Art therapy is one of the therapies which is used along with other psycho-pharmacological therapies in the recovery and rehabilitation of the psychiatric clients. The aim of this paper is to elucidate the importance of art therapy in the clients' assessment and evaluation of their progress in response to their treatment in a mental health setting. In this observational study, the art therapy was used as an intervention in a mental health setting and the clients' responses were noted. The paper presents various clinical observations of clients with different art therapies and its positive effects on clients with different mental health diagnosis. Art therapy was found effective to enhance a clients' focus, attention span and reality orientation. This therapy also helped them to enhance their reflective thinking, express their inner feelings, identify their moods, and to build a therapeutic relationship with staff and other patients. In addition, art therapy also improved problem solving and decision making capabilities in mentally ill clients. In conclusion, this therapy is found effective to evaluate clients' progression of treatment and counseling sessions. Thus, it can be one of the useful tools for a healthcare professional to promote mental health of clients.
Mental disorders alter a clients' psychological and emotional state, can affect their thinking, focus, attention span, reality orientation, decision making and problem solving skills. These alterations may lead to mental stress, which may block their inner feelings and their expressions ( Gillam, 2013; Shives, 2008). To cope up with this, art therapy can play a vital role as an intervention to promote expressions through art creativity ( Wood, 2013). Additionally, it helps to communicate repressed and unexpressed emotions that might be difficult to verbalize. Art therapy can be used as a creative medium that can help individuals to express themselves through music, photography, poetry, drama, drawing and painting ( Biley, 2007). According to Patterson et al., (2011) art therapy, specifically, drawing and painting is a mode of communication and expression that uses tools like colors, markers, paints, etc. Art therapy can be useful to provide a voice to the “voiceless” and create a connection with the unconscious mind. Thus, it can help clients to identify their deep down issues and help them solve their problems. Moreover, it can improve and strengthen cognitive and psycho-social wellbeing of psychiatric clients ( Spandler et al., 2007; Malchiodi, 2006).
The aim of this paper is to identify the positive outcomes of art therapy in the mental health settings.
In a private psychiatric hospital, as a part of their scheduled occupational therapy hour, the clients were asked to draw or paint whatever comes on their mind. To do this task, they were provided with tools like pencils, papers, color pencils and markers. After they had finished their drawings, they were asked individually to describe what they have made to maintain their confidentiality. One of the clients, diagnosed with mood disorder was asked about his drawing in which, he had drawn a picture of his hand, pointing his index finger on to others. On further inquiry, the client shared, “I have drawn a hand, showing that if you point out others with a finger to blame them, in fact, it means that you are only one pointing finger at them and indirectly the other three fingers are pointing your own self”. This scenario raised some important questions regarding the importance of art therapy and lead to the formation of the above mentioned objectives of this paper.
According to Joanne (2006), art therapy is useful for psychiatric clients as it helps them to reflect back into their unconscious emotions and memories and express their feelings in a form of drawing. Psychodynamic theory by Freud explains that, our past experiences influence our present life. These past experiences either positive or negative, are registered in our unconscious mind. Any stressful stimuli can trigger these experiences which are displayed as our conscious behaviors and actions. As psychiatric clients are not able to verbalize their emotions appropriately and easily, therefore, art therapy can be used to assist them to reflect their repressed and unexpressed emotions that are associated with their past experiences (Freud, 1896 as cited in Robb & Edwardsville, 2012 ). For example, one of the clients had drawn people with sad faces. On exploration, it was identified that this drawing was representing his family members and their sad faces were representing the effects of his conflicts with the family, which he was not able to verbalize initially. It was then discovered that, those painful family conflicts in the past were the reason behind his exacerbated symptoms of paranoid delusions and disease relapsed. Hence, this therapy provides this client an opportunity to explore and understand the connection of his past experiences with his current thinking and behavior through art therapy ( Secker, 2011).
Art therapy also serves as an important medium to develop therapeutic nurse-client relationship. In addition, it develops confidence in clients to express their feelings ( Debate et al., 2011). For instance, one of the clients with major depression was not able to initiate communication with a nursing staff. He was shy and lacked confidence. He was individually invited for the art therapy to join the group. With little hesitation, he joined the group. When the nurse gave him a chance to participate equally and treated him fairly, he acknowledged this gesture and started building his trust with the staff. Patient verbalized that “he found art therapy very safe because everyone was given a fair chance to participate” and this positive experience thus helped him to verbalize his feelings of his low self-esteem and lack of confidence. The art therapy in this case worked as introductory phase and simultaneously as a working phase. Therefore, it is clear that, art therapy makes the client comfortable to share their feelings with the nurse. Moreover, it can help to initiate and maintain therapeutic relationship.
Another significant role of art therapy is the Mental Status Examination of the clients. In particular, their artwork may give us an idea about their thinking, mood, reality, attention span, decision making and problem solving abilities ( Stevenson & Orr, 2013).
For instance, one of the clients drew a man holding a knife near to his neck. When asked about the picture, the client said “this is me in the picture. I just don't want to live in this world anymore. Everything seems so meaningless.” This approach of art not only helped the nurse to explore the thought content, i.e. suicidal ideation, but also helped to identify his depressed mood. Similarly, another client wrote words with incomplete spellings and jumped to the next word. He wrote “m friend tol m that fight in is a bad thin” but actually he wanted to write that “my friends told me that fighting is a bad thing”. Thus, the nurse was able to determine that the client's thoughts were very fast and ongoing.
Another client who was diagnosed with a Bipolar disorder was in a manic phase. He painted a flower in which each petal was of different color. A non-direct approach in intervening art therapy provides clients' autonomy in selecting art materials and an image to draw whatever they want. The nurse can use this approach to assess the clients' mood. Clients who chose sharp colors or multicolors were found to be with elated moods (maniac/hypomaniac) while, clients who used only black or dull colors, verbalized that their 'life is colorless'. Thus, these responses may suggest a depressive mood and a need to explore suicidal ideations in these clients ( Stevenson & Orr, 2013). The above cases reflect the thought content and mood fluctuations of different clients, which can be identified by the nurse through an art therapy.
Art therapy also helps in reality orientation, as the nurse and the client both reflect on the image drawn by the client ( Patterson et al., 2011). For example, one client who had drawn a heart shaped apple and another client had drawn a sun in purple color. For reality orientation, the nurse asked, “what do you think how does an apple look like?” and “When you look at the sky in the morning or afternoon, how does the sun look like?”. Along with it, the nurse drew the correct original image exactly next to the image drawn by the client and asked them to compare both the images. This will allow the clients to reflect back on the image's original and have a reality oriented idea of those unclear objects on their minds.
To assess the attention span, problem solving and decision making abilities, one of the clients was asked to solve an activity, 'find the way' by using a black marker. The client was given a paper with two types of routes formed to reach a relaxing place. The client was given two options, either to select a 'burning house' or to select a 'safe house'. The client chose the red marker and plotted his way towards the safe house for relaxation. This concludes that, the client was having a decreased attention span as he didn't follow the nurse's instruction of choosing a black marker to reach the safe house. Whereas, it was analyzed that, the client's decision-making and problem solving capability were intact.
Art therapy also facilitates in assessing the effect of cognitive- behavioral therapy. Mentally ill with aggression and manipulative behaviors tend to blame others and often get involved in fights. Such clients require counseling to modify their behaviors. Here, art therapy can be used as a potent tool to evaluate the effectiveness of counseling sessions. Like the first example of “pointing finger to someone” showed that, the client was moving towards recovery phase and counseling sessions led him to think positively ( Peters, 2011), which means that if you blame someone with one finger, the other three fingers pointing your part of blame so one should also look into his own behavior before pointing out others. This example also reveals that, the client is recovering, developing insight and ready to discharge.
Furthermore, art therapy can be used as a mindfulness activity, which focuses one's energy into a particular task and helps to avoid distractions like hallucinations. As one client mentioned that during drawing, he was only focusing to improve his art work, so his auditory hallucinations and ideas of reference were intensely decreased ( Spandler et al., 2007 ). In addition, the clients feel relieved after expressing their feelings with the nursing staff. For example, another client said that, she found it beneficial to express her feelings on a piece of paper rather than harming herself and it reduces her feelings of hopelessness ( Secker, 2011 ).
Clients who liked art therapy attended these sessions on a continuing basis. It was also evident that, most of the clients became a support for each other. It also decreased the chances of impaired social interaction ( Chandraiah et al., 2012 ). During the activity, one of the clients shared that the discussion of their art work with the whole group provided them an opportunity to initiate social interactions with others, and it felt very positive because they were encouraged by others. Another client who was very reserved shared her drawing about her “Dream house” with others. While she was sharing about her picture, she was more confident to interact with other group members and was found very happy to answer any question from the group. From this group, she was able to identify some support with the people whom she can share her feelings. This highlights that, art therapy plays a significant role in helping the clients to socialize. Moreover, the clients were also recognized for their work, they all clapped for each other, which created a sense of achievement resulting in increased self-esteem and self-confidence ( Stickley & Hui, 2012 ).
At individual level, a health care provider should first assess the interest of the patient because this therapy would be beneficial only for those who like to express through drawing ( Spandler et al., 2007). Moreover, as it is effective in building rapport, it should be used as an ice breaking activity in the introductory phase of the therapeutic relationship. In addition, this therapy should be incorporated in the routine mental status examination, because this will tell the condition of the client in a playful and joyous manner ( Maclagan, 2005).
At the institutional level, health care providers in a psychiatric setting should be trained about art therapy techniques to engage the clients in different activities and keep them out of their negative thoughts and perceptions. Materials for therapies should be made available to the clients. In addition, a proper scheduled art therapy class should be conducted during the occupational hours (Stuart, 2009). Moreover, new researches regarding art and client's psychological wellbeing can be done in future to explore the wider horizon of this therapy.
At the national level, the government should build some structures like a community center (a day care center) for mentally ill clients. These centers should be well equipped with art therapy material and with the nursing/ occupational therapist. This sort of center can help mentally ill clients engage every day. Thus, it can serve as a protective factor for their symptoms and condition ( Gillam, 2013 ).
In conclusion, art therapy is one of the important tools to assess client mental status examination and to assess their disease progress. It may serve as an expressive medium which helps to analyze the client's internal feelings, flourish communication, build social interactions, orient them to reality and evaluate counseling sessions. This therapy could be recommended for reducing negative symptoms of disorder, but only for clients who like drawing (NICE, 2009). Moreover, it can be used as a mindfulness activity to avoid distractions like hallucinations. This can be adopted as a hobby to engage the clients and developers as coping strategy to manage their stress. It is found to create hope, boost self-confidence and self-esteem, and make them feel worthwhile. Thus, it can be implemented and continued as a step towards the progress in psychiatric clients.
