomy concluded that the disabled were, "[t]he morally worst, the most deformed." ¹⁵ However, it is noteworthy that ancient Egyptian and Greek cultures at various times were generally accepting of individuals with physical disabilities, as illustrated in several of their works of art. 4,16,17 For example, a stone carving from approximately 1300 BCE shows a realistic depiction of an Egyptian leader with a withered leg, apparently from polio (Fig. 2). Greek vases show similar representations of dwarves who were valued as assistants within the medical field, and even portrayed as deities. 16,17 However, throughout history, such positive depictions of physical disabilities were the exception rather than the rule.

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By the Middle Ages, societies began to extend to people with impairments "an acceptance at times awkward, at times brutal, at times compassionate, a kind of indifferent, fatalistic integrations" to people with impairments. 8(p15) However, in general, individuals with disabilities were represented as abnormal, with early portrayals exploiting these abnormalities for amusement. Paintings from this time indicate that individuals with disabilities were viewed in terms of a religious model of disability, in that individuals were believed to be disabled secondary to spiritual transgressions and were thus treated with religious interventions, if they were even treated. Metzler 2(p89) reports "anecdotal evidence suggests that there was a very strong feeling that malformed babies indicated sin on the part of their parents." Spiritual interventions for disabilities were depicted in a painting by di Benvenuto (15 th Century), titled St. Catherine of Siena Exorcising a Possessed Woman (Fig. 3), in which individuals with both physical (ie, characters with crutches) and mental illnesses (central figure) caused by demonic possession were treated with religious interventions within a church setting.

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By the 16 th century, the Renaissance began to focus on classical forms of beauty, which did not typically include the disabled or deformed. However, art from the northern Renaissance depicted individuals with physical disabilities in a realistic manner, providing insight into the way they were treated and socially perceived at that time. Hieronymous Bosch painted a series of 31 'cripples' in 1500, illustrating the various disabling conditions and prosthetic devices used by these individuals. ¹⁹ Similarly, Bruegel's The Cripples (1568; Fig. 4) shows individuals with various prosthetics gathered together in a town square. However, historical context indicates that these individuals were forced to wear fox tails attached to their clothes as indicators that they were objects to be ridiculed at community festivals. 19,20 Similarly, Bruegel's Battle Between Carnival and Lent (1559; Fig. 5) shows the relative isolation faced by individuals with disabilities within their communities. Compared to the so-called 'normal' citizens participating in either carnival or lent, details from the painting show two groups of individuals with disabilities (ie, 'cripples' in middle scene, blind individuals by church entrance) as socially-isolated beggars. These community spectacles are precursors to the freak shows that gained popularity in the mid-16 th century and lasted to the mid-20 th century, which displayed physically unusual or deformed humans for a source of entertainment ²¹ (Fig. 6). By the 19th century, individuals with impairments were even criminalized through public policy (ie, 'ugly laws' involving social restrictions placed on those with physical appearances that might offend 'normal' people) ⁹.

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Paintings such as Wyeth's Christina's World (1948) provide an example of the social isolation and handicaps faced by many individuals with physical disability even in the middle of the 20 th century. This painting appears to show its subject, Christina Olson, admiring a homestead in a windswept field. However, an article in the Journal of Child Neurology ²² indicates that Wyeth was portraying a young woman suffering from a progressive neurological disorder that he observed crawling crab-like up to her farmhouse. This knowledge challenges the initial perception of the scene and shifts our position from viewer to Christina's own perspective. This is the power of studying art history: to guide the viewer by facilitating close looking, deeper contextual understanding, and empathy. An article by J.O. Ballard in JHR is an excellent resource for those who would like to use this painting to increase clinical observation and diagnostic skills regarding disability in health sciences education. ²³

Even within the past quarter century, controversy surrounding the Franklin D. Roosevelt (FDR) Memorial in Washington, DC illustrates the current difficulties society has in accepting individuals with physical disabilities. FDR's Splendid Deception ²⁴ recounts how the original statue of FDR to be placed at the front of his memorial in Washington, DC was designed to depict him in his wheelchair (he could not walk after contracting polio at age 39). However, when the original sculpture was finished, his cape covered his wheelchair completely, in effect hiding his disability (Fig. 7). A second statue, depicting FDR using his actual wheelchair and placed at the other end of the memorial, was completed only after significant advocacy efforts by disability rights groups. It is important to note that ancient Egyptian society could realistically portray important figures with disabilities with compensatory devices over 3,000 years ago (Fig. 2), but the FDR Memorial planners of the 20 th century had problems acknowledging his disability, despite the fact that he was one of the most important and powerful leaders in the world during his lifetime.

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PART 2: The Representation of Mental and Intellectual Disability in Art History

Up until the 19 th century, individuals with physiologically-based mental disorders were conceptualized in terms of 'madness' primarily related to spiritual disorders that needed to be treated through spiritual interventions (although these beliefs persist in some communities even today). For example, di Benvenuto's St. Catherine Exorcising a Possessed Woman, shows a demon being exorcised from a woman's head in the 1300s (Fig. 3). Similarly, Droeschout's To this Grave Doctor Millions do Resort from the 17 th century (Fig. 8) shows a scene in which demons were exorcised from an individual's head in a fancy contraption (figure on right), as well as from their bowels by the apparent use of an elixir to dispel demons (figure on left).

Similarly, a 16 th-century painting by Hieronymus Bosch titled The Extraction of the Stone of Madness (Stones of Folly) illustrates the belief at that time that 'madness' was due to the presence of a stone within the skull that required extraction in order for the person to be cured (Fig. 9). By 1514, mental illness was believed to be related to an imbalance of the four humors of the body (black bile, yellow bile, blood, phlegm) that led to the four primary human temperaments (melancholic, phlegmatic, choleric, and sanguine) ²⁵ as represented in Durer's Melancholia I (Fig. 10). Frans Hal's Malle Babbe (1633-1635) illustrates how mental illness (eg, insanity, alcoholism) was conceptualized in northern Europe during the 17 th century as being caused by the visitation of the bird of lunacy (Fig. 11).

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Art from the 19 th century demonstrates how mental (ie, lunacy) and developmental disabilities (ie, 'idiocy') started to be conceptualized in a different manner in some cultures, in that such disorders were transformed from being conceptualized as 'madness' to 'mental illness' (ie, a medical abnormality) ²⁶. For example, in the 1800s, health professionals attempted to distinguish between different types of mental disorders through the identification of unique facial features, similar to the field of physiognomy.

Theodore Gericault painted a series of 10 'portraits of the insane' ( The Madwoman, 1819-1822; Fig. 12) depicting physical attributes that were thought to be associated with specific psychological disorders-five of the paintings which still exist (Woman Addicted to Gambling, A Child Snatcher, Woman Suffering from Obsessive Envy, Kleptomaniac, Man Suffering from Delusions of Military Command). Although it is difficult to determine how physical features could reveal a 'child snatcher' or someone with 'military delusions,' it is noteworthy that mental illnesses were starting to be categorized in terms of specific abnormalities (ie, physical and psychological).

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Art from other historical periods also offers insight into the manner by which individuals with mental disabilities were segregated and isolated from their communities. Bosch's Ship of Fools (1490-1500; Fig. 13) depicts the practice during the 15 th century and beyond of rounding up the disabled and unwanted and placing them in a wagon with promises of goods, in order to remove them from society. ²⁷ This practice changed in the beginning of the 18 th century when individuals with mental and sensory disabilities began to be institutionalized in hospitals or asylums, but without prescribed care or interventions. 2,3 Goya illustrated such a lunatic asylum in the 1700s (Fig. 14), but incredibly, this representation differs little from the demeaning conditions depicted in the infamous 1970s documentary about the Willowbrook Mental Institution in New Jersey (Fig. 15). These works of art show how individuals with mental illnesses from the Middle Ages until the 1970s were removed from society and deemed unworthy of treatment, which differs considerably from current societal understanding and increasing acceptance of mental illness.

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Although artists throughout history have generally depicted individuals with intellectual disabilities in a negative manner (eg, village idiots, fools), several works of art illustrate how some societies had positive and accepting views of individuals with intellectual disabilities. For example, The Adoration of the Christ Child (circa 1515) offers a powerful message about the acceptance of individuals with developmental disabilities in Northern Europe in the 16th century (Fig. 16). In this painting, medical professionals have suggested that two of the angels surrounding the manger have Down's syndrome (although the syndrome was not known as such at that time). 28,29 This painting likely reflects the longstanding and continued willingness of communities in northern Europe to be inclusive of individuals with intellectual disabilities.

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PART 3: The Representation of Sensory Disability in Art History

Misperceptions and prevailing attitudes of individuals with sensory disorders date back to the biblical era. In its most dramatic fashion, select scriptures led many to believe that God used deafness and blindness as retribution for sin: "Who gave man his mouth? Who makes him deaf or mute? Who gives him sight or makes him blind? Is it not I, the Lord?" (Exodus 4:11); "...if you do not carefully follow His commands and decrees...all these curses will come upon you and overtake you: the Lord will afflict you with madness, blindness, and confusion of the mind. At midday, you will grope around like a blind man in the dark." (Deuteronomy 28:15). This demonization of the blind carried on through the Middle Ages and into the Renaissance.

For example, a manuscript from the 14 th century, The Romance of Alexander, ³⁰ includes illustrations, in the margins, of the daily customs, work, dress, leisure activities, and social norms that existed in Medieval Europe at that time. Of interest, one border illustration shows how individuals with visual impairments were paraded before communities as a form of entertainment at times of festival (Fig. 17), similar to Bruegel's The Cripples (Fig. 4). Writings from 1425 describe a similar event:

"Note, the last Sunday of the month of August there took place an amusement at the residence called d'Arminac in the Rue Saint Honore, in which four blind people, all armed, each with a stick, were put in a park, and in that location there was a strong pig that they could have if they killed it....and there was a very strange battle, because they gave themselves so many great blows with those sticks that it went worse for them, because when the stronger ones believed that they hit the pig, they hit each other, and if they had really been armed, they would have killed each other. Note, the Saturday evening before the aforementioned Sunday, the said blind people were led through Paris all armed, a large banner in front, where there was a pig portrayed, and in front of them a man playing a bass drum" (as cited in Wheatley 26( p1)).

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Throughout history, images of the blind beggar have rendered public perception of blind individuals as helpless, useless, and passively dependent. Given the social, vocational, and financial difficulties associated with blindness and marginalization, some blind individuals have succumbed to accepting this role. For example, Millais (1856) portrayed a young blind girl relegated to beg for money by playing her concertina while wearing a sign on her neck displaying the words, "Pity the Blind" (Fig. 18). This was also depicted in a notorious photograph by Strand in 1916 of an impoverished blind woman in New York City, identifying her disability with a sign around her neck saying "Blind," below the metallic license she needed to obtain to legally beg ³¹ (Fig. 19).

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Beginning in the 17 th century, the perception of individuals with visual disabilities as defective, expendable, and intellectually disabled led to the social control movement of institutionalization for the disabled. In fact, one of the first institutions for disabled individuals was intended for the deaf and the blind, as depicted in Goya's Yard with Madmen (1794; Fig. 14), which represented scenes of institutions he personally witnessed, and was said to be painted at a time when he feared similar consequences from his own mental illness and deafness. The emotional toll of the blind and deaf, due to marginalization and social stigma, can also be seen in Goya's Two Old Men (from his Black Painting series; Fig. 20), capturing the darkness and isolation felt during his years plagued with deafness and physical ailment. Similar sentiments are aroused in Degas' Madame René de Gas (1872/1873; https://www.nga.gov/collection/art-object-page.46599.html), a portrait of his blind sister-in-law's vacant gaze representing her solitude and isolation, and Picasso's The Old Guitarist (1903), both depicting tones of sorrow and loneliness. The sorrow and frustration were a product of living in a society that deemed them incapable and blemished, therefore discounting their intact capabilities that could benefit from accommodation.

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During the mid-20 th century, Americans with visual impairments described the impact of the beliefs, superstitions, and the social/physical environment as the primary obstacle to the emotional and physical adjustment to their disability, as cited in The War Blind in American Social Structure:

"All too frequently the great tragedy of a blind person's life is not primarily his blindness, but the reactions of the family and social group toward him as a non-typical member." ³²

Today, while ambiguous perceptions of those with sensory impairment still exist, knowledge, technological innovation and accommodations leading to expansive and ready access of support helps afford these individuals education and greater independence. Interpreters are more readily available in health care and educational facilities, along with the transcription of texts to Braille or auditory recordings. With these supports and greater public knowledge, individuals with sensory disabilities have disproved past perceptions of being passive, dependent, helpless, unproductive, or intellectually disadvantaged.

PART 4: Modern Artistic Representations of Disability

Although beyond the scope of this article, it is noteworthy how primary art forms of today (ie, movies, TV) have played a substantial role throughout the 20 th and 21 st centuries in shaping societal attitudes toward disability. Thus, it is not surprising that the manner by which disability is represented in media art today has also led to greater acceptance of disability. Such realistic and positive representations of disability will continue to teach people who are secure in their beliefs and perceptions of 'normalcy' that individuals with disabilities are not subjects to be gawked at or marginalized.

For example, children today are exposed to positive images of disability and representations of characters with disability as leaders, such as those portrayed in the Disney movie Finding Nemo (2003). X-Men is a popular comic magazine that has been made into a series of movies (2000-2019). Of note, Charles Xavier, the leader of this band of individuals with superhuman powers, is confined to a wheelchair. Similarly, the critically acclaimed Murderball (2005) is a documentary film that shows individuals with various forms of paralysis engaging in full-contact rugby in the Paralympic Games in Athens, Greece.

The depiction of mental illness in film has also improved over the past 50 years, with individuals with mental illnesses and sensory disabilities portrayed more realistically and empathetically ( One Flew over the Cuckoo's Nest (1975); Rain Man (1988); Children of a Lesser God (1986)). Rehabilitation trainees and professionals can watch these and other movies that show the human experience of disability with subsequent discussion at scheduled training opportunities (Table 2). These movies offer opportunities to discuss differences in how individuals with disabilities have been portrayed and treated in the past and currently, and how more positive portrayals can lead to the development of better skills for rehabilitation professionals-and ultimately greater understanding and acceptance of the personal experience of disability.

PART 5: Disability Training Through the Arts

It is suggested that rehabilitation training guidelines promote opportunities for both students and professionals to become aware of the "cognitive, affective, and societal sources of handicapped myths about disability and ways to counteract them" (see APA Division 22 training guidelines) through the study of disability in the visual arts. It is recommended that rehabilitation students and professionals review and discuss the visual arts (and literature) relating to the personal experiences of, and societal perceptions of, disability in existing didactics, grand rounds, and journal clubs. Students and professionals can easily review paintings and articles presented in this article for discussion, and particularly those presented in articles from traditional medical journals and art history journals and textbooks (see References below).

Training directors can also find appropriate topics and offerings on art and disability through many websites and organizations (Appendix 1). Review of the representation of disability in the visual arts can also be discussed based on academic sources that provide contextually-relevant cultural information related to specific eras, as well as autobiographies, novels, and collections of short stories that provide examples that relate the personal experiences of persons with disabilities, the challenges they have faced, and the successes they have had in becoming full members of society (Appendix 2).

Conclusion

In conclusion, this article reflects the benefits and necessity of training in the health humanities (versus medical humanities) for both rehabilitation professionals and those individuals with disabilities they serve. Specifically, the health humanities apply transdisciplinary practices that draw on the humanities, fine arts, and social sciences to bring meaning to human experiences of health and illness, to increase social justice for individuals with illness and disabilities. ³⁴ Training in the health humanities can complement training in the medical humanities-which focus on the use of the humanities in service to medicine-to help practitioners learn attributes such as empathy, communication, and compassion.

The authors wish to acknowledge the assistance of Josiah Scott in editing and formatting this article.

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18 Stiker HJ. A History of Disability. Ann Arbor: University of Michigan Press; 2019.

19 Dequecker J, Fabry G, Vanopdenbosch L. Hieronymous Bosch (1450-1516): Paleopathology of the Medieval disabled and its relation to the bone and joint decade 2000-2010. Int Med Anthro J. 2001;3:864-871.

20 Dequecker J, Rico M. Rheumatoid arthritis-like deformities in an early 16th century painting of the Flanders-Dutch school. JAMA. 1991;268:249-251.

21 Barth M, Siegel A. Step Right This Way: The Photographs of Edward J. Kelty. New York: Barnes & Noble; 2001.

22 Patterson MC, Cole TB, Siegel E, Mackowick PA. A patient as art: Andrew Wyeth's portrayal of Christina Olson's neurologic disorder in Christina's World. J Child Neurol. 2017;32:647-649. doi: 10.1177/0883073817700603.

23 Ballard JO. Inside Christina's World. J Human Rehabil. 2017. Available at: https://www.jhrehab.org/2017/10/17/inside-christinas-world/. Accessed August 31, 2021.

24 Gallagher HS. FDR's Splendid Deception: The Moving Story of Roosevelt's Massive Disability and the Intense Efforts to Conceal It From The Public. Vandemere; 1999.

25 Bartrum G. (ed.) Albrecht Dürer and His legacy. London: The British Museum Press; 2002.

26 Wheatley E. Stumbling Blocks Before The Blind: Medieval Constructions of a Disability. Ann Arbor: The University of Michigan Press; 2010.

27 Maher WB, Maher B. The ship of fools: Stultifera Navis or Ignis Fatuus? Am Psychol. 1982;37(7):756-761.

28 Levitas AS, Reid CS. An angel with Down syndrome in a sixteenth century Flemish nativity painting. Am J Med Gen. 2003;116A:399-405.

29 Robotham J. Nativity scene paints different picture of Down syndrome; 2003. Available at: https://www.smh.com.au/national/nativity-scene-paints-different-picture-of-down-syndrome-20030127-gdg67d.html. Accessed 8/15/2013

30 Romance of Alexander (Bodleian Library, Oxford, England); Hasenohr G, Zink M, eds. Dictionnaire des lettres françaises: Le Moyen Age. Collection: La Pochothèque. Paris: Fayard, 1992. ISBN 2-253-05662-6.

31 Chouard G. A Weltian rhapsody: Paul Strand, "Blind" (1917) and Eudora Welty, "Blind Weaver on the WPA, Oktibbeha County, 1930s." Transatlantica 2009;2:27. Available at: https://journals.openedition.org/transatlantica/4696. Accessed 7/24/2020.

32 Gowman AG. The war blind in American social structure. New York: The American Foundation for the Blind; 1957.

33 Wedding D, Boyd MA. Movies & Mental Illness: Using Films To Understand Psychopathology. Boston: McGraw-Hill College; 1999.

34 Klugman CM, Lamb EG. Research methods in the health humanities. New York: Oxford University Press; 2019.

Appendix 1: Art and Disability-related Organizations, Bibliographies, and Training Websites

Disability Studies programs

Appendix 2: Disability-relevant Art and Medicine Books
Albrecht GL. The Encyclopedia of Disability. London, UK: Sage Publications; 2006.

Barth M, Siegel A. Step Right This Way: The Photographs of Edward J. Kelty. New York, NY: Barnes and Noble; 2002.

Bettman OL. A Pictorial History of Medicine. Springfield, IL: Charles C. Thomas Publisher; 1972.

Carmichael AG, Ratzan RM. Medicine: A Treasury of Art and Literature. New York, NY: Hugh Lauter Levin Associates; 1991.

Greenspan RE. Medicine: Perspectives in History and Art. Alexandria, VA: Ponteverde Press; 2006.

Lyons AS, Petrucelli RJ III. Medicine: An Illustrated History. New York, NY: Harry N. Abrams; 1987.

Porter R (ed.). The Cambridge Illustrated History of Medicine. Cambridge, UK: Cambridge University; 1996.

Scull A. Madness in Civilization: A Cultural History of Insanity. Princeton, NJ: Princeton University Press; 2015.

Figures

Figure 1: Jean-Baptiste Grueze's The Paralytic, 1763, Hermitage Museum, St. Petersburg, Russia. ( File:Jean-Baptiste Greuze - Filial Piety - WGA10664.jpg - Wikimedia Commons).

Figure 2: The Polio Stele, Egypt 18 th Dynasty, 1403-1365 B.C., Deutsches Grunes Kreug, Copenhagen, Denmark. ( File:Polio Egyptian Stele.jpg - Wikimedia Commons).

Figure 3: Girolamo di Benvenuto's St. Catherine of Siena Exorcising a Possessed Woman, c. 1500, Denver Art Museum, Denver, Colorado. ( File:'St. Catherine of Siena Exorcising a Possessed Woman', painting by Girolamo di Benvenuto.jpg - Wikimedia Commons).

Figure 4: Pieter Bruegel the Elder's The Cripples, 1568, Louvre, Paris, France. ( File:Pieter Bruegel the Elder - The Cripples - WGA3518.jpg - Wikimedia Commons).

Figure 5: Details from Pieter Bruegel the Elder's Battle Between Carnival and Lent, 1559, Kunsthistorches Museum, Vienna, Austria. ( File:The battle between Carnival and Lent, by Pieter Bruegel (I).jpg - Wikimedia Commons).

Figure 6: Edward J. Kelty, photograph from Madison Square Garden, 1933. Published in Barth M., Siegel AM. Step Right This Way: The Photographs of Edward Kelty (p. 107). New York, NY: Barnes and Noble Books. 2002

Figure 7: Franklin Delano Roosevelt Memorial, Washington, D.C. (https://www.nps.gov/frde/learn/photosmultimedia/index.htm).

Figure 8: Martin Droeschout's To this Grave Doctors Millions do Resort, c. 1620 - 1630, British Museum, London, England. ( File:To this grave doctor millions do resort (BM 1854,1113.154).jpg - Wikimedia Commons).

Figure 9: Hieronymous Bosch's The Extraction of the Stone of Madness (Stones of Folly), c. 1501 - 1505, Prado, Madrid, Spain. ( File:Cutting the Stone (Bosch).jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/the-extraction-of-the-stone-of-madness/313db7a0-f9bf-49ad-a242-67e95b14c5a2).

Figure 10: Albrecht Durer's Melancholia I, 1514, Stadl Museum, Frankfurt, Germany. ( File:Dürer Melancholia I.jpg - Wikimedia Commons).

Figure 11: Frans Hal's Malle Babbe, 1633-1635, Gemaodegalerie, Berlin, Germany. ( File:Frans Hals 021.jpg - Wikimedia Commons).

Figure 12: Theodore Gericault's The Madwoman, 1819-1822, Museum of Fine Art, Lyon, France. ( File:The mad woman-Theodore Gericault-MBA Lyon B825-IMG 0477.jpg - Wikimedia Commons).

Figure 13: Hieronymous Bosch's Ship of Fools, 1494 - 1510, Louvre, Paris, France. ( https://collections.louvre.fr/en/ark:/53355/cl010062860; https://commons.wikimedia.org/wiki/File:Jheronimus_Bosch_011.jpg).

Figure 14: Francisco de Goya y Lucientes's Yard with Madmen, 1794, Meadows Museum, Dallas, Texas. (https://meadowsmuseumdallas.org/collections/pages/objects-1/info/?query=Artist_Maker%3D%2239%22&page=7).

Figure 15: Willowbrook Asylum. Photograph by William Bronston, 1979, from unpublished book (Public Hostage: Public Ransom - Inside Institutional America; online Archive of California: Finding Aid to the William Bronston Papers, 1961-2008 (cdlib.org)).

Figure 16: School of Jan Joest, The Adoration of the Christ Child, 16 th century, Museum of Modern Art, New York, New York. ( File:The Adoration of the Christ Child MET DT8852.jpg - Wikimedia Commons).

Figure 17: Illustration from The Romance of Alexander (artist Jehan de Grise), Flanders, Belgium, 1338-1344 (permission from the Bodleian Library).

Figure 18: John Everett Millais' Blind Girl, 1856, Birmingham Museum and Art Gallery, Birmingham, England. ( File:Millais-Blind Girl.jpg - Wikimedia Commons).

Figure 19: Paul Strand's The Blind Woman, 1916. ( https://commons.wikimedia.org/wiki/File:Blind_Woman.jpg).

Figure 20: Francisco de Goya y Lucentes' Two Old Men, 1821-1823, Prado, Madrid, Spain. ( File:2 alte Männer, um 1821-23.jpg - Wikimedia Commons; https://www.museodelprado.es/en/the-collection/art-work/two-old-men/cde9bf01-7535-4a62-8f73-a22d6a68d9a5?searchid=433a4981-4175-39e4-581f-0cc97a3dd2ad).

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Brick Johnstone, PhD, ABPP | Gretchen E. Henderson, Ph.D | Aimee Tessar, Psy.D | Stacey Bayan, Psy.D | Alexandra Chukabarah, MS | Pete Anziano | Mark Johnson, M.Ed

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Art History as a Resource for Understanding Social Bias in Disability

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Download the article (pdf) Training guidelines for rehabilitation disciplines are generally based on medical models that focus on acquisition of knowledge (eg, anatomy, diagnoses, policies) and skills (eg, discipline-specific interventions) related to different disability diagnoses. However, there are mounting calls to expand the sensitivity of rehabilitation professionals to the personal experiences of, and social biases toward, individuals with disabilities (ie, issues of 'attitude').

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Chuck Close, in full Chuck Thomas Close, (born July 5, 1940, Monroe, Washington, U.S.), American artist noted for his highly inventive techniques used to paint the human face. He is best known for his large-scale Photo-realist portraits.

Close began taking art lessons as a child and at age 14 saw an exhibition of Jackson Pollock's abstract paintings, which helped inspire him to become a painter. He studied at the University of Washington School of Art (B.A., 1962) and at the Yale University School of Art and Architecture (B.F.A., 1963; M.F.A., 1964), and in 1964 he won a Fulbright scholarship to study in Vienna. While teaching at the University of Massachusetts at Amherst (1965-67), he gradually rejected the elements of Abstract Expressionism that had initially characterized his work.

Close's first solo exhibition included a series of enormous black-and-white portraits that he had painstakingly transformed from small photographs to colossal paintings. He reproduced and magnified both the mechanical shortcomings of the photograph-blurriness and distortion-and the flaws of the human face: bloodshot eyes, broken capillaries, and enlarged pores. To make his paintings, Close superimposed a grid on the photograph and then transferred a proportional grid to his gigantic canvases. He then applied acrylic paint with an airbrush and scraped off the excess with a razor blade to duplicate the exact shadings of each grid in the photo. By imposing such restraints, Close hoped to discover new ways of seeing and creating.

Throughout his career, Close continued to concentrate on portraits-from the neck up-based on photographs he had taken. In addition to self-portraits, the portraits were usually of friends, many of whom were prominent in the art world. These images represent a very human, flawed view of the subjects, given the scale of attention given to imperfections, while also presenting a rather grand, iconic view of the sitters, given the monumental and confrontational quality of the works. During the 1970s and '80s, Close began to use colour and to experiment with a variety of media and techniques. One technique involved simulating the printing process: he used only cyan, magenta, and yellow and applied one layer of colour at a time to the canvas. He developed one of his most innovative techniques for his "fingerprint series," in which he inked his thumb and forefinger and pressed them to the canvas to achieve a subtle range of grays. Viewed up close, the whorled patterns of his fingerprints can easily be seen; from a distance the method is unidentifiable, and the fingerprints combine to create an illusionistic whole.

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In 1988 a spinal blood clot left Close almost completely paralyzed and confined to a wheelchair. A brush-holding device strapped to his wrist and forearm, however, allowed him to continue working. In the 1990s he replaced the minute detail of his earlier paintings with a grid of tiles daubed with colourful elliptical and ovoid shapes. Viewed up close, each tile was in itself an abstract painting; when seen from a distance, the tiles came together to form a dynamic deconstruction of the human face. In 1998 the Museum of Modern Art in New York City mounted a major retrospective of Close's portraits. Close has been called a Photo-realist, a Minimalist, and an Abstract Expressionist but, as the 1998 retrospective proved, his commitment to his unique vision and his evolving techniques defy any easy categorization.

Close continued to experiment with portraits at the start of the 21st century, creating a series of large daguerreotypes, an early form of photography. His work continued to appear in exhibitions and group shows, and many major museums acquired his pieces for their collections. In 2018, however, the National Gallery of Art in Washington, D.C., announced that it was canceling a forthcoming exhibition of his amid allegations of sexual misconduct from several of his potential models. Although he apologized for inappropriate comments, Close denied any wrongful actions.

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Chuck Close, American artist noted for his highly inventive techniques used to paint large-scale portraits. By reproducing and magnifying photos, Close highlighted the mechanical shortcomings of photography and the flaws of the human face. Learn more about his life and work.

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Chuck Close - 331 Artworks, Bio & Shows on Artsy

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Find the best of Chuck Close including his biography, paintings & prints for sale, shows and articles on Artsy. Chuck Close reinvented painting with his monumental portraits...

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“Following the transformative power of social justice art education, through promoting critical awareness within diverse types of cultural and political oppressions (Dewhurst, 2014), disability studies has a great potentiality to inform arts learning from non-ableist perspectives (Derby, 2016; Eisenhauer, 2008a; Penketh, 2014). On the other hand, arts learning offers multiple ways to explore disability cultures and their representations and scrutinize them in creative and critical ways, and ultimately imagine alternative non-ableist futures.”

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“The real cause of disability is discrimination and prejudice, not an impairment.”

# data[].attributes.body
While society has made strides in realizing the deep seeded prejudice against those with disabilities, there is still more that we need to change our thinking and understandings of. Art either painted by someone with a disability and/or featuring someone with a disability, especially in contemporary times, is challenging the viewer to think and address their own convictions and understandings of disabilities.

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How do you view disabilities and people with disabilities?

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Do you have certain assumptions and prejudices about these things?

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Is there room for improvement in the way that you see disabilities and people with disabilities?