Creative Arts in Counseling and Mental Health

Philip M. Neilsen, Robert J. King, Felicity A. Baker

• Publisher: SAGE Publications, Inc
• Year: 2015
• ISBN:
  9781483324913
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Drawing on new paradigms and evidence-based discoveries in neuroscience, narrative psychology, and creativity theory, this text explores the beneficial role of expressive arts within a recovery perspective. A framework of practice principles for the visual arts, creative writing, music, drama, dance, and digital storytelling is addressed across a number of settings and populations, providing readers with an accessible overview of techniques taught in counseling programs in the U.S. and abroad.

Chapter 1 Introduction

Robert King

Felicity Baker

Philip Neilsen

We know that not everyone reads the introduction to a book, but if you are the kind of person who likes to read the introduction, here is what you can expect. We will try to explain why we think that engagement in the creative arts promotes recovery of mental health. To do this, we will have to explain what we mean by creative arts, what we mean by recovery, and what we mean by mental health. We will also have to provide you with something of a theoretical framework or explanatory model and have reference to some of the empirical evidence that is discussed later in the book. We will also give you a sense of the contents of the book and share with you some of our expectations and fantasies about who you, the reader, might be.

This book begins with the proposition that there is something therapeutic about engagement in the creative arts. There are of course lots of other forms of creative activities—such as building useful things, gardening, and nurturing animals—that have therapeutic benefits; however, our interest is in the creative arts—by which we mean activities such as art making, music making, drama, dance, and creative writing. These activities might be described as forms of self-expression, but we think they are more than this. We think that what makes them therapeutic is not just that they give expression to the person but that they are also artistic performances that are occurring through other relational experiences with the recipient—the viewer, audience, listener, or reader. In other words, while creativity is often an individual act, it is not the act of an individual in a void but always performed within relational experiences.

At first glance, the proposition that creative activity is therapeutic might seem a little counterintuitive. After all, words like poet and tormented seem to have a natural affinity. Jackson Pollock, Sylvia Plath, Syd Barrett, and Eric Satie were among many successful creative artists whose mental health was suboptimal. It is even possible that a little madness, or at least the ability to experience things differently to most other people, assists creativity. However, the possibility that creative people are more emotionally unstable than the rest of the population (and we are far from sure this is the case) does not mean that it is the creative activity that destabilizes. More likely, the creative activity is a stabilizing force for people who otherwise would be much less able to manage in life.

In any case, a focus on famous and successful artists would be misleading. This book is about ordinary people and their struggles with anxiety, mood disturbance, substance use, and psychosis. It is mostly about their work with therapists and the role that creative activity plays in these struggles. We have adopted the widely used term recovery instead of struggles. Recovery is a positive term that evokes the restoration of lost capacity, whereas struggles can sometimes be futile. Recovery can be misunderstood as it can have the connotation of restoration of full health. However, in the context of mental health, it often means learning to live with persistent symptoms and may be more concerned with the restoration of identity, the establishment of meaningful social connections, and the development of a belief that life can be worthwhile rather than with the complete elimination of illness.

This book is not just about people who have a diagnosed mental illness. We are also interested in people whose well-being has been compromised by severe physical illness or social disadvantage. In other words, we are interested in how creative activity can promote well-being.

We wrote this book for therapists (and people training to become therapists), but we hope it will also be of interest to others. We suspect that many readers will be specialists who are working or training in areas such as art therapy, music therapy, or drama therapy. However, we have a much wider audience in mind. We hope that the book will inspire therapists—such as nurses, social workers, psychologists, occupational therapists, and the small army of support workers and counselors who do not have formal professional designations—to encourage and support their clients to explore their creativity. We also hope that people who are searching for ways to overcome their personal difficulties or better manage difficult emotional states will read this book and be stimulated to try for themselves one or more of the creative arts.

So why are we confident that engagement in creative arts will assist your clients (if you are a therapist) or yourself? We have both a theoretical framework and an increasing body of empirical evidence. The empirical evidence is mostly linked to specific creative arts interventions (especially music therapy and art therapy) and you will find detailed discussions of this evidence in later chapters. In the introduction, we will confine ourselves to some more general observations about the status of the evidence. We think we can offer you a theoretical framework that has application to the therapeutic impact of all forms of creative activity, so we will outline this first.

A Theoretical Framework for Creative Arts in Recovery

We think that creative activity promotes mental health because of a combination of factors and not because of any single factor. The factors or components that are likely to contribute are

• behavioral activation,
• self-efficacy/mastery,
• overcoming experiential avoidance,
• strengthening of personal identity, and
• social connectedness.

We will consider each in turn, but before doing so, we think it is important to emphasize that we are not suggesting that all will operate in equal measure for any specific person. In some cases, just one or two may be present. However, all have the potential to contribute. They are also interlinked. While they are presented here as discrete factors, in practice changes in one often have implications for others. For example, behavioral activation can impact on social connectedness. However, it is not unreasonable to think of these factors as having at least some characteristics of a hierarchy with behavioral activation as the most basic step toward recovery and social connectedness as the ultimate aim of recovery.

Behavioral Activation

Many forms of mental illness, but in particular depression, tend to deactivate the person both mentally and physically. The result is extended periods of time spent sitting or lying, brooding or ruminating, but achieving very little. This becomes a self-perpetuating cycle, whereby inactivity results in feelings of inadequacy and guilt that further depress the person. Additionally, disuse of mental and physical capacities leaves the person with reduced capacity for activation, even if the mood lifts a little. Activation reverses this cycle. As the person starts to engage in meaningful activities, confidence begins to develop and physical and mental capacity starts to grow. Much of the early work in creative arts therapy is concerned with activation. Art therapists sometimes engage clients in simple squiggle games, where the aim is not to give expression to feelings or create anything but simply to get the person moving. Likewise, early work in music therapy is often concerned with musiking—making music within a relational experience. Readers with an interest in exploring this component of the model further are recommended to look at the work of Neil Jacobson and others in his Seattle group who were able to show that behavioral activation alone was a highly effective treatment for depression.

Self-Efficacy/Mastery

Mental illness commonly impacts on motivation as well as impairing basic cognitive functions such as attention and concentration. The result is that many people affected by mental illness experience reduced efficiency and capacity when performing a range of activities. Over time, this diminishes confidence and self-belief and can lead to a generalized loss of self-efficacy.

People who engage in creative arts therapies often discover they are more capable than they imagined—in activities for which they thought were usually reserved for those with special talents. Discovering their own creative capacity challenges their generalized lack of self-belief and helps people focus on what they can do rather than on what has been lost or diminished. As a result, they are more willing to try things and more likely to approach challenges with a sense of possibility rather than with the expectation of failure. Readers interested in learning more about self-efficacy are recommended to look at the classic work of Albert Bandura as well as more recent work in the positive psychology tradition.

Experiential Avoidance

There is a substantial body of theory and evidence to suggest that emotional difficulties are often associated with the avoidance of difficult or painful experiences. It is not surprising that people avoid these kinds of experiences, but the problem is that avoidance is not an effective strategy for managing them. There are two reasons for this. First, avoiding experiences associated with past trauma or that provoke social anxiety does not offer the potential to resolve them. In fact, it means that the opportunity for learning to deal with situations that are emotionally challenging is diminished and the difficulty is likely to persist. The second reason is that the process of avoidance often has further adverse impacts such as social isolation or nonspecific anxiety or depression.

Creative arts may provide people with a means of approaching and engaging with pain or difficulty in an indirect manner. It allows for a gradual approach and sometimes a symbolic, rather than direct, processing of experience. It is thus less threatening than a head-on confrontation with a problem but still a means by which the person can engage with, rather than avoid, the issues. This is akin to what Freud meant when he referred to creativity as a means by which unconscious conflicts can be sublimated rather than repressed. Further, many contemporary practices that draw on philosophies of empowerment, equity, human rights, and resource-oriented practices completely avoid the notion of “healing” and view cultural participation as a medium to reconnect those who have been excluded from social participation due to mental illness with sociocultural community practices. Readers interested in learning more about experiential avoidance and its consequences are encouraged to explore the work of Steven Hayes and acceptance and commitment therapy, which developed as a result of this work.

Personal Identity

Personal identity is a term used to describe how we view ourselves. It represents what we know, understand, and feel about ourselves and is most actively shaped during our adolescence. However, it is continually transformed throughout life as we encounter new experiences and events that threaten our self-concept and leave people questioning who they are as people. In other words, self-concept is not fixed and unchanging but a dynamic process shaped by the world around us, the people we interact with, and life events. People’s self-concept is comprised of six domains—the personal self, social self, family self, academic/vocational self, moral self, and physical self—that impact the roles they take in various contexts within their environment. People with a low self-concept are doubtful about their own worth.

Because mental illness can have a pervasive impact on functioning and role performance, it can often compromise one or more components of identity and self-concept. People often identify themselves by occupational role, family role, or role in community activities. When people find themselves unable to manage these roles as a result of mental illness, there is a risk that their sense of identity will be compromised and, instead, the disability narrative becomes the dominant narrative in their lives. This is what Erving Goffman referred to as spoiled identity, and it results in diminished self-esteem, lowered expectations, and eventually loss of hope.

Engagement in creative arts can foster the development of an identity and strengthen the self-concept that is independent of illness. Where appropriate and safe for the artist, creative arts therapists may facilitate public performance, exhibition, or publication of artistic works, in part because this provides community endorsement of an emerging identity as a musician, artist, or writer. This is particularly effective if engagement with the community is not strongly linked to having a mental illness. This is not to say that public display or performance is always a good idea. Any artistic communication can involve some sharing of self, and sometimes this may mean sharing personal experience of mental illness. It is important that the artist or performer understands this and the implications for loss of privacy and potential exposure to stigma. The therapist has a responsibility to weigh the potential benefits of wider distribution of the work with the potential risks. Aside from the classic work by Goffman, readers who want to learn more about identity and mental illness are encouraged to explore more recent work by Paul Lysaker and his colleagues.

Social Connectedness

Chronic mental illness often leads to social isolation. This perpetuates mental illness since isolated people do not experience the sense of community and support that connected people experience. Social isolation occurs as a result of a combination of the previously outlined factors. People affected by mental illness often lose confidence interacting with others because of a sense that other members of the community look down on them (stigma) or that they are not worthy of participating in the community (self-stigma). Social isolation also occurs because of reduced opportunity for interaction with other people. This is often exacerbated by unemployment, which is high among people affected by mental illness because of loss of efficiency. Employment is important to most people not just because it yields an income but also because it typically engages people in meaningful interaction with others.

Participation in creative arts activities can be solitary but it often takes place in groups. Some creative arts such as choral singing, ensemble music, dancing, and theatre are inherently social activities. However, even more solitary activities such as writing or painting can occur partly through workshops, readings, and exhibitions that bring people together to share and try out ideas and techniques or to show completed work to others and the public. Furthermore, creative arts activities often lend themselves to natural transitions from rehabilitation settings to community settings. People with mental health problems may become sufficiently interested in and confident with creative arts in a rehabilitation setting to engage with community groups engaged in similar activities.

A Note on the Evidence Base for Creative Arts in Recovery

This book has reference to many kinds of evidence from anecdotal and personal accounts to meta-analyses of randomized controlled trials (RCTs). We think that the evidence base for the effectiveness of music therapy in recovery is strong. The reason for this is that there are sufficient RCTs to create confidence that people who participate in music therapy experience improvements in their mental health and well-being that are not experienced by those who are randomly assigned to a control group. These benefits are robust across a range of populations, age groups, and mental health problems. As Claire Edwards’s chapter shows, the evidence base for art therapy is also quite strong. There are fewer well-designed studies for art therapy than is the case with music therapy, but there are enough RCTs showing benefits to warrant the presumption that art therapy is broadly equivalent in effect to music therapy. There are fewer well-designed studies investigating the effectiveness of other kinds of creative arts therapies, which means that we need to be a little cautious about benefits. However, because creative arts interventions tend to have broadly similar characteristics, we think it more likely than not that these too will eventually have a strong evidence base.

When considering the effectiveness of creative arts therapies, it is worth bearing in mind what we know about the effectiveness of the so-called talking therapies, which have been investigated very rigorously over an extended period of time. Whereas it was once thought that the specific characteristics of these therapies were critical to the outcome and that some kinds of talking therapy were more effective for some kinds of problems than others, it is increasingly clear that this is not the case. Rather, verbally mediated therapies are broadly equivalent and contemporary therapies tend to be as effective as older therapies. Furthermore, recent research developments suggest that the relationship between a therapy and a disorder is much less specific than might be expected. While some therapies might have a...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Brief Contents
• Detailed Contents
• Acknowledgments
• Chapter 1 Introduction
• Chapter 2 Lived Experience Writing and Recovery
• Chapter 3 Lived Experience Visual Art and Music in Recovery
• Chapter 4 Visual Art Principles and Evidence Base for Art Therapy
• Chapter 5 Visual Arts Multidisciplinary Day Program in Practice for Young People With Severe Mental Health Problems
• Chapter 6 Visual Arts The Place of the Art Exhibition in Mental Health Recovery
• Chapter 7 Creative Writing Literature Review and Evidence-Based Research
• Chapter 8 Creative Writing A Practice-Based Account of Designing and Facilitating Life-Writing Workshops for a Group With Severe Mental Illness
• Chapter 9 Music Therapy and Mental Health Recovery What Is the Evidence?
• Chapter 10 Music The Interface of Music Therapy and Psychotherapy With Adolescents in a Hospital-Based Consultation-Liaison Mental Health Service—Eclecticism in Action
• Chapter 11 A Dance/Movement Therapy Recovery Model Engagement in Stages of Change
• Chapter 12 The Evidence Base for Dance/Movement Therapy in Mental Health Moving the Body of Knowledge
• Chapter 13 Applied Theater for Mental Health Literature Review and Evidence-Based Research
• Chapter 14 Respect Yourself Drama Education Program in Practice
• Chapter 15 Digital Storytelling for the Self-Advocacy of Marginalized Identities Theory and Practice
• Index
• About the Editors
• About the Contributors