The Arts in Psychotherapy 40 (2013) 312–321

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The Arts in Psychotherapy

Expressive art therapy for psychosis: A multiple case study

a r t i c l e i n f o a b s t r a c t

Keywords: A number of researchers have pointed to the value of art therapy for patients suffering from psychosis.
Art therapy Even so, it still remains unclear how and why art therapy works. This article describes the course of an art
Psychosis therapy group for five women suffering from psychotic disorder and their statements of the usefulness
Spirituality
of the therapy. The group focused on exploring the patient’s psychotic experience expressed through her
Self-awareness
artwork. Hopefully, this study will contribute to deepen the understanding of the working mechanisms
Religious delusions
Case study of art therapy.
Method: A multiple single case study where the group process, the artwork produced and the semi-
structured interviews of the patients were analysed qualitatively.
Results: All the patients met our preposition that they would be capable of exploring their psychotic
experience through art therapy. Two of the participants described how they, by the help of art therapy,
were able to control their psychosis. The rest reported an improvement in mastering their psychosis.
One of the participants described that the exploratory artistic work had opened a new ability for her
to distinguish between her helpful spiritual experiences and her hallucinations and religious delusions
connected to her psychotic experience.
© 2013 Elsevier Inc. All rights reserved.

The present study aims to explore the working mechanisms Art therapy has been used in psychiatry for decades in order
of art therapy for psychotic illnesses. It describes the use of art to further the patient’s healing process. However, the evidence for
therapy as an exploration process of the psychotic experience its usefulness, as well as the working mechanisms of art therapy,
and studies how this intervention helped the patients to cope is sparsely documented as to psychotic disorders. As to scientific
with their psychosis. In defining the concept psychosis, DSM-IV research/evidence, there are some randomized controlled trails
describes psychosis as a neurological syndrome. Patients suffering (RCT) on schizophrenia and art therapy, but none on psychosis in
from psychosis may experience hallucinations and delusions, suffer general. It is noteworthy, however, that the National Institute for
from disorganized thought patterns and actions, and generally dis- Health and Clinical Excellence in Britain (NICE Guideline) recom-
play a change in behaviour. Common psychotic disorders include mends that clinicians should consider offering art therapies to all
schizophrenia, delusional disorders and affective disorders (APA, patients suffering from schizophrenia (NICE, 2009). Their recom-
2000). The phenomenon hallucinations will in the present study be mendation is based on a review of 6 published RCTs concerning
defined as perceptions without external stimuli, and a delusion will art therapy (Green, 1987; Richardson, Jones, Evans, Stevens, &
be defined as a false belief that the patient holds as true but which Rowe, 2007; Rohricht & Stefan, 2006; Talwar et al., 2006; Ulrich,
an observer would consider false (Oyebode, 2008). Houtmans, & Gold, 2007; Yang, Li, Weng, Zhang, & Ma, 1998). This
review found consistent evidence that art therapies are effective in
reducing negative symptoms of schizophrenia (NICE, 2009, p. 255).
Examples of negative symptoms are apathy, paucity of speech, and
∗ Corresponding author at: Jaeren DPS, Postboks 163, 4349 Bryne, Norway. blunting or incongruity of emotional responses, usually resulting
Tel.: +47 92617790/51776950; fax: +47 51776999. in social withdrawal and a lowering of social performance (WHO,
E-mail address: [email protected] (H. Hanevik). 1992). In addition to these publications, a review from Crawford

0197-4556/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
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 H. Hanevik et al. / The Arts in Psychotherapy 40 (2013) 312–321 313

and Patterson (2007) concluded that there is growing evidence of their selves, a delusional system will often try to explain and
as to the effectiveness of art therapy for patients suffering from interpret the patients’ altered perception and may thus provide a
schizophrenia (Crawford & Patterson, 2007). However, the latest relief of anxiety (Chadwick, 2006; Cullberg, 2005).
contribution to the research field, does not find any support that art If we consider artistic expression as a way of exploring, and
therapy improves mental health in this group of patients (Crawford through this, understanding emotions and bodily sensations, this
et al., 2012). also opens up the possibility of exploring the psychotic experi-
There are many different forms of art therapy available. ence itself through art therapy. Cognitive behavioural therapy (CBT)
Prinzhorn (1972) was a pioneer in this field, important for the focuses on the exploration of the psychotic experience by using
development of art therapy for patients suffering from mental ill- words, in order to help the patient master her symptoms. An exam-
nesses. He collected and studied artwork created by mentally ill ple of this verbal approach is by questioning the omnipotence of
patients, most of them suffering from schizophrenia (Prinzhorn, the patient’s hallucinations. Originally, CBT had a verbal approach,
1922/1972). Adamson (1984) developed this further by founding but the latest contribution to the field also utilizes meditation to
an art studio inside a large psychiatric hospital in London, thereby explore the psychosis in order to endure, understand and cope
establishing art therapy as an important part of the psychologi- with the psychotic experience (Chadwick, 2006). ExA is building on
cal treatment of patients suffering from schizophrenia (Adamson, this theory, but will utilize artistic expression instead of meditation
1984). in the exploration process. As we see it, ExA presents an alterna-
Traditionally art therapy was based on an analytical under- tive method of exploring the psychotic experience. The creation
standing of psychotherapy and was practiced as a supplement of art may open up the possibility of exploring and understand-
to this form of therapy (Killick & Schaverien, 2006; Rubin, 1999; ing the wordless emotions and bodily experiences in psychosis.
Schaverien, 1992). However, during the past decades, a new form This may contribute to the understanding of the psychotic expe-
of art therapy, called Expressive art therapy (ExA), has emerged from rience and help the patient manage her symptoms in a better
the art studios. Artists, trained as psychotherapists, have developed way.
this new approach. Of course, in every kind of art therapy the artis-
tic expression is the main focus. However, in ExA the very process
of artistic expression is itself regarded to have a healing poten- Aim
tial. Important pioneers in the field of ExA were Knill, Levine, and
Levine (2005), and McNiff (1981, 1992), who all contributed to an Thus, our initial proposition in this multiple single case study
enriched conceptualization of expressive art therapy (Knill et al., was that ExA therapy understood as exploration of the psychotic
2005; McNiff, 1981, 1992). In addition, Stubbe Teglbjaerg (2011) experience would help the patients to understand their psychotic
has put a huge effort into explaining the theoretical framework experiences and that they through this exploration would be able
of ExA in the treatment of psychotic disorders (Stubbe Teglbjaerg, to cope with their disorder in a better way.
2011). In her PhD thesis she concludes that ExA may contribute to
a reduction of psychotic symptoms and anxiety in some patients Research questions
suffering from schizophrenia as a result of a strengthening of the
primary sense of the self (Stubbe Teglbjaerg, 2009). ExA is rooted 1. How do participants in an ExA group, suffering from psychosis,
in a phenomenological tradition, in which the artistic expression is explore their psychotic phenomena through arts?
seen as something new and unknown, perceived for the first time 2. In which ways do the participants in the ExA group consider art
(Løgstup, 1995). This idea opens up the possibility of exploring any therapy to be helpful in coping with their disorder?
emotion, as well as the psychosis itself, through arts. The artistic
expression may provide a new perspective to an experience or emo-
tion and by means of this it will reveal new abilities or possibilities Method
for a new course in life for the artist. By means of this the patient
may be able to reconstruct her self through interacting, not only Ethical considerations
with other people, but also with her environment, including her
artistic expression. Actually, the artistic process involves more than The Norwegian Social Science Data Services and the Regional
just interacting; the patients will also create a new “world” and will Committee of Ethics in medical research gave approval to the
in turn “recreate” themselves by their artistic expression (Stubbe project. All participants gave written informed consent.
Teglbjaerg, 2011). In order to deepen the artistic process and the Design. The present study is a multiple single case study inspired
exploration process, ExA utilizes various artistic modalities such by the methodology of Yin (2009). It was carried out under natu-
as music, poetry, painting or sculpturing. Moving from one modal- ralistic clinical conditions. Art therapy as described in this paper is
ity to another opens the possibility of exploring her emotion or offered on regular basis in a group therapy setting in our psychiatric
bodily experience from different angles, thus improving the artist’s hospital.
understanding. This process was coined crystallization by Knill et al. Inclusion. The participants of the first ExA therapy group for
(2005). patients suffering from psychosis at our hospital were all invited
From a phenomenological perspective, the onset of schizophre- to participate in the study. All the five participants who completed
nia is characterized by a disturbed perception of the self (Estroff, the therapeutic process agreed in participating. The patients were
1989). Patients often report a sense of being external to the rest of diagnosed by their clinicians to have various forms of psychotic
the world, feeling profoundly different from others; unreal, dead, disorders: bipolar disorder, schizoaffective disorder, schizophrenia
separated, changed and with a lack of emotions. Moreover, patients and paranoid psychosis, all diagnoses in accordance with the ICD-
suffering from schizophrenia describe their experience of psychosis 10 diagnostic system (Table 1) (WHO, 1992). Most of the patients
as an alienation from themselves and the world, a wordless expe- still had residual symptoms of psychosis in the form of halluci-
rience, which in psychiatric terms may be described as a “seriously nations or abnormal thought content (Table 1). Their age varied
disturbed perception of the self” (Sass, 1992). The patients struggle from 31 to 58 and had all been ill for several years. One participant
to find an explanation for, and significance in, their new reality in decided to quit after second group session because he found it dif-
psychosis. Since a psychotic experience usually results in a lot of ficult to be the only man in the group, and was then replaced by a
anxiety due to an altered perception of the external world and woman (Rita). The participants are given fictitious names.
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