Review Article

The “State of The Art” of Art Therapy in Psychiatry: Reflections on International Evidences and Italian Experiences

Caterina Viganò¹*, Michela Wenk², Luca Ferrara^1,3, Roberta Magnotti³ and Serena Borsani³

¹Department of Biomedical and Clinical Sciences “Luigi Sacco”, Università degli Studi di Milano, Italy

²Bachelor’s Degree Course in Psychiatric Rehabilitation Techniques, Università degli Studi di Milano, Italy

³ Psychiatric Rehabilitative Centres Unit, ASST Fatebenefratelli Sacco, Italy

Submission:October 14, 2019; Published:October 31, 2019

*Corresponding author:Caterina Viganò, Department of Biomedical and Clinical Sciences “Luigi Sacco”, Università degli Studi di Milano, Psychiatry 2 Unit, Pad 60, PO Sacco, Via GB Grassi 74, 20154 Milano, Italy

How to cite this article: Caterina Viganò, Michela Wenk, Luca Ferrara, Roberta Magnotti, Serena Borsani. The “State of The Art” of Art Therapy in Psychiatry: Reflections on International Evidences and Italian Experiences. J Complement Med Alt Healthcare. 2019; 10(5): 555796.DOI: 10.19080/JCMAH.2019.10.555796

Abstract

The complex and reciprocal dialectic between art and psychiatry has represented the object of investigation of many researchers for many years in last century, although a specific role of art therapy in psychiatric. The art-therapies are currently conceptualized as forms of psychotherapy employing artistic media (painting, dance, theatre, music etc.) as an expressive and receptive communication modalities. In Italy, along the XX century there has been a growing diffusion of art-therapies as rehabilitation techniques in several settings. The currently available empirical evidence suggests a relevant role for art-therapies in psychiatry, especially for psychotic’s patients with negative symptoms and depression. This brief summary has not set as its objective a critical reevaluation of all the studies present in the literature on Art Therapy, a task left to the experts of the meta analyses and reviews but wants to be a reflection on some limits of the current studies. Final point is on the Italian reality: despite the evidence and the ten-year tradition on Art Therapies in Italy, they have a fairly wide spread in the rehabilitation services of the Mental Health Departments and Art Therapy is still confused as “socialization” or as techniques of which little is known about the effect. This confusion refers to the need for training on the subject to be constant for psychiatric service operators and for scientific researchers to produce evidence that can be used to finalize its use in a personalized way with a view to an increasingly modern precision medicine.

Keywords: Art therapy; Psychosis; Depression; Psychiatric rehabilitation

Introduction

The complex and reciprocal dialectic between art and psychiatry has represented the object of investigation of many researchers for many years in last century [1-9]. In the last few decades the concept of “Art Therapy” has been developed and reshaped in many different ways and has often been associated with various Anglo-Saxon expressions such as “Creative Art Therapies” or “Expressive Therapies”. Following the definition given by the British Association of Art Therapists, Art Therapy is a “form of psychotherapy that uses graphic-pictorial artistic means, but not only, as a primary mode of communication” [10]. This definition, however, favours a conceptualisation of Art Therapy meant as “art in therapy” (art represents an expressive and emotionally immediate means to be placed within a more structured psychotherapeutic path), to the detriment of the conceptualization known as “art as therapy” (that is, art as a form of re-socializing therapy and that eases emotional expression itself), doubtful for many, but still widely represented in the context of psychiatric rehabilitation [11,12].

In Italy, Art Therapy has experienced a substantially bimodal spread. An initial interest in the use of the arts in psychiatry in Italy lies at the end of world conflicts and has substantially followed, in the context of psychiatric hospitals, the international orientation ruled by the current psychoanalytic thought [13,14]. In the subsequent decades of the twentieth century, different art-therapeutic approaches have spread in Italy, based on empirical evidence (although not systematically collected and sometimes anything but methodologically flawless) relating to the good impact on resocialisation processes and reasonable costs. However, after the gradual closure of psychiatric hospitals, the parallel shift towards community-oriented psychiatry paradigms, the critical review of psychoanalytic paradigms, associated with an indiscriminate (or, more often, inappropriate) application of the above mentioned techniques have probably led to a drift that has dragged the Art Therapies, like other rehabilitative approaches, increasingly towards entertainment and less and less towards a real psychiatric rehabilitation [15-18].

With the transition to the third millennium, the use of art in psychiatric rehabilitation has experienced a new impulse associated with greater methodological rigor and the accumulation of growing scientific evidence. Several randomized controlled trials have been conducted and they have demonstrated the effectiveness of such rehabilitative approaches as an additional treatment in different mental and neurological disorders [19-29]. This second peak of interest in the application of artistic disciplines to psychiatric rehabilitation was not only associated with a greater methodological rigor in documenting the effectiveness of these approaches, with standardized and reproducible outcome assessments, but also and above all through the application of reference models that are no longer exclusively psychoanalytic (many approaches of cognitive, narrative, systemic-relational orientation, centered on the person, etc. have spread), extension to populations (not just patients with chronic psychoses, but patients with various psychiatric diagnoses, often with a recent history of illness and different levels of severity) and different settings (above all, territorial psychiatric facilities and rehabilitation residences, in short-term and long-term programs) as analyzed in recent reviews and meta-analysis [30,31]. Finally, the National Collaborating Center for Mental Health [32] has also included the “Art Therapies” among the recommended treatment to promote (together with a structured psychotherapy) the healing of patients with schizophrenia, especially if young and with prevalent affective and/or negative symptoms. In the last decade some evidences of its effectiveness on specific psychological and symptomatological dimensions and in different age groups are appearing, even if an agreement does not yet exist.

Art Therapy and Psychotic Disorders

A few years have passed since the well-known RCT of the English group of Mike Crawford (Matisse Project Team) [33] which, through a severe RCT, stated that the use of Art Therapy was not more effective than other standard techniques in improving global functioning for schizophrenic patients [34]. Since then, studies have appeared in literature that, always analyzing the therapeutic effect of Art Therapy for schizophrenic patients, have used less quantitative standard dimensions as indicators, that show that they seem to reduce the expression of negative symptoms in schizophrenia, improve self-knowledge, interpersonal skills and affective development. For example, another study always conducted in the United Kingdom on acute psychiatric inpatients has stressed that participation in structured sessions of Art Therapy can change the subjective experience in a positive sense and restore a sense of hope in the future, increase participants’ level of emotional awareness and ability to reflect on other people’s emotional states, thus indirectly acting on positive affective dimensions and recovery [35]. Very similar is the result of another study conducted in Norway [36] that aimed more at investigating the mechanisms of action of Art Therapy rather than the effects on psychiatric symptoms, observing an improvement in the insight and management of positive symptoms. The authors confirm that Art Therapy is effective especially when inserted into integrated treatment programs.

In a meta-analysis conducted by De Silva MJ et al. [37] the Art Therapies still show common positive efficacy profiles like other psychosocial interventions conducted for psychotic patients.

Angelica Attard and Michael Larkin published a review of the literature on the effectiveness of Art Therapy for psychotic patients in 2016 and concluded that valid studies are still a small number in literature. Among these 18 High-quality quantitative articles provided inconclusive evidence for the efficacy of Art Therapy in adults with psychosis. However, high-quality qualitative articles should be considered as Art Therapy to be beneficial, meaningful, and acceptable, although this conclusion is based on a small number of studies [38]. A limitation inherent in randomized clinical trials that aim at measuring the effectiveness of Art Therapy in psychotic patients is the use of standard symptom outcome indicators (positive symptoms, negative symptoms) [39] while it would be more appropriate to use more extensive indicators that also take into account qualitative and subjective dimensions and emotional experiences, indicators more suitable to measure the subjective effect of these techniques that have a psychotherapeutic value. In a study conducted on patients dwelling in community facilities (psychiatric rehabilitation community and day center) using the ESM (optimal experience or flow method, to evaluate a state characterized by the perception of high challenges and high skills, deep concentration, positive affect, clear goals, control and autonomous motivation, which contributes to individuals’ well-being) this state is most evident in some rehabilitation activities including Art Therapy and instead does not occur in non-structured or leisure time [40]. Several authors have emphasized as a limit in the design of RCT for these techniques the need for patient motivation to the activity, a condition that enables a constant adherence to the activity itself [34].

Art Therapy and Non-Psychotic Disorders

A recent 2017 review of the Uttley and Sutton (UK) group conducted on articles published up to 2013 highlighted that benefits associated with Art Therapy included the following: the development of relationships with the therapist and other group members; understanding the self/own illness/the future; gaining perspective; distraction; personal achievement; expression; relaxation; and empowerment. Small numbers of patients reported varying reasons for not wanting to take part, and some highlighted potentially negative effects of Art Therapy which included the evoking of feelings which could not be resolved. The findings suggest that for the majority of respondents Art Therapy was an acceptable intervention, although this was not the case for all respondents. Therefore, attention should be focused on both identifying those who are most likely to benefit from Art Therapy and ensuring any potential harms are minimized [41].

Art Therapy and Action on Internalizing Symptoms and Depression

Most studies in the literature on art and depression concern the elderly population. Dunphy K et al. [21] have published a systematic review on the use of artistic techniques for elderly depressed patients, selecting those conducted by specialized professionals came out to confirm the use of artistic techniques in the improvement not only of mood and of physical state of the people, more connected to the techniques like dance movement- therapy and dramatherapy but more generally of the subjective perception of well-being and enhanced self-concept, of the processes of elaboration of the emotions, of the cognitive functions like memory [20,21].

Less data are available on the very young even if for the 14- 18 age group, in a controlled clinical study, we have seen that participation in Art Therapy sessions for short periods (6 sessions) improves the dimension of internalization, which is often linked to depressive and anxiety symptoms and withdrawal, thus providing a more solid theoretical basis for the use of these techniques in adolescents with anxiety, depression and withdrawal disorders [42].

Conclusion

This brief summary has not set as its objective a critical re-evaluation of all the studies present in the literature on Art Therapy, a task left to the experts of the meta-analyses and reviews, but wants to be a reflection on some limits of the current studies that use only the impact of the technique on symptom resolution as indicators, classic approach for clinical trials on psychiatric drugs or punctual interventional techniques (surgery) but less suitable to probe the effect of intervention techniques that act on more complex dimensions of the person, such as self-perception and of one’s emotions, the ability to get in touch with one’s own intrapsychic experience, with the emotions of others, without falling into the classic bias of product measurement (artistic product) because the product of the creative action of the Art Therapy session in psychiatric rehabilitation often finds its explanation in the dimension of the relationship more than in the product itself. What is now shared by several authors is that Art Therapy is not improvisation, it is a psychotherapeutic and rehabilitative technique that requires specialized training to be applied; it is therefore a technique that cannot be improvised.

Despite the need for trained personnel, it seems that in the studies on the costs of the different interventions, Art Therapy does not seem more expensive than other ones, as highlighted by Lesley Uttley in 2015 with the PROSPERO study for the National Institute for Health Research Health Technology Assessment [29] where he states that Art Therapy was associated with positive effects when compared with a control in a number of studies in patients with different clinical profiles, and it was reported to be an acceptable treatment and was associated with a number of benefits. Art Therapy appeared to be cost-effective compared with waitlist, but further studies are needed to confirm this finding as well as evidence to inform future cost-effective analyses of Art Therapy versus other treatments. Final point on the Italian reality. Despite the evidence and the ten-year tradition on Art Therapies in Italy, they are still perceived as “socialization” or as techniques of which little is known about the effect. Although expressive techniques, including Art Therapy, have a fairly wide spread in the rehabilitation services of the Mental Health Departments, reaching about 10.5% of all structured group activities implemented in Lombard rehabilitation services [43] and about 8.5% in the national average, as shown in a survey conducted in 2013 on the national territory by the Italian Society of Psychosocial Rehabilitation [44]. There is still a lot of confusion among operators in differential terms between what is defined as an artistic expressive technique and what is instead a simple socialization intervention or an occupational activity during which sonorous means are used, such as singing, drawing, or still production of artefacts. These interventions also have their own dignity but cannot be defined as “expressive” and are often conducted by operators without specific training in arts-therapies or at least in psychotherapy. In the reality of psychiatric services it is not rare to see activities such as singing, painting, decoration, production of artefacts or to generally socializing activities (for example, karaoke) conducted by personnel without a specific artistic or psychotherapeutic training defined as “Art Therapies” or structured group activities led by trained therapists to be ascribed into the performance registration system as “group socializing activities”. This confusion refers to the need for training on the subject to be constant for psychiatric service operators, taking into account the turnover that is occurring in this field and for scientific research to produce evidence that can be used to finalize its use in a personalized way with a view to an increasingly modern precision medicine.

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