Art therapy for people diagnosed with schizophrenia: Therapists’ views about what changes,how and for whom

Abstract

National guidance recommends that clinicians consider the offer of arts therapies including art therapy to people diagnosed with schizophrenia. However, because schizophrenia is a heterogeneous condition and this recommendation is based on population-level evidence, it may be difficult to meaningfully apply locally. Whilst art therapy is inextricably linked with ‘psychosis’ and receives clinical support, those charged with implementing guidance, developing and delivering services need to know more about art therapy, specifically what changes, how and for whom. We used grounded theory methods to address these questions from the perspective of art therapists. The data demonstrate richness and diversity in practice and therapists’ abiding belief in its inherent value; art therapy is ‘good’ for those who engage. We present therapists’ understandings of schizophrenia, conceptualise therapy as occurring in the complex interaction of use of art materials, space, therapist and participant and propose mechanisms of action, understood as both unique and universal and potential ‘outcomes’. Whilst therapists’ dedication to their practice is apparent and the potential benefits of its non-medical system status cannot be ignored it seems that integration of art therapy within the spectrum of care necessary to effectively support people diagnosed with schizophrenia will require clear articulation of theory and practice.     

Art therapy and poverty: examining practitioners’ experiences of working with children and young people in areas of multiple deprivation in West Central Scotland

ABSTRACT

Poverty can have a detrimental impact on the emotional well-being, educational attainment and future life chances of children and young people (CYP). It is known that poverty can also create several barriers to CYP and families accessing services. Furthermore, structural factors such as spending cuts on public services mean that professionals working with people affected by poverty have to ‘do more with less’. Practitioners could fail to acknowledge the impact of poverty if they have little cultural experience of poverty through their professional discourses and training. This could create a social distance between service-users and practitioners, as well as a misalignment of priorities, which could lead to inappropriate interventions being offered and opportunities missed to tackle the impact of poverty.

This study gathered the views of 10 Art Therapists working in areas of multiple deprivation as determined by the Scottish Index of Multiple Deprivation (SIMD) in West Central Scotland. The aim was to examine practitioner’s perspectives on poverty and what they notice about its exploration by CYP in art therapy sessions. The study also considered if art therapists working in areas of multiple deprivation adapted their practice to create a contextualised and flexible service that would address the practical as well as the emotional impact of poverty. Data was collected through semi-structured interviews and analysed using thematic analysis.

Whilst most participants showed an awareness of the difficulties faced by CYP affected by poverty, there was evidence that there were numerous cultural barriers meaning the indicators of poverty could be missed by some practitioners. Despite this, participants were clear on the various ways poverty is explored in sessions by CYP. Some art therapists adapted their practice on occasions to address the practical impact of poverty. However, several art therapists faced structural barriers to being able to tackle poverty. Therefore, the data suggests that cultural and structural barriers made it difficult for practitioners working in areas of multiple deprivation to consistently adapt their practice to create a contextualised and flexible service that fully addresses the emotional and the practical impact of poverty.     

The bird's nest drawing and accompanying stories in the assessment of attachment security

ABSTRACT

Art therapists recognise the importance of clients’ early attachment experience. The Bird's Nest Drawing (BND) is an attachment security measure with potential for research and practice, developed by American art therapists. The client draws a bird's nest and writes a corresponding narrative, the latter assisting an integrative evaluation. A systematic rating procedure currently only exists for the drawings. The present study was conducted to determine the psychometric properties of the BND after adding new ratings of the BND story using data from an earlier study with university students. The current investigators established a systematic method for coding BND stories (N?=?136). Content analysis yielded five ratings, which were examined in conjunction with the corresponding drawings and existing drawing ratings, and two self-report attachment questionnaires. Four of the 11 drawing rating items and the overall attachment rating had acceptable psychometric properties, as did two of the new story ratings. However, the seven items did not inter-correlate consistently, nor yield improved internal reliability. Construct validity using the established attachment scales was not established convincingly. Results suggest a need for further development of the BND taking greater account of psychometric principles of scale development, with implications for art therapy research and practice.

Plain-language summary

The relationship people have with others can be greatly affected by the childhood experiences they have with those caring for them and can cause what art therapists call ‘attachment difficulties’. The Bird's Nest Drawing, first developed in America, provides a way for therapists (and researchers) to understand people's attachment difficulties. Drawings can express what is difficult to say in words. The person draws a bird's nest and writes a short story about it. Inclusion of the story is intended to provide richer information about the client and his or her drawing.

It is important that the drawing and accompanying story provide an accurate view of people's attachment experiences. This is more likely if they use a tested set of instructions to rate elements in the drawing, such as how the nest is positioned on the tree. Instructions for rating drawings already exist, however no instructions existed for rating the stories people tell. In this study, we used 136 drawings and stories from a previous study with American university students, and also participants’ scores (from the same study) on well-established questionnaires about attachment relationships. We devised a rating system for the stories. Then we checked how reliable and accurate the ratings were for both the drawings and the stories. Part of this checking involved comparing the ratings with the questionnaire scores.

We found that neither the existing drawing ratings nor the new story ratings were sufficient when judged by established principles for good design of assessment measures. For example, the ratings did not sufficiently fit the pattern of scores on the established questionnaires. Although drawings can be helpful in art therapy when people find it difficult to use words, we suggest that therapists and researchers exercise caution in how they use the Bird's Nest Drawing (even with stories) until it can be further developed as an assessment measure.     

Using the clay slip game in art therapy: a sensory intervention

ABSTRACT

The goal of the present study was to achieve a better understanding of the experience of playing with slip and the ways in which participants experience the Clay Slip Game and how they perceive the therapeutic qualities of the material, thus including the potential for art therapists to add the Slip Game to their toolbox. Ten experienced qualified art therapists and 48 art therapy students took part. All participants engaged in the Slip Game during the study and reported their experiences in an interview (therapists) or in written personal reflections (students). Data analysis adhered to the principles of Grounded Theory [Charmaz (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage Publications]. The findings indicate that the experience of the Slip Game is mainly a sensory (tactile), playful, pleasant and calming experience of making without the need to produce an end product. The experience is more internal (meditative) and stimulates feelings of regression. The therapeutic qualities of the material, as discussed by the participants, are related to the regressive and sublimative processes afforded by the material, and as a material that enables sensory, behavioural, emotional, and motor regulation.

Plain-language summary

Art therapy is a type of psychotherapy that uses artistic materials and creative processes in the therapeutic process. Since art materials are the primary tools through which the art therapy processes occur, therapists need to have an in-depth understanding of the art materials they offer to their clients [Moon (2010). Materials & media in art therapy: Critical understandings of diverse artistic vocabularies. New York, NY: Routledge].

Slip is a mixture of water with an additional substance that produces a thick and saline-type paste [De Montmollin (2010). The barbotine game-challenge of creativity. Antwerpen.]. It can be made by diluting and filtering any kind of clay to make it semi-fluid. Playing with slip as a distinct and separate technique was defined as a ‘game’ by Daniel De Montmollin, a ceramicist. De Montmollin created the Slip Game as a way to help people free themselves from internal and external censorship or criticism.

The goal of this study was to understand the participants’ experience of the Slip Game and whether they found the process therapeutic. Forty-eight art therapy students and 10 art therapists took part in the study. After engaging in the Slip Game, the art therapists reported their experiences in an interview and the students wrote personal reflections. These were then analysed using Grounded Theory.

The findings show that the participants experienced the Slip Game as mainly sensory and reported it was pleasant, calming, playful and tactile, a way of ‘making’ without the need to produce an end product. They also found the experience to be meditative, that it stimulated feelings of regression and felt that engaging with slip also improved behaviour, emotional control and fine hand-movement skills.     

Art therapists with experience of mental distress: Implications for art therapy training and practice

ABSTRACT

As part of its ongoing work to support and value the contributions to art therapy from service users, the British Association of Art Therapists (BAAT) conducted a survey of art therapists with dual experience as professionals and mental health service users. The survey aimed to establish if art therapists disclosed their experiences as service users when applying to train, during their art therapy training and/or when qualified. Participants (N?=?20) were also surveyed on their motivation for disclosure or non-disclosure, their experiences of the process and the quality of responses they met. They were additionally asked whether their experiences of mental health services had impacted on the quality of their art therapy practice and if so, how. The findings from this small sample suggest that disclosure was not easy. Reported responses to participants’ disclosures were mixed, with many experiencing both helpful and unhelpful responses. Emotional support appeared to be important for helping people both to normalise and to contain current distress. Another finding concerns self-reported increased empathy for service users. Awareness and management of one’s own limitations was another reported gain, since reflecting on oneself and one’s life was usually enforced through the ‘breakdown’, hospitalisation or disruption of career path.     

Self-criticism in therapist training: A grounded theory analysis

Objective: The primary objective of this study is to engender an understanding of how therapists-in-training experience and cope with self-criticism in the context of their clinical training and therapy experiences. Method: In this study, trainees were interviewed about their experience of self-criticism related to psychotherapy practice and these interviews were subjected to a grounded theory analysis generating a core self-critical process. Results: The analysis highlighted the vulnerability of self-criticism in therapists‘ training experiences, especially when they related to balancing the ”expert“ role while maintaining authentic interactions with their clients. The results also described ways in which self-criticism is mitigated by a sense of interpersonal safety and the provision of clinical freedom and flexibility in therapists‘ training. Conclusions: The implications for future psychotherapy research and clinical training within clinical training environments are discussed.     

Acceptance in the Hearing Voices Movement: how might this be relevant for art therapy service-users?

ABSTRACT

This paper considers what is shared by voice-hearers in the Hearing Voices Movement (HVM) and by service-users in art therapy. Both highlight what they see as the value of acceptance, peer-support, and clear collaborative communication. The paper considers how research and literature informed by lived-experience in the HVM and, UK art therapy might strengthen practice.

Life-stories by voice-hearers, included in the HVM literature, explain what has helped them and what is meant by acceptance within the movement. For those voice-hearers with a psychosis-related diagnosis, joining HVM could mean they find hope, even though the diagnosis means that they may face deep prejudice and some of their unusual experiences are frightening.

The paper also looks at what art therapy clients voice as helpful: the support found in group work; art-making; and honest, collaborative styles of communication overlaps with much that is described and explored in the work of HVM.

Although much smaller in scope, feedback given by art therapists to a professional regional-group provides additional indications that the profession is responsive to service-user perspectives, collaborative work, and to HVM.

Plain-language summary

This paper considers the Hearing Voices Movement in relation to adult mental health. Often people who hear voices receive a psychiatric diagnosis for which the primary treatment is medication. These diagnoses are known as ‘psychosis-related’. In the psychiatric system, voice-hearers are not usually encouraged to speak about their unusual experiences. In the Hearing Voices Movement, those who hear voices are encouraged to speak about their voices and other unusual experiences and to find ways of coping with them.

This paper looks at the literature of the Hearing Voices Movement to explore what ‘accepting voices’ means and how this may be relevant for art therapy clients. People who hear voices, family members, friends, health professionals, and social workers make up the movement and, they are all asked to work alongside one another in the interests of authentic collaboration aimed at improving the lives of voice-hearers.

The paper also looks at what is said in life-stories by voice-hearers about the value of acceptance, peer-support, and clear collaborative communication. Even though some people with a psychosis-related diagnosis are afraid of their experiences and face damaging prejudice, joining the Hearing Voices Movement can mean they find hope. Also, the art-making, group work, and honest, collaborative styles of communication valued by art therapy clients overlaps with much of the work and research of the Hearing Voices Movement.

Being respectfully accepted as a voice-hearer seems to help people feel that they can work towards a sense of control, self-direction, and self-acceptance in their lives.

Feedback given by art therapists to a professional regional-group offers indications that the art therapy profession is responsive to service-user perspectives, collaborative work, and to the Hearing Voices Movement.     

Therapists’ perspectives on suicide: A conceptual model of connectedness

Background: A sense of disconnection for people who are suicidal seems to be a key construct of previous literature. Therapists’ ways of encountering and understanding people who are suicidal have not been previously researched in depth using qualitative methodologies. Aims: The current study aims to develop a theoretical framework for the role played by connectedness in relation to suicide based on the perspectives of psychotherapists working in the field of suicide intervention. Method: Psychotherapists (N?=?12) from a suicide intervention service in Ireland were interviewed in relation to connectedness and suicide. The interviews were analysed using Constructivist Grounded Theory. A tentative theoretical model for connectedness in relation to suicide was developed. Results: Therapists view self-disconnect as at the core of suicidality and note that toxic relationships also play a critical role. Therapeutic connection can present as a life-saving paradox for people who are suicidal. Risk of death and therapeutic endeavour may present as challenging dynamics for working with people who are suicidal. Some discussion points include the worth of self-compassion development for people who are suicidal, the rephrasing of “psychotherapy” when trying to save someone’s life and the emphasis on relationship skills for all healthcare professionals who encounter people who are suicidal.

Clinical or methodological significance of this article: This article is one of the first in which therapists are interviewed about their understandings of suicide and the processes of suicide in the therapeutic space. It offers novel insights about how people who are suicidal present in therapy and what may be contributing to this presentation. The research also gives insights on the struggles for therapists working with people who are suicidal and who may be ambiguous about the prospect of therapy and connecting. The study also offers important direction for future studies in relation to what requires further discussion and exploration regarding engaging in therapy with people who are suicidal. In addition, the current study can offer previously unexplored insights regarding suicide and therapy that may have the potential to assist in future intervention for people who are risk of killing themselves.     

Therapists’ honesty,humor styles,playfulness, and creativity as outcome predictors: A retrospective study of the therapist effect

Objective: This study examined whether therapists’ honesty, humor style, playfulness, and creativity would retrospectively predict the outcomes of therapies ended five years earlier. Method: In the Jerusalem-Haifa study, 29 therapists treated 70 clients in dynamic psychotherapy for 1 year. The Outcome Questionnaire 45 scores were collected at five time points. Five years later, the therapists were contacted via email and asked to fill out honesty, humor styles, playfulness, and creativity self-report questionnaires. Five were excluded since they had only one client in the study each. The remaining 24 therapists treated 65 clients out of whom 20 therapists with 54 clients completed the questionnaires. Results: Therapists’ Aggressive Humor Style (AHS) was a significant negative predictor of clients’ symptom change over time. The therapists’ honesty scores were positively correlated with symptom change. That is, higher AHS therapists were more effective, while higher honesty therapists were less effective. Conclusions: Therapists’ inferred traits of Honesty–Humility and AHS may influence the effectiveness of their treatments.     

UK art therapy practice-based guidelines for children and adults with learning disabilities

ABSTRACT

Art therapy is a form of psychotherapy that uses art media as its primary mode of communication. Having skill and experience in art is not a pre-requirement for people to benefit from art therapy. Making art work can offer the opportunity for expression and communication within a psychological therapy for people who find it difficult to express their thoughts and feelings verbally, and it is an accessible approach for children and adults with learning disabilities. An estimated 20% of art therapists working in the UK have some involvement with children or adults who have learning disabilities. These clinical practice guidelines were devised within the UK by the British Association of Art Therapists. A guideline development group was formed by the Learning Disability Special Interest Group and a national consultation was carried out among its membership. Ten overarching guideline recommendations for clinical practice were identified, namely ‘working relationships’, ‘communication’, ‘support networks’, ‘managing risk and vulnerability’, ‘establishing therapy agreements’, ‘assessment, formulation, and therapeutic goals’, ‘working creatively and flexibly’, ‘working psychotherapeutically’, ‘monitoring progress’ and ‘professional responsibilities and self-care’. The published art therapy practice-based guidelines for children and adults with learning disabilities are an example of a clinical consensus on current best practice in the UK.     

A listening perspective in psychotherapy with suicidal patients: Establishing convergence in therapists and patients private theories on suicidality and cure

Objective: To explore ways that psychotherapists and suicidal patients handle suicidality as a topic, and how it impacts the bond between them. Method: Nineteen suicidal patients and their therapists participated in a naturalistic study. Patients were interviewed before they started in therapy, and both patients and therapists were interviewed after three sessions and after one year. Results: Whether suicidality was frequently or seldomly addressed during the sessions did not bear any direct influence on the establishment of a working alliance. Rather, the sense of being engaged in a process of change followed from the therapist’s capacity to establish a wide listening perspective, with sensitivity towards their own uncertainties, as well as to implicit and explicit messages about the patient’s state of mind. The “private theories” of suicidality and cure that were held by the two parties tended to converge as a result of their work together. If convergence was not established early on, what mattered was their capacity to detect and work on their divergences. Unaddressed divergences led to vicissitudes and eventually resignation. Conclusions: Listening and exploring divergences in private theories of cure mattered for the creation of a viable working alliance directed at the patient’s efforts to live their life.     

Dementia in the movies: the clinical picture

Objectives: Visual media influence the general public's perceptions and attitudes regarding people with mental conditions. This qualitative study investigates the depiction accuracy of dementia's clinical features in motion pictures.Method: Using the search terms ‘dementia’, ‘Alzheimer's disease’ and ‘senility’ movies with release dates between January 2000 and March 2012 were sought on the Internet Movie Database. Based on four selection criteria 23 movies were included. Independently, three researchers watched all movies, scored symptoms, capacities, and behaviors. Scores were discussed and refined during consensus meetings, resulting in a taxonomy of clinical features.Results: Various features are found, most often cognitive symptoms. Behavioral features are also shown – retiring behavior more than agitation – and various emotions, but physical symptoms are rarely depicted. Capacities are infrequently presented and are unrealistic in several of the movies.Conclusion: The clinical picture of dementia portrayed in fictional movies is mild and may be misleading.     

Developmental trajectories and milestones of lesbian,gay, and bisexual young people

Abstract

Lesbian, gay, and bisexual (LGB) young people experience a variety of developmental trajectories that consist of milestones, the sequence and timing of which differ across individuals. They include early feelings of being different from peers, the onset of same-sex attraction, questioning one's sexuality, first same-sex sexual experience, recognition and self-labelling, disclosure to others, first romantic relationship, and self-acceptance. The invention of ‘gay youth’ during the 1970s and 1980s is briefly reviewed with an emphasis on the ways in which the portrait created by early research fails to capture the developmental trajectories of millennial young people. Although some young people struggle with mental health problems as they navigate these milestones, research documents the complexity, variety, and normative nature of the vast majority of LGB young people. A growing chorus of developmental, behavioural, and social scientists now emphasize that many contemporary young people forego sexual confusion, recognize the sex or gender to which they are attracted to and love, and believe they are as mentally healthy as heterosexual young people.     

Review: Can digital mental health interventions bridge the ‘digital divide’ for socioeconomically and digitally marginalised youth? A systematic review

Background

Digital mental health interventions (DMHIs) have the potential to improve the efficiency, accessibility and effectiveness of mental health services for young people, with the potential to reach socioeconomically and digitally marginalised young people with mental health needs who would otherwise not seek help in person. This review aims to investigate the characteristics, acceptability and efficacy of DMHIs specifically developed for socioeconomically and digitally marginalised youth.

Method

Key databases were searched widely and systematically (EMBASE, MEDLINE, PsycINFO, OpenGrey). Final inclusion in this review required studies to evaluate DMHIs specifically targeting socioeconomically and digitally marginalised children and young people through a broad range of research designs.

Results

Ten studies, describing seven DHMIs, were included in this review. Studies varied in terms of methodology, population, intervention, outcome measures, technologies used and methodological quality. Qualitative and quantitative results are synthesised across three key phenomena of interest: effectiveness, acceptability and feasibility. Findings suggest that there is moderate but limited evidence supporting DMHIs for improving mental health outcomes among these populations.

Conclusions

While there is moderate evidence suggesting that digitally delivered interventions can be effective in improving mental health outcomes among socioeconomically and digitally marginalised youth, more high-quality research is needed in order to determine whether DMHIs can fully bridge the so-called ‘digital divide’.     

‘And the pain just disappeared into insignificance’: The healing response in Lourdes – Performance,psychology and caring

Abstract

Three academic/practitioners from different disciplines (performance, medicine and psychology) describe the ways in which observing, and importantly, participating in the healing rituals of the French pilgrimage site of Lourdes challenged their ways of thinking about both their discipline's research approaches and their understandings of community, caring and healing. By positioning themselves as both first-person and third-person researchers, they suggest that a new type of ‘trans-disciplinary’, longitudinal, reflexively sensitive methodology is needed in order to investigate activities involving groups of people and spiritual practices as a whole system in order to better understand how they can positively affect our innate healing response.     

Profiles in emotional aging: does age matter?

ABSTRACT

Objectives: The aim of this research project was to define emotional profiles in elderly people and to analyze the presence of each one in different age groups (from 65 to 74, 75 to 84, 85 to 94 and 95 to 104).Method: The sample group comprised 257 elderly people not suffering from cognitive impairment who were independent in the Basic and Instrumental Activities of Daily Living. The following emotional variables were analyzed: positive and negative affect, life satisfaction, loneliness, and regulation strategies.Results: Cluster analyses revealed three emotional profiles: ‘dissatisfied’ (elderly people with high levels of negative affect and loneliness who are unhappy with their lives and use problem solving to regulate their emotions), ‘happy’ (those with good levels of positive affect and life satisfaction, low levels of loneliness and negative affect and little use of passive strategies), and ‘resilient’ (those with low levels of positive and negative affect and medium levels of loneliness who are more or less satisfied with their lives and who use passive strategies to regulate their emotions). A relationship was observed between age and profile. Among the under 85s, the most common profile was ‘happy’, while among the over 85s, the most common profile was ‘resilient.’ The ‘happy’ profile was also observed in participants over the age of 85, although to a lesser extent. The prevalence of the ‘dissatisfied’ profile decreased with age.Conclusion: These results highlight the fact that although age seems to be a key factor in determining profile, individual differences should not be overlooked, even among the oldest old.