Motivation and emotion/Book/2020/Art therapy and emotion

Overview
''A knife is a response to our need, yet inability, to cut. A bottle is a response to our need, yet inability, to carry water. To discover the purpose of art, we must ask what kind of things we need to do with our minds and emotions, but have trouble with'' (de Botton, 2015, p.5).

There is an increasing acknowledgment that engaging with the arts can be beneficial for mental health. The World Health Organization's 2019 scoping review on arts and health highlights results from over 3,000 studies that show how arts engagement can enhance subjective well-being and support positive emotions, reduce the risk of developing a mental illness, and be of help in the management and treatment of a wide range mental health conditions (World Health Organization, 2019).

This chapter looks at the value of visual art therapy as a way to engage and influence emotions with a focus on art as means for therapeutic intervention. Art therapy has been shown to be effective in reducing symptoms of psychopathology as well as enhancing general well-being and quality of life (Haeyen et al., 2018b). The ability of art to influence emotion is explored through three key psychological approaches: psychodynamic, positive psychology and cognitive. Using these approaches, art therapy has been used in the treatment of a number of conditions that have a strong emotional component, including anxiety and depression (Rosal, 2016), posttraumatic stress disorder (PTSD) (Gantt & Tinnin, 2009) and emotional regulation issues faced by people with personality disorders (Haeyen et al., 2018a). With the prospect of building a stronger evidence base, a brief discussion is included about how proponents of art therapy are increasingly looking to brain imaging, which is offering tangible information about how people are processing stimuli that cannot otherwise be observed or self-reported (Kapitan, 2014).

Emotions are inextricably linked to engagement with art. Drawing on a psychological interpretation of emotions as being comprised of " feeling - purposive - expressive - bodily responses" (Reeve, 2018, p.288), the ways art acts upon the four characteristics that work together and influence our emotions serve as a useful framework (see Table 1) for considering the relationship between art therapy and emotions and will be considered throughout the chapter.

Table 1. The components of emotion and the ways that art acts upon the its four characteristics

Focus questions:
 * How does art therapy help people recover from, or cope with, emotional difficulties?
 * What is the relationship between art therapy and psychological theory?
 * What is the evidence for the benefits of art therapy?

What is art therapy?
Art therapy is an experiential method of treatment that involves the use of visual stimulus and creative activities, such as drawing, painting or sculpting, to help people express themselves, and to understand and examine psychological and emotional states, thus providing a therapeutic benefit for those who are experiencing psychological distress (American Art Therapy Association, 2013). It can be offered as a stand-alone therapy or be integrated into more traditional forms of psychotherapy (Rubin, 2016).



Art is not used as a diagnostic tool but serves as a medium to address emotional issues (British Association for Art Therapy, 2020). The focus in art therapy is the act of art making, not the product, therefore artistic skill is not a necessity, but rather it requires a genuine willingness to engage to enable personal insights to emerge (Rogers, 2016). The art therapist works with the client in establishing goals and objectives for their sessions, and designs individual treatment plans that incorporate arts therapy and psychotherapy techniques. They then instruct individuals or groups in the use of arts media with a view to providing guided self-expression through art (Rubin, 2016) (see Figure 1).

While not distinct processes, there are two central features of art therapy. One is the "decoding" aspect of art therapy, whereby nonverbal messages and symbols found in artworks produced lead to a better understanding of feelings and behavior, and assist in identifying and resolving deeper issues (Rubin, 2016). And the other feature is the effect that occurs with the act of art making or looking at art, including the facilitation of flow (Beard & Csikszentmihalyi, 2015) or physiological states of calm (Kaimal et al., 2016).

The relationship between art therapy and psychological theory
Psychological theory plays an integral role in how art therapy helps people explore their emotions and inner life (Wilson, 2016) and is important in a number of ways. It provides structure for planning interventions and a lens through which to conceptualise practice; it helps reach an understanding of the meaning as well as the process by which people express themselves; and it helps demystify art therapy for other mental health professionals (Rosal, 2018).

Three key approaches that have played significant roles in shaping the course of art therapy's development are outlined below - psychodynamic, positive psychology and cognitive approaches. Of the many approaches, these have been addressed in this chapter because they encapsulate the key aspirations of art therapy and speak elegantly to its effectiveness in contributing to existing treatments and therapies in the area of mental health. Importantly, art therapists may integrate a variety of approaches in their practice to support client needs (Van Lith, 2016).

Psychodynamic approach
The origin of art therapy as a therapeutic method to treat mental health disorders lies in the psychoanalytic approach of Freud and Jung (Junge, 2010). Indeed, art was central to Jung's outlook and he believed it to be the outward projection of inner experience, using art to both gain insight into the mind and to heal when problems emerged (Junge, 2010). Proponents of a psychodynamic approach to art therapy argue that art helps people understand unconscious drives, formulate visual symbols and reformulate emotional responses to existing symbols (Lobban, 2012) which is fundamental to a higher level of functioning (Wilson, 2016). Symbolic formulation (making visual images) is particularly useful for situations where language (another form of symbolic representation) is too difficult or frightening (Wilson, 2016).

In a contemporary psychodynamic art therapy setting, participants might be asked to think about the role of the image during the art making process by undergoing a mentalising process that identifies the underlying thinking structures. This forms interpretations based on anxieties, feelings, needs and beliefs (Holmqvist, et. al.,2017). The images created serve as an anchoring point from which to identify and sort through disordered thought processes with a view to establishing a greater consciousness of emotions and improved ego strength (Holmqvist, et. al.,2017).

While many aspects of the psychoanalytic approach have been discredited as lacking in scientific credibility in the field of psychology (Fonagy, 2015), there is still much in the psychoanalytic approach that interests the art therapist based on its usefulness in creative settings (Fonagy, 2015). Indeed, neurological studies suggest that creativity benefits from unconscious processes that occur via the engagement of the interconnected brain regions known as the default mode network activated when cognitive control is low (Kühn et al., 2014). Art also serves a transitional role that facilitates a connection between the client and the therapist. It also enables a process of sublimation whereby difficult emotions can be expressed safely and in a healthy way through the art work (Waller, 2006).

Positive psychology approach
With a starting point of the individual's experience, and a focus on the attainment of personal understanding and 'self actualisation' (Junge, 2010), positive psychology has had a significant influence on art therapy in recent years. Importantly, because the focus of positive psychology is not only on developing the ability of the client to gain mastery of their own life, but for them to be an active participant in the therapeutic process (Wilson, 2016). Art making is an experiential process, and the client directly controls the process of gaining greater emotional awareness.

Identifying and building on a person's individual strengths helps develop resilience against stressors (Wilkinson & Chilton, 2013) and art therapy provides a way to guide people through difficult emotions (Wilkinson & Chilton, 2013). According to positive psychology, one of the major components of well-being is 'life-meaning' or purpose (Hill & Turiano, 2014) and although many people who undergo trauma experience posttraumatic stress, it is not uncommon for them to also experience posttraumatic growth and find new meaning and purpose after struggling with a highly challenging life situation (Tedeschi & Calhoun, 2004). A positive psychology approach, when applied to art therapy, draws on the benefits of the creative process in illuminating and creating new meaning that leads to positive emotions and increased well-being (Wilkinson & Chilton, 2013).

Art making can promote a state of flow; a positive and holistic psychological state people experience when they act with total involvement (Beard & Csikszentmihalyi, 2015). Indeed the father of the concept of flow, Csikszentmihalyi did his dissertation on artists, creativity and art. "I was most interested in the fact that these people would spend weeks and weeks working on a painting and they would forget everything while they were working" (Csikszentmihalyi in Beard & Csikszentmihalyi, 2015, p.355). Being in a state of flow also fosters intrinsic motivation which in turn can enhance personal growth and positive mood (Keller & Bless, 2008).

Case study: Escapism and expression: Art therapy helping women with breast cancer

A study by Collie et al. (2006) found art therapy to be beneficial for a group of 17 Canadian and American women as they went through breast cancer. The purpose the study was to gain an in-depth understanding of how the women used art therapy to address their psychosocial needs. Making meaning out of their cancer experience was the focus of the study given the challenges posed and the threat of death. With the goal of identifying specific therapeutic mechanisms, researchers considered how art therapy was used for communication and self-understanding. After attending art therapy sessions, many of the women told stories about being energized by art making and about using it as an antidote to illness.

The study used narrative research methods through in-depth interviews in which women were asked to express beliefs about themselves, breast cancer, cancer treatment and healing. In the course of the interviews women showed their artwork and used it to trigger memories of how art making was meaningful to them at the time. Four main storylines came out of the analysis:


 * Art therapy as a haven
 * Getting a clearer view of the illness and life
 * Clearing the way emotionally
 * Enhancing and enlivening the self

Participants also expressed a concern about "annihilation of the self" whereby they felt reduced to only a cancer patient. They found that art therapy counteracted this effect by affirming their existence and expressing a presence of themselves as an ongoing physical and psychological person.

Two extracts from the Collie et al. (2006) study highlight the benefits provided by the therapy in light of its ability during a very challenging time to facilitate positive emotions, growth and flow:

"I never thought, I never presumed, I never imagined that that amount of information would come out of a small drawing that’s on paper. It was amazing how much did come out of that. I was surprised. I was given insight that I wasn’t aware of, which gave me a sense of empowerment, and then I was able to make the decision that I wanted to from that." (p.767)

"It was the first time in two months that I didn’t think of the cancer. It was the first time that the nightmare had stopped. When I was in there, it just seemed to be like a gentle rain falling on me." (p.765)

Cognitive approaches
The effectiveness of cognitive approaches, such as cognitive behavioural therapy (CBT), in treating mental health disorders is widely accepted in a range of clinical contexts (Szarbo, 2017). Cognitive therapies help people understand and overcome the psychosocial stressors that set negative cognitions into play by restructuring thoughts through the observation of cognitive distortions and creating a more balanced and rational set of thoughts in relation to emotions (Hofmann et al., 2013). In recent years, cognitive approaches have been adopted by many art therapists because art making is itself a cognitive process in that it engages and explores the senses and emotional states; it facilitates thinking and generating solutions; and involves a feedback process in the creation of the artwork (Rosal, 2018). The images in Figures 2 and 3 show clients' explorations of their experience with depression and PTSD respectively with a view to identifying its components and overcoming the obstacles it presents.

Third wave cognitive interventions, such as dialectical behavioural therapy (DBT) and acceptance and commitment therapy (ACT), have proven particularly appealing to art therapists as they focus on a client's relationship to their thoughts and emotions, as much as on their content (Rosal, 2018). Third wave approaches emphasise mindfulness, meditative practices, acceptance and meta‐cognition (Hayes & Hofmann, 2017). Art making and viewing is ideally suited to inducing a state of mindfulness and bringing state of inner quiet to one’s thoughts and feelings (Herbert & Forman, 2011).

Mindfulness based cognitive art therapy has been used to help clients understand emotions and develop self-compassion. Rosal (2016) draws attention to a highly traumatised client experiencing anxiety and depression who through drawing sessions was able to gain more control of feelings and explore mind-states. By contemplating the drawings representing different points in their life and comparing them with their understood experience the client was provided with a tool to help appraise and attribute the significance of their emotions. With greater awareness of anxious feelings as they emerged, the client was able to gain more control of how the emotions played out. And, with the addition of drawings made to represent serenity, which provided a self-soothing component of treatment, emotional growth ensued (Rosal, 2016).



Studies have also shown that a therapeutic model consisting of art therapy, CBT and DBT methods can be valuable in treating childhood anxiety and trauma related disorders (Cecil, 2016) in that art therapy provides a playful, non-threatening, and engaging environment for children who are yet to develop the cognitive abilities to verbally communicate feelings and problems. The art component of such treatment contributes to the creation of an avenue for children to begin to think about self-awareness and behaviour changes, and provides the therapist with an additional way to understand what the clients are saying (Cecil, 2016).

Physiological evidence
Despite the reported positive outcomes, there is a general acceptance that more empirical evidence is needed to substantiate art therapy as intervention (Slayton, et al., 2010). This is because the research is still emerging (Kapitan, 2014), and findings tend to be anecdotal and unspecific, in that it is difficult to isolate the effects of art therapy as it is often offered in combination with other forms of therapy (Haeyen et al., 2018a). However, physiological evidence is not only showing the benefits of arts engagement, but serving as an important method in building scientific credibility. For example, studies show reduction of the stress hormone cortisol when engaging in art (Kaimal et al., 2016) and brain imaging is producing a range of findings (Hass-Cohen et al., 2008).

While appreciating there are many neural systems that are engaged when participating in art therapy, such as the visual, somatosensory and motor systems (Lusebrink, 2004), studies show that engaging in art can influence how the brain functions emotionally:
 * Processing of a work of art is accompanied by greater neural activity in the medial orbitofrontal cortex and ventromedial prefrontal cortex, regions strongly associated with the experience of reward and emotion processing, increasing positive emotions (Mastandrea et al., 2019).
 * During pleasing aesthetic experiences a network of the brain known to be involved in making judgments about yourself or close others is recruited. This includes the orbitomedial prefrontal cortex, the dorsomedial prefrontal cortex, and the anterior cingulate cortex, implicated respectively in the representation, evaluation and monitoring of the self (Morrissey, 2017). The value of art in contributing to a deepening of self-understanding, perhaps goes some way to explaining the success of it's application in mental health contexts.
 * In treating trauma it has been suggested that art therapy taps into primitive brain networks and helps establish new neural pathways that could alter how the brain functions in relation to traumatic memories and emotional responses (Lobban, 2012).
 * Art therapy provides a way to communicate non-verbally, this may be important when one considers the apparent deactivation of the speech related Broca’s area of the brain in trauma clients, thus affecting the ability to relay personal experience in words. Art may offer a way to bypass this neural pathway blockage and allow clients better communicate and deal with trauma (Gantt & Tinnin, 2009).

Conclusion
This chapter considered how art therapy serves as a valuable therapeutic tool in reducing symptoms of psychopathology and supporting emotional health by engaging and influencing emotions. It considered the close and bi-directional relationship between art and emotions, i.e. emotions drive our approach to art therapy (Collie et al., 2006), and art therapy can act on the way emotions are processed (Rosal, 2016).

Psychological theory plays an integral role in how art therapy is understood in terms of exploring emotions and how the strategies the art therapist applies in their practice can be appreciated. While three psychological approaches have been identified independently, there is overlap. Certainly, each has its particular method; from looking to the unconscious and delving deep into the mind (psychoanalytic), appraising and gaining awareness of emotions (cognitive) and facilitating the right environment to grow emotionally (positive). All approaches aim to explore emotions and promote psychological well-being.

The evidence for the benefits of art therapy, and its utility in relation to psychological interventions for conditions that have a strong emotional component, are important factors in providing clients with the knowledge that art therapy works (Slayton, et al., 2010). However, in order raise its status in the field of psychology, further work is required, in addition to brain imaging, to develop more standardised measurement tools to appreciate the effects of art therapy (Haeyen et al., 2018a). More precisely, experimental designs are needed with control groups, as well as the replication of studies (Slayton et al., 2010). With an outlook for continued improvement, the fields of art and science should see their future as working in synergy to understand the power of creative expression in healing. The establishment of a more coherent research agenda for art therapy implementation is needed to support the development of agreed standards and a better body of knowledge about the short- and long-term effects of art therapy interventions.