Published:
July 2021

Issue:
Vol.16, No.1

Word count:
5035

About the authors

  • PhD, MPsych(Clin), MBA, BSc(Hons), MAPS, FCCLP

    Tavis has held various roles in human resources and director level appointments in the university sector. He has been involved in the Australian Army Psychology Corps and has deployed on international military operations and disaster recovery activities such as bushfire recovery. More recently, he has supported the Australian Defence Force – Art for Resilience Recovery and Teamwork Skills (ARRTS) program, the 2018 Invictus Games team and the Geelong AFL Club, ‘The Cats’. He currently works as a clinical psychologist in private practice at the Wave Health Group.

  • MARe ATh, Grad Dip ATh, BA FA, PACFA Clinical Registration, EMDRAA

    Michelle is an artist, art therapist and psychotherapist. She practices at a private psychiatric hospital, leading inpatient and outpatient groups including art therapy, DBT and ACT. She is PACFA accredited and has more than 20 years’ experience working in the community services sector. She is the founder of Informemotion, her private practice. She has initiated several community arts projects such as the Red Tepee, informed by her interest in women’s health and rites of passage. Michelle facilitates Celebration Day for Girls for pre-menarche girls. She is the mother of five children.

  • PhD, MA, BA (Cum Laude)

    After completing his PhD at the University of Iowa, James came to Australia in 1977 to take up a lectureship at the University of New South Wales. Following his retirement in 2021, he held the title of Emeritus Professor and was past Director of Organisational Psychology in the School of Psychology. He served in the Australian Army Psychology Corps, was a Fellow of the Royal Society of New South Wales, and was a member of the Association for Psychological Science (USA), and the Psychonomic Society. Professor Kehoe conducted 45 years of research in psychology and published more than 100 articles in peer-reviewed scientific journals.

This work is published in JoCAT and is licensed under a CC BY-NC-ND-4.0 license.

Benefits of a psychiatric hospital outpatient art therapy group

Tavis Watt, Michelle Buggy, E. James Kehoe

Abstract 

The present article describes research into the benefits of group art therapy perceived by outpatients during weekly attendance over a ten-month period in a psychiatric hospital. Respondents reported consistently high levels of benefit from the program, including a positive mood, positive insights, and improved functioning, after 80 percent of their attendances. Respondents also experienced high levels of four candidate mechanisms that are potential contributors to the perceived benefits, specifically: anti-depressive behavioural activation, a sense of belonging, a sense of alliance with the therapist, and positive flow states during the activities.

Keywords

Art therapy, flow, behavioural activation, belonging, therapeutic alliance

Introduction

In Australia, private psychiatric hospitals offer a variety of programs beyond traditional medical interventions. Art-based therapies are increasingly being offered in both inpatient and outpatient formats. However, providers – including hospitals, and funding agencies such as insurance companies – require evidenced-based research, both qualitative and quantitative. The current research stems from the request of one such hospital to provide independent evidence of the therapeutic outcomes of its art therapy program, which is conducted by an art therapist. In this instance, the evaluation was designed and conducted by two Australian-registered psychologists. 

Art therapy is defined through its methodology and the therapeutic assistance it gives clients by creating a safe vehicle to explore meaning. The experiential experience of art therapy enables the decoding of thoughts and emotions by finding meaning in symbols, and metaphors in the art forms. This can lead to greater understanding of experience of the world and how to respond, therefore supporting improved well-being.

The creation of art through activities incorporating painting, drawing, music, writing, dance, and dramatic performance has long been recognised as a cost-effective intervention for people undergoing therapy and rehabilitation (Agell, 1980; Howarth, 2018). In this context, there is increasing interest among the wider community of mental health professionals in the possible added therapeutic benefit of pursuing arts in a variety of modalities with the inquiry-based facilitation of the art therapist (Kaimal et al., 2018). The mental health concerns that have been shown to benefit from art therapy include post-traumatic stress disorder (PTSD) in veterans (Smith, 2016; Uttley et al., 2015a), stress in university students (Abbott, et al., 2013), depression in a broad review of a variety of settings (Blomdahl et al., 2016), and Cluster B personality disorders including identity disturbance, affect dysregulation and cognitive misunderstandings (Havsteen-Franklin et al., 2019).

In art-based therapeutic activities, the materials used for making art provide connection to the subtleties of experience, openness, flexible thought, and curiosity in relation to the present. The application of materials allows the senses to be heightened, leading to a relatively greater mindfulness (Chilton, 2013). The senses can be activated through music, touch, sound and colour, thus heightening the experience of the art-making process and enabling participants to engage in the present, which is understood to be akin to mindfulness. The process of mindfulness (Chilton, 2013) becomes an internal and external inquiry that offers an experience of what is not yet known (Lett, 2001). This offers a new ‘sense’ or connection between the artist and their art-making that is ‘felt’. Eugene Gendlin (1978) speaks of this felt sense as a tool for understanding our unclear feelings and inventing new patterns for living, by connecting our kinaesthetic experience with the posing of a question from any form of ‘stuckness’. 

The creative process allows the participant to focus on the theme and safely connect with, and express thoughts and feelings through, the use of art materials. The final image is the result of many decisions, thoughts and ideas, representing the participant’s discoveries and experiences. Subsequently the artwork offers an abstract ‘felt sense’ of their experience. The process of making ‘unknown forms’ or gathering imagery together, piece by piece, delays the cognitive role in trying to understand ‘what it is’ or what the art ‘means to them’. The result offers a new reflection through the image, which is not preconceived. Later, the image can be used as a source for understanding that generates fresh perspectives on personal experience (Kaimal & Ray, 2017). Beyond the individual, the group can offer an opportunity for shared understanding and/or personal acknowledgement, through understanding and connecting with each other’s art (Holttum, 2018).

In a systematic review of the effects of art therapy on adult cancer patients, Archer et al. (2015) concluded that these activities benefit the patients with respect to anxiety and depression, quality of life, coping, stress, anger and mood. A meta-analysis of the effects of art therapy on breast cancer patients yielded a more modest conclusion that there was a reduction in anxiety but no discernible change in depression, coping, mood or functional assessment (Boehm et al., 2014). In addition to these quantitative reviews, Hogan (2013) describes qualitative research in which the provision of art materials assisted pregnant women and new mothers “to explore their changed sense of self-identity and sexuality” (p.71). Similarly, Macpherson et al. (2016) conducted a series of weekly four-hour workshops in the creation of visual art with 16–25 year olds (n = 10) who were facing a mixture of challenges from anxiety and depression, but also learning difficulties and autism. Participation in the workshops increased self-reported resilience, coping with difficult feelings, and a sense of belonging to a group. These conclusions were based on qualitative observations of the participants plus their own entries in reflective diaries, their contribution to a focus group, and their responses to a semi-structured interview. 

Although the previous results are promising, there remain doubts about the efficacy of art therapy and the variable quality of its evaluative research (Archer et al., 2015; Phillips, 2019; Uttley et al., 2015a, 2015b). Some of these doubts revolve around the relative merits of different methods for measuring the effects of art therapy, most prominently quantitative versus qualitative approaches (Edwards, 2016; Gerge & Pedersen, 2017; Pounsett et al., 2006). Other unknowns include the psychological mechanisms that may or may not be engaged during art therapy (Havsteen-Franklin et al., 2019). In this respect, art therapy, like many other therapeutic interventions, needs to develop a stronger evidence base, including identification of the mechanisms that mediate change in individuals (Kazdin, 2009). The aim of the current research is to assist providers of art therapy with further quantitative and qualitative evidence on the efficacy of programs offered in a psychiatric outpatient setting.

The underlying mechanisms

The present study was conducted to help identify the mechanisms that may underpin the benefits of art therapy as perceived by its participants. In other types of psychological therapy, four mechanisms are prominent contributors to therapeutic success. The current research is innovative in that it aims to move beyond theoretic propositions, to qualitative and quantitative evidence that these previously established psychological constructs are also relevant to the success of art therapy. As will be detailed below, these four mechanisms are behavioural activation, belonging, therapeutic alliance, and flow states (Watt & Kehoe, 2020). 

Behavioural activation

Behavioural activation entails the enhancement of an individual’s sense of purpose, enjoyment, meaning, personal accomplishment and mastery (Kopytin & Lebedev, 2013; Soucy-Chartier & Provencher, 2013). The development of behavioural activation has been used as the main objective of a therapy of the same name for successfully treating depression (Mazzucchelli et al., 2016) and possibly anxiety (Boswell et al., 2017; Dimaggio & Shahar, 2017). Scheduling meaningful activities and skills training into art therapy may be an effective way of engaging the same mechanisms as in the behavioural activation therapy (Richards et al., 2016).

Relationship mechanisms 

Sense of belonging 

As defined by the American Psychiatric Association (2013), conditions such as PTSD, personality disorders, depression and anxiety imply elements of social isolation and difficulties with interpersonal relationships as part of their diagnostic criteria. A sense of belonging protects individuals from developing depressive symptoms during periods of adjustment (Bryan & Heron, 2015). A lower sense of belonging has also been associated with developing depression in young people (Williams et al., 2002). 

The links between belonging and anxiety have been demonstrated in a variety of contexts (Herbert, 1997; Lee & Robbins, 1998). Among other things, anxiety resulting from social exclusion has been identified in students being bullied in schools (Søndergaard, 2012). Lack of ‘belongingness’ has been associated with increases in both attachment anxiety and depression (Overup et al., 2017). Moreover, belonging to a group can contribute substantially to individual effectiveness and resilience (Wessely, 2006). In the context of group-based art therapy, Holttum (2018) proposes that the cultural meaning of an individual’s art to the group’s participants may provide the means of expressing difficulty, joy and achievement. 

Therapeutic alliance

Beyond the specific features of therapeutic interventions, the relationship between patient and therapist may contribute to therapeutic success (Wampold, 2015). The most widely studied factor in this relationship is the ‘alliance’ between the patient and therapist (Del Re et al., 2012; Stamoulos et al., 2016). This alliance is a bundle of three components: the bond of mutual trust and connection, agreement about the goals of therapy, and agreement about the tasks of therapy. Meta-analysis has revealed that these components of alliance collectively have a medium-sized positive effect on therapeutic outcomes (Horvath, et al., 2011; Wampold, 2015). Additional important facets of the patient–therapist relationship have been the therapist’s empathy and the patient’s positive expectations of success (Constantino et al., 2011; Elliott et al., 2018; Wampold, 2015). 

Flow states

The flow state is commonly described as living in the present, including the ability to become fully immersed in an activity, with a feeling of energised focus and enjoyment, and potentially losing one’s sense of space and time (Harmat et al., 2016). Although the concept of flow is subject to continual development (Swann et al., 2018), the flow state has been theorised to be an underlying contributor to the benefits of art therapy (Chilton, 2013). Activities that produce this state may be connected to relief from debilitating anxiety (Kapitan, 2013). Along similar lines, absorption in an activity can increase the levels of satisfaction achieved from an optimal challenge and can increase belief in competence, thus influencing the enjoyment of activities (Abuhamdeh & Csikszentmihalyi, 2012). 

Research questions

The present study aims to test the relative contribution of each of the four identified mechanisms to the perceived benefits of art therapy. To do so, this study used a mixture of quantitative and qualitative methods to answer the following research questions:

  • Do participants in an outpatient art therapy program experience benefits, including a positive mood and worthwhile insights for their functioning?

  • To what extent do the participants experience the identified mechanisms of behavioural activation, belonging, therapeutic alliance and flow states?

  • Do ratings of behavioural activation, belonging, therapeutic alliance and flow states correlate with an overall wellness measure, and to what extent do they correlate with each other?

  • When given the opportunity to respond qualitatively, what themes do participants identify as a result of the art therapy? 

Method

Program design

The art therapy program was conducted at a private hospital in a large regional city located on the coast of Victoria, Australia, and was designed for individuals who expressed an affinity for creative arts as part of their therapeutic process. The program was conducted by a qualified art therapist (Master’s level) who is a registered clinical psychotherapist.

Participants in the program (19 females, two males, zero other; median age = 57 years with an age range of 20 to over 60, Australian residents) had been referred by their treating psychiatrist as suitable for the program. Before data analysis, all participant information was permanently de-identified by randomly assigning a number from one to 21. The sample size of 21 had statistical power to detect a large effect size of .60 SD or greater (Faul et al., 2009; Faul et al., 2007). Among the participants, eight reported being diagnosed with anxiety and depression, while another 8 had one or more comorbidities with anxiety or depression, including PTSD (n = 3), bipolar disorder (n = 4), borderline personality disorder (n = 1), social phobia (n = 1), and addictive behaviours (n = 2). Another six participants refrained from reporting their diagnosis. The participants were outpatients under their psychiatrist’s care, but, in each case, the psychiatrist attested that the participants were stable and able to benefit from the program. All participants lived on their own in the general community and transported themselves to and from the outpatient program, where they meet each week. Some participants had already known each other for more than a year through the outpatient program or from inpatient admissions.

Risk management was undertaken by the art therapist, who monitored the participants’ mental state, including affect and their narrative. Concerns were discussed with the participant privately to clarify thoughts, feelings, urges and behaviour. If necessary, the client was encouraged to use strategies outlined in a predetermined safety plan. If these actions were insufficient, the art therapist made contact with the referring or in-house psychiatrist.

After meeting the art therapist and being inducted into the program, each participant could attend the program on one of two days available per week. Each week, they could freely choose the day that best fit their schedule. The program was originally designed to run on a twelve-week cycle, but it allowed for intermittent attendance as desired by the participants. When attending, the daily routine for each participant included:

  • 9:30am: Check-in – This time at the beginning of the day was designed to acquaint/reacquaint the group members with one another. It gave time for personal sharing of mood, experience and stories in a safe way so that the group could work together. Group rules were established or revisited. Furthermore, breathing and grounding exercises were incorporated, to allow individual participants to separate themselves from daily unhelpful cognitions and emotions, thus encouraging a focus on gaining the most from the therapeutic session.

  • A warm-up – The participants were asked to create a visual representation (for example, a drawing) with the aim of releasing residual tension.

  • Morning tea – Time to break, rest, and reflect either individually or with other participants.

  • A focused art theme – The core part of the day was focused on personal exploration and the development of meaning. Building on the previous activities, the art therapist provided the participants with a themed task aimed at increasing their psychological flexibility for the creation of helpful meanings. As the art was developed, the further purpose was to provide personal clarity about memories and future goals. Themes were chosen by the art therapist from the participants’ visual descriptions of their personal challenges, including insights identified through the weekly morning check-in. The general therapeutic theme was chosen with the objective of being personally relatable to the individuals as well as facilitating a common connection. Example themes included ‘Acceptance’, ‘Letting Go’ and ‘Values’. Such themes gave individuals a process in which to challenge and explore their own personal considerations. For example, the theme ‘Letting Go’ might be explored by ripping up the initial art expression and creating another by using the torn-up artwork. Such art creates a new form and experience from which alternative meanings can be derived.
    The art directive gave individuals a process by which to challenge and explore the theme with their own personal considerations, through prompting questions or art processes directly related to the experience: for example, describing an art piece in order to create ‘key words’, to then ‘cluster’ and then find new meaning, thus leading to different somatic experiences.

  • Lunch – Physical movement, socialising, rest, and – for those with social anxiety – an opportunity to practise skills learnt. 

  • Individual directed creative time – Participants were encouraged to socialise through a discussion facilitated by the art therapist. After discussing any potentially distressing themes, relaxation was encouraged, as were changes in understanding and goal-setting.

  • Conclusion of day: 2:30pm.

Excluding the two half-hour breaks, the day contained four hours of art therapy time, in an overall five-hour period. Fatigue and stress were managed throughout the day by the art therapist checking in with each participant. Finally, the day was constructed to provide a predictable sense of beginning, middle and closure.

Procedure and questionnaire

Respondents were recruited to the art therapy program over a ten-month period, based on referral and clearance from their treating psychiatrist. Ethical approval for recruiting the respondents was obtained from the relevant Human Research Ethics Committee (HREC). Respondents were given a written participant information statement. After reading it, each respondent provided signed consent before responding to the surveys. 

The respondents were surveyed at the end of each weekly session they attended. Their responses were collected and scanned by the art therapist. Where required and if requested, the art therapist would assist individuals to provide qualitative information. Otherwise, the feedback was kept between the subjects and the researcher. Among the 21 respondents, data from one participant had too many gaps to be useable in either the quantitative or qualitative analyses. For the final sample of 20 individuals, attendance ranged from one to 27 weeks. In particular, nine individuals attended between one and five weeks, seven attended six to 20 weeks, and four attended more than 20 weeks (median number of attendances = eleven).

A self-report questionnaire (overleaf) was developed by the authors, covering the mechanisms of behavioural activation, belonging, therapeutic alliance and flow states. Specifically, Table 1 lists the 16 items in the questionnaire. There were four items for each mechanism, broadly derived from existing questionnaires. These were, respectively: Behavioural activation, being the Behavioural Action for Depression Scale – Short Form (BEDS – SF) (Manos et al., 2011); Belonging, as measured by integration into, and independent participation in, a community, being the Community Integration Measure (CIM) (McColl et al., 2001); Therapeutic alliance as a factor common to most therapies – as identified by Stamoulos et al. (2016) and developed by Watt and Kehoe (2019); and Flow states being the Short Dispositional Flow Scale (SDFS) (Jackson, 2009). The first column shows the item number as presented, and the second column shows the item’s wording. The response scale consisted of five points: “None of the time” (1), “A little of the time” (2), “Some of the time” (3), “Most of the time” (4), and “All of the time” (5). The total score across the four items for each mechanism ranged from 4 to 20. Preliminary validation of the 16 items using 395 first-year university students revealed a Cronbach’s Alpha of 0.803, indicating good internal consistency and reliability (Watt & Kehoe, 2019). 

Table 1: Mechanism questionnaire.

Overall perceived benefit of each attendance was measured with a single item, using the same five-point response scale as described above. Thus, Benefit had a total range of 1 to 5. In addition to the item measuring overall benefit, the survey included three further questions concerning the specific benefits of art therapy (as originated by Price and Pellmann, 1989). Specifically, the respondents were asked whether (a) their mood was influenced by attendance at an art therapy session (positively or negatively); (b) whether they gained insight to their condition (yes or no): and (c) whether any insight improved their functioning (yes – today, yes – from a previous attendance, or no). As a supplementary question to determine engagement with art, the respondents were asked if they undertook art in their own time (yes or no). 

Finally, for qualitative analysis, the respondents had the option of freely writing any additional comments they considered important. The responses were examined by two researchers using a hybrid process of inductive and deductive thematic analysis to interpret raw data (Fereday & Muir-Cochrane, 2006). The thematic analysis was a three-stage process, in which 20 thematic clusters were initially identified inductively. In the second stage, these inductive clusters were consolidated into ten themes. Thirdly, these themes were then examined for their deductive alignment with the four underlying mechanisms (described in the introduction, above). At each stage, discrepancies were resolved by consensus.

To monitor their psychological wellness during the program, respondents were asked to complete the Kessler Psychological Distress Scale (K10) (Brooks et al., 2006). This questionnaire consists of ten questions, such as “How often did you feel nervous?”, “About how often did you feel depressed?”. The same five-point response scale, as described above, was used. The raw scores ranged from 10 (no distress) to 50 (high distress). To create a positive scale with scores comparable to the 16-item questionnaire, the raw item scores were reversed, and the total score was multiplied by .4 to create a total score ranging from 4 to 20. Therefore, a low score indicated substantial distress, and a high score indicated a more positive state or, at least, an absence of psychological distress. For reporting purposes, the reversed scores were labelled “K10R”. 

Preliminary analysis revealed that the K10R scores for each participant remained consistent throughout the program, indicating that the respondents remained in a stable state – as attested in the initial referral from their psychiatrist. For example, differences in scores between the first and last attendances did not show any significant rise or fall (single sample t test, p > 0.50). For the purposes of further analysis, the K10R scores plus the scores from the 16-item questionnaire were averaged across all attendances.

Results

Overall benefit

Aggregating across respondents and their weeks of attendance, there were 189 ratings of overall benefit, of which 66% (124) were “strongly agree”, 32% (60) were “agree”, and only 3% (5) were “neutral”. There were no “strongly disagree” or “disagree” responses. On an individual basis, 18 individuals showed an average rating of 4.0 (“agree”) or greater, and the remaining two individuals showed average ratings of, respectively, 3.0 (“neutral”) and 3.6 (between “neutral” and “agree”). The reported benefit thus appeared consistent across respondents. Between the first attendance and the last attendance, 14 individuals showed no change, three individuals showed an increase of one point in their ratings,
and three showed a decrease of one point (single-sample t test for any change was not statistically significant, p > .05).

Among the three questions for the specific benefits of art therapy (Price & Pellmann, 1989), the yes/no responses were consistently positive. Among the responses received, the respondents reported simultaneously experiencing a positive mood, positive insights, and improved functioning during 80% of attendances. A positive mood was reported after all attendances (100%), positive insights were reported for 97% of attendances, and improved functioning was reported for 81% of attendances. Finally, 72% of respondents reported undertaking art-based activities in their own time following their attendances at the program.

Mechanism scores

Table 2 shows the means, standard deviations, and pairwise correlations among the four mechanism scores, namely: behavioural activation, belonging, therapeutic alliance, and sense of flow. In addition, the corresponding means and correlations are shown for the Benefit rating. All the means were in the top half of their respective scale ranges. (The binary yes/no responses used for the Price and Pellmann (1989) specific benefit questions did not permit a useful computation of correlation coefficients.)

Pairwise comparisons among mechanism scores revealed that the mean therapeutic alliance score was significantly greater than all the other mechanism scores, all Fs (1, 19) ≥ 11.88, ps ≤ .01. According to Cohen’s criteria (1992), these differences are all statistically “large” (d ≥ .80). All other differences among the mechanism scores were not statistically significant when adjusted to protect for multiple pairwise comparisons.

Despite the small number of respondents, the four mechanism scores all had statistically significant correlations with each other. More importantly, these correlations ranged between .527 and .844, all of which are “large” according to the conventions of Cohen (1992). Together, these correlations indicate that the four mechanisms had a consistent relationship across respondents. Finally, the mechanism scores all had positive correlations with the Benefit score. All these correlations were consistently significant and large (rs > .597). 

Table 2: Correlation matrix.

Qualitative analysis

Figure 1 shows the percentage of the main inductive themes identified when the respondents were given the opportunity to describe what was important to them following each attendance. Table 3 lists each of the themes, including a non-identifying, coded quotation that illustrates that theme. Inspection of the figure reveals that enjoyment of the program was the most common theme (30%), and a further 5% of statements expressed looking forward to each attendance at the program. The respondents also made more specific references aligned in a deductive sense to the four mechanisms under investigation here. Behavioural activation was expressed in statements about enjoyment of art (13%). Belonging, as expressed in terms of safety, acceptance and integration in the program, appeared in 11% of the statements. Moreover, belonging may have also been reflected in statements about comfort and support in the program (9%). Therapeutic alliance appeared in 5% of the statements, which expressed appreciation for the therapist. More speculatively, flow states may have been expressed in statements concerning mindfulness (5%) and being relaxed (7%). In addition to themes related to the four mechanisms, respondents described external stressors that reduced their enjoyment of the program on particular days (11%) and/or hindered their settling into the program (5%).

Figure 1: Individual themes.

Table 3: Participant quotes by theme and non-identifying code.

Discussion

Summary of findings

Benefits. More than 90% of the individuals agreed or strongly agreed that the art therapy was of benefit, and no one reported being dissatisfied with the program. Across 80% of attendances, the respondents simultaneously experienced a positive mood, positive insights and improved functioning. More than 84% of the qualitative themes were positive, referring to appreciation of the program, its activities, the therapist and the mindfulness training. In addition, the respondents reported feeling safe, accepted, supported and relaxed. There were a few reports of difficulties settling in and/or fluctuation in feelings related to external stressors. Moreover, apart from reports of positive feelings, a solid majority of the respondents (72%) reported undertaking art-based activities outside the therapeutic sessions. The scores of the four identified were positively experienced by the respondents in both the quantitative and qualitative answers. 

Implications

The current study confirms that art therapy has a demonstrable benefit as seen by people who are undergoing or have undergone psychiatric treatment (Abbott et al., 2013; Blomdahl et al., 2013; Blomdahl et al., 2016; Gantt & Tinnin, 2007; Kapitan, 2013; Smith, 2016; Uttley et al., 2015a). Beyond this confirmation of benefit, the current study demonstrated that art therapy engages the mechanisms of behavioural activation, belonging, therapeutic alliance, and flow states as contributors to the perceived benefit of participation. In addition, the present study complements our recent findings that the same mechanisms are engaged by artist-educators in a residential program with wounded, injured and ill members of the Australian Defence Force (Watt & Kehoe, 2020; Williams, et al., 2019).

Previously, only belonging, flow states, and therapeutic alliance resulting from art therapy have been associated with symptom-reduction and well-being (Chilton, 2013; Holttum, 2018; Lee, 2013; Schofield, 2019). The observed correlations of behavioural activation help illuminate the many ways in which art therapy has value for its respondents when provided in conjunction with medical psychiatric interventions. Specifically, the large correlation between therapeutic alliance and benefit is consistent with previous research demonstrating that, when using other therapeutic interventions, the therapeutic alliance has an important effect on results, including group programs like the one used in the current study (Del Re et al., 2012; Heynen et al., 2017; Holttum, 2018; Wampold, 2015). 

Although the therapeutic sessions were conducted in groups, each participant engaged in drawing, painting or sculpture on an individual basis. Interactions among the respondents were also of a social nature, such as sharing lunch, or conversing informally about their activities. In this context, the high belonging scores and their strong association with perceived benefit were consistent with previous findings that belongingess’ can be achieved through group-based art therapy. For example, Macpherson et al. (2016), with a sample of ten young respondents, found that an improved sense of belonging resulted from art therapy. Furthermore, Holttum (2018) in a review of recent research speculated that the sense of belonging gained from sharing art insights was one of the mechanisms leading to benefits for the participant. 

Limitations and future directions

The sample in the current study, while small, did have the power to detect significant, large effects on the respondents. Nevertheless, caution is required. Specifically, future research could expand on the current study’s small number of respondents, who were primarily female and older in age. A bigger, more demographically diverse sample could increase the applicability of results in the broader community.

There was evidence that therapeutic alliance and sense of belonging were prominent, as might be expected for group programs. Given that visual art, used in the current study, was set as an individual activity, the overall art enquiry suggests that the observed high levels of belonging could have been achieved through the three interacting contributors. Specifically, the therapist, the group and the art activity may all create a platform for social identification and group cohesion (Walker, et al., 2017).

Art includes music, drama, dance and creative writing, not just visual expression. Investigation of programs that incorporate such types of art may be helpful for understanding the role of the identified mechanisms in the benefits of art therapy. The recent development of the Art Therapy-Working Alliance Inventory could serve as a useful tool in measuring this concept in further detail (Bat Or & Zilcha-Mano, 2018). Although four candidate mechanisms were proposed, the list was by no means exhaustive. For example, the process of externalising a problem through art to allow greater self-understanding has been proposed as a means to improve functioning (Keeling, 2006; Smith, 2016).

The present results demonstrated that the respondents reported benefits from the program and remained in a stable, functioning state consistent with their initial referral. At the same time, they did not report either a rise or a fall in their level of wellness as measured using the K10 instrument. The K10, however, is largely used as a brief screening device limited to depression and anxiety (Brooks et al., 2006). It may have lacked fidelity to detect further changes in patients who were generally stable at the start of the program. Furthermore, the K10 is not suitable for detecting changes in comorbidities. Accordingly, for future identification of the benefits of art therapy, a more thorough psychiatric interview would be warranted.

Conclusion

The current research provides art therapists working in a psychiatric setting with valued quantitative and qualitative evidence of the efficacy of the offered psycho-therapeutic programs. Quantitatively, from the respondents’ perspective, participation in the art therapy program had several benefits. Throughout their attendances, 90% of respondents reported a high level of benefit, and 80% simultaneously experienced an improved mood, greater insight and improved functioning. With respect to the candidate mechanisms, the respondents’ voices confirmed their experiences through comments including “I explored and discovered the freedom and creative flair” and “The therapist always reminds me of my creative strengths, to keep grounded and enjoy the process”. The results indicate that, alongside the individual’s behavioural activation and flow states, the relationships of the respondents with each other and with the art therapist play a prominent role in achieving the benefits of the program. 

In memory of Professor E James Kehoe

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