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Art Therapy: Beneficial Schizophrenia Treatment?

Art Therapy: Beneficial Schizophrenia Treatment?

Recent findings question the popular use of art therapy for people with schizophrenia.

Schizophrenia affects up to one in a hundred people at some point and can cause hallucinations, delusions, and loss of energy and motivation. Creative psychological interventions such as art therapy are widely used in combination with drugs. But the effectiveness of art therapy is unclear.

Professor Mike Crawford of Imperial College London, UK, and his team examined the benefits of group art therapy among 417 adults with a diagnosis of schizophrenia. The patients received group art therapy or non-art group activities each week for a year, or standard care.

The art therapy involved a range of art materials which the patients were encouraged to use “to express themselves freely.” Non-art group activities included board games, watching and discussing DVDs, and visiting local cafes.

This study differs from previous trials of art therapy by focusing on clinically important differences in outcomes. It also provides detailed information about attendance rates, and offers art therapy of a duration that is more like that in real-life clinical practice.

When patients were assessed after two years, overall functioning, social functioning, and mental health symptoms were similar between the groups. Levels of social functioning and satisfaction with care were also similar.

Patients offered a place in an art therapy group were more likely to attend sessions than those offered a place in an activity group. However, the levels of attendance at both types of group was low, with 39 percent of those referred to art therapy and 48 percent of those referred to activity groups not attending any sessions.

Writing in the British Medical Journal, the researchers state, “While we cannot rule out the possibility that group art therapy benefits a minority of people who are highly motivated to use this treatment, we did not find evidence that it leads to improved patient outcomes when offered to most people with schizophrenia.”

They conclude that art therapy, as delivered in this trial, “did not improve global functioning, mental health, or other health related outcomes.” They point out that “[T]hese findings challenge current national treatment guidelines that clinicians should consider referring all people with schizophrenia for arts therapies.” The authors suggest that art therapy should not be offered on a broad basis to all patients, but targeted at those most likely to make use of it, based on an assessment of the patient’s interest and motivation to attend sessions.

Currently, the UK’s National Institute for Health and Clinical Excellence recommends that doctors “consider offering arts therapies to all people with schizophrenia, particularly for the alleviation of negative symptoms.” This should be provided by a registered therapist who has experience working with people with schizophrenia.

The guidelines describe arts therapies as “complex interventions that combine psychotherapeutic techniques with activities aimed at promoting creative expression. The aesthetic form is used to ‘contain’ and give meaning to the service user’s experience, and the artistic medium is used as a bridge to verbal dialogue and insight-based psychological development.

“The aim is to enable the patient to experience him/herself differently and develop new ways of relating to others,” the guidelines add.

Professor Crawford and his team think that the lack of clinical improvement in their trial may be due to “the high degree to which people with established schizophrenia are impaired in their clinical and social functioning.” They explain that these impairments are known to increase over time, and the participants had been diagnosed for around 17 years.

It may be that to benefit from group art therapy, “patients need a greater capacity for reflective and flexible thinking,” so targeting interventions at an earlier stage of the illness may be more effective.

Commenting on the study, Dr. Tim Kendall of the UK’s National Collaborating Centre for Mental Health believes that, while art therapy is unlikely to be of clinical benefit for schizophrenia, it “still has great potential for success in the treatment of negative symptoms.”

In an online response to the study, psychiatric hospital art therapist Betsy A. Shapiro, of Alvarado Parkway Institute, La Mesa, California, says the once-weekly nature of the art therapy sessions in the study is a potential problem.

She writes, “I work with patients with schizophrenia and see them 3-5 times a week. Patients not only enjoy group art therapy, they excel in it. Working with a variety of materials keeps them focused, encourages their creativity and appears to increase self-esteem.”

She adds that patients can “show their auditory or visual hallucinations, and express feelings which are difficult for them to do verbally. It provides for safe release of strong emotions such as rage and has prevented them from hurting themselves, others or property.”

Overall, she concludes, “It would be a great disservice to patients if this study influenced a cut-back in art therapy services.”


The use of artistic methods to treat psychological disorders and enhance mental health is known as art therapy. Art therapy is a technique rooted in the idea that creative expression can foster healing and mental well-being.

People have been relying on the arts for communication, self-expression, and healing for thousands of years. But art therapy didn't start to become a formal program until the 1940s.

Doctors noted that individuals living with mental illness often expressed themselves in drawings and other artworks, which led many to explore the use of art as a healing strategy. Since then, art has become an important part of the therapeutic field and is used in some assessment and treatment techniques.


Art therapy for people with psychosis: a narrative review of the literature

Art therapy enables individuals to use art to creatively express themselves and communicate differently with themselves, others, and their reality. The National Institute for Health and Clinical Excellence guidelines for psychosis and schizophrenia suggest that arts therapies, which include art therapy, are considered to improve negative symptoms of psychosis. We examined the effectiveness of art therapy for people with psychosis and explored whether art therapy is a meaningful and acceptable intervention in this Review. Seven electronic databases were searched for empirical papers that concerned the use of art therapy for adults with psychosis that were published from 2007 onwards. The search identified 18 papers. High-quality quantitative articles provided inconclusive evidence for the effectiveness of art therapy in adults with psychosis. However, high-quality qualitative articles indicated that therapists and clients considered art therapy to be a beneficial, meaningful, and acceptable intervention, although this conclusion was based on a small number of studies. In this Review, we discuss the theoretical, clinical, and methodological issues in light of the development of more robust research, which is needed to corroborate individuals' experiences and guide evidence-based practice.


Health Issues Treated by Art Therapy

Art therapy has been shown to benefit people of all ages. Research indicates art therapy can improve communication and concentration and can help reduce feelings of isolation. This type of therapy has also been shown to lead to increases in self-esteem, confidence, and self-awareness.

Positive results in art therapy may often be achieved by those facing issues such as:

Because art therapy allows people to express feelings on any subject through creative work rather than with speech, it is believed to be particularly helpful for those who feel out of touch with their emotions or feelings. Individuals experiencing difficulty discussing or remembering painful experiences may also find art therapy especially beneficial.

Recent research suggests art therapy may help individuals diagnosed with schizophrenia see improvement of some of their symptoms, although trials are still being conducted.

The memoir, Sybil, and two movies of the same name, describe a woman diagnosed with dissociative identity disorder who, through the use of art, appeared to gain greater insight about her alters and trauma she had experienced in childhood. Painting both provided an outlet for Sybil and her alters to express feelings and rediscover memories of the trauma, which could then be discussed in therapy.

Melinda, the main character of the 1999 young adult novel, Speak, uses art to cope with traumatic mutism&mdashher inability to speak following a traumatic event&mdashand isolation.


Key Takeaways:

Facilitated by an art therapist, therapy is usually conducted in a group setting in which patients paint, draw, sculpt, and participate in other artistic activities. The therapist can later assess a person’s artwork to gain insight into his or her world.

Some studies have found that art therapy can increase self-esteem, reduce negative symptoms, and reduce social and emotional withdrawal in people with schizophrenia.

Current national guidelines for treating schizophrenia include the use of art therapy.


Abstract

This systematic review aims to develop a bridge between what art therapists know and what they do in supporting those with mental health issues. Research undertaken between 1994 and 2014 was examined to ascertain the art therapy approaches applied when working with people who have mental health issues, as well as to identify how art therapy approaches were used within the clinical mental health system. Thirty articles were identified that demonstrated an art therapy approach to a particular mental health issue. The search strategy resulted in articles being grouped into four diagnostic terms: depression, borderline personality disorder, schizophrenia, and post-traumatic stress disorder. A synthesis of the identified articles resulted in the identification of research areas that need advancement. Future studies could incorporate more details on the art therapy approaches used to enhance transferability of practice. Moreover, adding art therapists’ critique about the art therapy approach from their applied perspective, would assist in the development of evidence-based practice that is not just current, but feasible, too. Finally, the client voice needs to be incorporated in future studies to address questions of the relationship between client expectations and the perceived success of art therapy.


Combination therapy might be beneficial in schizophrenia

Functional magnetic resonance imaging (fMRI) and other brain imaging technologies allow for the study of differences in brain activity in people diagnosed with schizophrenia. The image shows two levels of the brain, with areas that were more active in healthy controls than in schizophrenia patients shown in orange, during an fMRI study of working memory. Credit: Kim J, Matthews NL, Park S./PLoS One.

Combining certain types of two antipsychotic agents in the maintenance treatment of schizophrenia is associated with a lower risk of relapse than using monotherapy. This is suggested in a paper published by researchers at Karolinska Institutet in the journal JAMA Psychiatry. The current treatment guidelines should modify their categorical recommendations discouraging all antipsychotic polypharmacy, according to the researchers.

The effectiveness of antipsychotic combination therapy in schizophrenia relapse prevention is controversial, and use of multiple agents is generally believed to impair physical well-being. But the evidence for this is weak and antipsychotic polypharmacy is widely used.

Now researchers at Karolinska Institutet in Sweden have conducted a large registry based study to see if there is any difference in the risk of relapse in schizophrenia when patients use antipsychotic polypharmacy compared to monotherapy.

The study was based on more than 62,000 patients all persons with schizophrenia treated in the inpatient setting during 1972-2014 in Finland. The researchers then followed the patients to see to what extent they were rehospitalised for psychiatric care, which was used as a marker for relapse. The median follow-up time was 14.1 years and to avoid bias each patient was used as his or her own control (so called within-individual analysis).

The results show that antipsychotic polypharmacy in general was associated with a slightly lower risk of psychiatric rehospitalisation than monotherapy. They do however not indicate that all types of polypharmacy are beneficial. Combining aripiprazole with clozapine was associated with the best outcome, with a 14-23 per cent lower risk of rehospitalisation compared to clozapine alone which was the monotherapy associated with the best outcomes.

Current treatment guidelines state that antipsychotic monotherapy should be preferred and polypharmacy should be avoided if possible. This study should change that view, according to first author of the study, Jari Tiihonen, specialist doctor and professor at Karolinska Institutet's Department of Clinical Neuroscience.

"Our results indicate that the current treatment guidelines should tone down their categorical recommendations discouraging all antipsychotic polypharmacy. The evidence of superiority of polypharmacy might be sparse, and should be replicated in other countries, but there is no evidence at all on superiority of monotherapy over polypharmacy in the maintenance treatment of schizophrenia," says Jari Tiihonen.


Study Questions Whether Art Therapy Helps Reduce the Symptoms of Schizophrenia

The results of a comprehensive review of art therapies has shown that the treatment has little or no therapeutic impact on the positive (hallucinations and delusions) or negative symptoms (social withdrawal and loss of motivation) of schizophrenia.

The research was conducted by Keith Laws, Professor of Cognitive Neuropsychology at the University of Hertfordshire, with William Conway, former student at University of Hertfordshire, and is to date the largest analysis of the effects of art therapy in reducing the symptoms of schizophrenia. The study looked at data from 948 participants who participated in nine randomised controlled trials of art therapies over the last decade.

While the National Institute for Health and Care Excellence advocates the use of art therapy for patients with schizophrenia, there have been several more, larger-scale and well-controlled trials published over the last decade, which prompted the review.

Art therapies for the treatment of schizophrenia were developed to help patients who may have lost verbal function as a result of their condition, or as a way for individuals to engage with psychotherapy in a non-judgemental, creative space.

While much research and debate has centred on the value of cognitive behavioural therapy (CBT) in psychosis, much less attention has been paid to the role of art therapies as part of the spectrum of treatments.

The review found that while art therapies had no impact at all on positive symptoms, a ‘small’ benefit emerged for the negative symptoms of schizophrenia. However, this reduction only occurred in non-blind trials, where those rating the symptoms knew who had received the art therapies and who had not – suggesting some possible bias.

Keith Laws, Professor of Professor of Cognitive Neuropsychology at the University of Hertfordshire, commented: ‘Art therapy has some advantages over more traditional talk-based psychological interventions for those who might find conventional talking therapies difficult. However, as the largest assessment of available data, our review indicates that national guidelines proposing art therapy to reduce negative symptoms may require some reconsideration.’

Editor’s note: This article was published originally by the University of Hertfordshire . Read the original article .

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Background

Schizophrenia is a severe mental illness affecting up to one in a hundred people at some point in their lives. As well as positive symptoms, such as hallucinations and delusions, many people also experience negative symptoms, such as apathy and reduced organisational skills that can greatly impair their everyday functioning [1]. Art therapy, a form of psychotherapy which uses the medium of art to facilitate personal expression and understanding of emotions [2], has been shown through one exploratory trial to be associated with improvement of negative symptoms of schizophrenia (3) and, along with other arts therapies, is included in [3] the United Kingdom (UK) National Institute for Health and Clinical Excellence (NICE) guidelines for the treatment of schizophrenia [4]. However, a recent large pragmatic randomised controlled trial, the “MATISSE” study (Multicentre study of Art Therapy In Schizophrenia Systematic Evaluation), found no evidence of a population-level effect of group art therapy over treatment as usual in terms of global functioning or symptoms of mental illness [5]. Nevertheless, results from a qualitative sub-study conducted alongside the MATISSE trial suggested that some patients reported benefits from the intervention, such as improvement in self esteem and social confidence [6]. Identifying subgroups of patients who are most likely to benefit from an intervention is obviously important when resource constraints limit its provision. However, large datasets are required to identify factors predictive of better outcome (such as patient characteristics). The MATISSE study included over 400 participants with a diagnosis of schizophrenia, an adequate sample size to explore potential predictors of difference in effectiveness. Based on previous research, two factors appear to be of particular interest: the severity of negative symptoms experienced [3, 4] and having a preference for art therapy. One possible explanation for the lack of effectiveness reported in the MATISSE trial was the low uptake of art therapy groups [7]. The trial was pragmatic in nature and included a heterogeneous group of participants. Beyond a general willingness to be randomised to one of the trial arms and adhere to the allocated treatment, no specific account was taken of participants’ interest in art therapy before recruitment and randomisation. Participant preference for the interventions offered in a randomised trial may influence recruitment, attrition and adherence [8, 9]. It follows that those who are randomised to receive their treatment of choice may derive greater benefits than those with little interest in it, possibly through higher adherence to the intervention. It is also possible that those who were more comfortable talking about their feelings and more interested in creative arts may have derived more benefit from the art therapy groups. Similarly, those who are generally more adherent with their mental health treatment may have been more likely to engage constructively with the intervention. Finally, the participants recruited into the MATISSE trial had a median duration of illness of 15 years and it may be that the intervention has greater effectiveness at an earlier stage of the illness.

In this study, we sought to investigate the hypotheses that the clinical effectiveness of group art therapy delivered in the MATISSE trial was related to (a) the severity of negative symptoms of schizophrenia and (b) having a preference for the art therapy intervention. We also explored other related participant characteristics for their association with the effectiveness of the intervention: gender, adherence with current treatment and support degree to which they felt comfortable talking about their feelings interest in creative arts and length of contact with mental health services.


Benefits

  • Self-discovery. At its most successful, art therapy triggers an emotional catharsis (a sense of relief and wellbeing through the recognition and acknowledgement of subconscious feelings).
  • Personal fulfillment. The creation of a tangible reward can build confidence and nurture feelings of self-worth. Personal fulfillment comes from both the creative and the analytical components of the process.
  • Empowerment. Art therapy can help individuals visually express emotions and fears that they were never able to articulate through conventional means, and give them some sense of control over these feelings.
  • Relaxation and stress relief. Chronic stress can be harmful to both mind and body. It can weaken and damage the immune system, cause insomnia and depression, and trigger a host of circulatory problems (e.g., high blood pressure, atherosclerosis, and cardiac arrhythmia). When used alone or in combination with other relaxation techniques such as guided imagery, art therapy can be a potent stress reliever.
  • Symptom relief and physical rehabilitation. Art therapy can also help individuals cope with pain and promote physiological healing by identifying and working through anger and resentment issues and other emotional stresses.


Watch the video: schizophrenia art therapy (January 2022).