Research into Process and Outcome of Art Therapy Claire Edwards Tom OBrien Robert King

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

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)

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

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

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

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

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. Cohens 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 Cohens 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

Results Number of participants –Total = 1053 –Mean = 45.8 –Range = 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)

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

Effect Size by Study Type

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

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

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

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

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.