Back to Table of Contents | July 2010

Clinical and Health Affairs

The Creative Arts Therapies: Making Health Care Whole

By Sharon W. Goodill, Ph.D., BC-DMT, NCC, LPC

Abstract
The creative arts therapies are six fields that combine artistic expression with psychotherapy to promote healing, wellness, and personal change. Although they are well-established fields, they are garnering renewed attention with the recent focus on health care and the arts. This article describes these fields and provides information about the training and professional standards of creative arts therapists and examples of how these therapies are being used in health care settings.

The creative arts therapies (CATs) are mental health specialty disciplines that use arts modalities and creative processes to enhance self-awareness; foster health, communication, and expression; promote the integration of physical, emotional, cognitive, and social functioning; and facilitate behavioral and personal change.¹

There are six CAT specialties: art therapy, music therapy, dance/movement therapy, poetry therapy, drama therapy, and psychodrama. Each is inherently interdisciplinary, combining psychotherapy and counseling with the curative power of creative expression and communication through the arts.

The CATs gained professional status in the United States in the 1950s. Each is now organized and represented by its own national organization that confers professional credentials, provides continuing education, engages in public advocacy, and supports research and development (Table). All operate with codes of ethical conduct and standards of practice, and procedures for ensuring that therapists comply with them. In addition, the National Coalition of Creative Arts Therapies Associations serves as an umbrella organization for all of the fields.¹ Creative arts therapists specialize in one of the aforementioned art forms. Another closely related specialty, expressive arts therapy, is multimodal in that therapists combine two or more art forms during the course of a session or treatment.

The academic path to practice the CATs involves coursework in general psychology and counseling as well as specialty coursework and supervised internships. Altogether, there are approximately 170 CAT graduate programs in the United States, as well as approximately 70 undergraduate music therapy programs (music therapy is the only CAT specialty to credential at the undergraduate level). Training programs are approved or accredited according to published academic standards that are maintained through oversight committees.

Each CAT specialty publishes at least one peer-reviewed journal (Table). Scholarly articles on the CATs also appear in the Journal of Arts in Psychotherapy and in the journals of related disciplines such as nursing, counseling, and psychology.

Approximately 14,000 professional creative arts therapists currently are practicing in the United States. As members of multidisciplinary health care teams or in private practices, they work in inpatient, outpatient, and partial hospitalization mental health and substance abuse care settings; prisons; nursing homes and other facilities for elders; and in community-based and school-based programs. During the last two decades, the CATs have been increasingly used in health care to provide psychosocial support for patients with cancer and chronic pain, with pediatric patients, and with people undergoing medical and neurorehabilitation.

Creative arts therapists are part of the current movement to integrate the arts in health care. Others involved in this movement are artists who might be employed by health care organizations to teach the arts to or make or perform art for patients, and other mental health specialists who use the arts in their practice.² The CATs also are part of the national trend to integrate complementary and integrative therapies into mainstream medicine. The NIH’s National Center for Complementary and Alternative Medicine classifies the CATs in the mind/body interventions subset of complementary and alternative medicine; research funding for the CATs is available through this NIH center.³

In many ways, health care is being enhanced and humanized through the infusion of the visual and performing arts, and research is showing that the arts have a positive impact on both patient satisfaction and clinical outcomes.² The arts are also being used to support both professional and family caregivers, promote community well-being, and enhance health care environments. The CATs are applied primarily in the patient care, caregiver, and community arenas.

Distinguishing Features

The key difference between creative arts therapists and artists who provide programming for patients or caregivers is the goal of their work. The visual or performing artist is likely working toward a general goal. For example, a musician might perform in a hospital lobby to provide a diversion for patients and their families. The creative arts therapist, however, is focused on the therapeutic needs of an individual patient. She will first assess the patient and then develop a treatment plan tailored to his or her specific needs. For managing chronic pain, a music therapist, for example, would take a biopsychosocial approach that might include using music-guided breathing exercises to help the patient focus attention away from their pain; songwriting or improvisation to express their pain (this can help the therapist guage its severity and the patient’s emotional state); linking the musical expressions to solving problems regarding expectations, mood states, and coping; and using patient-preferred music, breathwork, or meditation to music to achieve a brief state of relaxation.⁴

Another difference between creative arts therapists and artists who work in health care is related to training and education. A creative arts therapist will have completed a planned sequence of university study (usually with 700 to 1,100 hours of supervised practicum and internship) that gives them a background in psychology, research methods and findings, and assessment along with specialized clinical skills. Graduate level curricula are often designed to meet the educational requirements for counseling licensure. Thus, the creative arts therapist is prepared to address the stressors of cancer treatment or recovery from addiction, or struggles with depression, where an artist might not be.

Engaging in the creative process in and of itself offers some healing. As might be expected, creative arts therapists value the intrinsic healing potential of the arts. Artistic expression is a way to know one’s own state of mind and heart, a way to check in with the self, and a way to communicate the inner experience. And creative activity is evocative. When arts expression has evoked strong feelings or awakened memories or connections that had been previously kept out of one’s thoughts, the creative arts therapist is competent to safely address the responses so that they lead to insight, problem solving, and behavior change.

Therapeutic Approach

All of the CATs focus on psychotherapeutic goals and methods. All require practitioners to engage in ongoing assessment and evaluation and to track clinical progress using the expressive repertoire as well as observation of behavioral changes and verbal information.

The CATs are sometimes labeled “nonverbal” therapies. They can be a treatment of choice for people who because of developmental functioning or communication disorders may not be able to engage in verbal psychotherapy. This may include people with disorders on the autistic spectrum, patients in neurorehabilitation including those with aphasias, and people near the end of life. Because the arts are often nonverbal expressions and involve communicating through symbols, imagery, and metaphors, they are useful when words fail or cannot be summoned. For people who have experienced trauma or are dealing with feelings that are so intense that they cannot describe them, the arts provide a way to begin to bring up difficult issues in a way that is psychologically safe. Studies of CAT work with children who have symptoms of post-traumatic stress disorder, those exposed to war and violence, and those facing or grieving loss and death demonstrate this.^5-7

Although creative arts therapy can often be nonverbal, a good deal of verbal exchange often takes place during CAT sessions. Patients will complete a round of creative work such as drawing and then reflect on it during discussions with the therapist or, in the case of group therapy, the group.⁸ For example, an art therapist might ask the patient to draw a bridge and place himself on that bridge. The discussions might explore the patient’s reasons for placing himself near the beginning or end of the bridge or the meaning of the colors used to depict the destination. Therapists are trained to take what emerges through the music, movement, drama, or imagery expressed and apply those discoveries to clinical issues, life challenges, and treatment goals. The idea is that the depth of the experience in the CAT sessions will be supported by the therapist and that the patients’ learnings will be generalized to other areas of their life.

In the CATs, process is emphasized over product. Although a work of art is sometimes produced during CAT sessions, the point of the artistic endeavor is the therapeutic change that occurs while making, composing, or exploring it. Creative arts therapists draw from a variety of psychotherapeutic approaches including the humanistic, psychodynamic, Jungian, object relations, systems, feminist relational, and cognitive behavioral traditions as well as from the CAT fields themselves such as theories on aesthetics, creativity, and culture and development. Recent neuroscience findings such as the discovery of mirror neurons, new knowledge about neuroplasticity, and greater understanding of the neurobiological dynamics of trauma are also being integrated into the CATs.^9,10

Finally, the CATs invite the expression of emotion. In short, creative arts therapists work from the evidence-based premise that it is good for one’s health to express rather than constrain one’s feelings and that doing so is a necessary and natural part of moving through illness, injury, or loss. Researchers such as Pennebaker and colleagues have shown that even the expression of “negative” emotions has health benefits. They describe the link this way: “To the extent that the active ongoing inhibition of nonverbal expression influences autonomic [nervous system] activity and places continual stress on the body, it would follow that nonverbal expressivity would also be related to health. Although less research is available regarding nonverbal expression, it is also likely that the nonverbal expression of emotion bears some relation to health status.”¹¹

Creative Improvisation as a Clinical Method

Improvisation is used as a clinical method in the CATs. To improvise is not just to “make it up as you go along.” Rather, as any musician, dancer, artist, actor, or creative writer knows, improvisation is used to explore patterns, themes, and relationships within a structure. The improviser plays with the properties of the art and his or her own inner inclinations, motivated by a need to understand or express something from life and experience. Improvisation is always done in the presence of a creative arts therapist, who either witnesses or joins the creative process.

For example, a dance/movement therapist may ask a patient to perform a gesture that represents a current challenge. The patient might slowly make a fist with one hand and draw it toward his torso; he might then extend his other arm with his hand open, as if stopping traffic. He explains that the gesture expresses his wish to be left alone because of his fear of recurrent cancer. The therapist would repeat the gesture with him, and together they would amplify the movement until it became a full-bodied expression, trying it quickly, slowly, tentatively, with strength, with and without eye contact, and so on. During this exploration, the emotional connection to the image of bringing in and pushing away at the same time is clarified and communicated. The patient may then understand that he actually does want to gather his children and others close to him but that he has pushed them away at a time when he needs them most. The session makes him aware that the expression is about his most important relationships. The therapist may then use movement to help him allow others to come close and prepare him to accept offers of support.

Creative arts therapists see many parallels between artistic improvisation and the ways in which people who are ill or stressed need to behave in order to cope with their situation. During improvisation, the patient engages in ongoing adaptation to change and in creative problem solving. To improvise, one must be in the “here and now,” yielding to the present moment. This is not just analogy. Improvisation is essentially about accepting what has just happened and then shaping the next moments. If a patient can become comfortable with improvisation, he or she can apply it to the challenges and unknowns in his or her life. Improvisation requires people to learn to compensate for their limitations by drawing upon their strengths. When the therapy matches the individual’s threshold for ambiguity, the experience of creative improvisation is one of excitement and pleasure. It is a chance to access one’s vitality and sense of future. In this way, creative arts therapy promotes wellness, drawing for “that which is well within a patient.”¹²

Referrals

Patients can be referred for CAT for a variety of reasons. They might be referred to improve expressive competence, to gain empathy, to develop social skills, to build a capacity for trust, to promote self-awareness and self-reflection, for affect regulation, and to gain insight into problematic behavior patterns. In the medical context, the CATs might help patients reduce pain, expand their coping repertoire, garner social support, face painful or stressful medical procedures, engage in life review near the end of life, and mitigate obstacles to adherence to treatment and self-care.

Despite evidence of their effectiveness, the CATs are not uniformly covered by the major private or public health insurers in the United States. More advocacy is needed if we are to change regulations and insurance coverage so that these services can be made more widely available.

Conclusion

The CATs are well-established psychotherapeutic approaches that can enhance the care of patients with mental health and medical problems. Considered complementary and alternative approaches by the NIH, the CATs seek to evoke emotional expression through various art forms including dance, theater, music, and the visual arts. The assumption underlying the CATs, which is increasingly supported by research, is that creative expression promotes health and wellness. A growing body of research is demonstrating the effectiveness of the CATs in alleviating stress, helping patients cope with pain, and giving them the courage to adapt to their uncertain future. At this point in time, when health care is embracing the arts in so many ways, there is renewed interest in the CATs. MM

Sharon Goodill is chair of the department of creative arts therapies in Drexel University’s College of Nursing and Health Professions in Philadelphia. She spoke about the creative arts therapies at the Society for the Arts in Healthcare conference in Minneapolis in April.
 

References
1. National Coalition of Creative Arts Therapies Associations. Available at: www.nccata.org. Accessed June 15, 2010.
2. Society for the Arts in Healthcare. Arts in Healthcare. State of the field report. Available at: www.thesah.org/template/page.cfm?page_id=604. Accessed June 16, 2010.
3. National Center for Complementary and Alternative Medicine. What is CAM? Available at http://nccam.nih.gov/health/whatiscam. Accessed June 16, 2010.
4. Taylor ML. Music-based and Music Therapy Interventions Used to Address Chronic Pain in Adults: A Literature-based Study [master’s thesis]. Philadelphia, Drexel University; 2010.
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6. Harris DA. Dance/movement therapy approaches to fostering resilience and recovery among African adolescent torture survivors. Torture. 2007:17(2); 134-55.
7. Hilliard R. The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. J Music Ther. 2003;40(2):113-37.
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11. Berry DS, Pennebaker JW. Nonverbal and verbal emotional expression and health. Psychother Psychosom. 1993;59(1):11-9.
12. Nolan P, as cited in Pratt RR. Healing and art. Int J Arts Med. 1992; 1(2):3.