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This paper outlines a study which sought to understand how art therapists structure their approach to treating people who experience borderline personality disorder features. It outlines the understanding of the condition, controversies around diagnosis and its use by evidence based psychological therapies as a guide for structuring therapy. The paper considers how art therapists might utilise research to improve art therapy for this distressing condition. The authors argue that before undertaking clinical trials, art therapists need to build theory inductively so that there is clarity about what is tested. They surveyed art therapists internationally to try to understand how whether there was consistency in how they structured their approach and received usable description of 226 interventions with over 140 names. The results indicate that most art therapists carefully prepare service users for treatment through sharing a clear understanding of the condition and treatment aims and pay particular attention to the attachment issues involved. The study concludes by suggesting any trial of art therapy with borderline personality disorder features should include these structures in the approach studied. The authors suggest that the existing taxonomy for art therapy does not describe the approach of practitioners take and recommend terminology should reflect structure and not therapist intentions.

Both authors work as art therapists within the UK National Health Service and specialise in the treatment of people diagnosed with borderline personality disorder (BPD). Current research evidence (reviewed below) suggested that this group require a specifically tailored approach in psychological therapy, whatever the theoretical model of the practitioner. Our clinical experience as art therapists convinced us that this is the case for art therapy too. Moreover, we suggest that the number of people on art therapists’ caseloads needing a tailored approach is likely to be substantial because the diagnosis of BPD is often erratically applied and remains highly controversial as a clinical construct. Many adults who use art therapy service will have had the severe attachment traumas which result in problems regulating affect, sense of self and managing supportive interpersonal relationships that the BPD diagnosis attempts to describe. If this was the case then it was clearly under researched area for art therapy. In this paper we discuss how art therapy research might develop in relation to the difficulties the BPD diagnosis seeks to describe. We argue that recent experience in art therapy research indicated that attempting to address the deficit in evidence by leaping to undertake clinical trials cannot be viewed as a useful strategy because it misses out a vital, preparatory, step. To support our argument we critique the difficulties in conducting previous clinical trials in art therapy. We suggest that careful inductive research is required to build theory before deductive approaches, such as trials, tests theory. The study described in the present paper seeks to make a contribution to that preparatory phase. This involved surveying art therapists in relation to their approach to treating the people who experience the difficulties involved in BPD. We begin the paper by defining the terms used to define BPD difficulties. We then look at how those terms have been applied to art therapy in order to shape our research approach. Following this we discuss how the results of our research might contribute to an overarching research approach which might construct safe and effective art therapy for this important clinical population.

The strength of this study is that the survey sampled internationally on a specific area of art therapy practice. The limitations were that it relied on therapist report and could not indicate how the art therapists operationalised their approach within those structures. The study indicates that evidence for the consistency of the way art therapists structure their approach to BPD is growing. It includes attention to attachment issues and careful preparation before treatment in terms of sharing information and contracting the therapeutic alliance. We recommend that these structures should feature in art therapy manuals where BPD features are likely to dominate amongst the service users involved.