Art therapy and psychosis

Overview

• High-quality research has found that art therapy can be beneficial for people experiencing psychosis [4, 5, 6].
• Art therapy is included, along with other arts therapies, in the England and Wales national (NICE) guidelines [7] for psychosis care and treatment.

 

Why art therapy may be helpful

Expressing traumatic experiences

An extensive review of the research evidence suggests that for many people, traumatic experiences have contributed to them experiencing psychosis. These traumatic experiences tend to be of a kind that involves another person or people, often during childhood [8].

Some experiences can be difficult to put into words, and art therapy with an appropriately qualified therapist can be a way of beginning to express them, and having a different experience of oneself [9].

Making connections with life experiences

Some people can use art to make connections between their life experiences and their psychosis experiences [9]. This fits in with the work of Dutch psychiatrist Marius Romme, who collaborated with people who had experience of psychosis to develop a new approach, spawning the Hearing Voices movement in many countries [10].

Some people may also be able to express valued spiritual beliefs through their artwork [11, 12].

Supporting interactions in group art therapy

Group art therapy can provide a safe space, for example by the way that the art therapist organises the time, provides themes for the artmaking, or ensures each member of a group has their own space to make art [9, 13].

In a study involving interviews with service users who had attended group art therapy for first episode psychosis, some participants said that the “unpressured atmosphere” was helpful [14]. The art acted as buffer from direct interaction with others, enabling people to enjoy it. This in turn led naturally to talking with others, and in some cases lasting friendships developed.

The art therapy room and materials can also help if the service user is initially finding it difficult to talk, because the art therapist can use an invitational approach, such as showing the service user around the room and explaining the possibilities for artmaking, without expecting a verbal response [13, 15].

Both artmaking and being able to interact more with other people can lead to a sense of achievement for people who are initially finding it difficult to be in a group [16].

Research studies

There are several good research studies (randomised controlled trials) suggesting that art therapy can be helpful in relation to psychosis [^4-6].

One large trial [17^] reported that usual care plus art therapy did not lead to better outcomes when compared to usual care plus activity groups or usual care alone. However, after being enrolled into the trial, only a small percentage of service users attended either art therapy or activity groups. Therefore the comparison at the end of two years (from following people up irrespective of attendance) was mostly between people who had not attended any groups of either type. [18]

Guidelines

We produced evidence-based guidelines to inform art therapists, mental health professionals, the public, and people planning research on art therapy in relation to psychosis.

Read the guidelines

Evidence sources

1. The prevalence of voice-hearers in the general population: a literature review (2011)
   A review of 17 studies on the prevalence of people in the general population who hear voices that others do not hear.
2. Dissociation, trauma, and the role of lived experience: toward a new conceptualisation of voice hearing (2012)
   Draws on a range of research evidence to try to understand how people come to hear voices others do not hear, and includes estimates of prevalence of voice-hearing.
3. NICE, Psychosis and schizophrenia in adults: prevention and management (2014)
4. Group art therapy as an adjunct to treatment for chronic outpatients. (1987)
   A report of a randomised trial of usual care plus art therapy versus usual care alone in the USA.
5. A pilot RCT of psychodynamic group art therapy for patients in acute psychotic episodes: Feasibility, impact on symptoms and mentalising capacity (2014)
   A report of a randomised trial of usual care plus art therapy versus usual care alone in Germany.
6. Exploratory RCT of art therapy as an adjunctive treatment in schizophrenia (2007)
   A report of a randomised trial of usual care plus art therapy versus usual care alone in the UK.
7. National Institute for Health and Care Excellence: Psychosis and schizophrenia in adults: prevention and management (2014)
   The England and Wales national guideline on treatment and management of psychosis.
8. The traumagenic neurodevelopmental model of psychosis revisited (2014)
   A review of a large range of research evidence illustrating the effects of early trauma on the brain and development, and how such trauma can sensitise the individual to further stress in adulthood.
9. BAAT Guidelines on Art Therapy for People with a Psychosis-Related Diagnosis (2020)
   Evidence-informed guidelines for people with a psychosis-related diagnosis, which drew on consultations with service users and experienced art therapists.
10. Living with voices: 50 stories of recovery (2009)
    A book containing 50 personal accounts of recovery in relation to psychosis, showing the role of trauma in its development, and what helped people’s recovery. It also discusses the development of the Maastricht Interview, an approach to helping people to make sense of voices.
11. Expressive art therapy for psychosis: A multiple case study (2013)
    Reports in detail and systematically on each of five women who attended expressive group art therapy for psychosis in Norway.
12. Art making as a mental health recovery tool for change and coping (2015).
    Reports on three interviews with each of 12 people who used artmaking in the course of recovery in the context of rehabilitation services for severe mental health difficulties in Australia.
13. Art therapy with people diagnosed with psychosis: therapists’ experience of their work and the journey to their current practice (2021)
    Reports on an in-depth qualitative study involving interviews with 18 experienced UK art therapists who were delivering art therapy to people with psychosis-related diagnoses.
14. The experience of art therapy for individuals following a first diagnosis of a psychotic disorder: a grounded theory study (2018)
    Reports on an in-depth qualitative study involving interviews with service users who attended art therapy in the UK after diagnosis with first episode psychosis.
15. Toward an understanding of how art making can facilitate mental health recovery (2009)
    A report of interviews with three people who facilitated participants of mental health rehabilitation programs in Australia in making art as part of supporting their recovery from long-term severe mental health difficulties.
16. Considering referral to art therapy: responses to referral and experiences of participants in a randomised controlled trial (2013)
    Reports on an in-depth qualitative study of the experiences of service users who took part in a randomised trial [source 17], illustrating different pathways, including those who did not continue attending art therapy, as well as those who did, and who reported benefits of doing so.
17. Group art therapy as an adjunctive treatment for people with schizophrenia: A randomised controlled trial (2012).
    A detailed report of a UK randomised trial of usual care plus art therapy, compared with usual care plus activity groups, and usual care alone. It reported that usual care plus art therapy did not lead to better outcomes when compared to usual care plus activity groups or usual care alone. However, after being enrolled into the trial, only a small percentage of service users attended the groups.
18. The MATISSE trial – a critique: Does art therapy really have nothing to offer people with a diagnosis of schizophrenia (2014)
    This is a critique of the trial reported in source 17. Among other things, it finds the comparison at the end of two years (from following people up irrespective of attendance) was mostly between people who had not attended any of the activity or art therapy groups offered in the trial.