The present study aims to explore the working mechanisms of art therapy for psychotic illnesses. It describes the use of art therapy as an exploration process of the psychotic experience and studies how this intervention helped the patients to cope with their psychosis. In defining the concept psychosis, DSM-IV describes psychosis as a neurological syndrome. Patients suffering from psychosis may experience hallucinations and delusions, suffer from disorganized thought patterns and actions, and generally display a change in behaviour. Common psychotic disorders include schizophrenia, delusional disorders and affective disorders ( APA, 2000). The phenomenon hallucinations will in the present study be defined as perceptions without external stimuli, and a delusion will be defined as a false belief that the patient holds as true but which an observer would consider false ( Oyebode, 2008).
Art therapy has been used in psychiatry for decades in order to further the patient's healing process. However, the evidence for its usefulness, as well as the working mechanisms of art therapy, is sparsely documented as to psychotic disorders. As to scientific research/evidence, there are some randomized controlled trails (RCT) on schizophrenia and art therapy, but none on psychosis in general. It is noteworthy, however, that the National Institute for Health and Clinical Excellence in Britain (NICE Guideline) recommends that clinicians should consider offering art therapies to all patients suffering from schizophrenia (NICE, 2009). Their recommendation is based on a review of 6 published RCTs concerning art therapy (Green, 1987, Richardson et al., 2007, Rohricht and Stefan, 2006, Talwar et al., 2006, Ulrich et al., 2007 and Yang et al., 1998). This review found consistent evidence that art therapies are effective in reducing negative symptoms of schizophrenia ( NICE, 2009, p. 255). Examples of negative symptoms are apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and a lowering of social performance ( WHO, 1992). In addition to these publications, a review from Crawford and Patterson (2007) concluded that there is growing evidence as to the effectiveness of art therapy for patients suffering from schizophrenia ( Crawford & Patterson, 2007). However, the latest contribution to the research field, does not find any support that art therapy improves mental health in this group of patients ( Crawford et al., 2012).
There are many different forms of art therapy available. Prinzhorn (1972) was a pioneer in this field, important for the development of art therapy for patients suffering from mental illnesses. He collected and studied artwork created by mentally ill patients, most of them suffering from schizophrenia (Prinzhorn, 1922/1972). Adamson (1984) developed this further by founding an art studio inside a large psychiatric hospital in London, thereby establishing art therapy as an important part of the psychological treatment of patients suffering from schizophrenia (Adamson, 1984).
Traditionally art therapy was based on an analytical understanding of psychotherapy and was practiced as a supplement to this form of therapy (Killick and Schaverien, 2006, Rubin, 1999 and Schaverien, 1992). However, during the past decades, a new form of art therapy, called Expressive art therapy (ExA), has emerged from the art studios. Artists, trained as psychotherapists, have developed this new approach. Of course, in every kind of art therapy the artistic expression is the main focus. However, in ExA the very process of artistic expression is itself regarded to have a healing potential. Important pioneers in the field of ExA were Knill, Levine, and Levine (2005), and McNiff, 1981 and McNiff, 1992, who all contributed to an enriched conceptualization of expressive art therapy ( Knill et al., 2005, McNiff, 1981 and McNiff, 1992). In addition, Stubbe Teglbjaerg (2011) has put a huge effort into explaining the theoretical framework of ExA in the treatment of psychotic disorders ( Stubbe Teglbjaerg, 2011). In her PhD thesis she concludes that ExA may contribute to a reduction of psychotic symptoms and anxiety in some patients suffering from schizophrenia as a result of a strengthening of the primary sense of the self ( Stubbe Teglbjaerg, 2009). ExA is rooted in a phenomenological tradition, in which the artistic expression is seen as something new and unknown, perceived for the first time ( Løgstup, 1995). This idea opens up the possibility of exploring any emotion, as well as the psychosis itself, through arts. The artistic expression may provide a new perspective to an experience or emotion and by means of this it will reveal new abilities or possibilities for a new course in life for the artist. By means of this the patient may be able to reconstruct her self through interacting, not only with other people, but also with her environment, including her artistic expression. Actually, the artistic process involves more than just interacting; the patients will also create a new “world” and will in turn “recreate” themselves by their artistic expression ( Stubbe Teglbjaerg, 2011). In order to deepen the artistic process and the exploration process, ExA utilizes various artistic modalities such as music, poetry, painting or sculpturing. Moving from one modality to another opens the possibility of exploring her emotion or bodily experience from different angles, thus improving the artist's understanding. This process was coined crystallization by Knill et al. (2005).
From a phenomenological perspective, the onset of schizophrenia is characterized by a disturbed perception of the self (Estroff, 1989). Patients often report a sense of being external to the rest of the world, feeling profoundly different from others; unreal, dead, separated, changed and with a lack of emotions. Moreover, patients suffering from schizophrenia describe their experience of psychosis as an alienation from themselves and the world, a wordless experience, which in psychiatric terms may be described as a “seriously disturbed perception of the self” (Sass, 1992). The patients struggle to find an explanation for, and significance in, their new reality in psychosis. Since a psychotic experience usually results in a lot of anxiety due to an altered perception of the external world and of their selves, a delusional system will often try to explain and interpret the patients’ altered perception and may thus provide a relief of anxiety (Chadwick, 2006 and Cullberg, 2005).
If we consider artistic expression as a way of exploring, and through this, understanding emotions and bodily sensations, this also opens up the possibility of exploring the psychotic experience itself through art therapy. Cognitive behavioural therapy (CBT) focuses on the exploration of the psychotic experience by using words, in order to help the patient master her symptoms. An example of this verbal approach is by questioning the omnipotence of the patient's hallucinations. Originally, CBT had a verbal approach, but the latest contribution to the field also utilizes meditation to explore the psychosis in order to endure, understand and cope with the psychotic experience ( Chadwick, 2006). ExA is building on this theory, but will utilize artistic expression instead of meditation in the exploration process. As we see it, ExA presents an alternative method of exploring the psychotic experience. The creation of art may open up the possibility of exploring and understanding the wordless emotions and bodily experiences in psychosis. This may contribute to the understanding of the psychotic experience and help the patient manage her symptoms in a better way
