Medical Art Therapy
It’s my pleasure to share this excellent article from one of my students, Helen Gorgievski, a medical practitioner. Helen wrote this essay as part of her coursework for the Art Therapy Diploma Course.
Robert GrayDirector and Senior Lecturer at CECAT
Registered Art Therapist and Psychologist
MA A. Th., AThR; B. Soc. Sc. (Psych.) (Hons.), MAPS.; BA. Theol. (Hons), MA Theol.
Medical Art Therapy
As a medical practitioner, I am drawn the different ways Art Therapy can be used in medical environments which have traditionally shown little interest in treatments outside of a so-called “medical” framework.
In this essay, I will explore some of the areas of medicine in which Art Therapy is being recognised as having an evidence-based position in supporting a person’s journey towards mental and physical health.
Neuroscientific advances have added to our understanding of the mechanisms by which Art Therapy achieves its results – it appears that “non-verbal expressive therapies such as art, dance, music, poetry and drama all activate the subcortical regions of the brain and access preverbal memories” (Talwar in Rubin 2016, p. 155) and that Art Therapy facilitate the development of new neural connections through techniques such as Creative Mind Ordering (Gray, 2019).
In the context of a growing awareness of a biological basis for mind- body links, therapies outside the conventional medical treatments are gaining more acceptance within the medical field, assisted by researchers such as A/Prof. Juliet King, George Washington University, Washington, DC, with her research into Art Therapy and neuroscience (undefined [CPNAS]. (2018, October 3). Juliet King).
Medical Art Therapy
Malchiodi defines medical Art Therapy as “the use of art expression and imagery with individuals who are physically ill, experiencing trauma to the body, or who are undergoing aggressive medical treatment such as surgery or chemotherapy”. She contrasts this focus with the more traditional use of art as a component of psychotherapy (Malchiodi, 1993; Resources, 2019)
Within the medical and health areas, Art Therapy can be used both as ‘art as therapy’ (providing opportunities for people with a medical illness to participate in art-making activities to help them express their emotions and experiences related to their illness) and ‘art in therapy’ (helping reduce the negative psychological effects that people with a medical illness may experience, as well as enhancing positive responses which can occur including improve communication, empowerment, personal growth, and insight into illness).
It is well known that if we manage and improve a patient’s psychological health, their physical health recovery will also improve. (Resources, 2019)
Psychological benefits of Art Therapy include facilitation of communication (with family, other patients and health care providers), client/patient empowerment (in situations where they may experience significant loss of control), personal growth (with development or strengthening of personal strengths to assist them to cope with the difficult situation they are in) and insight into their illness (with patients developing an understanding of what their illness means to them and being able to communicate this to others including their treating medical team).
Medical Conditions & Art Therapy
There are numerous conditions in which Art Therapy is being utilised in some way and include cancer, epilepsy, chronic pain, mental health conditions such as depression and anxiety, schizophrenia, bipolar disorder and Borderline Personality Disorder, Autism Spectrum Disorder, dementias, traumatic brain injury, responses to traumatic events including combat-related PTSD and childhood sexual abuse (complex PTSD), eating disorders, substance use disorder and other chronic illnesses including asthma. More recently, interest has focussed on the use of Art Therapy in helping people experiencing burnout, especially in high-pressure medical environments such as oncology and palliative care. The COVID pandemic has widened this effect to include health workers generally.
I will consider some of these areas and some of the evidence that is being collated to support the use of Art Therapy as part of the holistic treatment of these conditions. (Malchodi, 2013, Stuckey & Nobel)
General symptoms of illness: A study of some very general symptoms – pain, anxiety and low mood – experienced by a wide variety of hospital patients with a range of medical conditions, showed bedside Art Therapy sessions resulted significant improvements in the symptoms, and the authors suggested the possibility of Art Therapy being a safe, cost-effective adjunct to traditional medical management in these situations (Shella, 2018).
Cancer: Studies have provided strong evidence that Art Therapy can have benefits for women undergoing treatment for breast cancer. A randomised controlled study showed an improvement in overall quality of life, more specifically in total health including physical and psychological health (Svensk etal.,2009). A recent literature review on the effects of Art Therapy in people with a range of different cancers suggested that art therapy could decrease symptoms of anxiety and depression and improve quality of life in these people. (Bosman et al., 2020).
Parkinson’s Disease: A study using a clay manipulation Art Therapy intervention found patients with Parkinson’s disease can benefit in psychological areas – decreased obsessive-compulsive thinking, depression, phobic changes. Physical changes in resting tremor, gait, affect, and movement fluidity are the subject of further study (Elkis-Abuhoff &Gaydos, 2018).
Mild Cognitive Impairment: Mild cognitive impairment (MCI) is usually seen before more severe cognitive deterioration and dementia. The possibility of treatment which may halt and even reverse this process is obviously very significant but there has been little progress in this area. Mahendran et al conducted a pilot study of the use of Art Therapy in patients diagnosed with MCI. The treatment group (guided art viewing, art creation and music listening and recall) showed significant improvement in the neurocognitive domains at 3 months, which was sustained at 9 months, compared with the control group (standard care – no intervention) (Mahendran et al., 2018)
Epilepsy: Observations following an Art Therapy focus group consisting of children with epilepsy indicated that the children were enabled to open up about their emotions related to having epilepsy and that they were able to make social connections with other children with epilepsy that they had not previously been able to make and which were able to continue after the focus group (Bitone & De Santo, 2014; Malchodi, 2013).
Asthma: A randomised controlled trial using Art Therapy (weekly for 7 weeks) with children with asthma showed improved worry and anxiety, communication and total quality of life scores in the treatment group, some of which were maintained at 6 months compared with the control group. The frequency of exacerbations did not differ between the two groups, but it is reasonable to assume that the treatment group were able to manage their asthma with less emotional distress. (Beebe and Bender, 2010).
Substance Use Disorder (SUD): Researchers have reviewed the use of Art Therapy in SUD in the United States, which has been utilised since the 1950s and is acknowledged as having a valid role in the management of addictions by the American Art Therapy Association, with a wide range of benefits documented. Some of the mechanisms include expression of emotions and feelings such as stress, anxiety through non-verbal, visual creative exercises. It can be seen that clients in the art therapy treatment show decreased denial, reduced opposition to drug and alcohol treatment and reduced shame (Aletraris et al., 2014)
Combat-related PTSD: Traumatic memories may be stored non-verbally and so may not be accessed with verbal therapies, and Art Therapy can access those memories in a safe way. Art making may involve bilateral stimulation of the prefrontal cortex which suggests a mechanism similar to EMDR therapy often used in treating people who have experienced trauma.
A small randomised controlled trial was carried out with veterans with combat–related PTSD, to assess if combining Art Therapy with Cognitive Processing Therapy (CPT – a therapy with similarities to CBT) was more effective than CPT alone. While the depression and PTSD symptom scores improved, there was no significant difference between the 2 groups. However, in the Art Therapy + CPT group, trauma processing improved, and veterans reported it provided healthy distancing, enhanced trauma recall and increased access to emotions. (Campbell et al., 2016).
Depression in older people: a multi-study review showed mainly positive findings for the use of creative arts therapies in helping with depression in older adults. In the studies looking Art Therapy interventions, proposed mechanisms by which these changes were achieved were common to many of the studies and included:
- the use of creative activities with physical aspects can result in relaxation and reduction in stress levels,
- the use of creative activities which are culturally appropriate for those people can evoke familiarity and positive memories
- creating art products can enable externalisation and visual communication of internal experiences and emotions as well as a sense of mastery with completing an artwork
- artmaking can assist in recalling positive memories
- group artwork can encourage socialization and sharing among participants (Dunphy et al., 2019).
Schizophrenia: (I have covered the use of Art Therapy in this area in slightly more detail as it is an area of interest of mine and the area in which I am currently working).
It has been suggested that Art Therapy can assist people with schizophrenia, but the evidence appears to be uncertain. Studies have provided some evidence that an Art Therapy intervention (painting therapy for 6 months) improved negative symptoms of schizophrenia in participants (Richardson et al., 2007) and that a group painting treatment (which included reflective activities with the artmaking) boosted self-esteem and social function in its participants (Teglbjaerg, 2011).
Montag (2014) carried out a study in which an Art Therapy group was compared with a treatment as usual (TAU) group and showed an improvement in positive (hallucinations, delusions, thought form disorganisation) and negative (withdrawal, loss of interest, loss of selfcare) symptoms in patients with schizophrenia ,as well as increased awareness of their emotions and those of others (Montag et al, 2014). This conflicted with an earlier study that concluded that Art Therapy interventions did not result in improvements in symptoms (Crawford et al, 2012). However, the design of the Art Therapy interventions differed between the 2 studies: the study by Montag, which showed symptomatic benefit, used a more psychodynamic approach with more active involvement by the therapist, who helped the participants to understand the images and provided time for viewing and reflecting on the images (art in therapy). Crawford et al utilised an intervention with very little structure (more of an art as therapy approach).
A more recent review of 20 studies concluded that it was not clear whether Art Therapy produces clinical improvements in people with schizophrenia (Ruiz, Aceituno & Rada, 2017). Some of the reasons for this, as well as variations in study designs and art therapy intervention as discussed above, may be low attendance and retention rates which may be inherent in working with people with severe mental illness such as schizophrenia where their illness impacts motivation, organisational skills, trust in health providers, financial limits on transport etc.
Burnout: An area that has attracted multiple researchers is the significant problem of health professional burnout (or compassion fatigue) and how it impacts not only on their personal health but also the quality of the care they are able to give to their patients. Many of the studies were completed pre-COVID and identified that burnout was a major problem– it can only have increased dramatically with the impact of the COVID-19 pandemic.
One specific group of healthcare workers who have attracted a lot of attention regarding burnout are staff in Oncology and Palliative Care and there have been several studies looking at the use of Art Therapy to assist with reducing burnout in these workers.
Studies have included dual arm designs and single groups and have used tools such as the Maslach Burnout inventory, which is a widely used tool in research and clinical settings. Groups commonly studied have been Oncology clinical staff and those working in Palliative Care – people who experience significant physical, psychological, and spiritual strain. The studies reviewed found that interventions including Art Therapy-based supervision (Potash et al., 2014), Mindful-Compassion Art-Based Therapy -MCAT (Ho et al, 2021) and a series of structured group activities (Italia et al., 2007, Tjasink & Soosaiplillai, 2019) all suggested that Art Therapy could reduce burnout in high-risk groups of health professionals.
Describing the history of Art Therapy and reviewing the effectiveness of its clinical applications in medical situations can only be a partial attempt to understand what Art Therapy is, and its value as a therapy in all aspects of people’s health.
What drives my passion for art in therapy is its ability to bring the unconscious to consciousness in a way that enhances self-understanding, both of personal identity but also of ongoing behaviours, including those affecting health. The ability of the Art Therapy process to bring forth thoughts and feelings that we are not aware of, but that influence our lives greatly is invaluable, especially for people who may struggle to put their thoughts into words. The fact that artistic “ability” is not required makes it more accessible and comfortable for many people.
Art as therapy provides benefits across a wide range of domains including the physical work of art making, enjoyment and sense of satisfaction in creating art, social interaction in group activities, potential opportunities for mindfulness activities, sense of mastery of new skills and playfulness, often in people who have not allowed themselves to enjoy artmaking for many years.
From a personal point of view, as well as my interest in the use of art therapy in medical settings, I have also been fascinated by the effectiveness of the art therapy exercises that I have completed in the CECAT Certificate of Art Therapy course. Their ability to uncover hidden schemas and increase my insight into how those schemas are operating in my life are experiences that I hope will give me insight into how different art therapy exercises may help my future clients:
Module 2: “Life scripts” – was very helpful in identifying those “rules” or schemas which are driving my choices and behaviours.
Module 10: “Emotions, Chaos and Creativity: draw your current feelings and emotions –identified aspects of my current state of mind that I had partial awareness of but prompted a response that, while quite counterintuitive, was surprisingly helpful.
This for me illustrated Pat Allen’s comment:
our particular feelings, like anxiety or anger, become like the colours we paint with, and we can decide to turn them down or eliminate them from a palette for a while and see how the overall work is shaping up with fresh colours.”
(Allen in Rubin, 2016)
Art Therapy is a wonderful blending of body and mind and strengthens our understanding of ourselves and our environments. For many people it can be a new avenue to experiencing a healthier way of living, mentally and emotionally, via means that are surprising and satisfying. It can also play a direct role in our physical health and healing from illness.
While many of the studies in the use of Art Therapy in medical contexts cited have small sample sizes, there are numerous other studies that I have not included, many of which are adding to the growing body of evidence for the specific benefits of art therapy as part of a wholistic approach to healthcare. However, lack of consistency in study design including intervention design can make it difficult to show statistical benefit. As it is not practical or therapeutic to develop a standardised therapy program for all study participants, and measurement tools are limited and subjective, study designs which may work well with a physical intervention, may not produce accurate results in a therapy such as Art Therapy (Chiang, Reid-Varley & Fan, 2019).
The mechanisms by which art therapy may result in physical benefits are topics being investigated, including research being carried out in the area of neuroscience and art therapy. The continuing growth in knowledge regarding connections between the body and the mind will help explore this area further.
This will hopefully bring the two disciplines of Medicine and Art Therapy closer and help implant Art Therapy in the range of treatments that we can offer people in their journey towards health, however that may look for the individual person.
However, while art therapy’s acceptance amongst more conventional medical practice providers may be growing, I suspect that there will always be a slightly tenuous connection between conventional medicine and art therapy. Potentially, medicine will attempt to develop it into an entirely ‘evidence-based’ therapy, which would lose some of the ‘magic’ and wonder that art therapy is able to bring to us.
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