Expressive therapies are “complex interventions that combine psychotherapeutic techniques with activities aimed at promoting creative expression.”1 The 2014 guidelines of the National Institute for Health and Clinical Excellence (NICE) on the Treatment of Psychosis and Schizophrenia in Adults recommend these modalities — including art therapy — in conjunction with pharmacotherapy to “enhance an individual’s creativity, emotional expression, communication, insight, and ability to relate to themselves and others.”2 A recent review of 18 studies on the use of art therapy as an intervention in adults with psychosis found that “high-quality qualitative articles indicated that therapists and clients consider art therapy to be a beneficial, meaningful, and acceptable intervention.”2
Art in Therapy and Art as Therapy
There is a difference between “art in therapy” and “art as therapy,” explained Susan Dingsor, MA, LPC, ATR-BC, a Pennsylvania-based art therapist who works with adults with psychosis in an acute care facility.
“Art in therapy” typically uses art as a component of a talk-based modality, while “art as therapy” suggests that the artistic endeavor is, in and of itself, therapeutic. “Change occurs during the process of physical involvement with the materials, through the making of a significant art object, through sublimation of feelings into the images, and through communication with the therapist via the art object.”3
Ms Dingsor recounted the story of a client with a history of severe trauma and self-injury, who was asked to make a sock monkey, which is “a form of sublimation, a healthy alternative to releasing otherwise misdirected behaviors.”
“Under close supervision, she worked with blunt plastic needles and scissors. Instead of cutting herself, she cut fabrics and used needles to sew them together.” After several months, the client discontinued the self-injury.
In addition to sublimation, the activity required creative problem solving, Ms Dingsor said. “We do not use a prepared ‘box kit,’ so the monkey might end up looking like a giraffe or a teddy bear, and I encourage that type of creative expression.”
The art piece can open a dialogue about feelings. “I ask open-ended, nonjudgmental questions, which encourages the person to talk about feelings, but it is done through talking about the art, which can be less threatening,” Ms Dingsor said.
Sheila Lorenzo de la Peña, PhD, ATR-BC, uses art as therapy in the group setting at the Florida state hospital where she works with psychiatrically ill forensic patients. However, she occasionally integrates art into individual therapy. “Depending on how the talk therapy is progressing, I might incorporate art as a form of relaxing or building rapport,” she said. She also encourages clients to create an art piece around an uplifting quote, bring it to their room, and look at it every morning. “They see it as simply a pleasant activity and may not realize they are building a skill per se. But the reminder continues to have a positive impact and is more effective than a work sheet.”
Can Art Therapy Be Used During Active Psychosis?
Disordered thinking and cognitive impairment are features of many psychotic disorders, which make it difficult for individuals to engage in primarily talk-based therapies, Ms Dingsor observed. But the mindful process involved in the art projects allows participants to bring their presentness, rather than verbal or cognitive processing, to the activity.
“Some clients with delusions or other forms of active psychosis tend to avoid groups,” Dr de la Peña reported. However, “some who have a positive rapport with me come out, even if they are having ‘one of those days.’ They might be irritable, but can still work and have a positive experience, even if they are unable to verbally follow or stay on track.”
She described an actively psychotic man who, at first, refused to attend groups. “I said good morning to him daily, and made him feel as comfortable as possible.” After a month, he decided to attend groups, during which he “described ‘something in the corner of the room staring at you.'” It was a “huge accomplishment” for him to describe a hallucination, Dr de la Peña stated. But he did so “because he was comfortable in the space with art materials and peers.” He often used art to express anger and paranoia, “but at least he participated, stayed in group without arguments and fights, and was even able to smile every once in a while.”
She emphasized that a person “does not have to be verbal to benefit” from art therapy. She related the case of a catatonic woman who “could barely move and did not speak in group.” However, as soon as she picked up the art materials, “she worked at the same speed as everyone else and was able to participate.”
The Value of a Group Setting
While art therapy can be used in individual therapy with clients, Ms Dingsor uses it primarily in a group setting, using the Sanctuary Model®.4,5 “This model incorporates 7 commitments: open communication, growth in change, democracy, social responsibility, social learning, nonviolence, and emotional intelligence,” Ms Dingsor explained. It encourages clients to “learn from each other and see how others work with the same symptoms they have, in an atmosphere of respect and safety.”
In addition to approaches based on the Sanctuary Model, Ms Dingsor integrates mindfulness and dialectical behavior therapy (DBT) techniques into her groups, stating that they are complementary and “embrace” each other.
Together with art, Dr de la Peña also utilizes DBT skills in her groups. “Typically, I start by asking group participants to mindfully focus on a theme that I suggest — for example, something you are grateful for. We then explore the theme using the art materials.”
Mindfulness-based interventions have been found to be effective in improving outcomes in patients with schizophrenia spectrum disorders.6,7 Mindfulness facilitates the breaking down of activities into smaller, simpler units because it looks at one thing at a time, Dr de la Peña said. “Clients begin by exploring the art medium in a sensory-oriented way, which keeps them in the here and now.” It can take time before the client is comfortable. “Some are scared of everything, or of specific triggers, such as a particular color, texture, or theme.” Moreover, it might take time for the client to become interested, which is necessary for effective engagement.
Working in a group setting offers several opportunities for skills development, Ms Dingsor noted. “I typically use 2 or 3 art media simultaneously. Some clients might be working on a collage, others might be drawing, and others creating sock monkeys. A dedicated, trained individual rotates among the different groups to provide support and ensure safety.” This teaches patience, delayed gratification, and learning to wait mindfully. “It is a microcosm of the external world, where people must wait in line at the grocery store, for example.”
When the group engages in conversation around the art, clients are trained to support and respect each other. “Instead of saying, ‘That’s ugly,’ we train clients to ask what the other person’s art means and represents,” Ms Dingsor said.
Types of Art Media
Art media must be chosen carefully, Ms Dingsor stated. She uses the Expressive Therapy Continuum, which “provides a theoretical model for art-based assessments and applications of media in art therapy.”8
“For example, paint is considered to be a more regressive medium that requires close monitoring, while pencils and markers are more controlled and manageable.” Paint, which is fluid, might be helpful to a person with high levels of anxiety, “while someone with attention deficit may need to learn more control.”
Therapists must be sensitive to clients’ triggers. For example, “we are often cautious about suggesting drawing people, or painting a human body with colors that reflect feelings.” This can be triggering for individuals who might have undergone sexual trauma.
Both experts emphasized that it is important for psychiatrists to be aware of the role of art therapy and to collaborate with art therapists. “Art therapy is not merely ‘arts and crafts,'” Ms Dingsor said.
She recommended “close partnership between psychiatrists and art therapists to open communication for mindful presence, partnering, and sharing our goals and objectives for the individual’s recovery.”