I would agree that arts therapies have the potential to be helpful in mental health work. But the key word is "potential." Mental health professionals have the ethical responsibility of testing their proposed interventions carefully before using them with clients or patients. A good place to start with that testing would be to draw from one's graduate coursework and supervised research experiences to design suitable studies, or to scan peer-reviewed journals for authoritative reviews of the pertinent literature. It could be unethical and dangerous to apply an intervention on purely notional grounds without first establishing that it has empirical support. If I were placing my healthcare in the hands of qualified professionals I would expect them to have a rational basis for the treatment plan they are recommending.

Yes, there has naturally been a strong rational approach in mental health therapies over the last decade in Australia, linked to the focus on evidence-based practice and the promising outcomes (albeit typically short-term outcomes) associated with cognitive-behavioural approaches in a number of studies, for a number of conditions/diagnoses, and across a range of contexts.

I remember though, when inpatient stays were longer in psychiatry, 15 years or so ago, we had a drama therapist who came in to the ward each week, and in the psychiatric disability support services at the same time there was a strong use of art therapy in residential programs.

These therapeutic approaches were very well received and regarded by people residing within these settings.

Geoffrey raises understandable concerns regarding the need for further empirical testing to clarify potential benefits and any problems arising from these approaches.

There are a couple of studies I am aware of, in adults, that would be worth a look:

Slayton, S. C., D'Archer, J., & Kaplan, F. (2010). Outcome studies on the efficacy of art therapy: A review of findings. Art Therapy, 27(3), 108-118.

This paper reviewed about 8 years of outcome literature regarding art therapy. Results were modest but indicate potential.

Colouring mandalas specifically has been found to reduce anxiety; though the test population was undergraduate students rather than participants experiencing psychiatric ill health and treatment:

Curry, N. A., & Kasser, T. (2005). Can coloring mandalas reduce anxiety?. Art Therapy, 22(2), 81-85.

Of course there is quite a sizeable body of literature regarding therapies that utilise drawing with children, and in particular children who have experienced trauma, abuse and/or mental ill health.

Dear Geoffrey, Melissa and Marisol,

thank you for interesting answers and links. In music therapy and also other arts therapies the corpus of evidences grow. And what we can probably conclude from psychotherapy research (e.g. Wampold et al.) that common factors are of much more relevance than specific therapy methods or techniques. But if an intervention is supported by the health care system it is hard to build up studies that compare the accepted intervention with new or alternative methods. I think that it is not only a question of evidences. Its also an ethical and humanistic question.

What do you think?

Regards Thomas

I add some music therapy meta-analyses:

Standley, J. (1986). Music research in medical/dental treatment. Meta-analysis and clinical applications. Journal of Music Therapy, 23(2), 56-122.

Koger, S. M., Chapin, K., & Brotons, M. (1999). Is music therapy an effective intervention for dementia? A meta-analytic review of literature. Journal of Music Therapy, 36(1), 2-15.

Standley, J. M. (2002). A Meta-Analysis of the Efficacy of Music Therapy for Premature Infants. Journal of Pediatric Nursing, 17(2), 107-112.

You, Z. Y. & Wang, J. Z. (2002). Meta-analysis of assisted music therapy for chronic schizophrenia. Zhongguo Yi Xue Ke Xue Yuan Xue Bao, 24(6). 564-567.

Silverman, M. J. (2003). The influence of music on the symptoms of psychosis. A meta-analysis. Journal of Music Therapy, 40(1), 27-40.

Gold, C., Voracek, M. & Wigram, T. (2004). Effects of music therapy for children and adolescents with psychopathology. A meta-analysis. Journal of Child Psychology and Psychiatry, 45(6), 1054-1063.

Vink, A.C., Birks, J. S., Bruinsma, M. S. & Scholten, R. J. S. (2003). Music therapy for people with dementia. The Cochrane Database of Systematic Reviews 2003, 4, DOI. 10.1002/14651858.CD003477.

Pelletier, C.L (2004). The effect of music on decreasing arousal due to stress. A meta-analysis. Journal of Music Therapy, 41(3).192-214.

Whipple, J. (2004). Music intervention for children and adolescents with Autism. A meta-analysis. Journal of Music Therapy, 41(2), 90-106.

Bradt, J. & Dileo, C. (2005). Meta-analysis cardio, cancer, and rehabilitation. Unpubliziertes Manuskript.

Gold C, Heldal TO, Dahle T, Wigram T (2005): Music therapy for schizophrenia or schizophrenia-like illnesses (Review) Copyright ©2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Pešek, U. (2005). Metaanalyse zur Effektivität von Musiktherapie. Eberhard-Karls-Universität Tübingen. Unveröffentlichte Diplomarbeit.

Gold C, Wigram T, Elefant C (2006): Music therapy for autistic spectrum disorder (Review) Copyright © 2010 The Cochrane Collaboration.

Bradt J, Dileo C: Music therapy for end-of-life care (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

Bradt J, Dileo C, Grocke D: Music interventions for mechanically ventilated patients (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

Bradt J, Magee WL, Dileo C, Wheeler BL, McGilloway E: Music therapy for acquired brain injury (Review) Copyright © 2010 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

Hello Thomas,

I was so pleased to read your question, and the responses. I look forward to more dialogue on your subject.

My dissertation research has been designated as one in the Medical Humanities. It was a quantitative study. I'm proud of it.

There are a number of factors that figure into your challenges with gaining legitimacy for your interventions You are you licensed? You have an advanced degree? You follow a code of ethics? Then you have permission to use therapies that resonate with the patients you treat. . "Do no harm" doesn't mean "Do no good".

Furthermore, I believe you have a responsibility to do some naturalistic research in order to inform and advance existing science.

You are talking about interventions that may not be measurable...YET...with existing methodologies, The time will come.

Lacking measurement tools does not mean that your ideas are notional. Creating concepts is your challenge, and for this, the existing research can be most useful.

Research is highly political; Funding is highly political too, with professions at odds instead of working together.

A very critical issue is concern about researching Vulnerable Populations. Human Subjects approval is very stringent, with good reason, but that doesn't mean that with a good research design, you should be denied access to study populations. Alas this is a struggle for anyone out of the medical profession and psychologist collaborators , or outside major research centers. Use your own small "N"s right now, and engage an academic colleague as an advisor

Things change significantly. There was a transition from Freud to Carl Rogers, wasn't there?

You have a good question. It deserves a search and a Re-search.

I support you. If you feel that my comments are helpful to you, I am happy to correspond some more.

Best Regards, Janet D'Arcangelo

Re 'I don't think there is a way in which art can do any harm'; art can tap in to both emotion and memory. [Indeed we choose to attend a concert, a play, a gallery, etc. to seek such experiences.] This can be risky if a participant is acutely unwell, if personality traits are such that emotion regulation is poor or impulsivity high, etc.

For example, a seemingly simple task - "Draw your family" - can produce distress or confusion at a time of parental separation or divorce in some children. Further, the task may not produce distress but the subsequent discussion then might; e.g. asking "Who is in the picture?" "Is anyone missing?" "Tell me about the family."

There will be a need to think through the right timing of art interventions, the right duration, the right explanation of the interventions, the required debriefing and or processing of content the art raises, and availability of support in the period thereafter should the intervention give rise to distress a few hours/a day/a week later, etc.

Dear Marisol,

Art interventions by an untrained therapist can definetly cause harm. This is why art interventions need to be left to the certified art therapist. Fluid mediums with tactile engagement are very regressive. Putting such art materials in front of a person not ready for the sometimes automatic regression that can transpire, is unethical.

As for the initial question posed here. I find it upsetting that after years and years of many empirical quantitative studies that we, the art therapists, are still be dismissed as "soft science" only. I think Psy.D's and MD's need to be more open minded and open their eyes to the research that already exists. Efficacy has been proven. What is needed is collaboration between us all, with respect for what we each bring to the table.

I think some of them definitely helps in patients such as dementia,depression and some problems of childhood disorders.But it will be a combination of medicinal treatment and art therapy for effective prognosis and better intervention of the disordered people.

There is sufficient literature related to the use of art, dance, and music as a treatment modality for psychology and psychiatry. There is an excellent film from the University of Berkeley that I have used in one of my classes re: dance - Looking for Me. The use of these therapies depends upon the institution-private versus public. Anyway, one just needs to spend time doing search. When it comes to music, I play the pedal harp, and I use music as an adjunct to treatment.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62246-1/abstract

Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs:

Art therapies themselves offer an effective way of diverting thought towards constructive and creative pathways if directed properly. I agree with Teresa above that where they are done by an untrained therapist that harm might occur and that of course is true with most untrained therapists. Improving cognition through art can distract thought away from the insidious and disturbing thoughts that might occupy a patient otherwise and even lead to changes in physical neural pathways that can positively effect thought processes. It is possible that any creative project would be able to do this and therapies based on scientific interests or drama should also work.

I further agree with Teresa that simply giving art materials to a disturbed person would be a mistake. Art can unloose dark and disturbing thoughts too and can provide a platform for presenting, and consequently exacerbating mental disorder. The work of many of our most famous artists and knowledge of their often awful mental trauma clearly shows that.

Hi Thomas, thank you so much for an initiating an extremely valuable discussion, at least from my perspective.

Having for a few years observed the positive impact of art psychotherapy on patients and service users, as well as organisational challenges faced by an art psychotherapy department of one of the NHS Trusts (eventually closed), I hoped to contribute to the development of research in the field of arts therapies and embarked on a PhD. I am a psychologist (and a believer in the value of arts in psychotherapy, in addition to verbal interventions) and I started my project in 2010 with a “mission” to raise awareness of often profound benefits of arts therapies. Little did I know at that time about the challenges of research in arts therapies (and psychotherapy in general). I was faced not only with the obvious demands of evidence-based practice, but also at times with arts therapists’ mistrust towards research, as well as various difficulties with obtaining necessary approvals for conducting psychotherapy research in the NHS. All of these, however, have only strengthened my belief that research in arts therapies is essential for placing the disciplines in their deserved place among psychiatry and other psychotherapies.

There is a huge amount of work ahead of those who, like myself, hope to reinstate the respect associated with the role of arts for mental wellbeing in ancient times. This work has of course already started on multiple levels. In my opinion, it involves: education of other professionals and general public about arts therapies and de-mystifying them, furthering research on what it is that works in arts therapies and eventually, conducting high quality studies to assess effectiveness. Recent developments in all of these areas are apparent.

I agree with Janet that currently acclaimed methodologies alone may not necessarily be suitable for research in arts therapies. I believe that development of creative study designs is essential here. On one hand, research needs to speak to the practitioners and on the other, it needs to adopt language understood by currently “leading” professions and guidelines makers. Innovative research methodologies may be a key here.

This is all challenging, but also possible, at least I still like to believe.

Hope to read more of your comments, thank you to all contributors!

PS. Just adding to the list of meta-analyses in the field:

Maratos et al. 2009 (music therapy for depression):

http://summaries.cochrane.org/CD004517/music-therapy-for-depression

Meekums et al. 2012 (dance movement therapy for depression):

http://summaries.cochrane.org/CD009895/dance-movement-therapy-for-depression

I once went to a meeting of the International Origami Society...Origami in Therapy, hed in England. There were speakers and artists from all over the world. Though it was some time ago, there was a presentation on Origami as a therapy among Populations of Substance Abusers, another one was in the use of Origami in teaching mathematics. Our presentation was for Using Origami for Stress Management among siblings of disabled children. I think the minutes of the conference are still online. One of the speakers was blind! Origami is an art that has many guiding principles. I am not aware of any systematic research thus far. Anecdotally, in my practice, I like it. It doesn't serve as a projective technique, but it is a wonderful relationship technique. The first activity is "choice" (an element of empowerment), as a child marvels over the colorful paper designs and picks a favorite one for his/her own project.

As an art therapy intern on an adult inpatient psych unit, it is indubitable that art plays an enormous role in the treatment and coping processes of anyone who attends group and individual sessions. The doctors at my site seem to respect our work, since it is the expressive arts therapists who have some of the most contact with patients and who help them process their emotions and past experiences beyond their medical conditions. There are modalities in place, such as art, music, dance, and drama therapy that can appeal to people no matter what is their preferred system of awareness…be it visual, auditory, or kinesthetic.

That being said, I have certainly experienced much skepticism at other sites and from other individuals about the legitimacy of our work. Hopefully, as it is evolving and becoming more widespread, creative arts therapy will be better understood and appreciated for its emotionally transformative potential. I don't really understand why people can't see that already…but perhaps professionals who have their own therapeutic goals in place feel threatened by this newfangled field which they do not understand.

Dear Marisol,

I am concerned by the statement that "art can do no harm." And while I understand your statement about the discussion following an intervention being the stimulus to evoke a negative response, I feel compelled to point you to the use of music as a device of torture. As one of my colleagues phrased it, "Any medium that can be used to torture, create altered states of consciousness, or destroy another culture needs to be handled carefully by someone who knows what they are doing." Creative art therapists who receive the appropriate training, education and certification understand this value. Most outside of our fields only view the aesthetic nature and not the potential harm that can be inflicted (and is inflicted) outside of our fields. This is one reason we adhere to our codes of ethics and scopes of practice.

I’ve been following the discussion with interest and would like to share one observation: While the initial question raised by Thomas implies (or at least this is my understanding) that a closer connection between the fields of arts therapies and other medical professions may be possible (beneficial?), some of the points raised in discussion seem to highlight that there are significant (and quite obvious) differences in understanding of the nature of arts therapies practice by the practitioners themselves and other professionals. Personally, I believe that any bridging needs to start with education on and de-mystification of arts therapies, so that their nature becomes comprehendible for those who are not experts in the field.

Initially, the meanings of arts in health and arts therapies should possibly be clarified. Again, I support interdisciplinary dialogue in general and definitely do not intend to pose artificial divisions, but I believe it is important that practitioners of other professions understand that the presence of the therapeutic relationship and focus on therapeutic process is what is crucial in arts therapies and not necessarily in the use of arts for health benefits. I second Virginia and Melissa in that the use of arts in psychotherapy may present risks and therefore requires skills and experience from the therapist. However, the therapeutic relationship in arts therapies includes the three essential elements: the client, the therapist and the arts, and it is the interaction of the three that makes arts so powerful and thus potentially harmful. However, arts themselves should not be considered dangerous and I believe it is important to remember that in arts therapies they have a special role to play, which differs from artistic engagement outside of therapy space.

I wonder what others think and whether you have any other ideas on how to improve the dialogue between the disciplines? (If you at all believe this is needed?)

Ania,

Thank you for your thoughtful response. I would like to share a true story with you. After completeing my degree in Art Therapy and unable to find a job without licensure, I opened my own art studio. I was teaching art lessons, not providing "therapy". A woman came in one day with a request to learn how to play in watercolors. She was interested in abstract painting. I gave her special paper and liquid watercolors that are sprayed with a bottle and we used other materials on the paper to create shapes and textures. Once the spraying of color was done and the added materials removed, she was free to explore the shapes and see what else she would like to do with the painting. Instead she began sharing with me her father's sexual abuse of her when she was a child. She was rapidly breaking down.

I wonder what would have happened to her if I had not been a trained art therapist.

Fortunaltey, I was. I actively listened while I pushed aside the piece we were working on and slid over a new sheet of paper and brought out the paint brushes. As I talked with her, finding out if she had seen a therapist (she had and had been hospitalized!) I encouraged her to follow up with her therapist, and now use the paint brushes to paint a new picture.

(I wan't going to step into the role of therapist). She then painted a tree and we brought the lesson to a close.

Excellent observation. I will be attending a seminar on "Art Therapy and Anxiety" here in Southern CA. One of the key points is: combining art and traditional talk therapy in either group or individual sessions. The presenter also points out that art therapy technics can be used to help individuals understand biopsychosocial perspectives of many disorders that fall under the DSM-5 categories. So we can't discount the use of art, dance and music as adjuncts to treatment approaches in our work with clients.

About 20 years ago there was a group in Montreal who were using music therapy to treat autism. I thought the idea interesting - but it seems not to have gone anywhere. Someone should pick it up again. Some autistic persons have very good musical ability. Tell me if you hear of any progress in this.

Peter Tanguay

Hi - I work in an arts therapies service service based in an NHS trust specialising in mental health problems. I see the arts therapies as very rational as well - in this context they are psychotherapy with the additional use of the art form to enable expression. This is particularly important for people who are severely traumatised or for people who are cut off from their emotions for a variety of reasons. Some people just find it incredibly difficult to express themselves purely through words. Although it has been hard for arts therapies to get as impressive an evidence base as say CBT, we are a recommended treatment (NICE) for schizophrenia (and schizophrenia type conditions) and are working hard to be included in the next set of guidelines for depression. The guidelines for personality disorder clearly say that choice is important and NHS therapiy services tend to be very cognitively based so arts therapies are a good adjunct to that in offering a much broader spectrum of treatment. A barrier to good RCTs has always been that arts therapists use such a variety of models and approaches - a strength of the therapy is that it has the ability to adapt to the needs of the client but that also makes it hard to research. There is also an improving evidence base for Music Therapy and dementia - evidence points to the reduction of agitation and anxiety in dementia where the sufferer has participated in a regular Music Therapy session.

To answer a query about Music Therapy as a treatment for autism - it is widely used in this way in the UK - not just with people who have "savant" abilities - it is a very non threatening way for people with classic autism to relate to someone else and as such can be used to work on problems that go with the condition. There is a good evidence base for Music Therapy in relation to improving interpersonal type problems in autism.

Marisol,

No apologies necessary. My response was intended to point out the necessity of trained individuals when utilizing arts in a therapeutic intervention. As Teresa pointed out, someone without the necessary training could inadvertently trigger responses that they are unable to handle. I have come across arts being used to help people, but because the person using the art did not know about previous experiences a client had with music (for example), triggered a response they could not anticipate. Luckily on that occasion someone who was trained was available and able to handle the situation.

Peter,

There has been an significant increase in the research literature for music therapy with individuals who have autism. I encourage you to review the Journal of Music Therapy and Music Therapy Perspectives (now available on Oxford University Press).

Best to you both,

Virginia