What role can art therapy play within mental health?

A p

T F

a

A A

K A M C S E

I

i 2 p e g 2 e s i s ( a d i a

E

h 0

The Arts in Psychotherapy 47 (2016) 9–22

Contents lists available at ScienceDirect

The Arts in Psychotherapy

rt therapy in mental health: A systematic review of approaches and ractices

heresa Van Lith, PhD, ATR, AThR ∗

lorida State University, Department of Art Education, 1033 William Johnston Building, Tallahassee, FL 32306-1232, United States

r t i c l e i n f o

rticle history: vailable online 21 September 2015

eywords: rt therapy ental health issues

linical approach ystematic review vidence-based practice

a b s t r a c t

This systematic review aims to develop a bridge between what art therapists know and what they do in supporting those with mental health issues. Research undertaken between 1994 and 2014 was examined to ascertain the art therapy approaches applied when working with people who have mental health issues, as well as to identify how art therapy approaches were used within the clinical mental health system. Thirty articles were identified that demonstrated an art therapy approach to a particular mental health issue. The search strategy resulted in articles being grouped into four diagnostic terms: depression, borderline personality disorder, schizophrenia, and post-traumatic stress disorder. A synthesis of the identified articles resulted in the identification of research areas that need advancement. Future studies

could incorporate more details on the art therapy approaches used to enhance transferability of practice. Moreover, adding art therapists’ critique about the art therapy approach from their applied perspective, would assist in the development of evidence-based practice that is not just current, but feasible, too. Finally, the client voice needs to be incorporated in future studies to address questions of the relationship between client expectations and the perceived success of art therapy.

© 2015 Elsevier Ltd. All rights reserved.

ntroduction

The goals and approaches used by art therapists working in health care sett- ngs are generally regarded as specific to the context in which they work (Jones, 005). An art therapist will often define his or her practice with orientations such as: sychodynamic; humanistic (phenomenological, gestalt, person centered); psycho- ducational (behavioral, cognitive behavioral, developmental); systemic (family and roup therapy); as well as integrative and eclectic approaches (Jones, 2005; Rubin, 001, 2005). There are also widespread variations in individual preference and ori- ntation by art therapists. For example, those using an observant stance would uggest their role is to be a witness to the experience of the inherent process of know- ng the self (Allen, 2008). Those valuing a more interventionist engagement would uggest their role is to elicit meaning making by engendering new perspectives Karkou & Sanderson, 2006), or to form a supportive alliance, which nurtures trust nd safety (McNiff, 2004; Spaniol, 2000). Finally, those valuing a more intentional irection would see their role as evoking multiple sensations of human experiences,

ncluding the sensory-motor, perceptual, cognitive, emotional, social and spiritual spects of a person (Bruscia, 1988).

vidence-based practice in art therapy

Over 30 years ago, pioneering art therapist Judith Rubin wrote:

Theory is only meaningful and worthwhile if it helps to explain the phenomena with which it deals in a way that enables us to work better with them [clients]. . .

∗ Tel.: +1 850 645 9890. E-mail address: [email protected]

ttp://dx.doi.org/10.1016/j.aip.2015.09.003 197-4556/© 2015 Elsevier Ltd. All rights reserved.

Theory and technique should go hand in hand; the one based on and growing out of the other, each constantly modifying the other over time (1984, pp. 191–192).

Later, Rubin (2001) noted “different models of the mind fit different patients, as well as the same patient functioning at different developmental levels at different times” (p. 345). In her conclusion, she stated: “A good art therapist strives to have both theory and technique ‘in her bones’ so that ‘relating to a patient through art’ can be truly spontaneous, flexible and artistic” (2001, p. 351).

With Rubin’s philosophies in mind, theoretically oriented practice is even more at the forefront of the work of today’s art therapists. Moreover, the increasing push for evidence-based practice (EBP), especially within mental healthcare, has been a drive for practitioners to be more accountable and transparent in the services that they offer (Wood, Molassiotis, & Payne, 2011). Nevertheless, as EBP requires a heavier emphasis on research to justify decision-making processes, there has been an inclination by art therapists to see it as a polarizing effort to push research into either one of two categories: those that fit the “gold standard” of empirical evidence or anecdotal evidence (Huet, Springham, & Evans, 2014).

Taken from another perspective, EBP also offers opportunities for art therapists to be more critically aware of research by moving toward amalgamating supporting research with pragmatic experience. The definition of EBP in ‘Navigating art therapy: a therapist’s companion’ (Wood, 2011) supports this position by stating it is: “the integration of individual expertise with the best available evidence from systematic research” (p. 83). Therefore, the intention of EBP ensures that practitioners “are practicing to the best of their abilities through constantly reviewing, updating and adjusting their practices according to the latest research findings” (Wood, 2011, p.

83).

Yet, EBP within art therapy need not be as daunting a task as some may believe. Previously, reviews have broadly investigated into how art therapy is of benefit to mental health (Perruzza & Kinsella, 2010; Slayton, D’Archer, & Kaplan, 2010; Stuckey & Nobel, 2010; Van Lith, Schofield, & Fenner, 2013). The intention of this review was

10 T. Van Lith / The Arts in Psychotherapy 47 (2016) 9–22

Table 1 Selection criteria process.

Total articles initially selected N = 120

Articles initially selected that addressed people who have Depression N = 43

Articles initially selected that addressed people who have BPD N = 12

Articles initially selected that addressed people who have Schizophrenia N = 16

Articles initially selected that addressed people who have PTSD N = 33

Articles selected that addressed people who have Depression N = 4

Articles selected that addressed people who have BPD N = 5

Articles selected that addressed people who have Schizophrenia N = 10

Articles selected that addressed people who have PTSD N = 11

s selec

t a

M

i w a a f

p w t d A a

i b w s t d p a w s d

t m T G r

g r t a a f u

Total article N = 30

o build on the previously accumulated clinical knowledge by providing a review of pplied knowledge that could increase understanding of how art therapists’ practice.

ethods

The systematic review had two main purposes. First, to exam- ne which art therapy approaches were being practiced with people

ho have mental health issues. Second, to identify how art ther- py approaches were used within the clinical mental health system nd aided in the improvement of client symptoms, relapse and unctioning.

The search strategy involved identifying peer-reviewed articles ublished in the English language between 1994 and 2014, a period hich enabled the most up to date yet comprehensive research on

his topic. A systematic search involved looking at the following atabases: ProQuest, PsycINFO, CINAHL, Informaworld, EMBASE, MED, OVID MEDLINE, as well as the online university library cat- log.

Initially, the terms clinical mental health, mental illness, and npatient were used to commence the search. However, it quickly ecame apparent that these did not elicit enough articles to arrant a review. Therefore, the criteria was revised to con-

ider certain mental health population groups, that resulted in he following terms being searched: depression, bipolar disor- er, dysthymia, manic depression, panic, obsessive–compulsive, ost-traumatic stress, social anxiety, specific phobias generalized nxiety, schizophreniform, brief psychotic, psychotic not other- ise specified, schizoaffective, pervasive developmental, paranoid,

chizoid, schizotypal, antisocial, borderline, histrionic, avoidant, ependent, and obsessive–compulsive.

Each of these terms were searched with the following descrip- ors: art therapy, arts psychotherapy, creative arts therapy and

ulti-modal therapy until every combination had been exhausted. hese terms and the possible combinations were also searched on oogle Scholar. The reference lists from these articles were also

eviewed for further relevant articles. A total of 120 articles were initially identified and were then

rouped by a diagnostic term (see Table 1). The selection crite- ia process resulted in articles being grouped into four diagnostic erms: depression, borderline personality disorder, schizophrenia,

nd post-traumatic stress disorder, which reduced the total to 104 rticles. Each article was subsequently examined to determine the ollowing inclusion criteria: (a) involved samples of adult individ- als, (b) involved individuals who had been formally diagnosed, (c)

ted for review

identification and explanation of the specific art therapy treatment approach or theory and (d) explanation of the methods used to conduct the investigation. Articles were excluded if they explored art-based assessments or art making tasks rather than specific approaches.

The selected articles went through another systematic analy- sis using the following criteria: description of study, identification of a theoretical approach, description of the art therapy approach, benefits of the approach, implications and limitations.

Findings

The following section explores how art therapy approaches were used with four diagnostic terms: depression, borderline personality disorder, schizophrenia, and post-traumatic stress dis- order. Each of the specific art therapy approaches are examined in reference to how they were used and if there were identified implications resulting from a study.

Art therapy approaches practiced with people who have depression

Out of the 43 articles initially selected as addressing art ther- apy approaches for people who have depression, the majority did not include participants with depressive symptoms, but rather relatable symptoms such as loneliness, helplessness, hopelessness, and/or sadness. Four articles were subsequently reviewed that met the criteria to some degree (see Table 2). One study described an anthroposophic therapy approach (Hamre et al., 2006) and another study demonstrated an art psychodynamic approach (Thyme et al., 2007). There were two articles that were not specifically studies about an art therapy approach. However, they still provided impor- tant information, and consequently, were determined essential to include (Blomdahl, Gunnarsson, Guregard, & Bjorklund, 2013; Zubala, MacIntyre, Gleeson, & Karkou, 2013).

A unique approach, the first of its kind, but that did not solely focus on art therapy, was called the anthroposophic ther- apy approach (AT). In the study by Hamre et al. (2006), AT included participation in creative activities, eurthythic movement exercises, rhythmical massage, counseling if necessary, and medication. The

combination of physical and artistic therapies either took the place of, or accommodated medication for depression. Anthroposophic art therapy (AAT) was defined as engagement with various art mediums including clay modeling, speech exercises, painting and

T. V

a n

Lith /

Th e

A rts

in P

sy ch

o th

era p

y 4

7 (2

0 1

6 )

9 –

2 2

1

1

Table 2 Articles demonstrating art therapy approaches practiced with people who have depression.

Author Country Description of study Identification of theoretical approach

Description of the art therapy approach

Benefits of the approach Limitations and implications

Blomdahl et al. (2013)

Sweden Summarized research from 16 articles on depression and art therapy and found common therapeutic factors. These were: self-exploration, self-expression, understanding and explanation, integration, symbolic thinking, creativity and sensory stimulation.

Direct and Indirect approach.

Direct approach: Addresses current problems. Indirect approach: Addresses client’s inner lives letting current issues remain unspoken.

Direct approach: Clients are aware that the exercise relates to them, so may consciously influence the content of the session. Indirect approach: Has capacity to approach problems slowly and perhaps more playfully.

Limitations: The review resulted in no general conclusions due to scarcity of articles in dealing with art therapy combined with depression. Implications: Understanding what is effective makes it possible to select the best method of treatment for each client, is important for development of therapeutic methods and for evaluating the results of treatment and leads to deeper knowledge that provides a basis for further studies.

Hamre et al. (2006)

Germany Cohort study of comprehensive Anthroposophic therapy for 97 outpatients diagnosed with depression from 42 medical practices in Germany.

Anthroposophic Art Therapy (AAT).

AAT includes engagement with various art mediums: clay modeling, speech exercises, painting and drawing.

The benefits of this approach were found to include increased dialog through the client-therapist relationship; increased emotional expression and can induce physiological effects.

Limitations: Absence of a comparison group receiving another treatment or no therapy. Self-selection bias possible- patient willing to try AAT may have had more favorable results. Implications: Study findings suggest that the AAT approach, with its recourse to non-verbal and artistic exercising therapies can be useful for patients motivated for such therapies. Results provide evidence that AAT has the same effectiveness as long-term psychotherapy for chronic depression. Results provide a positive incentive for further research on the effectiveness of AAT with clients diagnosed with chronic depression.

Thyme et al. (2007)

United Kingdom 39 women with depression (depressive symptoms/no clear diagnosis) were randomly assigned to time-limited psychodynamic art therapy or verbal psychotherapy.

Psychodynamic art therapy (brief).

The Art Psychotherapy method used was based on Schaverien (1995) and emphasized the transference relationship between the patient and artwork.

Art psychotherapy was found to reduce the number of depressive symptoms the participant experienced. These results were maintained at 3-month follow up. Psychodynamic verbal and art therapy had similar results such as improvement in reduced stress level and decreased number of depressive symptoms.

Limitations: Participants in this study did not receive a DSM IV diagnosis after treatment due to “administrative difficulties”. The participants of this study were all female. Inter-rater reliabilities were not estimated for the following measures of this study: Hamilton Rating Scale of Depression (HRSD), diagnoses, and Personality Organization (PO) judgments. Implications: The results of this study provide evidence that Psychodynamic art therapy is a successful approach for females who are diagnosed with depression, or experiencing depression symptoms.

Zubala et al. (2013)

United Kingdom Conducted a nationwide online survey consisting of 395 arts therapists in the UK. The data from the survey was used to compare and contrast the differences of arts therapists who specialize in working with clients who have clinically diagnosed depression.

It was found that the majority of art therapists who specialize in depression followed psychodynamic principals combined with additional theoretical approaches to support clients’ needs.

Not specified. Not specified. Limitations: Focused on the quantitative data from the survey. Refer to two supporting articles for qualitative data from survey. Implications: The results of this study are valid, reliable and can be generalized to the population of registered art therapists in the UK. Therefore, can be used as a reference tool for art therapists deciding on a theoretical approach when treating clients diagnosed with depression.

1 sycho

d a s i o f a t t

e e a a v n a o f i t t i

f ( p s i B t T t c 2 t “ 2 a a o

t s w q l d p w t c m r d r M 2 t i p c

d I a

2 T. Van Lith / The Arts in P

rawing (Hamre et al., 2006). The study involved 97 outpatient dults from 42 medical practices in Germany with depressive ymptoms lasting for a median duration of 5 years (6 months min- mum). The AAT component of the study was found to show a level f improvement in 91% of participants from baseline to 12-month ollow up (Hamre et al., 2006). However, little detail was provided s to how the AAT component was implemented, further informa- ion about this would assist in developing a control trial to compare heoretical approaches.

The art psychodynamic method used in the study by Thyme t al. (2007) was based on the model by Schaverien (1995) and mphasized the transference relationship between the patient nd artwork. Thirty-nine women with depression were randomly ssigned to either brief time-limited psychodynamic art therapy or erbal psychotherapy groups. Findings showed that the psychody- amic verbal and art therapy approaches had similar results such s improvement in reduced stress levels and decreased number f depressive symptoms, and these were maintained at 3-month ollow-up (Thyme et al., 2007). However, some of the limitations ncluded: that the findings can only be generalized to women, par- icipants did not receive a DSM IV diagnosis after treatment due o “administrative difficulties” (Thyme et al., 2007, pp. 261), and nter-rater reliability tests were needed among the measures.

In regards to art therapy being able to benefit people who eel depressed, but were not formally diagnosed, Blomdahl et al. 2013) summarized 16 articles and found eight common thera- eutic factors that art therapy was found to address. These were: elf-exploration, self-expression, understanding and explanation, ntegration, symbolic thinking, creativity, sensory stimulation. lomdahl and colleagues (2013) indicated two categories that the herapeutic approaches could be divided into: direct and indirect. he direct approach addressed current problems with the intention hat the “clients are aware that the exercise relates to them, so may onsciously influence the content of the session” (Blomdahl et al., 013, p. 329). On the other hand, the indirect approach concen- rated on the clients’ internal world with the intention of addressing problems slowly and perhaps more playfully” (Blomdahl et al., 013, p. 329). Nevertheless, there were no general conclusions bout the most appropriate theoretical approach, nor was there ny indication about how the art therapy techniques may effect utcomes (Blomdahl et al., 2013).

In determining the theoretical approach most preferred by art herapists who work directly with clients who experienced depres- ion, Zubala et al. (2013) surveyed 395 arts therapists (243 of which ere art therapists/psychotherapists) in the United Kingdom. The

uantitative data revealed that the majority of art therapists fol- owed a psychodynamic group approach for adults who were iagnosed with depression (Zubala et al., 2013). These art thera- ists’ tended to be older and more experienced than art therapists ho did not specifically work with this population. The two addi-

ional articles that reported on the qualitative data from the survey larified that although the psychodynamic approach influenced any art therapists practice, they also integrated systemic, nar-

ative, cognitive, humanistic, person-centered, solution-focused, irective, intercultural, interpersonal, attachment theory, object elations, cognitive-behavioral and mentalization theories (Zubala, acIntyre, & Karkou, 2014; Zubala, MacIntyre, Gleeson, & Karkou,

014). The rationale behind this was that the art therapists “tended o vary the theoretical model of their therapeutic approach depend- ng on individual client factors and often collaborated with other rofessionals using a variety of standardized tools to measure out- omes” (Zubala, MacIntyre, Gleeson et al., 2014, p. 535).

It is difficult to make inferences from the articles just reviewed ue to the limited scope and many reporting inconclusive findings.

n order to determine with more confidence the most suit- ble approaches, future research would benefit from including: a

therapy 47 (2016) 9–22

follow-up of symptoms, more details as to how the approach was administered, as well as an indication of the level of popularity and willingness to engage in the art therapy program.

Art therapy approaches practiced with people who have borderline personality disorder

Twelve articles were initially identified that examined an art therapy approach with adults who have borderline personality dis- order (BPD). Of the initial 12 articles, five met the selection criteria (see Table 3). These articles all used a variation of arts psychother- apy and were accordingly defined as the following: individual art psychodynamic therapy (Lamont, Brunero, & Sutton, 2009), men- talization based art therapy (Franks & Whitaker, 2007; Springham, Findlay, Woods, & Harris, 2012), Dialectical Behavior Therapy (DBT) (Huckvale & Learmonth, 2009) and feminist therapy with a DBT- orientation (Eastwood, 2012). While the focus of this paper was to examine articles that investigated art therapy approaches, it is noteworthy to mention that professional consensus guidelines for art therapists working with clients who have BPD were also devel- oped (Springham, Dunne, Noyse, & Swearingen, 2012). However, these have yet to be formally tested.

The study that examined an individual art psychodynamic approach was conducted through a qualitative case study with a consumer diagnosed with borderline personality disorder (Lamont et al., 2009). The art works made during the treatment process showed: “lived traumatic experiences, externalization of thoughts and feelings and intense emotional expression” (Lamont et al., 2009, p. 164). Analysis of the findings revealed that the participant developed a greater awareness of the experienced trauma, as well as positive coping skills, relaxation techniques and successful ways to communicate with staff about her needs (Lamont et al., 2009).

There were two studies that explored psychodynamic art ther- apy through mentalization. The pilot study by Franks and Whitaker (2007) integrated mentalization in art therapy by asking five par- ticipants to think about the role of the image during the art making process. Participants also attended individual verbal psychology sessions between scheduled group art psychotherapy sessions. Pre and post-measures were administered to the participants, which showed a decrease in intensity of symptoms/distress and improve- ment in social functioning. The results of the outcome measures suggested that the combination of treatments (group art psy- chotherapy and individual verbal psychotherapy) was effective, with benefits sustained over time by three out of five of the par- ticipants, with one participant dropping out of the study (Franks & Whitaker, 2007).

The study by Springham, Findlay et al. (2012) used a mixed method design, utilizing data from the whole treatment with six participants from pre/post-tests and an in-depth interview of one of the participants in the study. This form of psychodynamic therapy emphasized the mentalizing process by including under- lying thinking structures that form interpretations and perceptions based on beliefs, needs, feelings and assumptions (Springham, Dunne et al., 2012 and Springham, Findlay et al., 2012). The images created were seen as anchoring mental content, thereby helping to identify and sort through disordered thought pro- cesses. The findings also revealed that increasing mentalization capacity, diminished mood instability, identity diffusion, and con- flicted interpersonal relationship (Springham, Dunne et al., 2012; Springham, Findlay et al., 2012).

Huckvale and Learmonth (2009) used a DBT approach (a form of cognitive behavioral therapy) and also added a psycho-educational

component demonstrated through a case study. Overall, the par- ticipant reported positive effects of the art therapy intervention on: individual relationships, daily interactions, managing family conflicts, feeling less paranoid in public, reduced self-harming

T. V

a n

Lith /

Th e

A rts

in P

sy ch

o th

era p

y 4

7 (2

0 1

6 )

9 –

2 2

1

3 Table 3 Articles demonstrating art therapy approaches practiced with people who have borderline personality disorder.

Author Country Description of study Identification of theoretical approach

Description of the art therapy approach Benefits of the approach Limitations and implications

Eastwood (2012)

United Kingdom

Anecdotal case study example of a single feminist art therapy group session with 11 females between the ages of 18–65, on a ward specializing in Dialectical Behavior Therapy (DBT) treatment for individuals diagnosed with BPD at in-patient mental health facility.

Feminist art therapy. Women can deconstruct, subvert and dilute the power of such constraints, begin to envisage and make tangible a different and greater informed experience through the art making process. Egalitarian relationship between art therapist and client is essential. Art therapy sessions must have a feeling of collaboration to be effective.

Art making process is a safe place. Symbolism in art is alternative to verbal therapy to address lifetime traumatic experiences. Positive identity as an artist emerged.

Limitations: This is an innovative model not previously researched. Implications: Approach has many therapeutic benefits for positive change that require further investigation.

Franks and Whitaker (2007)

United Kingdom

A pilot study exploring the benefits of a combined art and verbal group psychotherapy treatment for five clients who have personality disorders.

Group art psychodynamic therapy.

Emphasis on mentalizing during therapy, which is the capacity to perceive and understand self and others in terms of mental states. Used in art therapy when client thinks about the role of the image within the art therapy.

Pre and post-measures administered to the participants (clinical outcome and routine evaluation outcome measure, and brief symptom inventory) showed decrease in intensity of symptoms/distress and improvement in social functioning.

Limitations: One out of the five participants dropped out of the study and 8-month follow up measures were only completed by two out of the five participants. Study implies that they have borderline personality disorder. Implications: Approach has many therapeutic benefits for positive change that require further investigation.

Huckvale and Learmonth (2009)

United Kingdom

Case study of a client diagnosed with BPD who participated in a combined Dialectical Behavior Therapy (DBT) and Group Art Psychotherapy approach.

Art therapy with DBT (a form of cognitive behavioral therapy) with psychotherapy education.

The main four components of the group art therapy treatment included; Behavioral control, processing past emotions and events, problem solving current conflict and experiencing joy. Art therapy interventions included: homework, the learning circle theory, and emotional regulation.

The combination of group art psychotherapy and DBT was found to address emotional regulation capabilities, acceptance and reflective ability in clients. Overall, participant reported positive effects of the art therapy intervention in areas such as; individual relationships, daily interactions, managing family conflicts, feeling less paranoid in public, reduced self-harming tendencies, and the ability to reduce intense or uncontrollable emotions.

Limitations: Not a rigorous study. Implications: The approach was identified as most effective when the skills acquired during therapy were applied in real life contexts. Opens up the possibilities of developing art therapy as an integrated aspect of DBT-based approach.

Lamont et al. (2009)

United Kingdom

A qualitative case study on one resident diagnosed with borderline personality disorder examining the benefits of an individual art psychotherapy intervention.

Art psychodynamic therapy.

Non-interpretive method was used during the art therapy sessions. Goals/objectives of the art therapy intervention provided a medium to allow participant to express her cognitions, emotions, and needs. Participant described and reflected on paintings during the process.

Approach increased greater awareness of experienced trauma. Helped the participant to develop positive coping skills, relaxation techniques and successful ways to communicate with staff about her needs.

Limitations: Lack of experience by facilitator. A pre/post-quantitative measure would have assessed the participant’s level of symptoms, or a follow up interview about the experience. Implications: Collaboration of other mental health professional and art therapist working together on a treatment team meant that the client outcomes were further realized.

Springham, Findlay et al. (2012)

United Kingdom

Pilot study examining the benefits of mentalization based art therapy as a treatment intervention for six individuals with Borderline Personality Disorder.

Mentalization based art therapy (form of psychodynamic psychotherapy).

Eight themes were described that explain approach: art replaces the words the service user cannot find, joint attention in art therapy is enhanced by homogenous group composition, therapist models the application of inquiry rather than pre-determined knowledge to exploration of artworks, service user to service user comments on artworks support capacity to accept multiple perspectives, continuous movement between art making and sharing artworks develops emotional regulation, the unresponsive therapist in iatrogenic in BPD treatment, art therapist’s ‘watchful not watching’ stance during art making supports immersion in art making, and art therapy can be used as self-help.

Using art therapy to increase mentalization capacity was found to enhance distress tolerance, stabilize emotional expression; enhance individual impulsivity, and strengthen sense of self.

Limitations: Included only one participant interview out of the six total participants. Implications: Art anchored mental content, which helped to identify and sort through disordered thought processes.

1 sycho

t t a a

s D s b t

s w g c l b i 2 “ a

A s

a t e a e T ( 2 2 b A w & ( 1 d

v e e 1 & w r o s s (

a s fi t l s i c o n t

4 T. Van Lith / The Arts in P

endencies, and the ability to reduce intense or uncontrollable emo- ions (Huckvale & Learmonth, 2009). The approach was identified s most effective when the skills acquired during therapy were pplied in real life contexts (Huckvale & Learmonth, 2009).

The anecdotal case study of a single feminist art therapy group ession was conducted with 11 women on a ward specializing in BT treatment (Eastwood, 2012). The case study method demon-

trated how women who may have a reputation of being “feared y others” can, through the use of art materials, find a place where hey can be seen as “human” (Eastwood, 2012, p. 107).

The articles just reviewed were designed as pilots using small ample sizes to initially test the theoretical approach. Going for- ard, using larger sample sizes to make stronger conclusions and to

eneralize the findings to a wider population will help expand this urrent knowledge base. Furthermore, in these studies there was ittle attrition at follow-up leaving open the question of whether the enefits were sustained over time. An important addition, to exam-

ning these theoretical approaches follows Huckvale & Learmonth, 009 recommendations to not just measure symptoms, but also fewer admissions, sections, overdoses, incidents of self harm or ttempted suicide” (p. 62).

rt therapy approaches practiced with people who have chizophrenia

Sixteen articles were initially identified that examined art ther- py with people who were diagnosed with schizophrenia, and of hese, 10 articles met the selection criteria (see Table 4). Although ach of these articles emphasized group art therapy, specific styles nd interpretation of this approach were different. One article mphasized role development theory (Schindler & Pletnick, 2006). wo articles identified using an expressive arts therapy model Hanevik, Hestad, Lien, Teglbjaerg, & Danbolt, 2013; Teglbjaerg, 011). Two articles used a group interactive model (Crawford et al., 012; Richardson, Jones, Evans, Stevens, & Rowe, 2007). The article y Crawford et al. (2012) was also part of the Multicenter Study of rt Therapy in Schizophrenia: Systematic Evaluation (MATISSE), along ith the following two articles by Patterson, Crawford, Ainsworth,

Waller (2011) and Patterson, Debate, Anju, Waller, & Crawford 2011). Two articles used psychoanalytical art therapy (Killick, 996; Michaelides, 2012). Finally, one article adopted a psycho- ynamic group art therapy approach (Montag et al., 2014).

The case study of role development as a treatment for indi- iduals with schizophrenia in a forensic psychiatric hospital was xplored using three studies: study A involved 42 participants in ach of the experimental and comparison groups, study B involved 0 participants and study C was an individual case study (Schindler

Pletnick, 2006). Role development theory applied to art therapy as an individualized intervention focused on identifying client

oles, tasks associated with those roles, and interpersonal devel- pment. Participants in the A and B study showed statistically ignificant improvement in the development of task skills, interper- onal skills, and role functioning (strongest at 4 weeks of training) Schindler & Pletnick, 2006).

There were two studies that explored expressive art ther- py, but each focused on a different part of the symptoms of chizophrenia. The study by Hanevik et al. (2013) explored how ve female participants used expressive art therapy to express heir psychotic experiences. Sessions were structured and involved istening to music, reading out poems, opening and closing discus- ion, movement therapy and art directives. Hanevik et al. (2013) ncorporated phenomenology and cognitive behavior therapy to

onceptualize the benefits and found that: “artistic exploration f the psychotic experience may contribute to the patients’ cog- itive understanding of their disorder, thus helping the patient o control her psychosis” (p. 320). All participants reported that

therapy 47 (2016) 9–22

they had experienced positive changes due to the expressive art therapy group intervention. This included an increase in: ability to manage psychotic experiences and behaviors, feelings of being valued, development of coping skills and problem solving skills to distinguish between different types of psychotic experiences (hallucinations, spiritual experiences, and grandiose delusions).

The interdisciplinary formative expressive arts therapy model developed by Teglbjaerg (2011) was designed to enhance sense of self, interpersonal contact, self-esteem and social competency. Sessions were based around a theme using paint, with group dis- cussions before and after sessions. There were no psychological interpretations of the artwork and verbal responses were seen to create a focus for the artwork, identify issues and help problem solve (Teglbjaerg, 2011). Five out of the 10 participants were diag- nosed with severe schizophrenia. The other five participants had depression and/or personality disorders that were nonpsychotic. Teglbjaerg (2011) postulated that a core part of having schizophre- nia was the weakening in a sense of self, and found that the art process facilitated a strengthening in the participants’ sense of self through: increasing presence of being, formation of new structures of meaning, increasing direct experience of self, setting up of a special social context, and stimulating creativity and play.

The studies using an art psychotherapy approach were all con- ducted in the United Kingdom and followed a similar model of practice. However, each study had a different focus and so has been explained separately. The study by Killick (1996) focused on how analytically informed art psychotherapy came to constitute a con- taining object for one participant’s un-integrated state of mind. As Killick (1996) explained, the artwork helped to contain the vio- lence of a patient’s intrusive identifications, when he was in an acute psychotic state, which resulted in the development of coping skills to decrease anxiety and disorganized thought processes. The images that emerged in the participant’s artwork were then used to increase his communication skills with the therapist. As Killick’s (1996) work was a descriptive case study, based on the art thera- pist’s experience and not measured quantitatively or qualitatively, it was difficult to determine the impact of this approach on the participant.

The case study by Michaelides (2012) focused on how group art psychotherapy with 16 participants could improve negative reflective functioning. Reflective functioning was defined as a developmental accomplishment that allowed an individual to appropriately respond to their personal beliefs, hopes, feelings, plans and pretenses, as well as others’ behaviors (Michaelides, 2012). Participants engaged in open art therapy, which were open to all who lived in the supportive unit. The article was not a rigor- ous study as such. Nevertheless, Michaelides (2012) concluded that the art work was used as a form of communication with non-verbal schizophrenic clients, for self-reflection and for individuation.

The randomized control trial by Richardson et al. (2007) focused on brief group interactive art therapy with 43 participants in the art therapy group and 47 in the standard psychiatric care condi- tion. During sessions, the triangulation between the client, art work and therapist was emphasized and seen to help: decrease paranoid suspicions toward therapist, reduce drop out rate, help to contain psychotic fears, increase engagement in psychological treatment, build trust in therapist, and improve ability to relate to other peo- ple (Richardson et al., 2007). The art therapy condition was found to have a statically significant positive effect on negative symp- toms, assessed by Scale for the Assessment of Negative Symptoms (SANS), though had little and non-significant impact on the other measures.

As part of the MATISSE, Crawford et al. (2012) conducted a multi- center pragmatic randomized trail to explore clinical effectiveness of group art therapy with 417 participants who had schizophre- nia. The study resulted in insignificant findings leading the authors

T. V

a n

Lith /

Th e

A rts

in P

sy ch

o th

era p

y 4

7 (2

0 1

6 )

9 –

2 2

1

5

Table 4 Articles demonstrating art therapy approaches practiced with people who schizophrenia.

Author Countries Description of study Identification of theoretical approach

Description of the art therapy approach Benefits of the approach Limitations and implications

Crawford et al. (2012)

United Kingdom

Multi-center pragmatic randomized trail to explore clinical effectiveness of group art therapy for people with schizophrenia with 417 participants.

Model was ‘group interactive’ art psychotherapy. No further details supplied.

Art therapy was carried out in keeping with recommendations of the British Association of Art Therapists and aimed to enhance self- expression, improve emotional health, and help people develop better interpersonal functioning.

The primary outcomes were global functioning and mental health symptoms. Secondary measures were group attendance, social functioning and satisfaction with care. Primary and secondary outcomes did not differ between those referred to art therapy compared to those referred to standard care at 12 and 24 months.

Limitations: Level of group attendance greatly fluctuated. The primary outcome measure in this study was the Global Assessment of Functioning (GAF) scale. The GAF was taken out of the current version of the DSM-5 due to problems with validity and reliability. Implications: Art therapy as delivered in this trial did not improve global functioning, mental health, or other health related outcomes.

Hanevik et al. (2013)

Norway Five case studies encompassing an expressive arts therapy group for women diagnosed with a psychotic disorder.

Expressive art therapy.

Expressive art therapy theory utilizes various artistic modalities such as music, poetry, painting or sculpturing. Builds off of phenomenological and cognitive behavioral therapy.

All participants reported that they had experienced positive changes due to the expressive art therapy group intervention. This included the increased ability to manage: psychotic experiences and behaviors, feelings of being valued, coping skills and problem solving skills.

Limitations: Research bias, researcher was also the therapist. Participants had a variety of different psychotic DSM diagnoses. Participants were all female. Implications: Artistic exploration of the psychotic experience may contribute to the participants’ cognitive understanding of their disorder, helping to control their psychosis.

Killick (1996)

United Kingdom

Case study of a participant diagnosed with schizophrenia who received art psychotherapy at an in-patient (18 months) and outpatient facility for approximately 6 years.

Psychoanalytical art therapy. No further detail required.

Analytically informed art psychotherapy setting came to constitute a containing object for the patient’s un-integrated state of mind.

Artwork helped to contain the violence of the patient’s intrusive identifications resulting in development of coping skills to decrease anxiety and disorganized thought processes when he was in an acute psychotic state. Images emerged in the patient’s artwork that was then used to increase his communication skills with the therapist.

Limitations: A descriptive case study based on the art therapists experience, not measured quantitatively or qualitatively. Implications: If a patient is acutely psychotic, a setting (in-patient) that can bear and contain the un-integrated state of mind over time is required.

Michaelides (2012)

United Kingdom

A case study to explore how 16 participants working at a negative reflective functioning level could be assisted in moving past the stage of ‘familiarization’ through group art psychotherapy.

Group psychoanalytical art therapy. No further detail required.

The artwork becomes important for visible progress indicators such as increased self- perception from personal and group members observations of them. Art work used as a form of communication with non-verbal schizophrenic clients, for self-reflection and for individuation.

The art psychotherapy group may work as a way of exploring the mind.

Limitations: Not a rigorous study. Implications: For some clients whose inner worlds are very fragmented the stage of ‘familiarization’ and ‘immanent articulation’ may be the limits of their therapy. Art psychotherapy, with the help of the group and its reflective functioning process, can help to assist a client to shift beyond these stages.

Montag et al. (2014)

Germany Evaluated the feasibility of an assessor-blind, randomized controlled trial with 58 participants.

Psychodynamic group art therapy.

The approach was non-directive and participants were encouraged to find their own image at their own pace. With invitations to discuss art works with the therapist and group members. Autonomous decision-making about the handling of participants art work was crucial.

Intervention significantly reduced positive symptoms and improved psychosocial functioning at post-treatment and follow-up, and with a greater mean reduction of negative symptoms at follow-up compared to standard treatment. Participants also showed a significant improvement in emotional awareness and in their ability to reflect about others’ emotional mental states.

Limitations: No standardized active comparison condition to control for the unspecific effects of therapeutic contact and group dynamics. Short follow-up period. Implications: Study shows feasibility of similar projects and points to a possible positive effect of the intervention on psychotic symptoms, psychosocial functioning and the ability to mentalize emotions.

1 6

T.

V a n

Lith /

Th e

A rts

in P

sy ch

o th

era p

y 4

7 (2

0 1

6 )

9 –

2 2

Table 4 (Continued)

Author Countries Description of study Identification of theoretical approach

Description of the art therapy approach Benefits of the approach Limitations and implications

Patterson, Crawford et al. (2011)

United Kingdom

24 art therapists’ views about what changes, how and for whom.

Majority identified using psychodynamic approach influenced by Kleinian object-relations theory or Jungian analytic concepts.

Clients may express and experience themselves differently, develop new ways of relating to others, organize themselves into a satisfying esthetic form and understand feelings that may have emerged during the creative process.

Outcomes of approach are difficult to obtain due to complexities of symptoms. Therapist and client relationship and clients’ willingness to engage in therapy determines benefits of therapy approach.

Limitations: Study does not give detailed explanation of how art therapists define their approach and how they evaluate progress. Implications: In relation to determining most suitable theoretical approach, difficulties defining and measuring outcomes amidst the puzzling changeable complexities of schizophrenia.

Patterson, Debate et al. (2011)

United Kingdom

Data from a national survey of 71 art therapists working throughout England in mental health facilities.

Majority used art psychodynamic therapy.

Art therapists typically adopted a non-directive approach encouraging clients to use image making for self-expression and reflection to develop self-understanding. Important components of an art therapy sessions: privacy, confidentiality and the safekeeping of client artwork.

Developed self-understanding and relief through expression of painful feelings, resolution of internal conflicts, increased therapist-client communication, development of self-control, increased ability to manage difficulties, increased ability to identify emotions, increased ability to develop new skills, which increased independent and self-control.

Limitations: data collected from the national survey based on the opinions of the participants (response bias). Implications: Results from this study provide evidence that the psychotherapy approach is beneficial when working with clients who have schizophrenia.

Richardson et al. (2007)

United Kingdom

Conducted the first exploratory RCT of group interactive art therapy as an adjunctive treatment in chronic schizophrenia. Forty-three participants in art therapy group and 47 standard psychiatric care (SPC).

Brief group interactive art therapy.

Psychoeducation on patterns of behavior that are causing distress. Triangulation between client, art, and art therapist. Art psychotherapy as a process of making images plays a central role in the context of the psychotherapeutic relationship.

Art therapy produced a statically significant positive effect on negative symptoms (assessed by Scale for the Assessment of Negative Symptoms) though had little and non-significant impact on other measures. Art therapy had slight improvement over the SPC group on the measures of the study.

Limitations: Lack of completed 6-month follow assessments by a large amount of the participants hindered the final outcome. Insufficient statistical power and a sub-optimal level of treatment (only 12 sessions). Implications: Results were sufficiently promising to justify further research along these lines.

Schindler and Pletnick (2006)

United States

Case study of role development as a treatment for an individual with schizophrenia in a forensic psychiatric hospital. Study A: adult males, 42 participants in each the experimental and comparison groups. Study B: 10 participants. Case study: male, 35 years old.

Role development art therapy.

Role development in art therapy becomes the vehicle for therapeutic change as the client develops task skills required for ark making and interpersonal skills needed to establish a therapeutic relationship with the art therapist.

Study A and B: participants in the role development program showed statically significant improvement in the development of task skills, interpersonal skills, and role functioning (strongest at 4 weeks of training).

Limitations: Case study was not tested like the previous studies A and B were. Implications: Used in collaboration with other multidisciplinary treatments, it is effective in promoting positive change and improved quality of life for individuals diagnosed with schizophrenia.

Teglbjaerg (2011)

Denmark Qualitative extended case report on the interdisciplinary formative expressive arts therapy model with 10 participants.

Expressive arts therapy.

An interdisciplinary formative approach with structured sessions. No psychological interpretations of the artwork.

The most important benefits of the art therapy were: strengthening of the patients’ sense of self, decreased tension from interpersonal relationships, increased self-esteem and social competency.

Limitations: Theoretical orientation used was confusing. Half of the participants had schizophrenia. Implications: Expressive arts therapy can enhance a reduced sense of self, a core issue in schizophrenia.

sycho

t n g c t o s e t I D 2

o C w s p b w a t a i b e t t

f a e t b a r r a t n i d I c

s t t p a a

( h i I w i p p

g a T t c

T. Van Lith / The Arts in P

o conclude that: “referring people with established schizophre- ia to group art therapy as delivered in this trial did not improve lobal functioning, mental health, or other health related out- omes” (Crawford et al., 2012, p. 1). It is also important to note hat the level of group attendance greatly fluctuated; “almost 40% f participants randomized to group art therapy did not attend any essions. Among those who did, few attended regularly” (Crawford t al., 2012, p. 4). Additionally, the primary outcome measure in his study was the Global Assessment of Functioning (GAF) scale. ncidentally, the GAF was taken out of the current version of the SM-5 due to reported problems with validity and reliability (APA, 013).

Together with the findings of the MATISSE study, two studies f art therapists’ perspectives were conducted. Firstly, Patterson, rawford et al. (2011) examined 24 art therapists’ views about hat changes, how and for whom in relation to the treatment of

chizophrenia. The majority of the art therapists identified their referred approach to be psychodynamic art therapy influenced y Kleinian object-relations theory or Jungian analytic concepts, ith the minority preferring psychoanalytic, humanistic or eclectic

rt therapy approaches (Patterson, Crawford et al., 2011). Never- heless, the consensus was that engagement with the therapist; wareness and acknowledgment of a problem; as well as the will- ngness to address the problem, were imperative for therapy to e beneficial, regardless of the approach used. Patterson, Crawford t al. (2011) concluded that: “ultimately, fit between therapist, par- icipant and modality was crucial” for the benefits of the approach o be realized” (p. 78).

The second study involving perspectives on practice gained data rom 71 art therapists to understand the provision and practice of rt therapy for people who have schizophrenia (Patterson, Debate t al., 2011). The survey indicated that art therapists’ preferred heoretical approaches were: psychodynamic (71.8%), followed y mixed/eclectic theoretical (14.1%), cognitive behavioral ther- py or cognitive behavioral art therapy approaches (9.9%). The emaining participants used humanistic and non-directive theo- etical approaches (Patterson, Debate et al., 2011). A non-directive rt psychotherapy approach was explained as: “rather than seek o explore underlying dynamics, art therapists typically adopt a on-directive approach encouraging patients to use image mak-

ng to express feelings and reflect on these in a concrete way to evelop self-understanding” (Patterson, Debate et al., 2011, p. 328).

mportant components of art therapy sessions included: privacy, onfidentiality and the safekeeping of client artwork.

Of concern, when reviewing these studies was that broad terms uch as ‘psychotherapy’ and ‘group interactive therapy’ were used o explain the art therapy approach used. However, little explana- ion was provided as to how this was defined and what theoretical remise underpinned the practice. This is an issue in regards to the bility to replicate the study, as well as the ease of being able to pply the approach into practice.

The findings from the MATISSE randomized control trial Crawford et al., 2012) indicate the need in further studies to review ow closely art therapists adhere to the approach that the study

s investigating. Their suggestions are also important to consider. n particular, the importance of trying art therapy on individuals

ho are committed and consistently attend, as well as incorporat- ng other means of data collection, as group art therapy “may help eople in ways that are difficult to quantify” (Crawford et al., 2012, . 4).

The study by Montag et al. (2014) adopted a psychodynamic roup art therapy approach. Researchers evaluated the feasibility of

n assessor-blind, randomized controlled trial with 58 participants. he approach was non-directive, and participants were encouraged o find their own image at their own pace. With invitations to dis- uss art works with the therapist and group members. Autonomous

therapy 47 (2016) 9–22 17

decision-making about the handling of participants art work was regarded as crucial.

Montag et al. (2014) found that participants who received the art therapy condition showed significant mean reduction of pos- itive and negative symptoms at 12-week follow-up compared to treatment as usual. These were measured by composite scores of the SANS and the Scale for the Assessment of Positive Symp- toms (SAPS). With the art therapy condition showing continued improvement for positive symptoms at follow up in comparison to the control condition which showed deterioration, Montag et al. (2014) speculated that art therapy during acute psychotic episodes might prevent an increase in symptoms after remission. There were significantly higher GAF mean scores in the art therapy condition at post-treatment and follow-up, but no significant group differ- ences for the Calgary Depression Scale for Schizophrenia (CDSS). No group differences were shown with secondary outcomes of cognitive empathy, quality of life, or overall satisfaction. But the art therapy condition showed significant improvement in levels of emotional awareness, and particularly in their ability to reflect about others’ emotional mental states. Montag et al. (2014) con- cluded that the intervention and follow up periods may have been too short to show overall improvements on most of the secondary improvements, which required the participants to alter perspec- tives on life situations and states of mind.

The approach by Montag et al. (2014) provided a promising direction for studies exploring art therapy practices and how it benefits for people with schizophrenia. The implications of this study not only demonstrated that studies are feasible during acute psychotic episodes, but also that using psychodynamic group art therapy at this stage can improve symptom reduction and recov- ery of mentalizing function. Further studies adhering to Montag et al., 2014 procedures might demonstrate if improvement can be sustained over time and indicate how the participants’ perceive change to their overall quality of life.

Art therapy approaches practiced with people who have post-traumatic stress disorder

Thirty-three articles were initially identified as examining an art therapy approach with post-traumatic stress disorder (PTSD) and 11 were found to meet the selection criteria (see Table 5). The majority of articles identified addressed the processing of traumatic events, whereby the participants were in a traumatized state, but these had not developed into PTSD. The other noteworthy find- ing was there were three main areas where PTSD was prevalent: war related, sexual abuse and refugees. However, the research was too limited to make any inferences about how approaches may be altered to suit the specific incident, as well as how cultural needs are met.

There were 7 articles that explored a specific art therapy approach by providing clinical implications. Yet, these approaches were not evaluated as such, but rather provide a rationale for future clinical trials. Therefore, these articles were not analyzed further, but are explained in Table 5 and include: the group art therapy model by Backos and Pagon (1999), the psychoanalytic art therapy approach by Buk (2009), the neurobiological art therapy model by Gantt and Tinnin (2009), the task-oriented art therapy approach by Rankin and Taucher (2003), the cognitive behavioral intervention art therapy approach by Sarid and Huss (2010), the art therapy trauma protocol by Talwar (2007), and the art therapy with eye movement desensitization and reprocessing through bilateral stimulation by Tripp (2007).

There were two articles identified that addressed PTSD using a specifically designed approach. They included the check art therapy protocol (Hass-Cohen, Clyde Findlay, Carr, & Vanderlan, 2014), and trauma-focused cognitive behavior therapy (Naff, 2014).

1 8

T.

V a n

Lith /

Th e

A rts

in P

sy ch

o th

era p

y 4

7 (2

0 1

6 )

9 –

2 2

Table 5 Articles demonstrating art therapy approaches practiced with people who have post-traumatic stress disorder.

Author Countries Description of study Identification of theoretical approach

Description of the art therapy approach Benefits of the approach Limitations and implications

Backos and Pagon (1999)

United States

Describes the components of an adolescent art therapy group for female survivors of sexual assault.

Group art therapy. Group model and integrated psycho-education. Format loosely structured with consistent tasks opening and closing each session. Involved parents and family work.

Issues addressed included: problem behavior, school avoidance, depression, suicidal thoughts, homicidal thoughts, explosive outbursts, drinking, running away, promiscuity, and bulimia.

Limitations: Not a rigorous study, however mentioned themes in the group member’s artwork. Implications: Provides a framework to trial that focuses on changing rigid, stereotypical views of rape and incest and provides an outlet for client anger.

Buk (2009) United States

Explores the mutative actions of psychoanalytically informed art therapy interventions with anecdotal case study.

Psychoanalytic art therapy.

Analyzed the client’s artwork through the art therapist’s intuitive response to images, symbolism and expressive elements (color, line, spatial composition) that were a representation of the client’s psychological state.

Reported that the art making process enabled the client to become conscious of and verbally process dissociated memories involving the threat of sexual abuse.

Limitations: Article describes model but not a rigorous study. Implications: Provides practice guidelines that require testing out in the field.

Collie et al. (2006)

United States

A conceptual foundation for research about art therapy as a treatment for combat-related PTSD.

Theoretical rationale identified through recommendations for practice.

Recommended focus for practice includes: relaxation, non-verbal expression, containment, symbolic expression, externalization and the pleasure of creation.

Perceived benefits include: reconsolidation of memories, progressive exposure, externalization, reduction of arousal, reactivation of positive emotion, enhancement of emotional self-efficacy and improved self-esteem.

Limitations: Little detail on how recommendations were analyzed verified. Implications: Provides practice guidelines that require testing out in the field.

Gantt and Tinnin (2009)

United States

Literature review of PTSD non-verbal treatments and presented a model of neurobiological art therapy.

Neurobiological art therapy.

Art therapy techniques utilize right brain processes by activating limbic structures in the brain involved in processing fear (trauma). During an art therapy session, clients express terror and trauma that has been stalled in somatic memory and then process the feelings associated.

Non-directive approaches take too much time. Other trauma-focused models defer trauma processing and excessively emphasize expressing emotion. Proposed model addresses the root cause (due to evidence of trauma involving an etiology of intrusive, arousal and avoidant symptoms).

Limitations: Article describes model but not a rigorous study. Implications: Thorough explanation of model provides groundwork for future study trials.

Hass- Cohen et al. (2014)

United States

Reviews the neurobiological systems involved in trauma processing. Demonstrates the Check protocol with the case of a woman who witnessed the September 11, 2001, attacks on the World Trade Center.

The Check art therapy protocol.

Sequence of directives for treating trauma that is grounded in neurobiological theory and designed to facilitate trauma narrative processing, autobiographical coherency, and the rebalancing of dysregulated responses to psychosocial stressors and trauma impacts.

A comparison of pre and post-treatment assessments (Beck Anxiety Inventory and Centrality of Event Scale) showed decreased anxiety and avoidance behaviors and improved resiliency.

Limitations: Results of study need replication and support from further experimental research. Implications: Provides groundwork for further investigation into how art therapy protocols: support safety and coherency, increase relational security and remembrance, improve social connection and long-term resilience, and rebalance brain functioning.

Kopytin and Lebedev (2013)

Russia Randomized control trial of group art therapy in a psychotherapy unit of a Russian hospital for 112 war veterans being treated for stress-related disorders.

Group art psychotherapy.

Goals of structured groups included: creative stimulation, safe release of emotions and stimulation, expression of current emotional state, development of interpersonal skills and mindfulness, understanding of their own self-perception, awareness of their attitude to others and their position in a group, psychoeducation on their illness and their internal resources to gain perspective on their past and present life situations.

Image formation and artistic activity fostered cognitive and creative problem solving and increased self-esteem. Humor served as an important therapeutic function in this population.

Limitations: Study did not focus on PTSD but more moderate stress-related disorders. Possible bias in drawing scores: no test–retest analysis and no inter rater measure. Cultural factors must also be taken into account. Implications: Results of the study indicate that brief group art therapy may exert a positive influence on war veterans; particularly on their symptomatic status, personality functioning, cognitive abilities and creativity and quality of life.

T. V

a n

Lith /

Th e

A rts

in P

sy ch

o th

era p

y 4

7 (2

0 1

6 )

9 –

2 2

1

9

Naff (2014) United States

Qualitative study proposed an art therapy treatment framework for cumulative trauma derived from semi-structured interviews with three art therapist and artistic representations of their approaches.

Trauma focused cognitive behavioral art therapy.

Phase-oriented treatment (objectives of each phase are closely related to TF-CBT and other published art therapy-based trauma protocols): Preparation: installation of hope, Containment: introducing security, Narration: exposure and allowance, and Integration: healing and maintenance.

Participants stated that they were committed to using the creative process to help clients concretize their knowledge, coping skills, and resources, and to reinforce an understanding of art techniques introduced in session.

Limitations: Study only interviewed 3 art therapists affiliated with the same university and clinical art therapy program. Implications: The lack of specific information about cumulative trauma in the art therapy literature signals an important opportunity to investigate characteristic factors that should be considered when treating this type of trauma.

Rankin and Taucher (2003)

United States

Provides an outline for how to use a task-oriented approach to art therapy.

Task-oriented approach to art therapy.

The model focuses on interventions to facilitate expression of current psychological and physiological states; that produce narration of events, promote exploration of meaning behind event; facilitate management of symptoms; and facilitate the integration of traumatic and non-traumatic elements into life history.

Six basic tasks within this model: safety planning; self-management; telling the trauma story; grieving losses; self-concept and worldview revision; and self- and relational-development.

Limitations: Not a research study. Implications: Suggestions for therapists working with this population include: progress in treatment varies substantially between clients, establish defined treatment goals that are measurable and reasonable, engage in self-reflection and awareness in order to prevent counter transference and supervision is essential for all trauma therapists.

Sarid and Huss (2010)

Israel Extensive literature review and 2 case examples illustrating the potential benefits of the proposed model.

Cognitive behavioral art therapy intervention.

Three levels of intervention in treating people with acute stress disorder involve physical, emotional and cognitive aspects of the traumatic experience.

The proposed intervention has the potential of creating new connections and pathways between the physical, emotional and cognitive components of traumatic memory. The proposed intervention decreases stress levels of the person experiencing ASD, which enables the restricting of fragmented traumatic memories into more coherent and positive memories.

Limitations: This is not a research study and has no clinical evidence to back up the claims. Implications: The theoretical model has implications on the theory and of practice of both CB practitioners and art therapists dealing with the symptoms of trauma during the acute stress period.

Talwar (2007)

United States

Proposal of an art therapy trauma protocol with 1 session example.

Art therapy trauma protocol.

Integrates the cognitive, emotional and physiological levels of trauma by combining eye movement desensitization reprocessing, bilateral art and painting.

Anecdotal client reports that approach helps to process non-verbal traumatic memories, creates sensory awareness, sensorimotor experience, and promotes proprioception.

Limitations: Article describes model but not a rigorous study. Implications: An integrative approach that supports adaptive functioning, but outcome depends on individual’s internal self-representation. Provides practice guidelines that require testing out in the field.

Tripp (2007)

United States

Describes a short-term bilateral with art therapy, approach includes an anecdotal case study.

Modified Eye Movement Desensitization and Reprocessing (EMDR) protocol with art therapy.

Associations of traumatic memory are brought to conscious awareness and expressed in a series of drawings. As new information is accessed, affective material is metabolized and integrated, leading to transformation of traumatic memory and an adaptive resolution of the trauma.

Report from case study indicated that participant gained a better sense of her underlying feelings of rage toward those who were connected to her trauma. Also helped to make new connections and to alter long held negative cognitions, increased a sense of her own power and control, and increased appropriate emotional responses to her feelings surround the trauma (anger).

Limitations: Article describes model but not a rigorous study. Implications: Modification of the (EMDR) integrated with art therapy. Art therapists using this approach should be experienced in working with trauma. Provides practice guidelines that require testing out in the field.

2 sycho

o o p w t d i p 2 u i r t t d h i t e

b t B m r o t a “ t u p

P s L M

( w T b r m a t t t g e o i

a P t i 1 w a o a t n b

0 T. Van Lith / The Arts in P

The check protocol was demonstrated with a woman who devel- ped PTSD through witnessing the September 11, 2001, attacks n the World Trade Center (Hass-Cohen et al., 2014). The check rotocol (check, change what you need to change and/or keep hat you want) was defined as a: “sequence of directives for

reating trauma that is grounded in neurobiological theory and esigned to facilitate trauma narrative processing, autobiograph-

cal coherency, and the rebalancing of dysregulated responses to sychosocial stressors and trauma impacts” (Hass-Cohen et al., 014, p. 69). A comparison of pre and post-treatment assessments sing the Beck Anxiety Index and Centrality of Event Scale resulted

n decreased anxiety and avoidance behaviors, as well as improved esiliency. Hass-Cohen et al. (2014) reported that increased ability o manage anxiety occurred through the utilization of stabiliza- ion techniques learned in art therapy, increased coping skills were eveloped through affect-regulation skills (quick recovery from abituated trauma responses), and relational support helped to

mprove communication skills. Results of the study need replica- ion and support through further experimental research and lived xperience accounts.

The framework for treating cumulative trauma with art therapy y Naff (2014) was derived from semi-structured interviews with hree art therapist and artistic representations of their approaches. ased upon participants’ descriptions of a typical course of treat- ent, trauma-focused cognitive behavior therapy was used to

esolve the first trauma presented and then continued treatment f each traumatic event in descending order of subjective dis- ress. Aspects of psychoeducation and a humanistic client-centered pproach were also integrated. Participants stated that they were committed to using the creative process to help clients concretize heir knowledge, coping skills, and resources, and to reinforce an nderstanding of art techniques introduced in session” (Naff, 2014, . 82).

Two articles were found to address symptoms of combat-related TSD through art therapy. These were a randomized control trial tudy examining a group art psychotherapy approach (Kopytin & ebedev, 2013), and best practice recommendations (Collie, Backos, alchiodi, & Spiegel, 2006). The group art psychotherapy approach by Kopytin and Lebedev

2013) was investigated using a randomized control trial with 112 ar veterans in a Russian hospital with stress-related disorders.

here were no significant overall differences in participants’ scores etween those who received art therapy and those who did not eceive art therapy. However, improvements were found after 1 onth between the groups in mean scores in depression, hostility,

nxiety, mood and quality of life. The ‘Draw A Story’ assessment and he silver drawing test indicated a significant increase in scores on he Emotional Content and Self-Image Scales and on three cogni- ive scales in the experimental group as compared to the control roup. Humor was particularly emphasized as important for recov- ry with this population and the findings revealed a high frequency f humorous responses in both groups, and an increase of humor n the art therapy group post-treatment.

According to Collie et al., 2006 best practice recommendations of rt therapeutic interventions for people who have combat-related TSD, an integrated approach is endorsed by combining cogni- ive behavioral therapy, prolonged exposure therapy, and stress noculation therapy. Based on the national association survey of 3 registered art therapists who treated people with PTSD and 10 ritten descriptions of art therapy approaches, the following ther-

peutic mechanisms were identified as important: reconsolidation f memories, progressive exposure, externalization, reduction of

rousal, reactivation of positive emotion, enhancement of emo- ional self-efficacy and improved self-esteem. However, there was o consensus on structured versus unstructured approaches. These est practice recommendations warrant further evaluation and

therapy 47 (2016) 9–22

investigation to routinely examine the utility as well as benefits to clients.

The art therapy approaches just reviewed suggest effective approaches to treating trauma. They also highlight significant top- ics within the recovery of PTSD that are currently limited in art therapy research. The conclusions from Naff (2014) reflect the implications of these studies just reviewed: “The formation of an evidence-based approach and further study of the cumulative effects of multiple traumas can only aid our efforts to positively impact the lives of those who seek our help” (Naff, 2014, p. 85).

Discussion

This review identified areas around the world where certain art therapy approaches are being practiced and studied. The four articles demonstrating art therapy approaches practiced with peo- ple who have depression came from Europe, with two based in the United Kingdom. All five articles demonstrating art therapy approaches practiced with people who have borderline personal- ity disorder came from the United Kingdom. Out of the 10 articles demonstrating art therapy approaches practiced with people who have schizophrenia, nine were based in Europe, while one was from the United States. Finally, with the 11 articles demonstrating art therapy approaches practiced with post-traumatic stress disorder, nine were based in the United States, one was from Russia and one was from Israel.

As indicated by Zubala et al. (2013), the majority of art therapists working in the United Kingdom with people who have depres- sion, adopted psychodynamic principals combined with additional theoretical approaches to support clients’ needs. Similarly, art therapists working with people who have borderline personality disorder also tended toward personalized variations of psychoan- alytic/psychodynamic approaches. Moreover, the British survey by Patterson, Debate et al. (2011) of art therapists working with people who have schizophrenia, found the majority were using a non- directive approach encouraging clients to express their feelings and create self-understandings of the image, rather than exploring underlying psychodynamics. These findings highlight the historical trend that European countries, such as the United Kingdom, incor- porate their favored psychoanalytic models with a person-centered approach to both explain and provide a structure for their practice (Greenwood, 2011).

On the other hand, art therapists working with people who have post-traumatic stress disorder revealed another pattern with the majority of articles based in the United States. These articles revealed that the art therapists tended to tailor and combine a num- ber of approaches. This follows a recent trend in the United States, where art therapists have been moving away from clinical models toward adapting their guidelines of practice to be more flexible to assist with a change process that is tailored to suit the context and culture of where an art therapy practices (Elmendorf, 2010). One major reason for this could be because in the United States, insur- ance providers and managed care funds strongly influence the level and amount of therapeutic services that clients can receive.

Limitations and implications

As this systematic review began to take shape, many reasons developed as to why it was not possible to compare and contrast the approaches. First, there was a limited amount of studies gath- ered, with many using different research methods and small sample

sizes. Second, many articles did not clearly explain how the art therapy approaches were applied. As art therapy is increasingly becoming more integrated with various models outside the tradi- tional psychological theories, it is more difficult to rely on historical

sycho

s i g a t fi p a

t t o t P Z M W t t c a

d s t f g & c s o h g s “ f a 2

C

b t r o w p a a o a b k c c w w

T. Van Lith / The Arts in P

chools of training, which also makes the transferability of their mplications difficult. Consequently, there is a need to clarify what eneralist terms such as ‘art psychotherapy’ mean when applied in

certain context. Additionally, without more amplification about he philosophical foundation behind the approach used, it was dif- cult to stipulate which elements were conducive to seeing client rogress or being able to conclude why this approach may be suit- ble for supporting a client who presents with a certain set of issues.

Third, the accumulation of reviewed articles indicated that cer- ain factors were important to therapeutic outcomes regardless of he approach. These included the agreed goals and expectations f therapy, the client’s level of engagement in art therapy, and the herapists’ own qualities (Blomdahl et al., 2013; Montag et al., 2014; atterson, Crawford et al., 2011; Patterson, Debate et al., 2011; ubala et al., 2013; Zubala, MacIntyre, & Karkou, 2014; Zubala, acIntyre, Gleeson et al., 2014). These aspects corroborate with ampold’s common factors model (2001), which also indicated

he importance of the therapist being transparent with their inten- ions to constantly strengthen the alliance, as well as therapists ontinuously asking for client feedback. As Miller, Hubble, Duncan, nd Wampold (2010) eloquently explained:

When clients are asked to reflect and report on the relationship and their improvement, it is as though they are being told, ‘Your input is crucial; your participation matters. We invite you to be a partner in your care. We respect what you have to say, so much so that we will modify the treatment to see that you get what you want’ (p. 424).

When art therapists emphasize a mental health diagnosis to etermine which issues are preventing their client from pursuing elf-determined goals, it can lead to unsubstantiated generaliza- ions. On the other hand, when art therapists value a diagnosis rom the client’s perspective, it can assist in creating purposeful oal setting. Expanding on this concept, Morgan, Knight, Bagwash,

Thompson, 2012 stated that through the art therapeutic process, lients come to terms with the experience of receiving the diagno- is and how the label has impacted their lives. This includes how thers have responded to them, whether the diagnostic term was elpful in receiving adequate support, and whether it helped them ain access to accurate information. The authors added that it is not o much the label that provides change to one’s circumstances, but instead, it is the importance of a shared description, experience or ramework of understanding of distress that feels validating, or acts s a vehicle for differentiation and discrimination” (Morgan et al., 012, p. 93).

onclusion

The ultimate aim of this review was to commence a bridge etween what art therapists know and what they do in helping hose with mental illness. Keeping this in mind, the systematic eview involved synthesizing the existing knowledge base, with- ut using hierarchical criteria, to determine which type of practices ere more credible. In order to continue improving art therapy ractice, future studies could incorporate more details on the pproaches used. This would make adoption of these art therapy pproaches more transferable, feasible and manageable. More- ver, adding art therapists’ critique about the approach from their pplied perspective would assist in the development of evidence- ased practice that is not just current, but realistic, too. Finally, a ey ingredient missing in most of the articles reviewed was the

ollaborative efforts with the clients. Questions to incorporate the lient voice in future studies could include: Did the client receive hat they expected to gain from art therapy? Do they feel therapy as successful as a result? And finally did the art therapy approach

therapy 47 (2016) 9–22 21

alter the clients’ perspectives so that they became more insightful of how they could improve their current situation?

References

Allen, P. (2008). Commentary on community-based art studios: Underlying princi- ples. Art Therapy: Journal of the American Art Therapy Association, 25(1), 11–13. http://dx.doi.org/10.1080/07421656.2008.10129350

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: VA Author.

Backos, A. K., & Pagon, B. E. (1999). Finding a voice: Art therapy with female ado- lescent sexual abuse survivors. Art Therapy: Journal of the American Art Therapy Association, 16(3), 126–132.

Blomdahl, C., Gunnarsson, B., Guregard, S., & Bjorklund, A. (2013). A realist review of art therapy for clients with depression. The Arts in Psychotherapy, 40(3), 322–330. http://dx.doi.org/10.1016/j.aip.2013.05.009

Bruscia, K. (1988). Perspective: Standards for clinical assessment in the arts thera- pies. The Arts in Psychotherapy, 15(1), 5–10.

Buk, A. (2009). The mirror neuron system and embodied simulation: Clinical implica- tions for art therapists working with trauma survivors. The Arts in Psychotherapy, 36(2), 61–74. http://dx.doi.org/10.1016/j.aip.2009.01.008

Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art therapy for combat- related PTSD: Recommendations for research and practice. Art Therapy: Journal of the American Art Therapy Association, 23(4), 157–164. http://dx.doi.org/10.1080/ 07421656.2006.10129335

Crawford, M. J., Killaspy, H., Barnes, T., Barrett, B., Byford, S., Clayton, K., et al. (2012). Group art therapy as an adjunctive treatment for people with schizophrenia: Multicentre pragmatic randomised trial. British Medical Journal, 344(e846), 1–9. http://dx.doi.org/10.1136/bmj.e846

Eastwood, C. (2012). Art therapy with women with borderline personality disorder: A feminist perspective. International Journal of Art Therapy: Formerly Inscape, 17(3), 98–114. http://dx.doi.org/10.1080/17454832.2012.734837

Elmendorf, D. (2010). Minding our p’s through q’s: Addressing possibilities and pre- cautions of community work through new questions. Art Therapy: Journal of the American Art Therapy Association, 27(1), 40–43. http://dx.doi.org/10.1080/ 07421656.2010.10129564

Franks, M., & Whitaker, R. (2007). The image, mentalisation and group art psy- chotherapy. International Journal of Art Therapy, 12(1), 3–16. http://dx.doi.org/ 10.1080/17454830701265188

Gantt, L., & Tinnin, L. (2009). Support for a neurobiological view of trauma with implications for art therapy. The Arts in Psychotherapy, 36(3), 148–153, 10/1016/j.aip.2008.12.005.

Greenwood, H. (2011). Long-term individual art psychotherapy art for art’s sake: The effect of early relational trauma. International Journal of Art Therapy, 16(1), 41–51. http://dx.doi.org/10.1080/17454832.2011.570274

Hamre, H., Witt, C., Glockmann, A., Ziegler, R., WIllich, S., & Kiene, H. (2006). Anthro- posophic therapy for chronic depression: A four-year prospective cohort study. BMC Psychiatry, 6(57.) http://dx.doi.org/10.1186/1471-244X/6/57

Hanevik, H., Hestad, K., Lien, L., Teglbjaerg, H., & Danbolt, L. (2013). Expressive art therapy for psychosis: A multiple case study. The Arts in Psychotherapy, 40(3), 312–321. http://dx.doi.org/10.1016/j.aip.2013.05.011

Hass-Cohen, N., Clyde Findlay, J., Carr, R., & Vanderlan, J. (2014). Check, change what you need to change and/or keep what you want: An art therapy neurobiological-based trauma protocol. Art Therapy: Journal of the American Art Therapy Association, 31(2), 69–78. http://dx.doi.org/10.1080/07421656.2014. 903825

Huckvale, K., & Learmonth, M. (2009). A case example of art therapy in relation to dialectical behaviour therapy. International Journal of Art Therapy, 14(2), 52–63. http://dx.doi.org/10.1080/1745830903329196

Huet, V., Springham, N., & Evans, C. (2014). The art therapy practice research network: Hurdles, pitfalls and achievements. Counselling and Psychotherapy Research, 14(3), 174–180. http://dx.doi.org/10.1080/14733145.2014.929416

Jones, P. (2005). The arts therapies: A revolution in healthcare. East Sussex, UK: Brunner-Routledge.

Karkou, V., & Sanderson, P. (2006). Arts therapies: A research-based map of the field. Edinburgh, UK: Elsevier Churchill Livingstone.

Killick, K. (1996). Un-integration and containment in acute psychosis. British Journal of Psychotherapy, 13(2), 232–242.

Kopytin, A., & Lebedev, A. (2013). Humor, self-attitude, emotions, and cognitions in group art therapy with war veterans. Art Therapy: Journal of the American Art Therapy Association, 30(1), 20–29. http://dx.doi.org/10.1080/07421656.2013. 757758

Lamont, S., Brunero, S., & Sutton, D. (2009). Art psychotherapy in a consumer diag- nosed with borderline personality disorder: A case study. International Journal of Mental Health Nursing, 18(3), 164–172. http://dx.doi.org/10.1111/j.1447-0349. 2009.00594.x

McNiff, S. (2004). Art heals: How creativity cures the soul. Boston, MA: Shambhala. Michaelides, D. (2012). An understanding of negative reflective functioning, the

image and the art psychotherapeutic group. International Journal of Art Therapy, 17(2), 45–53. http://dx.doi.org/10.1080/17454832.2012.694107

Miller, S., Hubble, M., Duncan, B., & Wampold, B. (2010). Delivering what works. In B. Duncan, S. Miller, B. Wampold, & M. Hubble (Eds.), The heart and soul of change (2nd ed., pp. 421–431). Mahwah, NJ; London, UK: Lawrence Erlbaum Associates.

Montag, C., Haase, L., Seidel, D., Bayerl, M., Gallinat, J., Herrmann, U., et al. (2014). A pilot RCT of psychodynamic group art therapy for patients in acute psychotic

2 sycho

M

N

P

P

P

R

R

R R

R S

S

S

S

S

S

org/10.1016/j.aip.2014.10.007 Zubala, A., MacIntyre, D., Gleeson, N., & Karkou, V. (2014). Description of arts ther-

2 T. Van Lith / The Arts in P

episodes: Feasibility, impact on symptoms and mentalising capacity. PLOS ONE, 9(11), e112348. http://dx.doi.org/10.1371/journal.pone.0112348

organ, L., Knight, C., Bagwash, J., & Thompson, F. (2012). Borderline personality disorder and the role of art therapy: A discussion of its utility from the perspec- tive of those with a lived experience. International Journal of Art Therapy, 17(3), 91–97. http://dx.doi.org/10.1080/17454832.2012.734836

aff, K. (2014). A framework for treating cumulative trauma with art therapy. Art Therapy: Journal of the American Art Therapy Association, 31(2), 79–86. http://dx. doi.org/10.1080/07421656.2014.903824

atterson, S., Crawford, M. J., Ainsworth, E., & Waller, D. (2011). Art therapy for people diagnosed with schizophrenia: Therapists’ views about what changes, how and for whom. International Journal of Art Therapy: Formerly Inscape, 16(2), 70–80. http://dx.doi.org/10.1080/17454832.2011.604038

atterson, S., Debate, J., Anju, S., Waller, D., & Crawford, M. J. (2011). Provision and practice of art therapy for people with schizophrenia: Results of a national survey. Journal of Mental Health, 20(4), 328–335. http://dx.doi.org/10.3109/ 09638237.2011.556163

erruzza, N., & Kinsella, E. (2010). Creative arts occupations in therapeutic practice: A review of the literature. British Journal of Occupational Therapy, 73(6), 261–268. http://dx.doi.org/10.4276/030802210X12759925468943

ankin, A., & Taucher, L. (2003). A task-oriented approach to art therapy in trauma treatment. Art Therapy: Journal of the American Art Therapy Association, 20(3), 138–147. http://dx.doi.org/10.1080/07421656.2003.10129570

ichardson, P., Jones, K., Evans, C., Stevens, P., & Rowe, A. (2007). Exploratory RCT of art therapy as an adjunctive treatment in schizophrenia. Journal of Mental Health, 16(4), 483–491. http://dx.doi.org/10.1080/09638230701483111

ubin, J. (1984). The art of art therapy. New York: Brunner/Mazel. ubin, J. (2001). Approaches to art therapy: Theory and technique (2nd ed.). New York,

London: Brunner/Routledge. ubin, J. (2005). Artful therapy. NJ, NY: John Wiley & Sons. arid, O., & Huss, E. (2010). Trauma and acute stress disorder: A comparison between

cognitive behavioral intervention and art therapy. The Arts in Psychotherapy, 37(1), 8–12. http://dx.doi.org/10.1016/j.aip.2009.11.004

chaverien, J. (1995). Desire and the female therapist: Engendered gazes in psychother- apy and art therapy. New York: Routledge.

chindler, V., & Pletnick, C. (2006). Role development applied to art therapy treat- ment of an artist diagnosed with schizophrenia. Art Therapy: Journal of the American Art Therapy Association, 23(3), 126–131. http://dx.doi.org/10.1080/ 07421656.2006.10129624

layton, S., D’Archer, J., & Kaplan, F. (2010). Outcome studies on the efficacy of art therapy: A review of findings. Art Therapy: Journal of the American Art Therapy Association, 27(3), 108–118. http://dx.doi.org/10.1080/07421656.2010. 10129660

paniol, S. (2000). The withering of the expert: Recovery through art. Art Therapy: Journal of the American Art Therapy Association, 17(2), 78–81. http://dx.doi.org/ 10.1080/07421656.2000.10129506

pringham, N., Dunne, K., Noyse, S., & Swearingen, K. (2012). Art therapy for person- ality disorder: 2012 UK professional consensus guidelines, development process

therapy 47 (2016) 9–22

and outcome. International Journal of Art Therapy, 17(3), 130–134. http://dx.doi. org/10.1080/17454832.2012.734834

Springham, N., Findlay, D., Woods, A., & Harris, J. (2012). How can art therapy contribute to mentalization in borderline personality disorder? International Journal of Art Therapy, 17(3), 115–129. http://dx.doi.org/10.1080/17454832. 2012.734835

Stuckey, H. L., & Nobel, J. (2010). The connection between art, healing, and public health: A review of current literature. American Journal of Public Health, 100(2), 254–263. http://dx.doi.org/10.2105/AJPH. 2008.156497

Talwar, S. (2007). Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP). The Arts in Psychotherapy, 34(1), 22–35. http://dx.doi. org/10.1016/j.aip.2006.09.001

Teglbjaerg, H. (2011). Art therapy may reduce psychopathology in schizophrenia by strengthening the patients’ sense of self: A qualitative extended case report. Psychopathology, 44(5), 314–318. http://dx.doi.org/10.1159/000325025

Thyme, K., Sundin, E., Stahlberg, G., Lindstrom, B., Eklof, H., & Wiberg, B. (2007). The outcome of short-term psychodynamic art therapy compared to short-term psy- chodynamic verbal therapy for depressed women. Psychoanalytic Psychotherapy, 21(3), 250–264. http://dx.doi.org/10.1080/02668730701535610

Tripp, T. (2007). A short term therapy approach to processing trauma: Art therapy and bilateral stimulation. Art Therapy: Journal of the American Art Therapy Asso- ciation, 24(4), 178–183. http://dx.doi.org/10.1080/07421656.2007.10129476

Van Lith, T., Schofield, M., & Fenner, P. (2013). Identifying the evidence-base for art-based practices and their potential benefit for mental health recovery: A critical review. Disability and Rehabilitation, 35(6), 1309–1323. http://dx.doi.org/ 10.3109/09638288.2012.732188

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ; London, UK: Lawrence Erlbaum Associates.

Wood, C. (2011). Navigating art therapy: A therapist’s companion. London, New York: Routledge.

Wood, M., Molassiotis, A., & Payne, S. (2011). What research evidence is there for the use of art therapy in the management of symptoms in adults with cancer? A systematic review. Psycho-Oncology, 20(2), 135–145. http://dx.doi.org/10.1002/ pon.1722

Zubala, A., MacIntyre, D., Gleeson, N., & Karkou, V. (2013). Description of arts ther- apies practice with adults suffering from depression in the UK: Quantitative results from the nationwide survey. The Arts in Psychotherapy, 40(5), 458–464. http://dx.doi.org/10.1016/j.aip.2013.09.003

Zubala, A., MacIntyre, D., & Karkou, V. (2014). Art psychotherapy practice with adults who suffer from depression in the UK: Qualitative findings from a depression- specific questionnaire. The Arts in Psychotherapy, 41(5), 563–569. http://dx.doi.

apies practice with adults suffering from depression in the UK: Qualitative findings from the nation wide survey. The Arts in Psychotherapy, 41(5), 535–544. http://dx.doi.org/10.1016/j.aip.2014.10.005