Throughout history there has been considerable speculation about the possibility of a link between creative expression and mental distress. Plato described artistic talent as “madness that comes from God”, and Aristotle claimed that “all men who are outstanding in … the arts are melancholic”.¹ In recent years the relationship betweenship creativity and mental distress has been explored in retrospective studies which have compared levels of mental disorder among successful artists with those among the general public. Andreasen² reported that among a sample of 30 well known authors 24 had experienced depression, and 13 had received treatment for bipolar affective disorder. Schildkraut and colleagues³ reported that 40% of notable abstract expressionists sought treatment for mental disorder and 20% were hospitalised for psychiatric problems.

There has also been longstanding interest in the role that the creative arts may play in helping people adapt to, or recover from, mental disorder. Healthcare staff have used art materials, music and creative writing for many years, a tradition which is especially strong in China, Japan and other parts of the Far East. In Europe and the US, artists who were interested in the creative abilities of people who experience mental distress began working in asylums in the first half of the 20th century.¹ However it was not until the 1940s that more formal efforts were made to combine the use of art materials and psychotherapy as the basis for “arts therapies”.⁴ Since then professional bodies have been established which regulate training of arts therapists. This includes a requirement to obtain a primary arts-based degree and specialist training in one of the arts therapies.

MECHANISM OF ACTION

Four main arts therapies are currently provided in the UK: art therapy, dance movement therapy, drama therapy, and music therapy. While each employs a variety of different techniques they all focus on non-verbal communication and creative processes together with the facilitation of a trusting, safe environment within which people can acknowledge and express strong emotions.⁵ The underlying assumption is that creative processes encourage self-expression, promote self-awareness and increase insight, thereby enhancing a person’s psychological wellbeing.

In art therapy people are encouraged to use a range of art materials to make images and the focus is on the relation between the image, the creator and the therapist. In dance movement therapy, therapists focus on the use of body movement and connections between mind, body and emotions are explored. Drama therapists use games, storytelling and role-play. Music therapists in Western Europe tend to use a range of “active” interventions such as co-creating improvised music; in the US “receptive” interventions, such as listening to live or recorded music, are more commonly practised.⁶

It has been argued that arts therapies are of particular value for people, such as those with cognitive impairment or psychosis, who find it difficult to express themselves verbally. In relation to people with psychosis it has been suggested that arts therapies have an advantage over traditional psychotherapies in that art materials (such as a story, painted image or piece of improvised music) provide a safe space between the patient and the therapist, which can help to contain powerful feelings that might otherwise overwhelm the patient.⁷ Arts therapists vary in the extent to which material created is explored verbally. This will depend in part on patient preference and clinical judgement, but it also reflects different traditions within arts therapies; one in which the process of creating is viewed as inherently therapeutic, and the other which sees the creative process and its results as revealing psychological phenomena which can then facilitate verbal therapeutic processes.

Arts therapies are often delivered to people in groups. Group-based arts therapies allow the use of art materials to be combined with group processes such as sharing information, receiving feedback and contributing to others’ ability to change.⁸ While arts therapists use a variety of psychotherapy models to understand and reflect on relationships between themselves, the patient and the art materials, psychodynamic models tend to dominate in the UK.

THE EVIDENCE BASE

Experimental studies examining the impact of arts therapies for people with schizophrenia were first conducted in the 1970s. Since then over 20 clinical trials have been conducted and systematic reviews of art therapy, drama therapy and music therapy have also been completed (table 1⇓). Of these, the review of music therapy reached the most positive conclusions: that music therapy for people with schizophrenia brings about improvements in mental state and global functioning.⁹ Reviews of drama therapy and art therapy have highlighted concerns about the methodological quality of trials conducted to date. Both reached similar conclusions: that while such trials are feasible, “the benefits or harms of the intervention are unclear”.^10,11 Since the review of art therapy was last updated, a controlled trial among 86 in-patients in a mental health unit in mainland China reported improved social functioning and improved mental health in people with schizophrenia who were randomly allocated to group art therapy, compared to standard care alone.¹²

We are not aware of any randomised trials of dance movement therapy for people with schizophrenia. However a trial of body-orientated psychological therapy was recently published in which 45 people with schizophrenia were randomly allocated to either 20 sessions of group body-orientated psychotherapy (BPT) or 20 sessions of group-based supportive psychotherapy.¹³ Symptoms of schizophrenia were assessed by a masked researcher at end of treatment and four months later. Levels of attendance at body-orientated psychotherapy sessions were higher than those at supportive psychotherapy groups, and those randomised to BPT had lower symptoms scores for negative symptoms at both follow-up interviews. Like dance movement therapy, BPT focuses on movement and emotion, though BPT places greater emphasis on physical activity rather than on the creative aspects of expression associated with dance.

Most trials of arts therapies conducted to date share a number of methodological weaknesses. Study samples have tended to be small, limiting study power. Follow-up periods have tended to be short making it difficult to establish whether any benefits associated with arts therapies are sustained. Most studies were conducted in single centres and used selected samples limiting the generalisability of study findings. While most studies described the intervention they planned to deliver, few made any attempt to measure treatment fidelity. Finally, most studies have compared arts therapies plus standard care to standard care alone, making it difficult to know if any changes seen are the results of specific effects of arts therapies or non-specific effects of time spent with professionals and peers (studies by Röhricht & Priebe¹³ and Nitsun et al¹⁴ are notable exceptions to this).

Interpretation of findings from systematic reviews of arts therapies has been made more difficult because of marked heterogeneity in interventions that have been examined. For instance, in the review of music therapy by Gold and colleagues⁹ the interventions that were delivered ranged from weekly sessions of co-improvised music making, to daily sessions of group singing. Studies of drama therapy have delivered interventions ranging from eight sessions in which social dramas were enacted to 60 sessions of intensive interactive role-playing.¹⁰

Nonetheless, findings from most trials of arts therapies for people with schizophrenia suggest that attendance at individual sessions and groups is high and that arts therapies are associated with improvements in mental health and social functioning. There is also some evidence to suggest that arts therapies have differential effects on symptoms of schizophrenia with a greater impact on negative and general symptoms such as feelings of depression, lack of energy, and reduced motivation than on positive symptoms such as hallucinations and delusions. Such outcomes are particularly significant as negative symptoms are important to people who have schizophrenia¹⁵ and tend to be less responsive to antipsychotic medication.¹⁶

Larger studies involving multiple centres are required to examine the effectiveness of arts therapies. Such studies should examine treatment fidelity and follow participants up beyond the end of therapy. Previous studies have not examined the costs of delivering arts therapies, and information about their cost effectiveness is also required. Concerns are occasionally voiced that arts therapies, through encouraging self-expression, could exacerbate rather than diminish mental distress among people with psychosis. While we are not aware of such incidents occurring these concerns should be explored through monitoring untoward incidents or other indicators of negative therapeutic reactions in future observational and experimental studies.

There has been much discussion about the mechanism of action of arts therapies, but there have been few attempts to examine this systematically. By combining quantitative and qualitative research methods it should be possible to develop a better understanding of the elements of these complex interventions that are associated with improved outcomes, and whether there are subgroups of people with psychosis for whom arts therapies may be more or less helpful.¹⁷

CONCLUSIONS

An evidence base for the effectiveness of arts therapies in the treatment of people with schizophrenia is beginning to emerge. Arts therapies combine the use of art materials with psychotherapeutic techniques that aim to encourage self-expression and promote self-awareness. They appear to be popular with patients and may result in improved mental health, especially reductions in negative and general symptoms of schizophrenia, which are those least responsive to pharmacological interventions. Further research is needed to establish the effects and cost effectiveness of arts therapies for people with schizophrenia outside of specialist centres.