اثرات درک شده از هنر درمانی در درمان اختلالات شخصیت، خوشه B / C: یک مطالعه کیفی

Art therapy (AT) is frequently used in the treatment of patients diagnosed with cluster B/C personality disorders, but there is little evidence for its efficacy. This study aimed to provide insight into the perceived effects of AT. We interviewed 29 adult patients in individual and focus-group in-depth interviews, including a ‘negative case’, starting with a topic list coming from the literature study. Data were gathered and analysed using the Grounded Theory Approach in order to generate concepts and interrelated categories. The constructed theoretical model of effects of AT consisted of five core categories: improved sensory perception; personal integration; improved emotion/impulse regulation; behaviour change; and insight/comprehension. Compared to verbal therapy (VT), patients experienced AT as an experiential therapeutic entry with a complementary quality next to VT and a more direct way to access emotions, which they attributed to the appeal of art materials and art making to bodily sensations and emotional responses. AT was found to fit well the core problems of patients with personality disorders, to offer a specific pathway to more emotional awareness and constructive emotion regulation. The perceived effects give input for further development and research and the development of an assessment tool to examine the efficacy of AT and within clinical practice.

Art therapy (AT) can be described as the therapeutic use of art making within a professional relationship by people who experience illness, trauma or challenges in living, or by people who seek personal development. The purpose of AT is to improve or maintain mental health and emotional well-being. Art therapy utilises drawing, painting, sculpture, photography and other forms of visual art expression (Malchiodi, 2005). AT is frequently used to treat people with personality disorders (PDs) who are struggling with serious emotional and self-regulation problems (APA, 2007). Therapists believe AT is a powerful intervention in the treatment of PDs, and patients report that AT has beneficial effects in daily clinical practice. Nevertheless, AT is not usually the first-choice treatment according to the basic principles of evidence-based medicine. This is because there is little empirical evidence for its efficacy, and the available evidence is not focused on the unique value of AT itself but on multidisciplinary treatment programmes, in which AT is important but plays only a secondary role. The specific effects of AT have not been isolated in these studies (e.g. Bateman and Fonagy, 1999, Bateman and Fonagy, 2004, Gatta et al., 2014, Karterud and Urnes, 2004 and Wilberg et al., 1998). There seems to be a discrepancy between the limited evidence for AT and the fact that AT is considered to be promising in practice. Since that is the case, why is AT used so often? Until now, we have relied on the clinical expertise of art therapists and their collective sense of profession. Experts describe a large variety of effects that AT can have on the recovery process of a patient with PD. First, they have noted that AT improves emotion and impulse regulation (Eren et al., 2014, Haeyen, 2005, Haeyen, 2007 and Morgan et al., 2012). AT seems to stimulate the regulation of overwhelming and poorly adapted emotional experiences by allowing the patient to express emotional themes in the artwork and to handle materials that appeal to different emotional responses. AT uses experiential techniques and effectively provokes mental states connected with ‘child modes’ and improves the ‘healthy adult mode’ known from Schema Focused Therapy (Van den Broek, Keulen-de Vos, & Berstein, 2011). In addition, experts stated that patients learn to reduce their tension and/or stop when their emotions become too overwhelming, to structure chaotic behaviour and to rethink behaviour before acting on it. This results in strengthened control, improved self-structuring skills and more positive behaviour (Eren et al., 2014, Haeyen, 2005, Haeyen, 2007 and Zigmund, 1986). Lack of self-control and structuring skills are typical behavioural problems for many patients with PD, especially Borderline PD (Linehan, 1996). The second effect mentioned by experts concerns stabilising and strengthening identity. Many art therapists and a few researchers have described the effect of strengthening identity: a more positive self-image (Chrispijn, 2001, Haeyen, 2007, Johns and Karterud, 2004, Morgan et al., 2012 and Neumann, 2001) and an increase in ‘self-cohesion’ (Levens, 1990 and Robbins, 1984). According to researchers and art therapists with many years of clinical experience, AT leads to increased self-awareness, improved self-perception, improved reflective abilities and self-insight (Bateman and Fonagy, 2004, Haeyen, 2007, Haeyen and Henskens, 2009, Jádi and Trixler, 1980, Levens, 1990, Ouwens et al., 2007 and Waller, 1992). Many patients with PD experience serious identity problems, also known as self-regulation problems. They suffer from a damaged or poor self-image, which consists of polarities. Various experts have stated that AT increases contact with one's own emotions, body and experience. In other words, intra-psychological integration is stimulated through artwork and the art-making processes, possibly resulting in a corrective emotional experience (Bateman and Fonagy, 1999, Goodwin, 1999, Gunther et al., 2009, Haeyen, 2007, Haeyen and Henskens, 2009, Lefevre, 2004 and Lev-Wiesel and Doron, 2004; Van Vreeswijk et al., 2008). As Bateman and Fonagy (2004) described, in AT, experience and feeling are placed outside the mind and into the world, a process that facilitates explicit mentalising. They further stated that AT creates transitional objects and that the therapist needs to work at developing a transitional space. The created objects can be used to facilitate expression while building stability of the self (Bateman & Fonagy, 2004). By creating playful safe transitional objects and space, identity may be strengthened and stabilised by the patients’ investigation of their own basic preferences and needs. The third effect mentioned by literature is about learning to express emotions more effectively. Many art therapists and a few researchers have mentioned that, by moving from images to words, patients learn to express themselves in a more implicit way through which explicit expression and mentalization can emerge. During AT, patients examine feelings without words, pre-verbally and sometimes less consciously (Eisdell, 2005, Haeyen, 2005, Johns and Karterud, 2004, McMurray and Schwarz-Mirman, 2001, Milia, 1998 and Springham et al., 2012). In this way, AT is said to contribute to the process of gaining insight and understanding about the patient's problem. AT potentially offers a different therapeutic entry than regular verbal therapies. Art therapists emphasise that, since this entry is indirect, AT breaks down barriers (Haeyen, 2005, Hartwich and Brandecker, 1997 and Robbins, 1994). Through AT, expression is used to improve communication and initiate contact (Daszkowski, 2004, Gatta et al., 2014, Haeyen and Henskens, 2009, Johns and Karterud, 2004, Karterud and Pedersen, 2004, Springham et al., 2012 and Zigmund, 1986). Expression of intra-psychological conflicts and traumatic experience during AT gives the patient the opportunity to experience (instead of avoid) and reframe these conflicts, which art therapists believe may be highly effective for trauma processing (Eastwood, 2012, Engle, 1997, Hitchcock Scott, 1999, Jádi and Trixler, 1980, Lyshak-Stelzer et al., 2007, Morgan et al., 2012, Moschini, 2005, Pifalo, 2006 and Van der Gijp and Kramers, 2005). Karterud and Pedersen (2004) also mentioned that the effect of learning to express emotions more effectively could explain the results of a quantitative study among 319 patients with PD. That study found that patients valued AT more highly than other treatment elements, such as verbal therapy (VT) and other therapy groups. The authors explained the high value assigned to AT as related to the ‘as-if situation’ that offers patients a safe way to explore their perception of feelings and emotions, express them and give them meaning by means of self-objects in the shape of works of art. As described by Fonagy, Gergely, Jurist, & Target (2002), AT adheres to a ‘pretend mode’ by using fantasy and imagination. The fourth effect to consider is about dealing with limitations and vulnerability by accepting limitations and using more effective coping skills. Experts have mentioned that acceptance, support and recognition are some of the effects of AT related to learning to deal with and accept one's own expression or artwork and that of others (Haeyen, 2007, Gunther et al., 2009 and Springham et al., 2012; Van Vreeswijk et al., 2008). Dealing with personal expressions validates vulnerabilities that are present in the AT process and product, and challenges coping skills. Entering new experiences in AT and having indirect experiences by working together on artistic assignments lead patients with PD to experience positive effects on self-acceptance, higher self-esteem and improved social functioning. Long-term psychodynamic art psychotherapy decreased symptoms of self-mutilation, suicidal attempts, self-harm behaviors (Eren et al., 2014). The expert opinions and evidence from multidisciplinary treatment studies suggest that AT may be promising. Coordinating treatment modalities may offer patients more therapeutic possibilities than one treatment modality may offer alone (Heckwolf et al., 2014 and Springham et al., 2012). This is also stated in recent publications on AT that describe contemporary PD treatment modalities combined with AT. Examples are: AT combined with Dialectical Behavior Therapy, Mentalization-based treatment or with Schema Focused Therapy (Haeyen, 2007, Heckwolf et al., 2014, Springham et al., 2012, Van den Broek et al., 2011 and Van Vreeswijk et al., 2012). However, we do not know the differential effects of AT compared to VT and to what degree patients recognise the supposed effects of AT. Literature provides us with many patient testimonies, most of which describe positive experiences with AT (Eisdell, 2005, Gatta et al., 2014, Haeyen and Henskens, 2009 and Moschini, 2005). Patients bring their own personal and unique concerns, expectations and values to AT. However, in those testimonials, little attention is paid to the difference between AT and VT. In addition, they do not provide a systematic view of the uniqueness and added value of AT. This study aimed to provide a systematic investigation of the patients’ experience of the benefits of AT. In addition to existing expert literature, this study could give a complete image of the effects of AT in treatment of adult patients with PD cluster B/C and develop a theoretical framework that is grounded in patients’ daily AT experiences. This framework would contribute to the theoretical formation of AT and also lead to a clarification of the possible specific qualities of AT compared to VT.

Core categories We found five core categories related to the effects of AT (see Table 1). Table 1. Core categories and subcategories of AT effects. Core categories Subcategories 1 Improved sensory perception and self-perception – discovering/experiencing materials and possibilities – discovering new opportunities and gaining consciousness of individuality/authenticity – emotional reaction to materials – perception/awareness of one's own feelings – experiencing the present moment –body awareness/perceiving the body/physical signals 2 More personal integration – seeing one's emotional experience through visual images/design – exploring, recognising and acknowledging feelings – portraying identity/self-image – portraying feelings of past and present – differentiating and clarifying feelings and thoughts – differentiating one's own patterns concerning feelings, thoughts and behaviours –differentiating between inner conflicts/themes 3 Improved emotion and impulse regulation – emotionally expressing personal themes – improving regulation skills – acting out and ‘living through’ emotions/feelings and directing this process –anchoring feelings/experiences 4 Behaviour change – applying alternative behaviour in dealing with oneself and one's own emotions – experiencing emotional contact with others – advancing social cooperation skills – adequately coping with social conflicts – giving/receiving social recognition and emotional support – improving feedback skills (giving and receiving) 5 Stronger insight and comprehension – improving the verbal expression of experiences – improving transcending thinking on the product/process – ameliorating understanding of one's own patterns regarding intra-psychic functioning – ameliorating reflection on one's own patterns in relation to others – drawing, transcending and connecting conclusions about this Table options Core category 1: Perception and self-perception Perception concerns the base of the experienced effects of AT. It is defined as discovering materials, feeling the accompanying physical effects and exploring possibilities and choices, which results in more self-awareness and a sense of individuality. Patients stated that working with art is an experience that one can enter into and that this experience leads to experiencing the present moment, to emotional responses and to more emotional and body awareness. Patients also indicated that, at first, they sometimes felt worse when they gained full perception of all their mutable, often negative, emotions and feelings and the accompanying destructive behaviour. They noted that this process consisted of starting to experience and recognise the actual burden of negative feelings, while simultaneously experiencing that they had so far made little progress in dealing with these feelings. Avoidance of negative feelings came forward in the interviews as a core problem for people with PD. Perception was the first step in this process of experiencing, recognising and validating emotions, as can be seen in the following quote: ‘I start with a heavy, big piece of clay …. I am an analyser in my profession, but this I do by intuition … and I need to use my force to get it in the first rough shape. I like to beat the clay …. I feel it's actually about power and aggression for me … but as the art process progresses, I need to be more careful, more refined and vulnerable in my actions.’ (Respondent 8, a 60-year-old male) This perception was a base for further therapeutic exploration and actions and for exploring changes in patterns of feelings, behaviour and thoughts. Core category 2: Personal integration ‘Personal integration’ is defined as the ongoing self-definition in which the integration of contradictive polarities in oneself leads to more self-coherence and self-acceptance. The patients mentioned that they could express and portray their personal issues, emotional experiences and identity or self-image in AT. They felt that their identities became visible, which led to an ongoing self-definition in which identity and self-image could be strengthened and become more positive. The patients noticed that another characteristic of AT is that the artwork confirms what is already there and that their development in the therapy process became visible in the work of art. They spoke of how a more coherent, more stable self-image and more self-acceptance arose. By expressing emotions through their artwork, they could further investigate and unravel their thoughts, patterns and inner conflicts. The following quote emphasises how art work can contribute to becoming aware and more accepting of oneself. Picture 1.