A brief report of Art therapy in an inpatient mental health unit Consumer feedback and experience

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1 Original article A brief report of Art therapy in an inpatient mental health unit Consumer feedback and experience Scott Lamont 1 RN, RMN Dianne Sutton 2 B.A. (History), Dip.Prim.Ed, Dip. Visual Arts (Ceramics), MA.ATh Scott Brunero 3 RN, DipAppSc, BHSc, MNurs (Nurs Prac) 1 Clinical Nurse Consultant, Mental Health Liaison, Prince of Wales Hospital, Sydney 2 University of Western Sydney 3 Clinical Nurse Consultant, Mental Health Liaison, Prince of Wales Hospital, Sydney Abstract Abstract This study aimed to review consumer feedback of group art therapy sessions within an inpatient This mental study health aimed unit. to A review post evaluation consumer study feedback of consumers of group attending art therapy group sessions art therapy within sessions an inpatient was conducted at an inpatient mental health unit. Twenty seven consumers returned written surveys mental health unit. A post evaluation study of consumers attending group art therapy sessions was reporting on their experience of the art therapy sessions. A content analysis of the survey conducted responses at was an conducted. inpatient mental Four health consumers unit. provided Twenty seven images consumers from group returned sessions written for a surveys visual appraisal of their work. Content analysis of the written surveys revealed expressing emotions, reporting on their experience of the art therapy sessions. A content analysis of the survey responses relaxation, distraction, clearer thought processes and enabling creativity as effects of the therapy. was The conducted. four images Four illustrate consumers the provided powerful images relationship from group between sessions the for artwork a visual and appraisal the consumers, of their cognitions, emotions and behaviours. The evaluation by consumers of the art therapy sessions work. Content analysis of the written surveys revealed expressing emotions, relaxation, distraction, reported varied benefits. Further investigations of this type of intervention are warranted. clearer Key words: thought Art processes Therapy, and Inpatient enabling mental creativity health, as effects Group therapy, of therapy. Psychotherapy The four images illustrate Introduction The theoretical framework for Art Therapy has been around for many decades. The art making itself, within the therapy, was theoretically proposed as a healing process during the 1940 s and 1950 s, whilst Freud viewed art as a method of accessing the unconscious (Ruddy & Milnes, 2008). Odell- Miller et al (2006) argue that arts therapies provide a therapeutic intervention that facilitates change and growth, which enables the development of insight and resolution of problems. This change and growth is reported as the outcome which art therapists seek to effect within a safe environment, as opposed to the interpretation of a patient s image (Ruddy & Milnes, 2008). The safe environment is said to enable the opportunity for patients to tell their stories, promote awareness and acceptance of their lived events (Johnson & Sullivan-Marx, 2006). Art Therapy is also reported to offer therapeutic non verbal ways of communication which allows for patients to be understood in a less threatening manner (Johnson & Sullivan- Marx; Odell-Miller et al 2006; Oster & Crone, 2004). Argyle and Bolton (2004) report therapeutic within the context of art therapy as being a healing, beneficial, curative or restorative activity. There is discussion within the literature as to whether the healing aspect of art therapy is in the process of making the art, the ensuing relationship between patient and therapist or a combination of both (Ruddy & Milnes, 2008).

2 The participatory effect is reported to offer social connection and an opportunity to express emotions via a creative process (Johnson & Sullivan-Marx, 2006). Art Therapy within mental health settings There is a growing body of research which suggests that engagement in creative activity can improve levels of mental and physical wellbeing (Johnson & Sullivan-Marx, 2006). It has been suggested that art therapies are well established within mental health services (Gallagher, 2007). Ruddy & Mines (2008), in a Cochrane review, report on its use in people with schizophrenia individually, in group settings, within inpatient and outpatient mental health settings. This form of psychotherapy is reported to be more beneficial within schizophrenia than other forms of psychotherapy due to its reported ability to act as a buffer and reduce the intensity of the relationship between patient and therapist (Ruddy & Mines, 2008). There is a lack of well designed literature within mental health which has sought to evaluate outcomes from art therapy as an intervention. It is argued that evaluating its therapeutic role is challenging. Gallagher (2007) poses the question as to how we know that the art makes a difference, as opposed to the social inclusion involved. Gallagher (2007) goes on to ask whether engagement in cookery or sport would yield similar results. Attempts to evaluate art therapy within mental health have focussed on the psychotherapeutic framework of art therapy rather than as a therapeutic activity in its own right (Argyle & Bolton, 2004). The use of art therapy within mental health is suggested to have the potential to enhance clinical environments, whilst being a useful adjunct to medication in helping people with schizophrenia (Ruddy & Milnes, 2008; Gallagher, 2007). Johnson & Sullivan-Marx (2006) suggest that observing and assessing processes of art making can be invaluable in assessing cognition and developmental deficits. Art therapy and groupwork The positive effects of group work in promoting wellbeing within mental health is well recognised and it is suggested that activity orientated groups can facilitate greater levels of interaction and symptom relief than verbally orientated groups (Argyle and Bolton, 2004). Johnson & Sullivan-Marx (2006) argue that the sharing of common experiences within groups can inspire participants to engage in purposeful discussion, which can lead to human connection. Johnson & Sullivan-Marx (2006) argue that art therapy in a small group format (5 7 participants) can provide a safe space for the exchange of stories and collaborative discussion. Argyle & Bolton (2004), in an evaluation of an activity orientated art project found that the intervention promoted a sense of belonging, group cohesion and collective esteem, which they argue are integral to therapeutic benefit within groupwork. With respect to inpatient hospital settings, Allen (1983) recommends that consumers with different needs or behaviours, consumers who come only to watch, only to paint or mainly to talk, be allowed to co-exist. Luzzatto (1997) recommends that inpatient groups be open to all consumers who wish to drop in, which contrasts with the mostly closed group nature of most psychotherapies, and further emphasises that consumers should be allowed to exist within the group without pressure on making an image or to discuss its contents. Webster et al (2005) suggest that art therapy groups represent an invaluable opportunity for staff and consumers to work creatively alongside one another as equals in a creative activity. At the study site, an affiliated university approached the inpatient mental health unit in search of a clinical placement for its art therapy students. It was agreed that this experiential process could be mutually beneficial and thus should be facilitated and evaluated.

3 Aim The aim of this evaluation is to determine consumer experiences of art as a therapeutic intervention in group settings of an inpatient mental health unit. Method The study site is an inpatient unit which admits people suffering from mental illness or severe behavioural disturbances from within the metropolitan suburbs of Sydney. Participation in the group art therapy sessions was open to all consumers irrespective of diagnosis and they could enter and participate as required by themselves. Consumers were invited to anonymously complete a questionnaire at the end of each group session. Three open ended questions were asked; 1) Did you benefit from participating in Art Therapy? (Did art help with your thoughts and feelings, or did it help you cope with any symptoms?) 2) Did you find working with the art therapist helpful? 3) Are there any other comments you would like to make about art therapy? A content analysis (Neuendorf, 2002) was undertaken of the open ended questions. The art therapy student facilitated one hour art therapy groups, with a mental health nurse in attendance, on a twice-weekly basis. The groups were open in format and boundaries were established from the outset. The sessions took place on the same day, at the same time and in the same area on each occasion. Further boundaries were agreed upon at the beginning of each session, such as confidentiality, respect for the space, each other and the art work, and the right not to engage in dialogue about the art work if so desired. The student received formal clinical supervision on-site by a mental health clinical nurse consultant (first author), using a framework described by Brunero & Stein- Parbury (2007). The clinical supervision was used to explore formative components (learning and new knowledge), normative components (standards of practice) and restorative components (emotional support), and their relationship to group members cognitions, emotions and behaviours. Four participants were asked to include examples of their artwork in this paper to illustrate the powerful relationship between the artwork and the consumers, cognitions, emotions and behaviours. All participants were informed of the process of publication and gave written consent for their work to be reproduced. The study was approved by the local human research ethics committee. Results A total of 27 consumers returned evaluation questionnaires. Table 1 report the answers to questions 1-3 which sought responses about perceived benefits of the sessions. The predominant themes yielded by content analysis were of expressing emotions, relaxation, distraction, clearer thought processes and enabling creativity. Consumers reported that the demeanour of the art therapist allowed them to express themselves freely and creatively, finding the therapist supportive and calming. Prominent themes expressed were around the therapy being good for them, providing a medium to help express thoughts and feelings and a good intervention which complimented other therapies. The following figures 1-4 are examples of work completed within the group sessions. Each figure is accompanied by a narrative from the art therapy student during the session. Figure 1 This is an image made by a woman. She made this plastercine and paper artwork on her first group art therapy session. She described this

4 Table 1 Question 1. Did you benefit from participating in Art Therapy? (Did art help with your thoughts and feelings, or did it help you cope with any symptoms?) Medium for expressing emotions, which they were otherwise unable to express n=11 Relaxing and reducing anxieties n=11 Engagement in positive activity and distraction from troubling thoughts or feelings n=10 Understanding their thought processes more clearly n=10 Enabled creativity n=8 Question 2. Did you find working with the Art Therapist helpful? Art therapist created a safe space for to express freely and creatively n=14 Helpful and supportive and calming n=13 Intellectually stimulating and helped improve their mood n=6 Question 3. Are there any other comments you would like to make about Art Therapy? Explored their thoughts and feelings, relaxing and subsequently helped with expression n=5 Being good for them n=4 Complimented existing interventions n=3 Art Therapist being friendly, and approachable n=2 Made to feel important by the Art Therapist n=1 Now interested in a new skill n=1 Valuable healing n=1 as her lifeline. She used pink to represent her beginning as a baby and white because she still had some purity. She explained that the yellow was her mother and the black was her father. She said she was at the very end of her lifeline, Right here, its death. I was at the end. Figure 2 medication side effects was shaky hands which proved a challenge for him. He asked me for a great deal of technical advice and wanted me to draw the image for him. I talked him through most of the drawing. He was very proud of his efforts in having done it himself. Figure 3 This patient enjoyed flipping through magazines to find something to draw. He chose this because he thought everyone looked like they were having a good time and he d like to have a good time too. One of his This woman consistently painted her delusions as she was talking. While it was interesting to hear her stories it was somewhat disruptive to the group as she spoke for most of the session. In this session, she said she was going to paint about the bombs. She

5 continued that Saddam Hussein will blow us all up if you kill his first love and I m going to help. There are bombs up on the moon you know and the glass house. I am Churchill s only daughter, the Princess Di of Astrid. Figure 4 This patient used humour to help him deal with the pain he was experiencing. He enjoyed making people laugh in the group and this followed through with the caricatures he made of himself and other members of the group. Discussion Our results suggest that consumers find that this type of intervention allows for the expression of emotions, which they felt otherwise unable to express. Our sample described the intervention as relaxing and anxiety reducing, whilst engagement in the intervention distracted from troublesome thoughts or feelings. The enabling of creativity was also a predominant theme. Survey respondents described some relief from symptom activity. Being able to understand one s thoughts and express them via the medium of art materials was important to respondents. Graphic images also offer clinicians invaluable opportunities to pursue the inner and outer world of consumers in a unique non threatening manner (Oster & Crone, 2004). The participants described the art therapy students role in the creation and maintenance of a safe space which enabled their creativity. They also reported the student being helpful, supportive and calming. It has been argued that supportive interpersonal qualities are essential to purposeful therapeutic relationships (Gijbels, 2005; Rydon, 2005; Hewitt & Coffey, 2005). It is important to note that the art therapy student was not perceived as being part of the clinical decision making processes in the unit. It seems likely that this separate status enabled the timely development of a therapeutic relationship. This is supported by Joseph (2006) who argues that healing is more likely to be effected if therapists do not perceive themselves as elitist. Some comments made indicated that the art therapy student complimented other interventions. This feedback supports an emphasis on a multidisciplinary and holistic approach to care and may support art therapy being recognised as an allied health profession. Johnson & Sullivan-Marx (2006) support this arguing that art therapists can collaboratively work with other care providers as a consultant, collaborator, co therapist, or researcher. Methodological rigour could improve future studies by assessing psychosocial functioning before and after art therapy interventions. This study provides further evidence for exploring the role of art therapy within an inpatient mental health setting. Future studies should determine the place of art therapy more broadly within mental health services and provide more detailed scope for art therapies use with specific mental health disorders. Conclusion This small study highlights the need for further well designed controlled trials of this intervention. Within contemporary inpatient mental health care, short hospital admissions and increasing demand for inpatient hospital beds can compromise attention to quality therapies; however the participants in these group sessions articulated benefits from being in the art therapy sessions. Due to the size of the study, it is difficult to make specific recommendations; however, this study provides some stimulus for clinicians to consider the benefits of art therapy and its

6 place within modern inpatient mental health care. Effective holistic care involves a diverse range of clinical and psychosocial interventions, with collaborative input from a multidisciplinary team. References Allen, P. B. (1983). Group art therapy in short term hospital settings. American Journal of Art Therapy, 22, Argyle, E., Bolton, G. (2004). The use of art within a groupwork setting. Groupwork, 14(1), Brunero S, & Stein-Parbury (2007). The effectiveness of clinical supervision in nursing: an evidenced based literature review. Australian Journal of Advanced Nursing, 25(3), Oster, G. D., Crone, P. (2004). Using Drawings in Assessment and Therapy: A Guide for Mental Health Professionals (2 nd Edition). New York: Brunner- Routledge. Ruddy, R., Milnes, D. (2003). Art therapy for schizophrenia or schizophrenia-like illness. Cochrane Database if Systematic reviews. Rydon, S. (2005). The attitudes, knowledge and skills needed in mental health nurses: The perspective of users of mental health services. International Journal of Mental Health Nursing, 14, Webster, S., Clare, A., Collier, E. (2005). Creative solutions: Innovative use of the arts in mental health settings. Journal of Psychosocial nursing and mental health services, 43, Gallagher, A. (2007). The Role of the Arts in Mental Health Nursing Emperor s New Suit or Magic Pill?. Journal of Psychiatric and Mental Health Nursing, 14, Gijbels, H. (1995). Mental Health nursing skills in an acute admission environment: perceptions of mental health nurses and other mental health professionals. Journal of Advanced Nursing, 21, Hewitt, J., Coffey, M. (2005). Therapeutic working relationships with people with schizophrenia: literature review. Journal of Advanced Nursing, 52, Johnson, C. M., Sullivan-Marx, E. M. (2006). Art Therapy: Using the Creative Process for Healing and Hope Among African American Older Adults. Geriatric Nursing, 27(5), Joseph, C. (2006). Creative Alliance: The Healing Power of Art Therapy. Journal of the American Art Therapy Association, 23(1), Luzzatto, P. (1997). Short-term art therapy on the acute psychiatric ward. Inscape, 2, 2-9. Neuendorf, K. (2002). The Content Analysis Guidebook. Sage Publications, London. Odell-Miller, H., Hughes, P., Westacott, M. (2006). An investigation into the effectiveness of the arts therapies for adults with continuing mental health problems. Psychotherapy research, 16(1),