This review presents available evidence regarding the benefits of art therapy and therapeutic arts interventions for stroke survivors. Whilst available evidence is very limited, it suggests that art therapy may address many of the diverse cognitive, emotional and functional needs of people disabled by stroke. Attention, spatial processing, sequencing and planning seem to improve among those who persist with art therapy. Use of the stroke-affected limb may increase. Several studies report improvements in social interaction, and emotional expression. Most published reports offer single case examples, which are idiographic and illuminating. Nonetheless, the brevity of these reports, the reliance on therapist's own accounts, and uncertainties surrounding case selection make generalization of the findings uncertain. There is a pressing need for multi-method research studies. These could use quantitative standardized scales to explore changes in stroke survivors’ physical and emotional functioning, and qualitative enquiry to gain the insights of stroke survivors concerning the art therapy process. Such research designs might help to establish a better recognized role for art therapy within multidisciplinary stroke rehabilitation programs.► Art therapy is a complex intervention capable of addressing the diverse disabilities of stroke survivors. ► Case studies and a few interview studies show that stroke survivors improve use of the affected limb or learn adaptational techniques through participating in art therapy. ► Art therapy facilitates focused attention, social interaction, communication, and emotional expression. ► As formal research evidence is so limited, few explicit guidelines emerge for achieving best practice with stroke survivors. ► Mixed-method research might provide the foundation for art therapy to become a better recognized component within stroke rehabilitation programs.
Long-term disabling conditions threaten a person's identity and well-being in many ways, through loss of function and discomforting symptoms, changes in roles and occupations, altered social relationships, and a disquietening sense of liminality (Hammell, 2006). There is limited but increasing research into the benefits of creative arts therapies (including art, music, dance and movement, and drama) for people living with various long-term physical conditions, but stroke has largely been neglected (Michaels, 2007). This paper explores evidence regarding the contribution of visual art therapy to the rehabilitation of stroke survivors.
Medical art therapy may be regarded as a ‘complex intervention’ (Campbell et al., 2000 and Redfern et al., 2006), as it comprises a multi-faceted array of therapeutic components. In the context of neurorehabilitation, each component appears to have great potential to address the functional, emotional and cognitive needs of stroke survivors. It is a form of nonverbal psychotherapy that results in both client and therapist having a tangible object to explore together. Such tangible objects offer powerful confirmation of the existence of the client. Creative self-expression may help the client to make contact with disturbing emotions in oblique ways that by-pass internal defenses and self-editing processes (Dekker, 1996). Given the profound and sudden loss of function that commonly follows a stroke, and the relatively high incidence of depression that affects about one third of stroke survivors (Hackett, Yapa, Parag, & Anderson, 2005), self-expression through visual media may have much therapeutic potential.
Art-making as a therapeutic process offers diverse experiences (including kinaesthetic-sensory, expressive, cognitive and creative aspects) and may even influence physiological and neurological functioning (Hass-Cohen, 2008 and Long, 2004). Emotional expression, particularly at the non-verbal symbolic level, is recognized as an important element of all creative arts therapies (Long, 2004, Malchiodi, 1999 and Sell and Murrey, 2006). It may therefore be a particularly helpful outlet for the 20% of people who are left with long-term speech and language impairments following stroke (Pedersen, Jørgensen, Nakayama, Raaschou, & Olsen, 1995).
Art therapy is thought to help participants gain insight into the psychosocial consequences of their disabling condition, to express their feelings about change and loss, and to make known their wishes for the future. Changes that are created in the art image may help to enhance perceived control and transform feelings about self and illness (McNiff, 1992). Creative arts therapies also offer empowering experiences for people who are otherwise faced with profound powerlessness, not only associated with illness and disability but with medical treatments, the patient role, and altered social relationships. The choices experienced when engaging in creative arts therapies ‘contribute to feelings of autonomy and dignity when other aspects of life seem out of control’ (Malchiodi, 1999, p. 16). Furthermore, the person may reclaim aspects of self and identity through their creative self-expression, finding it possible ‘unfold the cramped self, uncover losses and strengths, and gain the courage to begin a process of reclamation of story and life’ (Ferris & Stein, 2002, p. 47). Identity loss is now being recognized as a great challenge for stroke survivors (Ellis-Hill, Payne, & Ward, 2000), and the contribution of art therapy to identity reclamation and transformation is an important issue to explore.
In addition to its deeply expressive and coping functions, creative arts therapies offer the opportunity to move away from illness-related preoccupations to enjoy the ‘life-affirming pleasures of making art’ (American Art Therapy Association, quoted by Jones, 2004, p. 23). Although there tends to be a focus on process rather than product in the creative arts therapies, participants may nonetheless derive great satisfaction and self-esteem from witnessing the quality of their artwork and gaining positive feedback from others (Sell & Murrey, 2006). Given that loss of occupations and meaningful activities reduce life satisfaction post-stroke (Hartman-Maeir, Soroker, Ring, Avni, & Katz, 2007), art therapy may have great potential for helping stroke survivors manifest their preserved skills and develop new ones.
Through the skilful presence of the art therapist, the art therapy experience may be regarded as distinct from art practiced in other contexts (such as community groups or as a solitary leisure occupation). The therapist is important for providing emotional containment and a safe space in which to explore difficult, perhaps shameful, experiences (Malchiodi, 2003 and Schaverian, 1991). This is a relevant issue as some stroke survivors’ report feeling ashamed by their disabilities and altered selves (Dowswell et al., 2000). Such feelings can be difficult to disclose for fear of burdening others, or disclosing vulnerability, and art therapy might offer a means of acknowledging and working through such difficult thoughts and feelings. Whilst there are sound reasons for anticipating that art therapy may meet the diverse needs of stroke survivors, a review of evidence was sought to establish whether these expectations are justified.
On the basis of the very limited evidence available, art therapy appears to provide multiple benefits to stroke survivors. A number of case examples and qualitative evaluations of therapeutic art groups suggest that art therapy may help stroke survivors to recover aspects of their cognitive functioning, such as attention, spatial processing, sequencing and planning (Kim et al., 2008 and Wilson, 2001). Art therapy may also offer experiences of intense absorption which encourage persistent effort, leading to improvements in physical functioning such as using the stroke-affected limb or adapting to using the non-dominant hand (Symons et al., 2011 and Yaretzky and Levinson, 1996). However, some stroke survivors experience continuing frustration in using the stroke-affected hand in their art-making (Beesley et al., 2011). Several studies have reported that art therapy promotes increases in social interaction and social recognition of the stroke survivors’ artistic abilities and competence (Beesley et al., 2011, Johnson and Sullivan-Marx, 2006, Kim et al., 2008, Symons et al., 2011 and Yaretzky and Levinson, 1996). Emotional benefits include the experiences of pleasure, challenge, achievement, freedom and flow, as well as taking pride in developing artistic skills and artwork (Beesley et al., 2011, Horovitz, 2005, Johnson and Sullivan-Marx, 2006, Symons et al., 2011 and Wald, 1999). Another recurring finding is that art therapy enables stroke survivors to express their concerns symbolically, discharging feelings of anger, loss and abandonment, and achieving new insights (Beesley et al., 2011, Carmi and Mashiah, 1996, Gonen and Soroker, 2000, Horovitz, 2005, Kim et al., 2008, Moon, 2009, Sell and Murrey, 2006, Wald, 1999 and Wilson, 2001).
