Research into Process and Outcome of Art Therapy

1. Research into Process and Outcome of Art Therapy Claire Edwards Tom O’Brien Robert King

2. Research Paradigms • The psychotherapy research paradigm • Outcomes are health, social adjustment and well-being which are measurable and normative • Processes are interactions/settings/activities associated with such outcomes • Ethos is that therapy should be ‘evidence-based’ • The creative arts research paradigm • Outcome is a unique product which is not measurable but is capable of non-normative appreciation/interpretation • Processes are traditions/materials/techniques • Ethos is therapy is release/discovery of creativity

3. Art Therapy: Theoretical Model • Engagement with art making as an enabling activity for exploration of difficult emotional experience – initially facilitating experience and ultimately cognitive processing of the experience • Creation of a safe space for creativity (cf Winnicott) - enhanced creativity as a means of building psychological resourcefulness – affinity with play • Enhanced personal efficacy as a non-specific mediating variable. • Relationship with therapist and/or with peers as non-specific mediating variable (trust, affiliation, altruism etc)

4. Art Therapy Outcomes • Outcomes may be conceptualised as common with those of other therapies • Creativity may be an outcome and not just a process – especially if evidence of generalisation • Possible implication for personality change • One previous attempt to systematically review reported outcomes concluded that there were insufficient studies of adequate standard to conduct a reliable meta-analysis

5. Study Aims • Identify characteristics of published research involving art therapy • Investigate types of client outcome studied • Estimate size of art therapy effects • Evaluate impact of research quality on effect sizes • Make recommendations for future research

6. Study Approach • Given previous unsuccessful attempt at systematic review, we adopted a more exploratory approach using looser criteria for inclusion • We set out to obtain a picture of the state of the research rather than to determine whether or not art therapy is an effective intervention • Calculation of effect sizes was undertaken to identify trends rather than to estimate probable effect of an art therapy treatment

7. Methods: General • Search terms = “art therapy” plus either “outcome” or “research” • Databases = medline, psychinfo, cinahl, cochrane library, embase and amed • Additional search of publications cited in two reviews • The search initially yielded 48 publications but these included case studies and non-empirical reports, which were excluded • Studies were included if: • the language of publication was English • the participants were in receipt of art therapy as a treatment for an identified problem or issue • art therapy was either the only intervention or as a major component of the intervention, whether or not an art therapist conducted the intervention • results from use of one or more standardised measures were reported and sample was greater than 1 • This yielded a total of 23 studies, 20 of which enabled effect size calculation • Studies sorted into 3 categories: • No control (pre/post only) • Non-randomized control (comparison group) • Randomized control

8. Methods: Effect Size Calculation • Effect sizes were calculated for measures that were target outcomes and measured well-being. • Measures of personality, cognitive functioning and therapeutic processes were excluded • Few studies reported effect sizes. Cohen’s D was calculated from reports of either means and standard deviations or t scores. Where these scores were not reported but another effect size (eg partial eta squared) was, this was converted to Cohen’s D • Where multiple measures were used, separate effect sizes were calculated for each measure and then averaged to yield a study effect size • Where there was no data to calculate effect sizes, study authors were contacted with requests for means and standard deviations • When control data was reported, the effect size for art therapy was calculated relative to control • One RCT was excluded because authors attributed negative effect to unusual events

9. Results • Number of participants • Total = 1053 • Mean = 45.8 • Range = 7 - 158 • Study participants: age groups • Children/adolescents (n = 11) • Adults (n = 10) • Aged (n = 2) • Duration of treatment: • mean = 16 sessions (median = 8), range = 1 – 90 • Problem types • Mental health (n = 7) • Social adjustment/behavior problems (n = 6) • General health (n = 5) • Trauma (n = 4)

10. Results • Types of measures employed • Current state (depression, anxiety, general well-being, self-esteem) n=22 • Therapy process (mainly alliance) n=2 • Social functioning n=1 • Creativity/artistic control n=1 • Personality n=1 • Types of study • Repeated measures only (n = 9) • Non randomized control (n = 3) • Randomized control (n = 11) • Effects sizes (n = 18) • Range = 0.2 – 2.66 • Average effect size = 0.72

11. Effect Size by Study Type

12. Discussion – Study Characteristics • The number of empirical studies is small • Interventions are typically not standardised and little if any attempt to measure adherence • Art Therapy is often combined with another intervention • Limited information provided about training of therapists • Studies are highly variable with respect to: • Participant age • Participant problem • Study setting • Duration of intervention • Whether individual or group delivery

13. Discussion – Quality of Studies • The largest group of studies used a repeated measures design with no control • There was some evidence that higher quality was associated with recency and publication in a non Art Therapy journal • Those studies with control groups rarely utilised a balanced intervention for the control and often used wait or TAU • Allegiance effects not managed • Little evidence of measurement of possible AT related mediating variables such as creativity, expressive facility or self efficacy with art making

14. Conclusions • Published art therapy research has been developed within the psychotherapy research paradigm rather than the creative research paradigm • This may reflect the demands of the environment within which AT is provided and its links with other therapies • There is little evidence that AT research is informed by the creative research paradigm and the lack of cross fertilisation may explain the poverty of research activity – ie art therapists may be resistant to research with which they do not identify professionally

15. Recommendations: Empirical Research in Art Therapy There is need for clearer specification of AT interventions – although it is likely that specifications will be broad rather than narrow Management of confounds is critical • Where investigation is of a composite treatment the control must receive the non AT intervention • The use of non AT balanced interventions (eg exercise or other activity) in control groups is highly desirable Investigation of AT specific mediators is important

16. Recommendations:Bridging the gap between Artists and Psychotherapy Researchers • Effective collaboration between art therapists and researchers is likely require respect for the art research paradigm • Effective research will provide opportunities both for artists to explore the creative processes and psychotherapists to develop the evidence base • We have successfully adopted this practice in our teaching program and have also developed successful research partnerships with creative arts schools.