What role can art therapy play within mental health?

DISSDRAFT3KWORDS Art-therapy-in-mental-health–A-systematic-review-of-_2016_The-Arts-in-Psych Communicating_via_Expressive_A Clinical-outcomes-from-The-BodyMind-Approach–in-the-treatmen_2016_The-Arts- Observational_study_of_associa Arttherapy-anunderutilizedyeteffectivetool-RobertABitonte

 I′ve been told that to get 60%or more that the dissertation must have ′The presence of critique: the recognition that knowledge proceeds through a community of enquiry: comparison, contrast and argument between different theoretical perspectives, driven by a question. The recognition that claims and ideas are significant because…, where the because is created through comparison, contrast and argument within the community of enquiry. Signposting: each paragraph does one job, and the first sentence explains the relevance of the job to the essay question.′ I want the the dissertation to look into how art as a therapy that can be a benefit to an individual/groups mental health. I have added PDFs of articles etc I would like used and a PDF of my attempt to write some of the dissertation. (3,000 words) However, I am extremely dyslexic and I apologies if it doesn′t make sense. 

Art

therapy has become a fundamental element in many mental health settings. In today’s

modern society many individuals have encountered experience(s) with a mental health issue;
whether it be depression, bipolar disorder, personality disorder, anxiety, post-traumatic stress
disorder, schizophrenia, obsessive-compulsive disorder, disorder eating or brain injury. These are
only a few among the long list of mental health issues an individual can experience as all of these
mental illnesses can branch off into other problems or overlap with each other. There have been
many medical advances throughout history to help with these mental ailments, such as shock
therapy/insulin shock therapy and lobotomies. Thankfully these treatments are not the common go
to for a GP to prescribe you. The most common route now a days would be medication like
antidepressants, antipsychotics or mood stabilisers. (depending on the individuals mental health
problem)
A supplementary treatment would then be put along sides this, for example counselling or therapy.
Up until recently therapy has been a treatment that is mostly about talking, voicing the individual’s
thoughts/feelings and how they can then learn to change their thought process and make positive
changes in their life e.g. cognitive behavioural therapy.
But what can be said for the individual that feels like they can not voice their thoughts and feelings?
Whether they feel like they would be judge, it would be too painful to talk about or physically cannot
put it into words.
This is where I feel art(s) therapy can come into play. Can it be used as a therapy or aid in recovery?
Can it be used to improve the client’s way of life or benefit their wellness/well-being? Or can it
simply be a form of escapism for the service user?

Chapter one
In one case study that will be included is ‘Art therapy and Arts in health: Identifying shared values
but different goals using a framework analysis. This case study was an online survey taken by 60 art
therapists and 62 artists in health care. They were asked 12 questions in total but there were 5 main
questions to investigate how they perceive their own occupation. The 5 main questions were; ‘What
do you think art therapy/arts in health provides for program participants? Are there any
limitations to what art therapy/arts in health can provide to program participants? Are there
some approaches used by art therapists/artists in health care
that work better than others? If yes, explain. Are there any situations when the art therapy/arts
in health should not be used? How would you describe the art therapy/arts in health to
someone in a casual conversation setting?’ (Van Lith/Spooner pg89).
The common fundamental attributes between art therapist and artists in health care were;
‘Having the inherent belief in the healing capacity of creativity’. (Van Lith/Spooner pg 89)The art
therapists and artists in health care equally determined the significant that the arts contributed
to the healing process of the client, whether it be emotionally, physically, socially or spiritually.
‘Regarding the Creative process as a means for expression.’ (Van Lith/Spooner pg 89)
Contributors from both sides disclosed that art aided in the client’s communication skills and
gave them more ways of expressing themselves. Especially for clients that could not put
thoughts and feelings into words.

‘Working towards social engagement and inclusion.’ (Van Lith/Spooner pg 89)Both professionals
spare no effort to support social engagement by employing art as a form of encouraging
development in communication to endorse ‘social inclusion’. They found art-based projects
intercepted isolation and loneliness by introducing social interactions in a safe space. If therapy

is being done in a group setting the clients may learn about their behaviour patterns because of their
interactions with others.
‘Working towards empowerment’. (Van Lith/Spooner pg 90) The professionals from both groups
see art as a beneficial implement to empowerment, believing that this stimulated the recovery
process in a way that is personal to the client. Obtaining a feeling of achievement through their
art, the patient then could feel a sense of ownership and control in their life.
‘Working towards enhancing well-being and improvement to quality of life.’ (Van Lith/Spooner pg
90)The goal for both professionals is to apply art to enhance the clients well-being and build
upon their quality of life. Which would necessitate innovate/creative experiences to encourage
the clients own personal expression, allowing for relaxation and creative attentiveness.
In the health profession terms can easily be ‘interchangeable’, for example ‘wellness’ or ‘well-
being’.

‘Well-being’ is ‘the state of being comfortable, healthy, or happy.’
(https://www.mentalhealth.org.uk/blog/what-wellbeing-how-can-we-measure-it-and-how-can-we-
supportpeople-improve-it) Which the artist in health care will focus on the overall happiness of the
client or how it can be improved. The sessions are more so for a creative outlet. The artist in health
care is aware of the clients tells or signs of interest, engagement, enjoyment or discomfort. An
artwork that is completed is a reward in the artist in health cares eyes as they have taught the client
a number of skills and they are then able to appreciate their own artistic qualities, as well as others.
The outcome of the sessions is to promote the clients health and well-being through being
motivated to socially interact through art. Overall artists in health care provide a service that can be
used alongside medical treatment as it can be seen as a distraction or a form of escapism for the
client.
Whereas ‘wellness’ is the ‘state of being healthy in body and mind, especially as a result of
deliberate effort.’ (https://www.dictionary.com/browse/wellness) that the art therapists perceptive
would come from a multidimensional framework/approach. In sessions with an art therapist, clients
are encouraged to explore the materials that can be used, the use of symbolic imagery to externalize
what is internalised within the client. Bringing it into the real world, to possibly give the client a
different perceptive of there thoughts and feelings. To start to comprehend possible underlying
problems that they can then process and work through.
The main qualities among the two types of professionals are similar. Which I feel in any care giving
profess it is of paramount importance that the clients thoughts and feelings are put into
consideration. Whether that is finding other ways to aid the development and ways in which the
client can communicate and express themselves.
One major difference between the two professions is an art therapist is required to have formal
training, be nationally registered with the art therapy credential board and follow ethical and
professional guidelines for their practice. Whereas an artist in health care can access this profession
through varied routes. For the example, many may have different levels of training in the arts, some
have formal health care training and there is the option of work placement training. There is the
option of masters or doctorates in the arts but it is not a requirement to have if the person is looking
to go into the profession of an artist in health care.
When working in mental health I agree there should be a level of education to have the wealth of
knowledge needed to comprehend of all the different approaches, concepts, theorist, techniques
and correct terminology. A number of professionals may have the education to follow guidelines,
protocols and frame work that is used in order to carry out treatment but are these the only
elements to being a ‘good’ practitioner? I would disagree on the grounds that you cannot get be
educated in the ability to listen and communicate effectively, be empathic, have compassion and
being non-judgemental. These are some of the humanistic qualities that most humans have but not
all are attuned to them as well as others. Without these qualities an art therapist is just going

through the motions. This can be a hindrance to the client not receiving compatible treatment that is
right for them as every client is unique and will respond differently to approaches.
‘Art therapy is not specific in it’s practices, making it customizable to the ever-changing life of a
patient. (Robert A. Bitonte pg 18) However, there is also the factor of ‘the professional knows best’
(David Pfeiffer) mentality when the art therapist is involved. The practitioner may have the mentality
that a certain approach may work for the set amount of sessions with the client but not ask
themselves the question of what might work better for the individual.
‘Art therapy is likewise defined by many art as healing groups as a strictly diagnostic field, a field in
which practitioners are only interested in interpretation rather than in the artistic process and its
relationship to health and well-being.’ (Malchiodi pg 154) There could be a number of factors that
could hinder the developmental process of the client, such as their mental health issues, for
example, depression. The therapist may not take into consideration depression can lower the
motivation of a client. Their energy levels to be able to participate are lessened on certain days as
depression can fluctuate. (as can any other mental health problem). Their energy is maybe focused
in the wrong place by trying to ‘fix’ the client’s problems in a way which the client does not find
enjoyable or beneficial. Yes, I agree that there should be some sort of framework in place but it
should not be set in stone. Referring back to what (Bitonte, pg 18) said that it is imperative that the
practice is flexible to be able to adjust easily to the clients’ needs.
There is the question of is there a discussion between the art therapist and the client? Is the art
therapist taking into consideration what the client wants from their sessions spent together? The
answer could be yes or no depending on the art therapists’ ideas of what framework is used and
how they execute this in their own work with the client. For some clients the idea of discussing
expectations can be daunting (never the less it is important). In turn this can make them anxious,
less willing to be open to the experience and not be fully engaged in the process. There must be a
consistency in the attendance of the session to be able to build a repour with the therapist, for the
therapist to get to grips with what the clients ins and outs are so they can begin to build a sense of
trust within a safe space. ‘Although it may be difficult to quantify the effectiveness of art therapy,
studies have repeatedly shown that art therapy is beneficial to patients within a broad spectrum of
conditions.’ (Bitonte) However, often at the end of the program the therapist makes their own
conclusion on whether the client has made any progress. Which is based on the assumptions of what
they witness when they are with the client for a short space of time. For there to be any way
forward in the right direction concerning ‘customizable’ treatment, clients giving honest feedback is
a paramount. When it comes to feedback it should be optional to be anonymous as some clients
might be apprehensive to speak up if they feel that the sessions have not been beneficial.
Using an an example from (Bitontes pg 18-19) article there was a section about children and
adolescents with Epilepsy that they had come to realise that using group art therapy sessions could
be a helpful tool in aiding in social interactions as it can give the participants the chance to meet
others with the same condition(s). Being able to relate to others can help an individual not feel so
lonely in their illness.

Gestalt Approach

I feel the Gestalt theory is very relevant to the art therapy practice as art therapy is an outlet in
which the clients internalized thoughts and feeling can externalised by giving ‘shape, form or
figure’ to them.
(as ‘shape, form or figure (as in Gestalt theory = theory of shape or form)’ pg 15 )
This approach promotes the idea of individuality as it ‘aims for the development and maintenance
of such a harmonious state and not for a ’cure’. Cure refers implicitly to a state of ‘’normality’’
which is the opposite of the Gestalt approach. In Gestalt the right to be different is highly
valued, as is the uniqueness of each person’ (pg17) The word ‘therapy’ can be highly stigmatised
and the person receiving treatment can be harmfully labelled by others that could become a
deterrent for simply looking help. When in reality art therapy can be used as a way of exploring
self-expression to discover possible underlying problems the client may have. This in turn can
help them recognised contributing factors that may be a catalyst to their problem(s). By doing
this they can then start to work on coping mechanisms or possibly resolving some of their
issues.
When the individual is undergoing gestalt therapy, they ‘responsible for his own choices and
avoidances. The individual works at the rate and level that suits him, according to what emerges
in the present moment.’ (Gestalt pg22) which in comparison to the other case study I
mentioned above involving the art therapists that have a rigid framework, Gestalts idea of
letting the individual choose what they want out of their session gives them a sense of control
that they may not have outside of the sessions. However, to some professionals this could be
seen as too loose of a structure to be able to have a plan in place with a certain outcome but
having an expectation for the client from the beginning can add unnecessary stress or pressure
on the client. Perhaps using this approach within a framework could be a good combination if
used correctly. As ‘experimentation can employ any of a whole variety of media’ from physical
movement, sculpture, textiles, paint, dialogues/literature to encourage exploration of the self.
Again, I feel the Gestalt approach can be employed by art therapy in practice as a theme within
it is ‘to make explicit that which is implicit, to bring out in the open that which is hidden. When
the client can externalize what is going on inside, he can see a clear picture of how he “works”
here-and-now, and what goes on at the “contact boundary” between himself and his
environment.’(pg27) Once a client is able to externalize their thoughts and feelings they can
then begin to look at each individual point that has been brought to light and with the new
perspective be able to understand themselves more; why do they feel this way? Do certain
people or environmental factors influence their morals, self-esteem/self-worth, ideas about the
world around them? Do everyday life responsibilities impact on their mental wellbeing? Does
externalizing all of their issues/problems give the client some sort of relief and help put their life
in perspective, letting them almost have an outsider looking in feeling to perhaps let them
reflect and react logically and not irrationally.
Everyone’s experience of the world around them are different to another. It will depend on their
environment, their own morals, what influences them (consciously or subconsciously) with the
people they surround themselves with, the material they listen, read and watch. Other factors
could be if the individual has a mental health problem in which could distort their reality making
them perceive something differently than a person with no mental health problems.
Some may argue that how you feel/perceive things is a state of mind and that you are in control
of how you perceive the world around you. That the individual is able to control how it makes
them feel. This may be the case for some however, this is easier said than done for people with

mental or physical health issues. ‘What you see depends on how you look, and how you look
influences what you see.’(pg32 Gestalt) Yes, with the right treatment people are able to rewire
how they think/react with the likes of CBT (Cognitive Behaviour Therapy). This type of therapy is
not a cure but a way of learning about yourself, coping mechanisms and strategies to help with
how a person can manage their issues in a ‘healthier’ way.
In some cases, repeatedly going over painful or traumatic life events can sometimes have a
negative impact on the client. The same as ruminating on negative, damaging or self-destructive
thoughts or ideas. ‘In fact, continually going over a painful moment often serves to reinforce the
bad memory; continually talking about a difficult period of mourning is not enough to overcome
it … Reopening the wounds of childhood and making them bleed means they will never get a
chance to heal: once the wound is properly cleaned (but not before!) there is a necessary
convalescence while the scab forms and must not be scratched off.’. (pg36)
In the absence of art therapy, there are other types of creative therapies. ‘Monodrama allows

exploration, recognition and integration of the opposing “polarities” in relationships, without

getting arbitrarily “stuck in the middle”: a false, artificial and arid middle way. I can in fact feel

violently aggressive towards someone, and love him or her passionately, at the same time. Each

of these feelings deserves to be clarified as much as possible and not just “neutralized” by a

composite attitude of relative love, nor reduced to the “bland greyishness” which results from

the arbitrary algebraic sum of two violent and opposing feelings. In fact, strong and opposing

emotions are in reality more additive than canceling’. (pg29) Having many feelings can be

conflicting but giving them validation and transparency is a healthy way of dealing with them.

Not giving acknowledgement and acceptance to certain emotions like anger, love, fear, hatred,

jealousy can become a pressure cooker and in turn be let out in a way that could be harmful to

themselves or others.

References

Art therapy and Arts in health: Identifying shared values but different goals using a framework

analysis. Theresa Van Lith & Heather Spooner
https://doi.org/10.1080/07421656.2018.1483161

‘Art therapy: An underutilized, yet effective tool’ by Robert A, Bitonte and Marisa De Santo

‘Art as Healing, Art in Healthcare, and Arts Medicine: New Names for Art Therapy?’ By Cathy A.
Malchiodi
(https://www.tandfonline.com/doi/pdf/10.1080/07421656.1989.10759316?casa_token=aA2mX
IgQLGMAAAAA:ZJS_lHKkNMdGKaf5XsbN0rK_tsjW8cgl61GfllqnKmJSifoiGAVfo_7EL1YhgYbpLE7cv
5bUZpI)

Ginger, Serge. Gestalt Therapy: The Art of Contact, Taylor & Francis Group, 2007

https://doi.org/10.1080/07421656.2018.1483161%20%20PG%202-3

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The Arts in Psycho

therapy 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 201

5

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: tvanlith@fsu.edu

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

dx.doi.org/10.1016/j.aip.2015.09.003

http://www.sciencedirect.com/science/journal/01974556

http://crossmark.crossref.org/dialog/?doi=10.1016/j.aip.2015.09.003&domain=pdf

mailto:tvanlith@fsu.edu

dx.doi.org/10.1016/j.aip.2015.09.003

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

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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

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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.

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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.
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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.

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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.
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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.

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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.

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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).

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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.
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1
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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.

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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

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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?

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• Art therapy in mental health: A systematic review of approaches and practices

Introduction
Evidence-based practice in art therapy
Methods
Findings
Art therapy approaches practiced with people who have depression
Art therapy approaches practiced with people who have borderline personality disorder
Art therapy approaches practiced with people who have schizophrenia
Art therapy approaches practiced with people who have post-traumatic stress disorder
Discussion
Limitations and implications
Conclusion
References

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Communicating via Expressive Arts: The Natural Medium of Self-Expression for Hospitalized Children
Britt-Maj Wikström
Pediatric Nursing; Nov/Dec 2005; 31, 6; ProQuest Central
pg. 480

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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The Arts in P

sychotherapy 47 (2016) 55–65

Contents lists available at ScienceDirect

The Arts in Psychotherapy

linical outcomes

f

rom The BodyMind ApproachTM in the treatment of
atients with medically unexplained symptoms in primary health
are in England: Practice-based evidence

elen Payne, MPhil, PhD, UKCP

R

eg. Psychotherapist, ADMP UK, AVR a,∗,
usan D.M. Brooks, BSc, MA, MA, MBA b

School of Education, University of Hertfordshire, De Havilland Campus, Hatfield, Hertfordshire AL10 9EU, England, United Kingdom
Pathways2wellbeing, 27 Bridge Street, Hitchin, Herts SG5 2DF, England, United Kingdom

r t i c l e i n f o

rticle history:
vailable online 18 December 2015

eywords:
he BodyMind ApproachTM

edically unexplained symptoms
rimary care
ractice-based evidence

a b s t r a c t

This article builds on Payne (2015) and reports on practice-based evidence arising out of the delivery
of a new and innovative service using The BodyMind ApproachTM (TBMA) for the treatment of patients
with medically unexplained symptoms (MUS) in primary care in the National Health Service (NHS) in
Hertfordshire, a county near London, England, in the UK. The analysis of data collected for three groups
(N = 16) over 18 months used standardised assessment tools and other relevant information at pre, post
and at a 6 month follow up. The outcomes for patients in this small scale piece of practice based evidence
indicated that there were reductions in symptom distress, anxiety and depression, increased overall
wellbeing and improvement in activity levels. Patients developed self-management of their symptoms
through understanding, acceptance and coping strategies. The increased knowledge, exchange of expe-
riences together with understanding and acceptance from others promoted a sense of wellbeing. Thus,

the programme was experienced to be a beneficial intervention. In addition to the clinical outcomes
reported here there are other benefits for NHS England for example, savings on medication and referral
costs and General Practitioner (GP) capacity enhanced. The clinical service is based on previous research
conducted by Payne and Stott (2010). This article focusses solely on the analysis and interpretation of
clinical outcomes from the practice-based evidence.

ntroduction

The innovative clinical service reported in this article is bein

g

ffered to primary care patients with medically unexplained symp-
oms (MUS) through the National Health Service (NHS) in a county
n England. Edwards, Stern, Clarke, Ivbijaro, and Kasney (2010)
efine MUS as ‘a clinical and social predicament, includes broad
pectrum of presentations, difficulty accounting for symptoms
ased on known pathology’ (p. 1). They go on to say in Diagnos-
ic and Statistical Manual for Mental Disorders (DSM IV-TR) that

he nomenclature for MUS has several categories including soma-
isation disorder, conversion disorder, pain disorder, and that the
riteria is cumbersome and unhelpful in practice.

∗ Corresponding author. Tel.: +44 1707 285861.
E-mail addresses: H.L.Payne@herts.ac.uk (H. Payne),

.d.m.brooks@btinternet.com (S.D.M. Brooks).
URLs: http://www.herts.ac.uk (H. Payne),

ttp://www.pathways2wellbeing.com (S.D.M. Brooks).

ttp://dx.doi.org/10.1016/j.aip.2015.12.00

1

197-4556/© 2015 Elsevier L

td.

All rights reserved.

© 2015 Elsevier Ltd. All rights reserved.

Both the DSM-5 and the proposed International Classification
of Diseases – 11th Revision (ICD-11) change the criteria for MUS
and replace the term by Somatic Symptom and Related Disorders
(SSD). In DSM-5 F45.1 SSD is cross-walked to ICD9 code 300.82
(ICD10-CM F45.1). SSD is defined in DSM-5 as symptoms that are
distressing or result in significant disruption to feeling, thoughts
and behaviour, related to somatic symptoms as manifested by at
least one of the following: disproportionate and persistent thoughts
about the seriousness of one’s symptoms, or persistently high lev-
els of anxiety about health symptoms and excessive time and
energy devoted to these symptoms of health concerns (Diagnostic
and Statistical Manual of Mental Disorders-5, 2013). It states that
somatic symptom and related disorders includes the diagnoses of
somatic symptom disorder, illness anxiety disorder, conversion dis-
order (functional neurological symptom disorder), psychological
factors affecting other medical conditions, factitious disorder other

specified somatic symptom and related disorder, and unspecified
somatic symptom and related disorder. All of the disorders share
a common feature: the prominence of somatic symptoms associ-
ated with significant distress and impairment. Such patients are

dx.doi.org/10.1016/j.aip.2015.12.001

http://www.sciencedirect.com/science/journal/01974556

http://crossmark.crossref.org/dialog/?doi=10.1016/j.aip.2015.12.001&domain=pdf

mailto:H.L.Payne@herts.ac.uk

mailto:S.d.m.brooks@btinternet.com

http://www.herts.ac.uk

http://www.herts.ac.uk

http://www.herts.ac.uk

http://www.herts.ac.uk

http://www.herts.ac.uk

http://www.pathways2wellbeing.com

http://www.pathways2wellbeing.com

http://www.pathways2wellbeing.com

http://www.pathways2wellbeing.com

dx.doi.org/10.1016/j.aip.2015.12.001

5

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H. Payne, S.D.M. Brooks / The Ar

ommonly found in primary care and less encountered in mental
ealth settings. The term is thought to be more useful than that of
US in primary care (Creed et al., 2010).
SSD includes the former somatisation disorder, undifferenti-

ted somatoform disorder, and pain disorder. The change is that
he diagnostic criteria are no longer based on the presence of

US, but focuses on one or more somatic symptoms that are dis-
ressing and/or result in significant disruption of everyday life.
lthough there are criticisms (Frances, 2013; Voigt et al., 2012)

his change removes the diagnostic problem of having to distin-
uish between medically explained and unexplained symptoms
Creed et al., 2010). The shortcomings of the MUS category is
he mind-body dualism present in the unreliable classification of
omplaints as medically explained or not (Creed, 2009; Sharpe,
ayou, & Walker, 2006) and the random categorisation into dif-

erent somatoform disorders (Leiknes, Finset, Moum, & Sandanger,
008).

This dualism reinforces the GP training to address physical
ather than mental health issues and the patient’s perception that
heir symptom is purely physical because of the sensory experi-
nce. It reinforces dualistic thinking and the idea that illness is
ither biological or psychological. The term defines the illness by
hat it is not, i.e. it implies no organic cause which is not neces-

arily accurate and limits treatment. Research has shown that most
atients prefer a positive description of symptoms, i.e. an explana-
ion of what it is rather than what it is not. The term MUS may seem
lib communicating that nothing can be done. Cognitive Behaviour
herapy (CBT) with relaxation and/or graded exercise has some
ffectiveness for some symptoms (Whiting et al., 2001). Although
sychological treatment may work in some cases this does not
eflect that the symptoms are necessarily psychological (Creed,
enningsen, & Fink, 2011). Other terms in use in a Department
f Health (DH) recent document on MUS (DH, 2014) are claimed
o be more acceptable to patients such as persistent physical symp-
oms or functional syndromes/symptoms (FS) (Stone et al., 2002). The
erm “functional” here is used because it is assumed that the disor-
er is one of function, which may be physical and/or psychosocial
unction, rather than anatomical structure (Sharpe, 2000).

The clinical outcomes of TBMA as a treatment reported here are
ased upon the definition and criteria for MUS used in DSMIV, i.e.
efore the changes made with reference to MUS in DSM-5.

The treatment service is delivered in the English NHS primary
are setting by a University of Hertfordshire spin-out company
athways2Wellbeing (P2W)TM. Primary care in the NHS refers to
he first port of call for patients in the community which involves
Ps working in local practices. Secondary care involves hospitals
nd other medical establishments or treatments to which GPs refer
atients. GPs act as the access, by way of referral, to any specialist

nterventions in either primary or secondary care. The treatment
ervice offered by P2W is called Symptoms Groups to patients and
he MUS Clinic to the GPs referring patients with various medically
nexplained symptoms (such as fibromyalgia, IBS, chronic pain or
hronic fatigue) from primary care. At no time is the term MUS used
ith patients.

The groups use TBMA, which is based on a bio-psychosocial
odel derived from aspects of interpersonal therapy, embodied

roup psychotherapy (dance movement psychotherapy/authentic
ovement), the arts and mindfulness. It is not designed as a form of

sychotherapy, but an adaptation for non-psychologically minded
atients deriving from an integration of the above. The groups are
alled workshops and the treatment is a course. This approach has
een hitherto researched and delivered as a service in the NHS

ith patients with medically unexplained symptoms (MUS) (pre-

iously termed psychosomatic conditions). These patients have
ery limited pathways for supporting their wellbeing in primary
are and are high health utilisers (Bermingham, Cohen, Hague, &

sychotherapy 47 (2016) 55–65

Parsonage, 2010). They suffer with chronic, physical symptoms or
conditions which do not appear to have an organic, medical diagno-
sis and normally with co-occurring anxiety and/or depression. The
negative impact of the conditions and lack of curative treatments
means effective non-pharmacological interventions that promote
better coping abilities need to be developed.

TBMA treatment aims to bridge the gap between mental and
physical health services for these patients with chronic MUS. It
uses the inter-relationship between body and mind for the treat-
ment of such patients with these persistent symptoms. Further
details on the approach can be found in Payne (2015) and Lin and
Payne (2014). The University’s newly endorsed company P2W is
the vehicle for the service with the knowledge arising from the
pilot research being transferred into a real world service delivery
as clinical progress reporting. This recent service delivery project
(2012–2013) was funded by the DH initiative Quality, Innova-
tion, Productivity and Prevention (QIPP) scheme in a competitive
bid from the authors and Hertfordshire Primary Care Trust (Men-
tal Health). The delivery took place in community settings with
patients referred by GPs from primary care. The service was free
at the point of delivery. The naturalistic delivery and the lessons
learned from the experience are documented in Payne (2015). This
article focusses solely on an evaluation of the clinical outcomes
for the patients from a small scale implementation of TBMA in the
NHS. The small sample size (N = 16) and the lack of a control arm
means that the outcomes cannot be generalised with any confi-
dence. However, the indicative outcomes which are very positive
are consistent with a previous pilot study conducted at the Univer-
sity of Hertfordshire (Payne & Stott, 2010) and may be transferable.

Medically unexplained symptoms

Patients with chronic MUS (presenting for over 6 months with
the same symptom/s) are quite complex and are high health
utilisers for whom there are few pathways for support and self-
management other than (for a few symptoms) CBT and/or pain
relief. In a recent practice guideline published by the UK DH, (July
2014) as a part of Improving Access to Psychological Therapies
(IAPT) initiative, it is concluded that “community mental health
teams and primary care mental health services have not been suc-
cessful in engaging with patients experiencing MUS, as patients
often do not perceive their condition to be related to mental health
problems, and attempting to engage them in traditional mental
health approaches is often ineffective” (DH, 2014, p. 5).

Therefore to review the research on self-management in CBT is
not relevant to the purpose of this article.

A systematic review of research (Du et al., 2011) was conducted
for the self-management programmes on pain and disability for
chronic musculoskeletal pain conditions (not necessarily MUS).
For chronic back pain, there was insufficient evidence to deter-
mine the effectiveness of self-management programmes. In a more
recent review (Oliveira et al., 2012) for non-specific low back pain
results showed moderate-quality evidence that self-management
has small effects on pain and disability which challenge the
endorsement of self-management in treatment guidelines.

MUS patients are high utilisers of health care resources. In
2008–2009 approximately £3 billion was spent on patients with
MUS in the NHS (11% of total budget) rising to £18 billion includ-
ing the cost to the wider economy through lost productivity
(Bermingham et al., 2010).

No serious medical cause was the diagnosis in 25–50% of all pri-

mary care visits (Barsky & Borus, 1995) and only 10–15% of the
14 common, physical symptoms seen in half of GP consultations
over 12 months were found to be caused by an organic illness
(Morriss, Dowrick, & Salmon, 2007), resulting in 85–90% being of

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nknown biological aetiology. These patients are often taking med-
cation, regularly visit health professionals (more than five times
er year) and for longer consultations than the 11 min per visit
er symptom allowable in the NHS. Furthermore, they use many
esources accounting for as many as one in five new consultations
Bridges & Goldberg, 1985). They frequently have high cost referrals
o secondary care for tests and scans and usually present with anx-
ety and/or depression, which is understandable (Aguera, Failde,
ervilla, Diaz-Fernandez, & Mico, 2010; Simon, VonKorff, Piccinelli,
ullerton, & Ormel, 1999).

Dimsdale, Sharma, and Sharpe (2011) showed that although
US/somatoform disorders are common, for those health pro-

essionals seeing such patients there is considerable confusion
egarding the diagnostic terminology and a reluctance to use
hese diagnostic labels. For example, GPs rarely use the terms

US or somatoform disorder to their patients, instead diagnosing
bromyalgia, ME, IBS, chronic fatigue, etc. Neither do GPs routinely
se the ICD-10 subcategories of various somatoform disorders.
onsequently, in the experience of the authors the specific number
f this huge population in each GP practice is hidden from the GP
ractice database. However, GPs can identify those known as heart-
ink, frequent flyer and fat file patients whom they refer to the MUS
linic. As a result of a systemic lack of classification many patients
ho have MUS/somatoform disorder are not able to be identified

o receive the support of the MUS Clinic.
Grover et al. (2014) found no significant differences between

he various subcategories of somatoform disorders with regard
o the prevalence of somatic symptoms (including somatoform
ain disorder), anxiety or depression and psychological correlates
f alexithymia, hypochondriasis and somato-sensory amplifica-
ion. Their findings also supported the co-occurrence of anxiety
nd depression in two-thirds of this population. Anxiety disor-
er (formally hypochondriasis) or functional neurological disorder
formally conversion) may also be diagnosed.

Khan, Khan, and Harezlak (2003) call for better management
trategies to be developed in primary care for prevalent, medically
nexplained, persistent somatic symptoms which are a health care
riority and a long-term condition. Currently patients either attend
hysical or mental health services and the treatment is separately
elivered as medication/pain management or psychological ther-
pies, respectively. This system is unhelpful to the patient since
t splits off mental from physical health aspects. In England, CBT
or three conditions: IBS; chronic fatigue and fibromyalgia, has
een found to help mental health in the short term and encour-
ged through a government initiative called Improving Access to
sychological Therapies (IAPT) which also targets people with long-
erm conditions in which MUS can be categorised. However, only a
hird of MUS patients with varied symptoms attend this treatment
Hague, 2008), probably due to their physical explanation for their
ymptoms and the stigma attached to mental health services. Thus
t seems CBT is unacceptable to this patient population, they require
n accessible and integrated approach which acknowledges their
odily based physical experience whilst exploring this at emotional
nd cognitive levels.

he research on which TBMA is founded

A pilot study into the TBMA intervention took place near Lon-
on, England in 2005–20071 (Payne, 2009; Payne & Stott, 2010).

rom these earlier research studies, specifically the proof of concept
ilot study (Payne & Stott, 2010), patient benefits from TBMA inter-
ention were improved wellbeing and activity levels; decreased

1 Funded by the East of England Development Fund and The University of Hert-
ordshire.

sychotherapy 47 (2016) 55–65 57

symptom/anxiety/depression levels; improved self-management
of symptoms; and lower or stabilised medication levels. For GPs
the benefits included reduced attendance at GPs and/or hospitals
and reduced costs of medication.

Furthermore, a previous health economic analysis of TBMA com-
pared with CBT showed that the cost savings would be large in
primary care but that secondary care they would be even greater
(Payne & Fordham, 2008) the findings of which are supported by a
report from the DH (2012). Thus this evidence makes TBMA courses
attractive for the NHS due to the current austerity situation in
England.

Following extensive consultation with primary care GPs in a
market research study by Payne, Eskioglou, and Story (2009),
funded by the East of England Development Agency, a need was
identified by the GPs for a pathway for the treatment and sup-
port of this patient population, for most of whom they thought
CBT/psychological therapies was inaccessible and/or inappropriate.
In support of the lack of accessibility for patients of psychological
therapies and/or referrals from GPs psychologists in IAPT com-
plained that they were not getting enough referrals from GPs. When
TBMA was described to these GPs in a focus group (and later in the
QIPP project) as a possible pathway it was welcomed enthusiasti-
cally as being more acceptable and providing choice for patients.

The pilot study led to the development of a manual for the
delivery of TBMA by experienced and qualified Masters level
dance movement psychotherapists trained in TBMA by path-
ways2wellbeing. This manual is not a recipe for sessions but rather
offers nudges for the planning, specific themes which need to be
covered and when and for the conducting of group sessions. The
mind-set/attitude of the facilitator is described as the most impor-
tant ingredient for promoting change. The facilitator is encouraged
to be mindful, sensitive, adapting practices to each group’s needs,
ensuring interventions, aims and outcomes are explained clearly
to patients and addressing needs as they arise rather than being
prescriptive. The manual content gives examples of sessions and
case studies, emphasising the facilitator’s competencies expected.
The manual was further refined as the QIPP service delivery was
conducted in an evaluation by the facilitators during the delivery,
and no doubt it will be honed still further with each new delivery
of the groups by more facilitators.

As well as the manual being continuously updated TBMA is
being evaluated as an on-going process during delivery of the
service. Manuals developed for conducting psychological therapies
in research studies are not widely distributed and their contents
do not appear to have been evaluated (Payne, Westland, Karkou,
& Warneke, 2014). Research findings based on the application of
treatment manuals have led to the endorsement of psychological
treatments based on the use of brand names, e.g. Body Orien-
tated Psychotherapy, CBT or Interpersonal Therapy. Endorsing
brand-named treatments assumes they are practised in a man-
ner consistent with the research treatment manuals but without
evidence to support this assertion. In this service delivery treat-
ment integrity has been ensured by a triangulation (a three-way
comparative analysis) between what patients have said about their
experience of the approach what the facilitator says she did in the
pilot study (Payne, 2009), and the manual which will continue to
be evaluated by the facilitators and by expert opinion evaluators
external to the delivery.

The BodyMind ApproachTM

There are many different definitions of psychotherapy, for
example ‘The treatment of disorders of the mind or personal-
ity by psychological methods’ (Oxford English Dictionary, 2015)
or ‘the informed and intentional application of clinical methods

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nd interpersonal stances derived from established psychologi-
al principles for the purpose of assisting people to modify their
ehaviours, cognitions, emotions, and/or other personal character-

stics in directions that the participants deem desirable’ (Campbell,
orcross, Vasquez, & Kaslow, 2013, p. 98). It is normally the

esponse to specific or non-specific signs of clinically diagnosable
nd/or existential crises, often dubbed talking therapy aiming to
elp clients to fulfil their potential or cope better with the emo-
ional problems of life.

Whilst TBMA is not psychotherapy in the narrow definition of
he term it has its roots in a psychotherapy school of thought. It
orks not only with the mind, emotions and cognition but also
ith the physical symptoms, it is a bio-psychosocial model.

TBMA can be seen as one solution to the problem of patients with
US. It has been designed specifically to be accessible to this patient

opulation and to provide choice. It aims towards integrating body
nd mind, starting with the bodily symptom and its sensory expe-
ience to promote self-management and wellbeing in people with
hronic MUS. It employs somatic mindfulness (or bodymindful-
ess) – movement, a moment-to-moment awareness of the body

n motion or stillness, from the discipline of Authentic Movement
Adler, 2002; Chodorow, 1992; Payne, 2006; Whitehouse, 1999)
hich is sometimes employed in dance movement psychotherapy.
uthentic movement is where the mover moves spontaneously
ith eyes closed/downwardly focussed in the presence of a wit-
ess. In TBMA authentic movement is coupled with mindfulness
ractices, adapted to be accessible to people with persistent symp-
oms employing simple practices scaffolding them into elements
f the final form. There is no pressure to engage with anything
ith which patients might be uncomfortable. The facilitator always

ffers alternatives and choices.
Kabat-Zinn (1982), Kabat-Zinn, Lipworth, and Burney (1985)

nd Kabat-Zinn, Lipworth, Burney, and Sellers (1986) pioneered the
evelopment of mindfulness meditation with patients with chronic
ain and a mindfulness stress reduction programme for psoriasis
Kabat-Zinn et al., 1998) as well as applying it to patients with anxi-
ty (Miller, Fletcher, & Kabat-Zinn, 1995). Since then there has been

prolific study of mindfulness. It has been shown to reduce depres-
ion as well as anxiety. Hofmann, Sawyer, Witt, and Oh (2010)
onducted a meta-analysis of 39 studies that explored the use
f mindfulness-based stress reduction. The researchers concluded
hat mindfulness-based therapy may be useful in altering affec-
ive and self-regulatory processes that underlie multiple clinical
ssues particularly anxiety and/or depression. Others have sup-
orted these findings, for example, Vøllestad, Nielsen, and Nielsen
2012), Roemer et al. (2009) and an earlier study by Grossman,
ieman, Schmidt, and Walach (2004). A systematic review con-
ucted by Sharma and Rush (2014) found that out of 17 studies
ombining mindfulness meditation and yoga 16 demonstrated pos-
tive changes in psychological or physiological outcomes related
o anxiety and/or stress. Williams (2008) reviewed four stud-
es showing a correlation between measures of mindfulness as a
rait and cognitive features of depressive vulnerability, specifically
ecreased rumination, avoidance of internal experiences and an

ncrease in the relinquishment of negative thoughts and unattain-
ble goals. Other studies demonstrate that a mindful or experiential
ode of self-attention in depressed subjects is relatively more

onducive to both improved memory for autobiographical events
Watkins & Teasdale, 2004) and improved problem solving ability
Watkins & Moulds, 2005).

Nevertheless none of these approaches address the lived bodily
elt sensory experience from a phenomenological perspective

r address the importance of body awareness as a vehicle for
hange. The subjective experiencing body (Gallagher & Zahavi,
007), whether engaging with the world’s affordances (Gibson,
979) through the tactile sense, movement or in stillness, is
sychotherapy 47 (2016) 55–65

the fundamental basis for all feelings, sensations, perceptions or
object manipulation which in turn actively underlies cognition
and meaning-making (Dewey, 1991; Merleau-Ponty, 1962, 1965).
There is thus an integration of physical and mental aspects, per-
ception and action, doing and being. TBMA builds on this notion
of the body functioning as a dynamic constituent of the mind
rather than serving the mind. This enactive, subjectively body-felt
sense, as described by Gendlin (1982), expresses basic mean-
ing from a sensory–motor modality and reflects the individual’s
life history and current situation. It is pre-verbal and prelimi-
nary to habitual/pre-conceptual/abstract thinking patterns. During
TBMA the body is therefore experienced from inside-out, as a
lived container of sensations, images, thoughts and feelings, etc.
Joint attention with the facilitator or another participant as wit-
ness extends the experience as reflections are embodied from the
outside-in as well. This opportunity to experience the connection
between the body and mind whilst doing/being it opens up possi-
bilities for new discoveries about the nature, and the meaning of,
symptoms as located in the bodymind. This is an embodied way
of knowing (Panhofer & Payne, 2011), contrasting with conceptual
knowing.

Several disciplines cultivate mindfulness, such as yoga, tai chi
and qigong, although most of the research literature has concen-
trated on mindfulness developed through mindfulness meditation.
This self-regulation practice trains attention and awareness to
bring mental processes under greater voluntary control thereby
promoting wellbeing and/or capacities such as calmness, clarity
and concentration (Walsh & Shapiro, 2006).

Mindfulness refers to a psychological state of awareness, the
practices that promote this awareness, a mode of processing
information and a character trait and can be defined as a moment-
to-moment awareness of one’s experience without judgement. In
this sense, mindfulness is a state and not a trait. While it might be
promoted by certain practices or activities, such as meditation, it
is not necessarily synonymous with them. TBMA by using kinetic
mindful practices engages with the patient’s attention to, and rela-
tionship with, their bodily symptoms (including pain), for example
by exploring the sensory experiences, and engaging in action-based
inquiry such as examining the nature and purpose of the symptoms.
This mindful relationship to the body and symptoms helps patients
become less attached to/identified with their symptoms as well as
less reactive to them which diminishes their experience of them.

TBMA coaches patients through exercises involving postures
and movement, breath and voice, mindfulness and body aware-
ness. Practicing such exploratory exercises regularly in the group
session (and at home) the patient may regain balance and self-
regulation. For example, practising focussing on the breath (or the
symptoms), then noticing any thoughts, images or bodily sensa-
tions, followed by re-focussing on the breath, and then reflecting
on the experience through the creative arts thus nurturing a deep
awareness of the body. By putting difficult emotions and sensations
in a bodily context an indication of a new perspective and accom-
panying meanings can be gained. By holding all these aspects,
including pain, in direct sensory awareness metaphor/imagery can
be generated spontaneously. These can be drawn, made out of
clay or written about in a personal journal often leading to further
meaning-making and understanding of the role/nature/purpose of
the symptoms. Participants are engaged in synchronous, effort-
ful movement together in a circle (accompanied by music or not)
which has been shown to reduce pain and act as a way to increase
group cohesion (Tarr, Launay, Cohen, & Dunbar, 2015).

TBMA helps patients to connect cognitive and emotional aspects

with reference to their sensory/bodily states through the enact-
ment of expressive movement in structured exercises. Cognitive
activities are inseparable from the body as the brain takes an impor-
tant part in intentionality which involves the process of perceiving

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birth).
Gender mix: The ratio was 5:3 women to men in this small

sample of 16 completing the whole programme from pre-group

H. Payne, S.D.M. Brooks / The Ar

nd meaning-making (Koch, Caldwell, & Fuchs, 2013; Mills, 2005).
here is no explicit involvement of any underlying psychological
onflicts or the interpretation/identification (or subsequent modi-
cation of) unhelpful thought patterns. Patients learn to notice their
odily signals and explore their symptoms often without the need
or verbalisation (McWhinney, Epstein, & Freeman, 1997), thoughts
hange as a result of the embodied experience.

TBMA differs significantly from CBT in that it focuses on the
hysical symptom within an experiential inquiry-led learning
ramework to support patients to live well and cope better in a

ore meaningful way. There is an evidence base for the practice
f CBT with some specific conditions included in the MUS cate-
ory, e.g. IBS (Mahvi-Shirazi, Fathi-Ashtian, Rasoolzade-Tabatabaei,

Amini, 2012) and fibromyalgia (Woolfolk, Allen, & Apter, 2012)
ut the method does not address the body-felt sensory experience
f the symptoms, favouring solely the mental aspects of depres-
ion and/or anxiety. CBT has been researched in large trials and
s recommended by the National Institute for Clinical and Health
are Excellence (NICE) for chronic fatigue and fibromyalgia. How-
ver, patients and GPs in the service delivery reported in this
rticle spoke about patients’ reluctance to attend anything con-
erned with psychological/mental ill health, etc. There is evidence
Sartorius, 2007) to suggest that these patients are very wary of
he stigma attached to any mental health label. It can be concluded
hat patients with MUS may be less willing to access CBT as they
elieve they have an organic cause rather than give a psycholog-

cal explanation for their symptoms. Allen and Woolfolk (2010)
nd Gonzalez, Williams, Noel, and Lee (2005) demonstrate that this
atient population are often resistant to CBT.

In contrast TBMA is not presented to patients as a psychological
herapy. It allows patients in the early phase to concentrate on their
ensory experience and action patterns involved in the symptom.
owever, there is often a subtle psychological component to the

reatment discovered by the patient later in the process. Hence
atients do not concern themselves with the question of stigma

n relation to participating in the treatment. Furthermore, TBMA
ddresses a range of symptoms and the symptom itself. It can
nclude a number of different symptoms for a number of patients
n the same group, together with various accompanying aetiology
uch as alexithymia (Ogrodniczuk, Joyce, & Piper, 2013), in which
here is confusion between emotions and bodily experiences, poor
ffect regulation and a fearful/insecure attachment style (Payne,
016).

In TBMA the patient directs her/his attention to inner expe-
iences of self, actively reflecting and commenting on bodily
ensations as they are raised into awareness. Gradually participants
ecome more connected to their embodied, direct experience of
elf. A more positive re-association with the body emerges which
as often become dissociated due to the patient’s symptom distress.

n embracing the wisdom held by the symptom through the embod-
ed, enactive dream state the patient enters into a more meaningful
ialogue with their body. Levy Berg, Sandahl, and Bullington (2010)

n a study of patient perspectives of the process of change in
ffect-focussed body psychotherapy for generalised anxiety disor-
er found that ‘getting in touch with one’s body’ was a key (p. 151).
his in turn gave rise to feelings of being in control, for example
oticing bodily signals such as muscular tension and being able to

nfluence them, and understanding the link between bodily symp-
oms and emotions. They found that patients managed to integrate
odily feelings into their perception of themselves resulting in a
eeper experience of their lived body.

tructure of the TBMA course

TBMA groups are short term for up to 12 patients per group;
here are three groups per programme. Each session is two hours

sychotherapy 47 (2016) 55–65 59

for 12 sessions over 10 weeks as in brief therapy (Yalom & Leszcz,
2005). Groups are run locally in a suitable community setting.
Following the groups in phase one, in phase two, and over the
following 6 months contact is maintained. For example, a self-
addressed letter written by the participant in session 12 is sent
8 weeks after the end of the group, as is a letter personalised for
each participant written by their facilitator in month three after the
end of the group. Finally, a text/email message is sent asking how
they are doing, and, if indicated by their response to the question,
in month nine, a referral to a self-help group is made, otherwise a
discharge letter is sent to their GP.

Practice-based evidence

As well as the traditional trials in the evidence-based practice
paradigm another form of evidence is being derived from natural-
istic practice settings termed practice-based evidence (Barkham &
Mellor-Clark, 2000).

Practice-based evidence is described by Guy, Thomas,
Stephenson, and Loewenthal (2011) as complementary to the
quantitative, and dominant, randomised control trial-based
approach to evidence. A United Kingdom Council for Psychother-
apy (UKCP) report (Ryan & Morgan, 2004, cited in Thomas,
Stephenson, & Loewenthal, 2006) suggests that practitioners and
service users need to be given a voice, acknowledging that they
have direct knowledge and experience of what works and alter-
natively what needs to change, and how. Practice-based evidence
can give them these opportunities.

P2W employs this practice-based methodology, albeit with
smaller numbers. It contrasts with evidence-based practice in that
it starts with practitioners and patients in real-world settings
and builds up the evidence rather than as with the traditional
top down evidence-based medical paradigm. Furthermore, it uses
national/common psychological therapies and primary care out-
come measures such as PHQ9 for measuring depression. Patient
evaluations of experience and outcomes form an important part of
the evidence. Additionally, it is using real-world patients electing
to participate in the treatment group, rather than selected samples
willing to participate in research to which they would be blindly
allocated to either the treatment/treatment as usual without exert-
ing any choice.

With this practice-based methodology and its evaluation using
qualitative and quantitative patient feedback and the standardised
psychological assessment tools there is an opportunity to build an
evidence base rooted in routine service delivery. This could com-
plement the Cochrane data base2 and together with it, yield a more
robust knowledge base for the psychological/arts therapies.

This methodology values expert opinion and acknowledges the
need to adjust practice according to the needs and preferences of
the client and their socio-economic background. This complemen-
tary paradigm of practice-based evidence also provides a means
for practitioners to own and generate an evidence base embedded
in routine practice. Both paradigms are needed as the aim for all
practitioners and researchers alike is best practice.

Description of patients in the sample

Ethnicity: White British – 10; Chinese – 2; Indian – 4 (we do not
know if born in Britain from this background or if their country of

2 An international not-for-profit organisation preparing maintaining and promot-
ing the accessibility of systematic reviews of the effects of health care.

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hospital visits and improvement in their social support.
For the majority of patients’ depression scores were mild or

moderate reducing to zero, one patient reduced in her score
from severe to moderate. The literature (Löwe, Spitzer, Williams,

0
20
40
60
80

Percent age Improveme nt

Percentage Im proveme nt

0 H. Payne, S.D.M. Brooks / The Ar

ssessment to follow up at 6 months. This reflects the literature
hereby more women than men somatise.

Age distribution: Results from this small sample of 16 suggest
hat adults of all ages are likely to experience MUS. The biggest
ge group category was the 50–59 year olds (5/16 were from this
ategory). The youngest patient was just below 20 years of age and
he eldest patient was over 80 years old.

Number of patients in each group: Group 1: four; Group 2: six;
roup 3; six.

Number at completion: 16/19 patients completed the full pro-
ramme over the two phases to the end of the 6 month follow-up.

The number of group sessions attended per patient ranged from
to 11.

Attendance figures: Group 1 had 67%, Group 2 – 86% and for Group
it was 90%.

The following shows engagement throughout the programme:
Number entering treatment groups: 19 (one missed the intake

eeting but attended the first two sessions then withdrew, a fur-
her one withdrew after first two sessions as too unwell and one
ad to have an operation and could not drive so had to discontinue).

Number remaining in treatment: 17 (one remained until session
0 but could not sustain thereafter).

Number completing TBMA group treatment through to follow up:
6.

nalysis of questionnaire data

The majority of patients were in the moderate or mild cate-
ories for anxiety which is broadly consistent with the literature
hich states that at least two-thirds of patients with MUS will
ave anxiety (Grover et al., 2014). Higher levels of anxiety show
ore of an improvement than at these lower levels. The majority

f patients were women, a finding consistent with the literature
Speckens, VanHemert, Bolk, Rooijmans, & Hengeveld, 1996). They
ere of a mixed educational background similar to that found by
imnuan, Hotopf, and Wessely (2001). Some studies claim that

hose unemployed, senior women and those from a non-Western
rigin experience more MUS (Verhaak, Meijer, Visser, & Wolters,
006). However, participants in this project were from a variety of
ackgrounds and ages. This is inconsistent with some other stud-

es which found, for example, the older age group to be overly
epresented or, in contrast, younger, employed women to be over
epresented (Nimnuan et al., 2001). However, all of these outcomes
n the demographics in the project are consistent with the previous
ilot study.

Educational background: Patients came from a range of educa-
ional backgrounds.

Employment status: 5/16 retired, one of which was due to ill
ealth. 7/16 patients were in full-time employment; two in part
ime employment; one was unemployed and one a student.

Types of symptoms: There were 26 different symptoms for the
hole cohort of 16 patients completing the programme to follow
p. These included:

breathlessness,
headaches,
chronic pain,
tiredness,
insomnia,
hand pain,
leg pain,
chronic fatigue,

IBS,
ME,
palpitations,
seeing white lights,
sychotherapy 47 (2016) 55–65

• pain in the chest,
• backache,
• leg spasm and
• insomnia.

Assessment measures

Patients were assessed using standardised measures over the
telephone by a clinical psychologist on three occasions. Firstly at
pre-group, secondly in the final week of the group and thirdly at 6
months follow up. The measures used were:

PHQ9: This is a client rated tool for depression. It scores each of
the nine depression DSM-IV criteria as “0” (not at all) to “3” (nearly
every day).

Measure Your Medical Outcomes Profile (MYMOP2): This is an
individualised outcome questionnaire, problem-specific (measures
two symptoms chosen by the patient), including

general wellbeing

and impact of symptoms on a chosen activity. The greater the score,
the more severe the symptoms will be experienced.

Generalised Anxiety Disorder 7 (GAD7): This is a brief measure
for assessing Generalised anxiety disorder on a 7-item self-rating
scale. It scores each item as “0” (not at all) to “3” (nearly every day)
for each item. Severity of generalised anxiety is graded based on the
GAD7 score as 0–4 none/5–9 mild/10–14 moderate/15–21 severe.

The Global Assessment of Functioning Scale (GAF): A clinician rat-
ing tool used to measure overall level of psychological, social and
occupational client functioning on a scale ranging from 1 to 100.
The higher the score, the higher the level of functioning will be.
GAF covers the range from positive mental health to severe psy-
chopathology.

P2W questionnaire: During a telephone interview the asses-
sor collected self-reported information on the participant’s age,
gender, ethnicity, socio economic group, occupation, educational
levels, type and number of symptoms, amount of leisure activ-
ity, social support, work/school attendance, use of medication, and
attendance at GP/hospital. In addition, GP referrals contained case
histories and medical information.

Post-group outcomes from the standardised assessments

The outcomes are also presented as pie charts for greater visual
impact and ease of interpretation by the general reader.

Interpretation of outcomes pre to post group

Improvements are noted in all areas shown from pre to post
group on the Pie Charts 1–7 and in Graph 1. Particularly impor-
tant are improvements in the scores from pre to post group as
shown in Table 2 indicating decreased levels of depression, anxiety
and symptom severity. There are also improved feelings of overall
wellbeing, social support, activity levels and global functioning. In
addition, patients report decreased GP visits, medication usage and

medica�on social
support

GP visits Hospita l
visits

Pie Chart 1. Patients reporting reduced feelings of depression 81.25% of patients
reported a reduction in depression.

H. Payne, S.D.M. Brooks / The Arts in Psychotherapy 47 (2016) 55–65 61

depression

81.25% re duce d
6.25% increased

12.5% no change

Pie Chart 2. Percentage of patients reporting improved global functioning 81.25%
of patients report and improvement in global functioning.

global func�oning

81.2 5% improved
6.25% redu ced
12.5% no change

Pie Chart 3. Percentage of patients reporting increased overall score for MYMOP
including activity, symptom severity and wellbeing 81.25% of patients report
improvement in overall scores.

mymop overall

81.2 5% in creased
6.25% de creased
12.5% no change

Pie Chart 4. Percentage of patients reporting reduced anxiety levels 68.75% of
patients reported a reduction in anxiety.

anxi ety

68.75% reduced
12.5% increased
18.75% no change

Pie Chart 5. Percentage of patients reporting symptom severity 65.3% of patients
reported an improvement in symptoms.

symptom severity

65.3% decrease
7.6%incre ase
26.9%no change

Pie Chart 6. Percentage of patients reporting increased general wellbeing 62.5% of
patients report improvement in their feeling of general wellbeing. Key: blue = 62.5%;
green = 25%; red = 12.5%.

general wellbeing

increas ed wellb ein g
decreas ed well bei ng
no change

Pie Chart 7. Percentage of patients reporting improved activity 56.25% of patients
report improved activity.

MYMOP2

ac�vity

improved
worsened
no change

Graph 1. Example of percentage improvement in social support, medication, GP
and hospital visits.

Table 1
To show pre to post group analysis of questionnaire.

Test Improved Worsened No change

Leisure 9/16 (56%) 3/16 (19%) 4/16 (25%)
Support 7/16 (44%) 0/16 (0%) 9/16 (56%)
Absence from work (Group 3 only) 1/6 (17%) 0/6 (0%) 5/6 (83%)
GP visits (Groups 2 and 3 only.

Missing data: 1 person)
4/11(36%) 4/11 (36%) 3/11 (28%)

Hospital visits (Groups 2 and 3
only)

7/12 (58%) 1/12 (8%) 4/12(33%)

Medication 3/16 (19%) 1/16 (6%) 12/16 (75%)
Number symptoms 12/16 (75%) 0/16 4/16 (25%)
Employment status 0/16 (0%) 0/16 (0%) 16/16 (100%)

NB one person changed to a different type of medication and was entered under no
change.

Mussell, & Schellberg, 2008) states most patients with MUS will
have mild to moderate depression; consequently; the sample of
patients were more or less in a similar category in this regard. 13/16
of patients reported feeling less depressed after attending the group
intervention.

Global functioning (psychological, social and occupational) lev-
els also increased for 13/16 of patients post group. This is an
important finding as functioning is usually impaired as a result
of MUS causing inactivity, unemployment and a reduced capacity
to study. Furthermore, social support collected by a questionnaire
post group showed improvement for 7/16 of patients (Table 1) and
this increased for 9/16 patients following attendance post group.
This may refer to relationships with family and friends improv-
ing which could result from the higher levels of wellbeing – a
positive sign, especially for those with insecure attachments. This
increased social support (frequently continuing long after the facil-
itated group workshops have ended) may help to account for why
patients continue to improve long after the groups finish.

The overall MYMOP scores improved considerably for 13/16 of
patients at post group assessment when compared to pre group.
This groups the scores of wellbeing, activity, and symptom distress,
together to make an overall score. It is no surprise that this percent-
age is high when individual percentages for each aspect of MYMOP2
improved.

Anxiety levels decreased for 11/16 of patients at post group
when compared to pre-group scores. 3/16 showed no change and
2/16 worsened in their scores for anxiety when comparing pre-
group with post group. It appears from this result that patients
reduce their levels of anxiety after the group experience. How-
ever, without a control group it is not possible to reliably attribute
improvements to TBMA as a group experience solely.

Symptom severity is measured by up to two symptoms per
person being reported to be better, worse or no change. 17/26 of

symptoms were reported as improved post group compared with
scores at pre-group. This improvement in symptom distress may
help patients to feel less depressed and anxious and enable them
to engage in more activity day-to-day. Increase in activity may in

62 H. Payne, S.D.M. Brooks / The Arts in Psychotherapy 47 (2016) 55–65

Table 2
To show patient changes in function of pre to post group.

Test Improved Worsened No change

Depression PHQ9 13/16 (81%) 1/16 (6%) 2/16 (13%)
Global functioning GAF 13/16 (81%) 1/16 (6%) 2/16 (13%)
Overall MYMOP2 13/16 (81%) 1/16 (6%) 2/16 (13%)
Anxiety GAD7 11/16 (69%) 2/16 (13%) 3/16 (19%)
Symptoms MYMOP2 17/26 (65%) 2/26 (8%) 7/26 (27%)
General wellbeing MYMOP2 10/16 (63%) 2/16 (13%) 4/16 (25%)
Activity MYMOP2 9/16 (56%) 0/16 (0%) 7/16 (44%)

Table 3
To show patient changes in function post group to 6 months follow up.

Test Improved Worsened No change

Depression PHQ9 3/14 (21%) 9/14 (64%) 2/14 (14%)
Global functioning GAF 4/14 (29%) 4/14 (29%) 6/14 (43%)
Overall MYMOP2 8/14 (57%) 5/14 (36%) 1/14 (7%)
Anxiety GAD7 3/14 (21%) 5/14 (36%) 6/14 (43%)
Symptoms MYMOP2 10/27 (37%) 5/27 (19%) 12/27 (44%)
General wellbeing MYMOP2 3/14 (21%) 6/14 (43%) 5/14 (36%)
Activity MYMOP2 7/14 (50%) 3/14 (21%) 4/14 (29%)

NB percentages have been rounded up; symptoms category reflects numbers of
symptoms (up to 2 per patient).

ac�vity

56.25% improve d ac �vity

0% de creased ac�vity 0%

43.75%no change

t
f

b
s
g
r
t

t
r
t
b
i

t
p

P
a

C
o
w
g
depression

reduced
increased
no change

Pie Chart 9. Percentage of patients reporting global functioning.

global func�oning

improved
worsened
no change

Pie Chart 8. Percentage of patients reporting depression.

urn bring about greater social interaction resulting in improved
eelings of wellbeing.

For 10/16 of patients there was improvement in general well-
eing as measured by overall MYMOP2. In problem specific
ymptoms almost all patients improved as well as in the cate-
ory of symptom severity. Furthermore, the number of symptoms
eported by patients pre-group reduced at post-group in over half
he sample.

Activity levels increased for 9/16 (Table 2) of patients with half
he sample increasing their leisure pursuits (Table 1) probably as a
esult of the increased functioning levels, which in turn could lead
o feelings of wellbeing. No patients reduced their activity levels to
elow those at pre-group. For the remainder there was no change

n activity levels at post group when compared to pre-group levels.
These results, albeit based on a small sample, suggest that at

he post-group assessment, using standardised psychological tests,
atients report feeling the benefits of attending TBMA groups.

ost group to 6 month follow up outcomes from standardised
ssessments

See Table 3.

omparison between post group and the 6 month follow up
utcomes as demonstrated on the standardised assessments

The percentage for depression in Pie Chart 8 in particular
orsened for 9/143 patients (it was the highest percentage of all

3 There are now 14 patients because two patients withdrew in the 6 month post
roup to follow up assessment period.

Pie Chart 10. Percentage of patients reporting overall score for MYMOP2.

categories) as did general wellbeing in MYMOP2 at 6/14 of patients
(see Pie Chart 13) at follow up when compared to post group data
analysis. However, as there had been (13/16 patients) reduction
in depression at the earlier post group stage the worsening of this
percentage is not as great as might at first be thought. The post
group analysis for depression and general wellbeing had improved
for all but a very tiny percentage of patients when compared to
pre-group. Consequently, it could be said that there is a reduc-
tion in the maintenance of the improvement shown at post-group.
The higher percentage of increased depression at follow up may be
due to the loss of the support of the group during the 6 months
post-group to follow up. In contrast there were some participants
who improved on their previously improved or no change post-
group score for depression, others remained at the same level of
improvement. It would be understandable that general wellbeing
would decrease if depression increased. However, at follow up 3/14
patients improved in general wellbeing and 5/14 patients showed
no change when compared to the post group improvement. Conse-
quently, it could be said that 8/14 patients improved or maintained
their overall wellbeing.

It could be speculated that GPs advising that medication
for depression be tapered over a period of time influenced
patients’ perception of their levels of depression. Patients on
anti-depressants could want to give them up if they were feel-
ing better, however GP advice to remain on the medication due
to physiological dependency will prevent them from doing this
(Pie Chart 9).

Global Assessment of Functioning (GAF) appears to have been
about the same for each of the improvement and no change cat-
egories when comparing post to follow up. 10/14 patients either
improved still further from their post group scores or maintained
their improvement whilst only 4/14 patients reported feeling worse
at follow up than at post group (Pie Chart 10).

8/14 patients showed a large improvement in their overall
MYMOP2 score, whilst 5/14 got worse only 1/14 showed no change
when compared to the improvement shown in the post-group score
(Pie Chart 11).

Anxiety, as measured by GAD7, showed that there was improve-
ment in anxiety (i.e. reduction) in 3/14 patients and no change
from the post group levels of improvement for 6/14. Hence

approximately 9/14 of patients reported either improvement or
maintenance of their anxiety levels from post group as measured at
follow up. 5/14 patients reported feeling more anxious at follow up

H. Payne, S.D.M. Brooks / The Arts in Psychotherapy 47 (2016) 55–65 63

mymop overall

improved
worsened
no change

Pie Chart 11. Percentage of patients reporting anxiety.

Anxiety

Reduced
Increased
No Ch ange

Pie Chart 12. Percentage of patients reporting symptom severity.

symptom severity
reduced
increased
no change

w
t
t

s
1
r
i

s
p
r
o
c

o
6
w
1
o
i
t
i

w
m
a
c

e
s
m

MYMOP2 general wellbeing

improved
worsened
no change

Pie Chart 13. Percentage of patients reporting general wellbeing.

hen compared to post group. On balance most patients continued
o remain less anxious at the 6 month follow up when compared
o post group analysis (Pie Chart 12).

There was a reduction in symptom severity distress 10/27 of
ymptoms (as in the pilot study outcomes) at follow up, with
2/27 reporting no change. Hence approximately 22/27 of patients
eported either improvement or the same levels of symptom sever-
ty distress.

Even though some still experienced their symptoms maybe
ome could manage them better. Others remained the same as at
ost-group where there had been an improvement in coping. 5/27
eported a worsening of their symptoms. Once again the majority
f patients had maintained their improvement post group or had
ontinued to improve still further to the 6 month follow up stage.

8/14 of patients reported either improvement or maintenance
f their general wellbeing at 6 months follow-up. A larger number,
/14 patients, than at post group reported a decrease in general
ellbeing via MYMOP2 scores at follow up as shown in Pie Chart

3. This is inconsistent with the sustained improvement scores on
ther instruments. It is unclear why this is the case; perhaps miss-
ng the support of the group, leaving them feeling more alone with
heir symptoms. Nevertheless, 5/14 reported no change and 3/14
mproved still further at follow up (Pie Chart 14).

Levels of activity further increased at follow up in 7/14 patients
hen compared to post group demonstrating some capacity to do
ore, and feel better for it perhaps. This is contrary to the percent-

ge feeling worse for general wellbeing of 6/14 at follow up when
ompared to immediately post group.

Consequently, despite feeling less well overall in terms of gen-
ral wellbeing and more depressed than at post group patients were
till able to continue to maintain and even increase their engage-
ent in activity perhaps as result of increased global functioning,

Pie Chart 14. Percentage of patients reporting activity levels.

reduced symptom distress and anxiety levels experienced at follow
up.

Trends in the data

An important trend shown in the 6 month follow up data anal-
ysis is that the improvements made at post group are not only
sustained at 3 months post group, as in the previous pilot research
study, but patients report continued improvement at the 6 month
stage.

Patients maintained or improved their levels of progress on a
number of measures including overall global functioning, over-
all MYMOP, anxiety, symptom distress and activity. In the pilot
research study previously conducted with a bigger sample, which
had been followed up randomly in case studies to 4 years post
follow up, patients reported sustained improvement at that stage
too.

It is not possible to know precisely why improvement continues
so long after post group but it could be speculated that this may be
linked to their embodied change in perception towards their body
(and symptoms), the action plan to change the way they manage
their life (and symptoms) which is tailor-made by each patient, as
well as because of the group experience and the individual contact
experienced in phase one and two. From the Participant Experience
Form (PEF) patients appear to have enjoyed the group experience
and hence attendance at all the groups was excellent.

Discussion

This is a very minor piece of practice-based evidence and as
the numbers are still very small any interpretation must be under-
taken with extreme caution. Interestingly, some patients develop
new symptoms. Whilst this was not demonstrated previously in
the earlier pilot study (Payne & Stott, 2010), it has been reported in
the literature.

Patients appear to have found the programme acceptable and
were committed to attend the groups. From the PEF, they said that
they had benefited from the group experience having no hesitation
in recommending it to friends and family.

Therefore there are some hints from this treatment intervention
data analysis about how Symptoms Groups can mobilise patients
towards self-management. There is no alternative treatment avail-
able and appealing. This is because patients do not see the more
widely offered CBT as relevant as most have a physical explanation
rather than a psychological one for their symptoms. In addition the
stigma attached to psychological interventions means that they feel
unable to access such therapy.

These patients are extremely high utilisers of health resources
and consequently, supporting these patients is essential not only
for the patients but for saving NHS resources and increasing GP

capacity. The frustration experienced by both patients and GPs as a
result of the lack of treatment options to support these high health
utilisers can be resolved through delivery of programmes via The
MUS Clinic.

6 ts in P
S

s
s
s
v
p
f
t
c
i
s
a
t

w
i
f
a
l
g
g
h

A

H
a
M

R

R

A
A

A
A

B

B
B
B
C
C
C
C
C

D

p
l

4 H. Payne, S.D.M. Brooks / The Ar

ummary

First indications from the delivery of TBMA in primary care
uggest that it can benefit patients with MUS and the health
ervice by encouraging coping strategies which promote patient
elf-management thereby reducing the demand for and cost of ser-
ices. In addition, it is acceptable to patients and provides more
atient and GP choice of treatment for MUS. Furthermore, we know
rom patient self-reporting that the courses helped GP practices
o conserve costs by reducing consultation time, and increasing
apacity crucial in these times of low GP recruitment in the NHS
n England. If the apparent positive trends indicated in this very
mall sample were maintained after the sample is scaled up, with
ddition of a control, the findings would be of great interest. This is
herefore a subject for further research.

P2W intends to continue to improve the lives of patients
ith MUS in Hertfordshire, England and are actively pursu-

ng similar service delivery elsewhere through the training of
acilitators qualified in the fields of dance movement psychother-
py, body psychotherapy and appropriately qualified counsel-
ors/psychotherapists/health professionals. P2W has trained 30
roup facilitators in TBMA so far with a view to them facilitating
roups privately under licence and in the NHS and/or in the private
ealth care sector.4

cknowledgements

The authors wish to express gratitude to the UK Department of
ealth for their funding of this project and to Hertfordshire PCT,
s was, in particular the mental health lead commissioner Graham
unn, the patient participants, and the group facilitator Silvana

eynolds.

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• Clinical outcomes from The BodyMind Approach™ in the treatment of patients with medically unexplained symptoms in primary …

Introduction
Medically unexplained symptoms
The research on which TBMA is founded
The BodyMind Approach™
Structure of the TBMA course
Practice-based evidence
Description of patients in the sample
Analysis of questionnaire data
Assessment measures
Post-group outcomes from the standardised assessments
Interpretation of outcomes pre to post group
Post group to 6 month follow up outcomes from standardised assessments
Comparison between post group and the 6 month follow up outcomes as demonstrated on the standardised assessments
Trends in the data
Discussion
Summary
Acknowledgements
References

1Kaimal G, et al. BMJ Open 2018;8:e021448. doi:10.1136/bmjopen-2017-021448

Open access

Observational study of associations
between visual imagery and measures
of depression, anxiety and post-
traumatic stress among active-duty
military service members with traumatic
brain injury at the Walter Reed National
Military Medical Center

Girija Kaimal,1 Melissa S Walker,2 Joanna Herres,3 Louis M French,2,4
Thomas J DeGraba2

To cite: Kaimal G, Walker MS,
Herres J, et al. Observational
study of associations between
visual imagery and measures of
depression, anxiety and post-
traumatic stress among active-
duty military service members
with traumatic brain injury at
the Walter Reed National Military
Medical Center. BMJ Open
2018;8:e021448. doi:10.1136/
bmjopen-2017-021448

► Prepublication history for
this paper is available online.
To view these files, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2017-
021448).

Received 11 January 2018
Revised 11 May 2018
Accepted 18 May 2018

For numbered affiliations see
end of article.

Correspondence to
Dr. Girija Kaimal;
gk27@ drexel. edu

Research

AbstrACt
Objectives The study aimed tocompare recurring
themes in the artistic expression of military service
members (SMs) with post-traumatic stress disorder
(PTSD), traumatic brain injury and psychological health
(PH) conditions with measurable psychiatric diagnoses.
Affective symptoms and struggles related to verbally
expressing information can limit communication in
individuals with symptoms of PTSD and deployment-
related health conditions. Visual self-expression through
art therapy is an alternative way for SMs with PTSD
and other PH conditions to communicate their lived
experiences. This study offers the first systematic
examination of the associations between visual self-
expression and standardised clinical self-report measures.
Design Observational study of correlations between
clinical symptoms of post-traumatic stress, depression and
anxiety and visual themes in mask imagery.
setting The National Intrepid Center of Excellence at the
Walter Reed National Military Medical Center, Bethesda,
Maryland, USA.
Participants Active-duty military SMs (n=370) with a
history of traumatic brain injury, post-traumatic stress
symptoms and related PH conditions.
Intervention The masks used for analysis were created
by the SMs during art therapy sessions in week 1 of a
4-week integrative treatment programme.
Primary outcomes Associations between scores on the
PTSD Checklist–Military, Patient Health Questionnaire-9
and Generalized Anxiety Disorder 7-item scale on visual
themes in depictions of aspects of individual identity
(psychological injury, military symbols, military identity and
visual metaphors).
results Visual and clinical data comparisons indicate that
SMs who depicted psychological injury had higher scores
for post-traumatic stress and depression. The depiction
of military unit identity, nature metaphors, sociocultural
metaphors, and cultural and historical characters was
associated with lower post-traumatic stress, depression

and anxiety scores. Colour-related symbolism and
fragmented military symbols were associated with higher
anxiety, depression and post-traumatic stress scores.
Conclusions Emergent patterns of resilience and risk
embedded in the use of images created by the participants
could provide valuable information for patients, clinicians
and caregivers.

IntrODuCtIOn 
Since 2001, more than 2.7 million servicemen
and servicewomen have been deployed in
support of combat operations around the
world.1 A survey conducted by the Veterans
Administration from 2006 to 2010 estimated

strengths and limitations of this study

► This study offers the first systematic examination
of the  associations between visual self-expression
and how it relates to standardised clinical self-report
measures.

► This is the first study to demonstrate patterns of risk
and resilience as they relate to visual imagery creat-
ed by military service members with traumatic brain
injury and symptoms of post-traumatic stress.

► The visual imagery was created in art therapy ses-
sions and cannot be applied to other contexts of art
making.

► The study was performed within the framework of
a comprehensive integrative outpatient assessment
and treatment programme.

► The findings are associative and correlational in
nature, which precludes attribution of any causal
relationships.

► The study findings are limited to men and women
actively serving in the US military.

http://bmjopen.bmj.com/

http://dx.doi.org/10.1136/bmjopen-2017-021448

http://dx.doi.org/10.1136/bmjopen-2017-021448

http://dx.doi.org/10.1136/bmjopen-2017-021448

http://crossmark.crossref.org/dialog/?doi=10.1136/bmjopen-2017-021448&domain=pdf&date_stamp=2018-06-11

2 Kaimal G, et al. BMJ Open 2018;8:e021448. doi:10.1136/bmjopen-2017-021448

Open access

that post-traumatic stress disorder (PTSD) has affected
about 480 748 service members (SMs).1 Additionally,
379 5192 military SMs were diagnosed as having suffered
a traumatic brain injury (TBI), the vast majority of them
in the mild range.3 Recent research has highlighted the
co-occurrence of these severe diagnoses in military SMs,
with the total financial costs of treating these disorders
estimated as high as $6 billion for those with PTSD and
$910 million for those with TBI.4 Effective care for those
with persistent neurological and behavioural symptoms
from these injuries is imperative, both for the society and
for the military health system. PTSD and TBI are condi-
tions that are particularly prevalent among veterans.3 5
Individually complex, the effects of these conditions are
exacerbated when they occur together.6 Because the
neuroanatomical disturbances and the symptoms of
PTSD and TBI may be similar, it is possible that they share
some common mechanisms.6 Individuals with TBI often
develop PTSD and experience psychological health (PH)
symptoms such as irritability, anger, heightened arousal,
lack of concentration and sleeping difficulties.7 Psycho-
logical disorders such as depression and anxiety have also
been found to be common comorbid conditions in indi-
viduals with PTSD and TBI.8 9 In addition, demographic
characteristics like time in the service, including multiple
deployments,10–13 race/ethnicity,14 15 and rank (officer
or enlisted SM)16 17 have been associated with severity of
symptoms.

One of the challenges with treating PTSD can be the
limited ability of the patient to express his or her symp-
toms verbally.18–20 Thus alternative forms of communi-
cation such as visual self-expression through art therapy
are increasingly accepted as treatments for individuals
with PTSD, TBI and PH.21–26 Mask-making is one such art
therapy approach that has shown significant promise.27–29
Specifically, ‘trauma masks’ have assisted military SMs
to visually communicate the effects of combat-related
trauma to help build a coherent sense of self postin-
jury.30–32 Through the use of symbols and sensations that
are externalised and shaped into a narrative, art therapy
can assist in the processing of traumatic material,30
making the traumatic material more tolerable through
its externalisation, and enable narrative construction
of fragmented trauma memories.25 32–35 Art therapy is a
particularly useful approach for symptoms of combat-re-
lated PTSD, such as avoidance and emotional numbing,
while also attending to underlying issues for this popu-
lation, including relaxation, non-verbal expression,
containment, symbolic expression, externalisation and
pleasure.24 25

Although cognitive processing therapy is the first line
of psychotherapy in the military,36 other approaches like
art therapy have been shown to decrease anxiety in adults
with a variety of mental health conditions.37–41 Results
from the combination of cognitive behavioural therapy
and art therapy indicate that art therapy could be a viable
addition, particularly for patients with panic disorder
with agoraphobia and generalised anxiety disorder who

are not responsive to verbal therapies.41 By creating
visible depictions of their internal psychological states
in art therapy sessions, patients have the opportunity to
observe a tangible externalised object. This process and
the resulting image may aid them in developing strategies
to cope with feared situations, thereby desensitising them
to the fear at hand38 41 and helping them to engage their
senses to foster a connection between the mind and the
body.42 Similarly, art therapy has been found to reduce
depressive symptoms35 through evoking the expression of
positive emotions through the creative process, building
social connections43 and providing an alternative form of
self-expression.44

Most of the findings in art therapy and the military
have tended to be based on clinical observations and
small pilot studies.24 25 Despite clinical reports of the
potential of art therapy to address symptoms of depres-
sion and anxiety, no one has examined the associations
between the imagery created in art therapy sessions with
standardised measures of clinical symptoms. Analysis
of SMs’ visual representations in masks indicates that
they depict a range of experiences related to PTSD and
TBI, including the use of visual metaphors, depictions
of psychological injuries and reflections on the experi-
ences of belonging in the military and deployment in a
war zone. We present the associations between themes
in the mask imagery made during art therapy sessions
and corresponding measures of depression, anxiety and
PTSD.26

MethODs
setting
The National Intrepid Center of Excellence (NICoE)
located at the Walter Reed National Military Medical
Center (Bethesda, Maryland, USA) offers an interdis-
ciplinary intensive outpatient programme that uses an
integrative holistic model of care to serve active-duty SMs
with a history of TBI, a comorbid PH condition and symp-
toms that have not responded to first-line treatments. On
referral and acceptance, six new SMs and their families,
as available, are admitted to the centre each Monday and
move through the 4-week programme as a therapeutic
cohort. SMs undergo a standardised evaluation using core
assessment tools, which includes contact with 17 medical
and integrative health disciplines. As part of the initial
behavioural health assessment and treatment, all SMs
engage in a group art therapy mask-making session in
week 1 of their 4-week integrative treatment programme.
A series of neurological, psychiatric and psychological
assessments are conducted concurrently with the art
therapy sessions. The intake surveys are completed in the
same week as the mask-making (week 1), but prior to the
mask-making session as part of a battery of intake assess-
ments on admission.

The authors obtained the consent of the SMs to use all
of their clinical data for research purposes.

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Patient and public involvement
Patients and the public did not participate in the research
design or data analysis for this study.

Participants
Participants in the study included SMs (n=370). They
ranged in age from 20 to 50 years and included SMs from
all branches of the Armed Services, including the National
Guard, who were referred to the Walter Reed National
Military Medical Center (NICoE intensive outpatient
treatment programme). These individuals had a history
of mild TBI and comorbid PH concerns, including mood
problems, stress symptoms (or overt PTSD) or other
related conditions.

Data sources
All data at the NICoE are archived in a specialised de-iden-
tified database that can link mask images, participants’
narrative descriptions of mask imagery, experiences in art
therapy as described in the clinical notes of the therapists
and standardised measures of psychological functioning.
In a previous publication, we described the process of
identifying thematic classifications in the mask-making
products created by SMs.26 Figures 1–8 describe the prom-
inent themes in the masks used for analysis and a sample
image visually depicting those themes. (Artwork credit:

NICoE and Veterans Affairs National Center for Ethics
in Health Care.) The thematic classifications generated
from this analysis were converted into a database that

Figure 1 Psychological injury (depiction of psychological
struggles with sadness, anger, inability to verbalise and social
isolation).

Figure 2 Identification with military unit (depiction of
sense of belonging to a military unit, for example, explosive
ordnance disposal badge, also known as the ‘crab’).

Figure 3 Use of fragmented military symbols (depiction
of fragmented symbols associated with the military such as
flags, camouflage fabric and dog tags).

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included dichotomous variables (1=theme present and
0=theme absent). Thus, each SM’s mask included a 0 or
1 for each classification that was identified for the whole
data set. The data were coded by four members of the
research team. Two of the coders coded all the data and
then two more coders checked these codes. Discrepancies
in coding were reviewed, and a final code was assigned
as apt in consultation with the lead author. Masks were
coded for more than one thematic category if more than
one was represented in the image. Every mask had more
than one theme associated with the imagery and all of the
themes were included in the analysis. Additional details
on the coding process are described in a previous publica-
tion.26 Given that some of the themes recurred many times
and others only a few times, we chose a cut-off of n=20 for
the classifications to be included in the database in order
to have an adequate number for analyses. The coded
database was then integrated with the standardised data
from the PTSD Checklist-Military (PCL-M),45 the Patient
Health Questionnaire-9 (PHQ-9)46 and the Generalized
Anxiety Disorder 7-item (GAD-7)47 scale for further anal-
ysis. These questionnaires were administered to the SMs
during the same week as the mask-making art therapy
sessions. Although the data were collected at the Walter
Reed National Military Medical Center, the de-identified
data set was transferred to Drexel for analysis, per prior

agreement. No coded linkage information was kept at the
Walter Reed National Military Medical Center.

Data analysis
The data were first summarised using descriptive statistics
of study variables. For subsequent analyses, we focused
especially on the most frequently occurring elements
represented in the masks.26 Using the unique ID number
provided for each SM, we ran independent sample t-tests
to examine whether the mean scores for post-traumatic
stress symptoms as measured by the PCL-M, for depres-
sive symptoms as measured by the PHQ-9 and for anxiety
symptoms as measured by the GAD-7 differed depending
on whether the participants’ themes were psycholog-
ical injury, military identity or metaphors. Finally, we
explored the metaphor themes further by conducting
analysis of covariance tests to examine the unique effects
of the different uses of metaphors on the symptom scales.
Given that metaphors were represented in four different
ways, we wanted to examine if the type of visual metaphor
would be associated with symptoms of post-traumatic
stress, depression and anxiety.

results
Overall, based on clinical notes maintained by the art
therapist, when referring to the experience of making the
masks, SM participants reported that art therapy helped

Figure 4 Metaphors (depiction of inner psychological states
through a visual image).

Figure 5 Colour symbolism (specific individual colours as
metaphorical representations of experiences and emotions).

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mainly with enjoyment (n=136), with focus and concen-
tration (n=72) and with relaxation/calming (n=52). In
addition, SMs (n=74) said the mask-making helped with
socialisation and with opening up about their injuries,
treatment processes and struggles. A small proportion
of participants (n=11) did not report a positive experi-
ence and cited reasons like dissatisfaction with the final
product and disinterest in art making. Table 1 shows
the descriptive statistics for the study variables.

Table 2 shows differences in mean symptoms for the
mask themes of ‘psychological injury’ and ‘metaphors’.
Participants whose masks reflected evidence of psycholog-
ical injury (n=102) in the mask-making reported higher
PTSD symptoms, whereas those whose masks coded
positive for metaphors (n=125) had lower anxiety symp-
toms. Those who used symbols that included fragmented
representations of military symbols (n=44) reported more
anxiety, whereas those who used representations of their
military unit identity (n=41) reported less PTSD and
depression. Fragmented refers here to pieces of items
associated with the military such as camouflage fabric
and pieces of weapons, flags and tags. Table 3 provides
three univariate analyses of covariance used to determine
whether there were mean differences in the subtypes of

the broad theme of metaphors while controlling for time
in the service, race/ethnicity and officer status. These
covariates were chosen as controls based on the literature
in order to account for any effects that might be related
to these demographic variables. As shown, participants
whose masks showed evidence of colour symbolism (use
of colour as a metaphor) (n=46) had higher PCL-M and
PHQ-9 scores. Participants whose masks showed evidence
of cultural/historical characters (n=21) and cultural/
societal symbols (n=42) had lower GAD-7 scores and
tended to have lower depressive symptom scores. In addi-
tion, the use of nature-related imagery (n=33) trended
towards lower post-traumatic stress symptom scores, indi-
cating the potential health-promoting aspect when SMs
depicted such imagery.

DIsCussIOn
This study examined participants’ experiences of art
therapy and associations between the visual imagery in
the masks and clinical data from standardised measures
of symptoms of post-traumatic stress, depression and
anxiety. The findings indicate that there are patterns of
recurring associations between clinical symptoms in the
visual imagery created by SMs in art therapy sessions.
Some of the specific findings of note are that participants
whose masks depicted psychological injury reported

Figure 6 Cultural or historical characters (depiction of
characters from history, films and literature).

Figure 7 Sociocultural symbols (inclusion of images from
objects commonly seen in society).

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higher scores on the PCL-M scale. This finding indicates
a potential clinical significance when SMs depict their
psychological injuries and that this could be helpful to
direct specific focus on the clinical care of PTS symp-
toms when such imagery is depicted, such that depic-
tion of psychological struggles might be an indicator of
heightened symptoms of post-traumatic stress requiring
targeted care. When we reviewed artwork of combat
veterans with PTSD, we found evidence of ‘post-traumatic
conflict being experienced and depicted by the graphic
themes of war and the telling of self-portraits of disfig-
urement symbolic of alteration of one’s previous self’
(p44).30 SMs might be less likely to report mental health
issues due to the social stigma that these issues may be
misinterpreted as weakness or laziness.48–51 The associa-
tion between post-traumatic stress scores and visual depic-
tion of psychological injury suggests that this might be a
forum for safe self-expression.

Those participants whose masks coded positive for
metaphors also reported lower anxiety symptoms, indi-
cating that the use of metaphors is associated with the
SM reaching a level of insight into the psychological
issues in order to lower the level of anxiety and perhaps
develop some inner resilience that enables the SM to
depict images that involved imaginative variations on the
lived psychological experience. Further examination of
subtypes of metaphors revealed potential differences in
the associations with clinical data. For example, the use
of colour symbolism (eg, when an SM said that the colour
represented something specific like red represented
victory or blue represented sadness) was associated with
higher scores for PTSD and depression. These patterns
of association were also seen prominently in the use of
military symbols. Those who used fragmented military
symbols (eg, flag fragments, pieces of camouflage fabric
or dog tags) reported more anxiety. These fragmented
associations were associated with higher anxiety scores.

In contrast to fragmented symbols, those who used
visual symbols of their military unit reported less PTSD
and depression. These differences might imply that
representation of the military unit is akin to identifying
with a community and potentially reinforcing a sense of
belonging. The development of a group identity in the
military is well established as a means to ensure trust
and effectiveness in a war zone through shared commit-
ment and social cohesion.52–55 The findings highlight
the protective role of a sense of belonging and group
identity in the treatment process, beyond the period
of deployment in the war zones. In fact, a strong sense
of belonging could protect Air Force convoy opera-
tors against depression before and after their deploy-
ments.51 53 Some of the healing elements seen in art
therapy are the promotion of self-exploration, self-ex-
pression, symbolic thinking, creativity and sensory stim-
ulation.55 In a study of depression and dependency in
SMs, it was found that art therapy offered a sense of
control and served to integrate past experiences with
present connections.55

Figure 8 Nature images (inclusions of images from nature in
mask).

Table 1 Descriptive statistics for demographics and clinical
study variables

n % of sample

Male 361 97.0

African–American 14 3.8

Asian or Pacific Islander 8 2.2

Caucasian 329 89.2

Hispanic 15 4.1

Air Force 33 8.9

Army 119 32.2

Coast Guard 1 0.3

Marines 50 13.5

Navy 167 45.1

Officer 54 14.6

M SD

Age, years 36.08 7.62

Time in service, years 14.61 7.31

PCL-M score 51.98 15.86

PHQ-9 score 13.10 6.17

GAD-7 score 10.65 6.01

GAD-7, Generalized Anxiety Disorder 7-item scale; PCL-M, PTSD
Checklist for DSM-5; PHQ-9, Patient Health Questionnaire-9;
PTSD, post-traumatic stress disorder.

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The use of nature metaphors trended towards associ-
ation with lower PTSD scores. This finding suggests that
when SMs represented nature imagery, they might have
been tapping into inner resources of strength and resil-
ience. Reference to cultural historical characters was
also associated with less depression and anxiety. Taken
together, these visual metaphors might in general be
indicative of sources of creativity and resilience. However,
fragmented associations like depicting colours for specific
emotions might not be associated with the higher levels
of illness seen in PTSD and depressive symptoms. Imagery
that represents this integration might be associated with
more positive clinical scores compared with those repre-
senting more fragmented imagery.

This study has several limitations. All of the data related
to the masks are self-reported secondary data collected
as part of clinical practice. The findings indicate patterns
of occurrence in visual imagery and scores on stan-
dardised clinical symptoms and are not representative of
any causal relationships and must be interpreted accord-
ingly. The control variables in the study including time
in service, race/ethnicity and rank (officer or enlisted

SM) were selected based on information in the literature.
Most of the data are from male SMs; thus it is unclear if
similar patterns might be seen among female SMs. Addi-
tional research is needed to determine why metaphorical
depictions can denote the presence of different levels
of psychological risk and resilience and how they relate
to the demographic characteristics of the SM. In addi-
tion, further research is needed to determine why some
themes were more strongly associated with specific clin-
ical symptoms than others. One explanation for inconsis-
tent findings across symptom scales is the varying number
of participants who completed each scale. It is possible
that the study was underpowered for identifying differ-
ences in the GAD that were consistent with the PCL and
PHQ findings when the control variables were added to
the model.

In conclusion, this study addresses a new area of enquiry
associating patient clinical data with imagery to begin to
develop a framework for how psychological states might
be represented in visual media. The findings have the
potential to help clinicians identify sources of strength
and of risk factors for SMs with PTSD and TBI.

Table 2 Mean and SD for the symptom scores across mask classifications

Outcome

Psychological injury Metaphors

No Yes t No Yes t

PCL-M (n=349) 50.66 (16.26) 55.51 (14.24) −2.72** 52.06 (15.94) 51.83 (15.78) 0.132

PHQ-9 (n=282) 12.95 (6.16) 13.54 (6.22) −0.710 13.25 (6.23) 12.84 (6.09) 0.530

GAD-7 (n=75) 9.96 (5.74) 12.83 (6.47) −1.79 11.96 (6.05) 8.46 (5.36) 2.52*

Outcome

Military symbols Identification with military unit

No Yes t No Yes t

PCL-M (n=349) 51.51 (16.05) 55.54 (14.07) 1.53 52.59 (15.73) 42.52 (15.33) 2.847**

PHQ-9 (n=282) 13.03 (6.26) 13.72 (5.41) −0.572 13.3 (6.10) 9.75 (6.57) 2.255*

GAD-7 (n=75) 10.23 (5.87) 18.25 (2.22) −6.128** 10.93 (6.01) 6.80 (5.07) 1.497

*P<0.05, **p<0.01, ***p<0.1. GAD-7, Generalized Anxiety Disorder 7-item scale; PCL-M, PTSD Checklist for DSM-5; PHQ-9, Patient Health Questionnaire-9; PTSD, post- traumatic stress disorder.

Table 3 Mean differences in symptom scores for those whose masks showed evidence of metaphor subtypes

Variable (%
coded positive)

PCL-M (η2 =0.23)
sη2

PHQ-9 (η2 =0.28)
sη2

GAD-7 (η2 =0.50)
sη2No Yes F(1, 306) No Yes F(1, 245) No Yes F(1, 54)

Colour symbolism
(12.2%)

51.14 58.34 8.23** 0.03 13.92 16.96 7.18** 0.03 10.08 9.22 0.07 0.002

Cultural/historical
characters (5.7%)

55.71 53.78 0.27 0.001 16.80 14.07 3.53*** 0.02 13.10 6.20 9.19** 0.20

Sociocultural
symbols (11.4%)

56.08 53.41 0.88 0.001 16.33 14.54 2.09 0.003 13.22 6.08 6.57* 0.15

Nature metaphors
(8.9%)

57.46 52.03 3.38*** 0.01 16.11 14.77 1.23 0.003 10.53 8.76 0.92 0.01

All three analyses of covariance tests were controlled for time in service, ethnicity and officer status.
*P<0.05, **p<0.01, ***p<0.1 GAD-7, Generalized Anxiety Disorder 7-item scale; PCL-M, PTSD Checklist for DSM-5; PHQ-9, Patient Health Questionnaire-9; PTSD, post- traumatic stress disorder.

8 Kaimal G, et al. BMJ Open 2018;8:e021448. doi:10.1136/bmjopen-2017-021448

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Author affiliations
1Creative Arts Therapies, Drexel University College of Nursing and Health
Professions, Philadelphia, Pennsylvania, USA
2National Intrepid Center of Excellence, Walter Reed National Military Medical
Center, Bethesda, Maryland, USA
3Department of Psychology, The College of New Jersey, Stockton, New Jersey, USA
4Center for Neuroscience and Regenerative Medicine, Uniformed Services University
of the Health Sciences, Bethesda, Maryland, USA

Acknowledgements We are grateful to Dr Jesus Caban, Ms Kathy Williams, Ms
Pamela Fried, Ms Rebekka Dieterich-Hartwell and Ms Adele Gonzaga for help with
gathering literature and preparing the data set for analysis.

Contributors All the authors contributed to the study as follows: GK led the study
and conducted the review of the masks with MSW. JH conducted the statistical data
analysis. LMF and TJD helped with manuscript review, including the discussion and
implications sections. TJD designed the database protocol from which the clinical
data for the analysis were used and patient consents were obtained.

Funding We are grateful to the National Endowment for the Arts’ Creative Forces:
The NEA Military Healing Arts Network for providing funding to support this study.

Competing interests None declared.

Patient consent Not required.

ethics approval The study was conducted with approval from the Walter Reed
National Military Medical Center (Bethesda, Maryland, USA) institutional review
board, in accordance with all federal laws, regulations and standards of practice, as
well as those of the Department of Defense and the Departments of the Army, Navy
and Air Force and the partnering university.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement The raw data were shared between the institutions as
part of a data-sharing agreement. These data are not available for public sharing.

Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http:// creativecommons. org/
licenses/ by- nc/ 4. 0/

© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.

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• Observational study of associations between visual imagery and measures of depression, anxiety and post-traumatic stress among active-duty military service members with traumatic brain injury at the Walter Reed National Military Medical Center

Abstract
Methods
Setting
Patient and public involvement
Participants
Data sources
Data analysis
Results
Discussion
References

[page 18] [Mental Illness 2014; 6:5354]

Art therapy: an underutilized,
yet effective tool
Robert A. Bitonte,1 Marisa De Santo2
1Department of Physical Medicine and
Rehabilitation, University of California,
Irvine Medical Center, Orange, CA;
2University of California, Irvine, CA, USA

Abstract

Art therapy has been recognized as beneficial
and effective since first described by Adrian Hill
in 1942. Even before this time, art therapy was
utilized for moral reinforcement and psycho-
analysis. Art therapy aids patients with, but not
limited to, chronic illness, physical challenges,
and cancer in both pediatric and adult scenarios.
Although effective in patient care, the practice of
art therapy is extremely underutilized, especially
in suburban areas. While conducting our own
study in northeastern Ohio, USA, we found that
only one out of the five inpatient institutions in
the suburban area of Mahoning County, Ohio,
that we contacted provided continuous art ther-
apy to it’s patients. In the metropolitan area of
Cuyahoga County, Ohio, only eight of the twen-
ty-two inpatient institutions in the area provided
art therapy. There could be many reasons as to
why art therapy is not frequently used in these
areas, and medical institutions in general. The
cause of this could be the amount of research
done on the practice. Although difficult to con-
duct formal research on such a broad field, the
American Art Therapy Association has succeed-
ed in doing such, with studies showing improve-
ment of the patient groups emotionally and men-
tally in many case types.

Early works

Art is known as one of the earliest forms of
communication, dating back to the cave art of
the Paleolithic age.1 Art therapy has been
increasingly recognized as beneficial and
effective in the treatment of various types of
both mental and physical conditions. For
example, art therapy has shown to be effective
as a treatment for traumatic brain injury,
schizophrenia, sexual abuse, breast cancer,
post-traumatic stress disorder, as well as
numerous other conditions.2-6
This has been described and studied since

Adrian Hill’s published work in 1942. Art ther-
apy has been shown to be effective in a broad
range of conditions. It has been generally rec-
ognized that art therapy enhances communi-
cation, and bolsters self-esteem. Despite the

apparent effectiveness of art therapy, and its
ready acceptance by patients, the prevalence of
the utilization of art therapy was this studies’
inquiry. Despite ongoing and recent studies
showing art therapy to be beneficial, it’s uti-
lization appears to be underutilized for rea-
sons unknown at this time.
Adrian Hill is generally known as the first

person to use the term Art Therapy in 1942.
Many of his works of art are displayed in the
Imperial War Museum in London, works that
he painted from the front lines as an official
war artist during World War I. Hill personally
discovered the therapeutic quality of art mak-
ing when he was recovering from tuberculosis
himself in 1938, and recorded his ideas in 1945
in Art versus Illness.6 He was employed as the
first official art therapist in 1946 by the
Netherene, a state psychiatric hospital in the
United Kingdom. He later became the presi-
dent of the British Association of Art
Therapists. Hill’s contributions became a mile-
stone for the acceptance and practice of what
we know today as art therapy.

More developed practices
Art therapy is not specific in it’s practices,

making it customizable to the ever-changing
life of a patient. Adolescents who experience
abuse, low self-esteem, depression, or any
other psychological issues tend to withdraw
from their parental figures, which works
against traditional verbal therapy. Art therapy
is a way for these troubled adolescents to feel
expressive in a non-judgmental environment.7
Art therapy is also increasingly important with
children and adolescents facing chronic ill-
ness. These practices are used to enhance the
young patient’s emotional, physical, and cogni-
tive development. A very important example is
within the field of pediatric oncology, where
restoring self image for the patient is crucial to
continue battling their illness. Furthermore,
art therapy can provide some end-of-life care
for patients to create mementos for their fam-
ily before death, to help cope, and say
goodbye.6 These same principles are applicable
to adults as well. In adult oncology, art therapy
has been used to help survivors create a life
outside of cancer, helping these individuals
find their identity past their survivor label.6 Art
therapy in the healthcare setting has also been
used in adult cases of hemodialysis, HIV/AIDS,
Alzheimer’s, and traumatic brain injury. In
addition, adults with schizophrenia, bipolar
disorder, borderline personality disorder,
PTSD, trauma from sexual abuse, dementia,
and many other conditions can find lasting
benefits from art therapy.8 Again, although it
may be difficult to quantify the effectiveness of
art therapy, studies have repeatedly shown that
art therapy is beneficial to patients within a
broad spectrum of conditions.

Specific applications
Traumatic brain injury
In a pilot study addressing group art therapy for

patients with traumatic brain injury, six subjects
with traumatic brain injury between the ages of
24 and 71 participated in five one hour art therapy
sessions. The subjects were evaluated before and
after the study using the Depression Anxiety and
Stress Scales. Throughout the sessions, the sub-
jects participated in low-anxiety activities like
making collages and working with 3D figures.
After the study was completed, 4 of 6 subjects had
a decrease in depression, 3 of 6 had a decrease in
anxiety, and 5 of 6 had a decrease in stress.2

Schizophrenia
Several studies have been produced to show

the effectiveness of art therapy for schizophren-
ics. An interesting example is an 83-year-old male
schizophrenic who was not responding to med-
ications, and was reported by caretakers to have
very unusual behaviors. A psychiatrist initiated
art therapy practices with him, having him depict
parts of his life through drawing. The patient’s
verbal resistance began to disappear and the
patient’s progress was able to be documented.3

Sexual abuse
In a four-year follow up of a pilot study, it was

shown that for sexually abused children and ado-
lescents, art therapy, paired with cognitive behav-
ioral therapy, was an effective intervention to
reduce symptoms that are commonly associated
with childhood sexual abuse.4

Epilepsy in children and adoles-
cents
In a focus group with children with epilepsy,

the use of art enabled said children and adoles-

Mental Illness 2014; volume 6:5354

Correspondence: Marisa De Santo, 34102 Blue
Lantern, Dana Point, CA 92629, USA.
E-mail: mdesanto7@gmail.com

Key words: art, therapy, mental illness, head trauma.

Contributions: the authors contributed equally.

Conflict of interests: the authors declare no
potential conflict of interests.

Received for publication: 14 February 2014.
Accepted for publication: 14 February 2014.

This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).

©Copyright R.A. Bitonte and M. De Santo, 2014
Licensee PAGEPress, Italy
Mental Illness 2014; 6:5354
doi:10.4081/mi.2014.5354

[Mental Illness 2014; 6:5354] [page 19]

cents to express repressed emotions related to
their illness. With the finding that many of the
children in the focus group had never met
another adolescent afflicted with epilepsy, the
focus group served as an extremely valuable
outlet for these children and adolescents dur-
ing critical times in their lives. The art work
produced was able to record their growth along
the way, resulting in the participants feeling
self discovery and can be believed to aid in an
increase of social activity outside of the focus
group, rather than social isolation that can
become common in these cases.6

Acute stress disorder
In an intervention with a 48-year-old woman

who had injured a motorcyclist three weeks
prior in a car accident, the treatment seeked to
lower her overwhelming anxiety, sleep prob-
lems, heart palpitations, and excessive flash-
backs of the accident. With certain drawing
techniques and manipulation of various medi-
ums, and discussion of such in relation to her
experience with the art therapist, the client
was able to rearrange the sensory and cogni-
tive overexcitation, and thus feel a sense of
control over the traumatic experience.6

Study interest and design

The first author’s interest in the treatment

of traumatic brain injury, and the second
author’s interest in art, were the impetus of
interest for this study. Studied were two areas
in Ohio. An urban area Cuyahoga County
(which includes Metropolitan Cleveland), and
a more rural suburban Trumbull and Mahoning
counties were examined. The inquiry was to
determine the availability of art therapy servic-
es in both if these rural and urban atmos-
pheres in Northeast Ohio, in the midwest sec-
tion of the Unites States. The survey was per-
sonally conducted by the second author by
phone. Each listed inpatient psychiatric unit
was successfully contacted.

Results

Our study found that in urban Cuyahoga
County, only 8 of 22 (36%) inpatient facilities
utilize art therapy as a treatment modality. In
Trumbull and Mahoning counties, 1 of 5 (20%)
inpatient institutions offered and utilized art
therapy (Figure 1). Contrary to expectations,
we believed the practice of art therapy would
be much higher in urban areas, and our study
concluded that this is not necessarily true. We
attempted to clarify why art therapy was not
used in the non-utilizing-institutions. The
questionnaire included the response options
of i) lack of instructors; ii) lack of interest or
demand by staff or patients; iii) lack of support

personnel or administration; or iv) lack of
funding. This study was unable to locate per-
sons qualified to answer this inquiry and has
been left for further study.

Conclusions

Our concluding thoughts on this study is
that art therapy, although having the ability to
be beneficial to various patient populations, is
underutilized for unknown reasons at this
time. The underutilization of art therapy must
be studied and understood before progress can
be made. Advocacy can then be tailored to rem-
edy the precise reason for underutilization of
art therapy.

References

1. Roberts J.M. The new penguin history of
the new world. London: Penguin Books;
2007. pp 23-26.

2. Graves G. Group art therapy for patients
with traumatic brain injuries: a pilot study.
Degree Diss.; Virginia Commonwealth
University, Richmond, Virginia; 2006.

3. Morrow R. The use of art therapy in a
patient with chronic schizophrenia.
Jefferson Journal of Psychiatry. 1985.
Available from: http://jdc.jefferson.edu/cgi/
viewcontent.cgi?article=1084&context=je
ffjpsychiatry

4. Pifalo T. Art therapy with sexually abused
children and adolescents: extended
research study. Art Therapy 2006;23:181-5.

5. Chang F. From emptiness to energizing
body. In: Malchiodi CA, ed. Art therapy and
health care. New York: The Guilford Press;
2013. p 154.

6. Malchiodi CA. Art therapy and health care.
New York: Guilford Press; 2013.

7. Riley S. Art therapy with adolescents.
Western J Med 2013;175:54-7.

8. Rivera RA. Art therapy for individuals with
severe mental illness. Masters Diss.;
University of Southern California, Los
Angeles, USA; 2008.

Review

Figure 1. Institutions that conduct and do not conduct at therapy in Trumbull and
Mahoning Counties versus Cuyahoga County.