پیوست بیماران برای درمانگران در شبیه سازی هنر درمانی و واکنش آنها به تجربه استفاده از روش هنری

This study investigated the relationship between characteristics of the therapeutic relationship formed in an art therapy simulation and patients’ attitudes to the use of art materials in the therapeutic session. Fifty-one students, all women, who played the creator/patient role in the simulation, agreed to participate in the study. After the sixth of eight scheduled simulation sessions, the participants filled out the Client Attachment to Therapist Scale (CATS), the Art-Based Intervention Questionnaire (ABI), and the Session Evaluation Questionnaire (SEQ). The results suggest that the higher the creator/patients’ security of attachment to the observer/therapist in the simulation, the more positive the experience of working with art materials. Further, the greater the avoidance reported in the relationship with the observer/therapist during the simulation, the more negative the experience of working with art materials. No correlations were found between anxious-ambivalent attachment to the observer/therapist and the creator/patients’ attitudes toward the creative process. The discussion explores these findings in terms of Attachment Theory.

Art therapy theories based on dynamic approaches consider the therapist-patient relationship as a central component in the ternary patient-therapist-creative relationship, and see it as a process that helps patients explore themselves, develop, and achieve change through creative activity (e.g. (Case, 2000 and Robbins, 2001)). This study explored this view by investigating the relationship between characteristics of the therapeutic relationship formed in an art therapy simulation and the patient's attitude to the use of art materials. Concepts derived from Attachment Theory were used to characterize the therapeutic relationship.

The responses of all of the participants to the ABI and SEQ research questionnaires indicated that in general they enjoyed the creative process and had a positive and relatively deep perception of the situation. As shown in Table 2 and Table 3, relatively high averages were obtained for the positive subscales of the ABI questionnaire and for the subscales of the SEQ questionnaire. Table 2. Mean values and standard deviations for ABI items. Variable S.D. M ABI measures General .62 5.48 Before .90 5.32 Excitement 1.35 5.21 During .67 5.52 Pleasentness .83 5.33 Competence .77 5.46 Difficulties .85 2.01 Playfulness 1.14 5.70 Material .87 5.89 Attitude to product .97 5.09 Material is meaningful .92 5.96 Material is pleasant 1.05 5.83 Table options Table 3. Mean values and standard deviations for SEQ items. Variable S.D. M SEQ measures Depth .84 4.78 Smoothness .78 4.91 Positivity .82 4.77 Arousal .81 4.77 Table options The research hypotheses regarding the relationship between the creator/patients’ attachment to the observer/therapist in the simulation and their attitudes as measured by the ABI questionnaire (Hypotheses 1 through 4) were assessed using a Pearson correlation. As shown in Table 4, there were significant positive correlations between the secure attachment scale and feelings of excitement, pleasantness and therapeutic value, playfulness, competence, and attitude toward the artistic product and toward the material. Hypothesis 1 was supported: there was a positive correlation between the scale of secure attachment to the observer/therapist and the positive experience and pleasure derived from the use of art materials (with a median correlation of 0.42). A positive although non-significant trend was found between the perception of the material as meaningful and secure attachment. This suggests that the more the participants experienced safer attachment towards the therapist/observer, the more positive the experience with the materials. Table 4. Pearson correlations between attachment styles (CATS) and measures of attitude to art materials (ABI). Variable Secure attachment Avoidant attachment Anxious-ambivalent attachment ABI measures General .53** -.49** .08 Before .50** -41.** .12 Excitement .51** -.41** .13 During .40** -.40** .01 Pleasentness .41** -.41** .08 Competence .28* -.30* -.03 Difficulties -.04 .20 .12 Playfulness .29* -.18 .03 Material .35* -.31* .06 Attitude to product .49** -.41** .13 Material is meaningful .27 -.32* .09 Material is pleasant .33* -.22 .01 * p < 0.05; ** p < 0.01 Table options The second research hyphothesis was not supported, in that there was no correlation (negative or otherwise) between the scale of secure attachment to the therapist and difficulties encountered during the creative process, as measured by the ABI questionnaire (see Table 4). The third hypothesis, which predicted a negative correlation between the scales of insecure attachment and positive attitude towards the creative process, was partially confirmed. As shown in Table 4, significant negative correlations (with a median correlation of -0.413) were found between the avoidant attachment scale and feelings of excitement, pleasantness and therapeutic value, playfulness, competence, attitude toward the product, and the perception of the material as meaningful. This suggests that as participants experienced more avoidant attachment towards the therapist/observer, they also had a more negative experience with the materials. However, contrary to prediction, no correlation was found between the anxious-ambivalent attachment scale and attitudes toward the creative process, as measured by the different ABI scales. The fourth hypothesis predicting a positive correlation between insecure attachment to the observer/therapist and feelings of difficulty encountered during the creative process was not supported (see Table 4). Confirming the fifth hypothesis, Table 5 shows the significant correlations between the secure attachment scale and the perception of the situation as being deep, smooth and positive (with a median correlation of 0.450). A positive although non-significant trend was found between secure attachment and feelings of arousal. Table 5. Pearson correlations between attachment styles (CATS) and measures of situtation perception (SEQ). Variable Secure attachment Avoidant attachment Anxious-ambivalent attachment SEQ measures Depth .63** -.49** .20 Smoothness .45** -.46** .09 Positivity .31* -.37* .16 Arousal .27 -.35* -.03 * p < 0.05; ** p < 0.01 Table options The sixth hypothesis was only partly supported, as can be seen in Table 5. There were significant negative correlations (with a median correlation of -0.423) between the avoidant attachment scale and the perception of the therapeutic situation as deep, smooth, positive, and arousing. Thus, the more avoidant the attachment with the therapist, the more the therapeutic experience was deep, smooth, positive and arousing. Contrary to the hypothesis, no correlations were found with respect to the relationship between the anxious-ambivalent attachment scale and the dimensions that describe the perception of the therapeutic situation. Discussion This explorative study addressed the associations between the creator/patients’ style of attachment to the observer/therapist in an art therapy simulation and their attitudes towards the experience of creating with art materials during therapy. The hypothesis of a correlation between the secure attachment scale and attitudes towards the creative process and the session were partly supported. The higher the creator/patients’ security of attachment to the observer/therapists in the simulation, the more positive the general experience of working with art materials before and during the actual creative process, and the more positive the attitude toward the product and the material. The correlations indicate that stronger feelings of excitement, confidence, pleasantness and therapeutic value, competence, and playfulness and a greater perception of the material as pleasant and meaningful were associated with perceptions of a more secure simulated therapeutic relationship. Similarly, the stronger the security in the relationship, the deeper, smoother and more positive the situation was perceived to be. These findings support the assumption that creating with art materials can be conceptualized as a creative play space in art therapy, in which patients can actively become acquainted and explore themselves (Mallinckrodt et al., 2005). Thus people with a secure attachment style will perceive the therapist as a safe haven and a secure base for exploration (Mallinckrodt, 2010), and will therefore explore their surroundings freely and without fear of feeling failure (Elliot and Reis, 2003 and Coy et al., 2012). In general, people with a secure attachment style act out of a belief that their goal is attainable (Elliot & Reis, 2003), they enjoy their work more and derive greater satisfaction from it (Hazan & Shaver, 1990). These findings suggest that art therapy patients who feel secure in their relationships with their therapist are emotionally available to use the art materials as a base for self exploration. Stiles et al. (Stiles et al., 1994) argued that a positive perception of the therapeutic situation is highly important for the development and success of therapy and that it has great significance for the effectiveness of treatment both in the short term (each individual session) and in the longer term. According to Dalley (Dalley, 2000), when in a trustful setting, patients choose art materials as a way of self exploration. By contrast, the hypotheses of a correlation between the avoidant and anxious attachment scales and the creator/patients’ attitudes towards the creative process and to the simulation were only partially supported. Specifically, the greater the avoidance reported in the relationship with the observer/therapist during the simulation, the more negative the general experience of working with art materials, both before and during the creative process, as were the patients’ attitudes toward the product and the material. Furthermore, the greater the avoidance in the creator/patients’ reported relationship with the observer/therapist, the more negative the patients’ attitudes, as measured by the excitement, pleasantness and therapeutic value, playfulness, and perceiving the material as meaningful subscales. These correlations support the premises of Attachment Theory that high levels of insecure attachment hinder the development of the relationship with the therapist as a safe base for exploration and have a detrimental effect on the perception of the situation (Mallinckrodt et al., 1995). A good therapeutic relationship will give the patient an experience of secure attachment, which will provide a positive emotional experience, enhance the will to learn and the desire to become independent, and provide a base from which patients can increase the depth of their exploration (Mallinckrodt, 2010, Mallinckrodt et al., 2005 and Mallinckrodt et al., 1995). In the current study it was posited that patients would use the art materials as tools to create an exploration space since during the creative process patients create a new world for themselves (Wadeson, 1987), and the art materials are used to explore, experience, and satisfy patients’ curiosity (Luria, 2002). The correlations suggest that creator/patients with high levels of avoidant attachment insecurity in their relationship with the simulation observer/therapist experienced the therapeutic relationship as threatening and found it difficult to explore and examine their inner worlds within this relationship and using the art materials. On the other hand, and contrary to the above, no correlation was found between the anxious-ambivalent attachment to the simulation observer/therapist scale or the creator/patients’ attitudes toward the creative process, when measured by the ABI questionnaire and the SEQ. It is important to note that the distribution of patterns of attachment to the therapists in the simulation was similar to the distribution of attachment styles in the general population, as reported in several studies (Sagi et al., 1994), and that the standard deviations for the avoidant attachment and anxious-ambivalent attachment measures were similar. Hence, the reason for this difference appears not to have been statistical. One possible explanation for the lack of correlation between anxious attachment to the observer/therapist and the creator/patient's attitude toward the creative process is that the data were not collected during “real” therapy, but rather as part of a simulation in which students who study together practice a therapeutic situation. In such a case, typical items on the anxious attachment scale, such as “I think about phoning my observer/therapist at home”, which express anxious attachment in therapeutic relationships, can simply capture the friendly relationships between the two participants in the exercise. An alternative explanation makes slightly different use of certain Attachment Theory concepts to explain attitudes to the creative process in therapy. According to Attachment Theory, people with a secure attachment tend to see others, as well as themselves, in a positive light (Kobak & Sceery, 1988). They enjoy the company of others and can rely on their presence and availability in time of need (Bowlby, 1973). On the other hand, people with an avoidant attachment style based on a history of relationships of rejection and abandonment tend to view others in a negative light, so as to minimize the need for their presence and avoid the pain of rejection (Kobak & Sceery, 1988). The attitude of anxiously attached people toward others is ambivalent: on the one hand, they need others and depend on them, but on the other are angry and reject them ((Ainsworth et al., 1978 and Mallinckrodt, 2010); (Mikulincer, Shaver, Bar-On, & Ein-Dor, 2010)). Object relations approaches (Robbins, 2001) and intersubjectivity approaches (Markman-Zinemanas, 2012) to art therapy suggest that creation absorbs aspects of the creator's internalized world of representations. Thus the perception of the other which is projected or transferred onto the creative process may explain the result. The positive attitude of people with secure attachment towards others is projected onto the creative process and manifests in a positive correlation between individuals’ sense of security and their attitude towards the creative process. Similarly, the negative attitude of people with avoidant attachment to others may be projected onto the creative process as well. As a result, the creative process is perceived by the patient as a negative experience. The greater the avoidance, the more negative the attitude towards the creative process, which manifests in a negative correlation between the degree of avoidance and the attitude toward the creative process. Finally, the ambivalent attitude of individuals who are anxiously attached towards others is also projected onto the creative process. They perceive it, as they perceive significant others, as both needed and significant, but also as arousing objection and anger. In situations in which the relationship with the other changes, and is not linear, a linear relationship between the anxious attachment to the therapist and attitude toward the creative process variables may be hard to find. This issue could be investigated in future research by using additional tools to examine self-perception and the perception of others.