Therapist and client experiences of art therapy in relation to psychosis: a thematic analysis

ABSTRACT

Background

Evidenced-based theory of art therapy for people experiencing psychosis is relatively under-developed, especially in terms of the detail of what happens in art therapy sessions, and the role of the artmaking.

Aims

To explore in-session processes of art therapy from the viewpoint of both service users and art therapists using reflexive thematic analysis.

Method

Twelve participants, six service users and six art therapists, were interviewed.

Results

From the analysis, four main themes were created, specifically ‘safe space’, ‘power of artmaking’, ‘challenges’ and ‘supporting recovery’.

Conclusions

The findings offer triangulated themes from art therapists and service users and explicate the role of the artmaking. Artmaking offers service users a space to express and contain their feelings, needs, wishes and fears within the artwork. This can start a dialogue and provides them with an opportunity to shift how they view their artwork and themselves.

Practice implications

Artmaking helps service users express non-verbal and embodied material, which could then be explored through a therapeutic dialogue. Service users who struggle with verbalising their thoughts and feelings may particularly benefit from art therapy.

Plain-language summary

This study explored the processes of art therapy from the viewpoint of both service users and art therapists. Twelve participants, six service users and six art therapists, were interviewed. From the analysis, four main themes were created: ‘safe space’, ‘power of artmaking’, ‘challenges’ and ‘supporting recovery’. The results suggest artmaking offers people the opportunity to communicate their experiences within the artwork. This can start conversations, which may be particularly helpful when words are difficult, and provides people with an opportunity to shift how they view their artwork and themselves. Limitations, research recommendations, and clinical implications are discussed.

KEYWORDS:

• Art therapy
• art psychotherapy
• psychosis
• schizophrenia
• service user

Sparks. Mixed media on paper. “When I was a kid I used to love collecting flint stone. […] And the reason I loved collecting it was because you can hit them together and you can see that little spark […] it must’ve travelled with me throughout my life, without me even realising it. Because that picture that I just showed you, basically, it represents that act”. (John)¹

Introduction

Psychosis

In the British Association of Art Therapists’ Guidelines on Art Therapy for People with a Psychosis-Related Diagnosis (Wright & Holttum, 2020, p. 7) the term ‘psychosis’ refers to ‘experiences that can attract diagnoses such as ‘schizophrenia’ and ‘schizoaffective disorder’’. The British Psychological Society (BPS) advocates that there are diverse ways of understanding ‘psychosis’, which includes having unusual beliefs and hearing voices (Cooke, 2017). In diagnostic terms, these experiences are referred to as ‘positive symptoms’ whereas withdrawal and apparent lack of motivation may be described as ‘negative symptoms’ (American Psychiatric Association, 2013). Whether understanding psychosis as a medical condition, seeing it as mainly a reaction to trauma or a different explanation, many people for whom these experiences are distressing pursue mental health support (Kelleher et al., 2015).

Art therapy in relation to psychosis

Despite UK National Institute for Clinical Excellence guidance (NICE, 2014; 2017) recommending art therapy to be considered for negative symptoms in psychosis, evidence for its efficacy is mixed. One large scale randomised controlled trial (RCT) (Crawford et al., 2012) reported that art therapy showed no benefit over and above either usual care or a control group offering activities. However, Holttum and Huet (2014) doubted whether the RCT was founded upon a clear theory of change. Furthermore, the trial suffered from low participant engagement in both art therapy and control activities (Holttum & Huet, 2014; Kendall, 2012; Wood, 2013). Smaller research trials in the USA, Germany and UK (Green et al., 1987; Montag et al., 2014; Richardson et al., 2007), have suggested art therapy is beneficial compared to usual care. Reported benefits include improvements in global functioning and positive and negative symptom measures. The 2017 update to the NICE guidelines (2014) retained the recommendation of offering arts therapies (NICE, 2017). The quantitative studies tell us that art therapy can be beneficial in relation to psychosis, but they do not explicate how or why this should be so.

Theoretical explanations of art therapy

Historically, psychodynamic theories have influenced art therapy, including Jungian analytic theory (Hogan, 2015), object relations theory (Klein, 1964), and in particular Winnicott’s concept of the transitional object (Winnicott, 1971). Object relations can be defined as the unconscious internalisation of early significant relationships with others that define and structure the person's interpersonal life and experience of self and others (Greenberg & Mitchell, 1983). This thinking suggests the person’s internal object relations can emerge and be contained through the artmaking, whereby previously unarticulated experience can be integrated (Hogan, 2015; Robbins, 2016).

Consistent with, and building on earlier ideas, Czamanski-Cohen and Weihs’s (2016) ‘bodymind model’ of art therapy (not specifically for psychosis) drew from psychodynamic theory and recent studies in neuroscience to suggest unique processes in art therapy that may lead to reorganisation, growth and reintegration of the self. They theorised four core therapeutic processes: the triangular relationship (between the art therapist, service user and artwork), embodied self-expression (whereby implicit emotions are made explicit through art), self-engagement and meta-cognitive processes. The researchers suggested the triangular relationship provides an available attachment figure (art therapist) and safe base for the service user to explore and self-express through artmaking, citing Bowlby (1988). This relationship enables the externalisation of emotional and cognitive material into the concrete (embodied) form of an artwork, which can be engaged with and reflected upon, providing the opportunity for perspective taking and meaning making.

Similar to Czamanski-Cohen and Weihs’s (2016) theorised metacognitive processes, Springham et al. (2012) proposed that art therapy may increase mentalisation (a form of metacognition) through helping people think about their own and others’ mental states. There is research indicating that people who have received a psychosis diagnosis may experience mentalizing difficulties (Versmissena et al., 2008), making this a pertinent theoretical viewpoint. Furthermore, Montag et al. (2014) reported that one of the outcomes they measured was an increase in capacity for holding others’ emotional states in mind, an aspect of mentalising.

Regarding group psychotherapy generally, Yalom (2005) suggested 11 therapeutic factors that provide the catalyst for change, including universality and group cohesiveness. Consistent with Waller’s (2003) theoretical extrapolation of these to group art therapy, similar factors were found in Gabel and Robb’s (2017) thematic synthesis of evidence on group art therapy across different client groups. They identified ‘symbolic expression’, ‘relational aesthetics’, ‘embodiment’, ‘pleasure/play’, and ‘ritual’ (Gabel & Robb, 2017, p. 126). Relational aesthetics represents the overlapping triangular relationships between the art therapist, different group members and their artworks, enabling nonverbal and verbal relating (Franklin, 2017; Moon, 2016). The artmaking appears to be a uniting force (Dudley, 2012), and the art acts as the container for both the said and unsaid (Slayton, 2012). However, neither Gabel and Robb (2017) nor Czamanski-Cohen and Weihs (2016) focused on specific client groups. Thus, these processes may be different for adults experiencing psychosis.

Lynch et al. (2019) created a preliminary model of the experience of art therapy for people following a first episode of psychosis. Seven categories were generated from the data including ‘unpressured atmosphere’, ‘expression and communication’, ‘pleasure and engagement in artmaking’, ‘changing emotional experience and experience of self’, ‘connecting with others’, ‘supporting recovery and continuation of art’ and ‘not the right fit’ (Lynch et al., 2019, p. 1). The unpressured atmosphere seemed to play a key role in enabling the other processes to take place. Although Lynch et al. (2019) built on the previous studies, research needed to be expanded to other service users diagnosed with psychosis (beyond a first episode).

Other qualitative research exploring service users’ perspectives, but not focusing specifically on artmaking, reported that art therapy provides positive experiences for individuals with a psychosis diagnosis by connecting with others in a group and developing positive relationships, experiencing improvements in well-being, changes in experience of self, and feeling supported and hopeful for recovery (Allan et al., 2015; Colbert et al., 2013; Patterson et al., 2013; Teglbjaerg, 2011). However, these papers took a broader approach rather than focusing specifically on what happened in sessions and how people used artmaking.

Wright and Holttum (2020) developed a theory of art therapy for people experiencing psychosis, which they derived from existing quantitative and qualitative research as well as in-depth interviews with art therapists (Holttum et al., 2021) and their own consultations with service users. Wright and Holttum (2020) suggest multiple functions for artmaking in common with previous research and the theories discussed here, including calming, expression, and enabling connection with others in group art therapy. They cite a peer-reviewed paper for their therapist quotations (in preparation in 2020 and now published as Holttum et al., 2021) but they have not published a peer-reviewed paper on their service user consultation. Obtaining both therapist and client perspectives using the same rigorous approach enables triangulation, important in qualitative studies for cross-validation of findings (Mays & Pope, 2000).

Rationale

Although relevant theories and qualitative research relating to art therapy for people experiencing psychosis existed, there was a need for further systematic research on the perceived processes from both service user and therapist perspectives, with the aim of illuminating similarities and differences between these and focusing specifically on in-session processes and the artmaking.

Aim

This study aimed to focus on the following research question:

• What are the perceived processes within art therapy sessions from the perspectives of adult service users experiencing psychosis and art therapists?

To understand the perceived processes, this study focused on deriving themes to capture service users’ and art therapists’ experiences of art therapy processes within sessions.

Methods

Design

Reflexive thematic analysis (Braun & Clarke, 2019), which foregrounds researcher subjectivity, enabled the authors to deeply reflect whilst engaging with the data and generating themes. A social constructionist epistemological stance was adopted, whereby the researchers invited participants to interpret their own experiences, and thus they in turn constructed meaning from the data generated (Braun & Clarke, 2019).

Participants

Twelve participants took part in the study: six service users and six art therapists. Participant information is shown in Table 1. There were three male and three female service users. All but one art therapist identified as female, the other male. Three service users identified themselves as White British, two as ‘mixed race’ and one as Black British. One art therapist identified as White European and the rest as White British. Service user ages were between 41 and 70 years, and the number of years over which they had experienced art therapy was 1-29 (not continuously). Art therapists had been in practice for 8-26 years. Service users had experienced both group and individual art therapy, and art therapists had delivered both modes. Settings included both inpatient and community.

Table 1. Participant information.

Pseudonym	Gender	Age ranges in years^a	Ethnicity	Art therapist or service user	Time receiving art therapy (not continuously) / providing art therapy	Context of art therapy
John	Male	41-50	Mixed race	Service user	29 years	Group but has also had individual in the past in inpatient and community settings
Harry	Male	41-50	White British	Service user	7 years	Group and individual in community setting
Grace	Female	51-60	Black British	Service user	18 years	Individual and group in community setting
David	Male	51-60	White British	Service user	20 + years	Group in community setting
Jade	Female	61-70	Mixed race	Service user	4 years	Group but has also had individual in community setting
Pauline	Female	61-70	White British	Service user	1 year	Group in community setting
Alec	Male	31-40	White European	Art therapist	8 years	Open ward groups in inpatient setting
Laura	Female	31-40	White British	Art therapist	7 years	Open ward groups and individual inpatient and community
Katie	Female	31-40	White British	Art therapist	17 years	Group and individual in community setting
Becky	Female	41-50	White British	Art therapist	12 years	Group and individual in community setting
Rachel	Female	51-60	White British	Art therapist	15 years	Group and individual in inpatient and community setting
Sarah	Female	51-60	White British	Art therapist	26 years	Open ward groups and individual in inpatient setting

^a Age ranges have been used to protect the identity of the participants.

Procedure

This project received favourable opinion from a UK National Health Service (NHS) Research Ethics Committee (REC) and was approved by the participating NHS trusts. On the advice of the REC, it was decided that it would be better to recruit service users through art therapists who were not research participants themselves as there might be conflict of interest across NHS mental health trusts in the UK. Consent was obtained for anonymous presentation of artworks, where applicable, as well as quotations from the interviews. The BPS’s (2018) code of conduct and ethics was followed throughout. Initially, seven NHS trusts were approached. However, due to lack of available participants, only four NHS trusts eventually participated.

Inclusion criteria for service users included being aged 18 + years, having a diagnosis of a psychotic disorder, capacity to consent to taking part in the research and currently attending or previously attended (within past month) art therapy in a community setting. Recruiting service users who had recently experienced an art therapy session was important for their ability to reflect in detail on its processes. It was decided not to recruit service users from inpatient settings due to concerns regarding their vulnerability, however one service user previously attended art therapy in an inpatient setting. Exclusion criteria involved any communication or cognitive difficulties or current significant risk issues that would affect the interview process. Inclusion criteria for art therapists involved currently working with or previously worked with (within the last month) a service user diagnosed with a psychotic disorder in community or inpatient settings. Participants were reimbursed travel expenses up to £10 per person.

Art therapists used their professional and clinical judgment to assess whether service users were appropriate for interview by assessing their capacity to consent to the research and their mental state at that time. Service users meeting inclusion criteria were given the participant information sheet by their art therapist, with the researcher’s details if they wanted to ask any questions or discuss the study. A face-to-face interview was arranged through the art therapist. The first author conducted the interviews at NHS mental health service locations. Verbal and written consent was sought face-to-face before the interview for both art therapist and service user participants. The interviews were audio-recorded. The researcher agreed with the participant before the interview that they could interrupt at any time to stop the interview or take a break. If any of the participants became distressed, the researcher would have stopped the interview and followed local procedures, such as providing information about NHS and other support services. No participants became distressed during the interviews.

Interview schedule

Semi-structured interviews were utilised to investigate participants’ experiences of art therapy. These were developed in collaboration with the research team (including a second researcher, art therapist and service user consultant). Neutral open-ended questions were formulated about participants’ experience of attending or delivering an art therapy session (with suggested prompts). The duration of the interviews ranged from 35 minutes to 1 hour 14 minutes.

Data analysis

The data were analysed using inductive thematic analysis (Braun & Clarke, 2019). The audio recordings were transcribed verbatim. Initial codes were generated from close reading of transcripts. Focused coding was then utilised to create conceptual themes and sub-themes. These themes were refined to ensure their overall essence appeared consistent with transcripts. Memo writing and keeping a research diary helped inform coding decisions. Researcher reflexivity was practised throughout, considering how the author’s position, role and desires may have shaped the analysis (Braun & Clarke, 2019). It is critical to note that reflexive thematic analysis is not a linear process, but more iterative, shifting between the different process stages (Braun & Clarke, 2019).

Quality assurance

Measures employed for quality assurance (Mays & Pope, 2000; Yardley, 2000) included keeping a research diary as a way of exploring and highlighting potential presumptions and biases from the beginning. As part of the reflexive process, it was noted prior to interviewing participants, that the authors felt a potential bias in wanting to advocate for art therapy. This was explored further in discussions together, about possible effects on the analysis. Thus, it was important for the authors to pay attention to different and more negative perceptions of art therapy, for example by including interview questions eliciting these experiences.

To help ensure this, three different members of the research team (researcher, second author and service user consultant) independently coded one transcript and compared codes. A high degree of consistency was achieved across the focused codes. Furthermore, respondent validation questionnaires were sent to all participants along with the initial themes and sub-themes. Eleven out of twelve questionnaires were returned and their feedback was incorporated. Agreement with the themes and sub-themes was shared. Participants further commented on areas that felt important for them, including the relationship with their art therapist and their positive experience of art therapy.

Results

The inductive thematic analysis resulted in four main themes and thirteen sub themes (Table 2). Every theme is examined together with verbatim interview quotes.

Table 2. Themes and sub themes.

Main themes	Sub themes
Safe space	Containment Supportive art therapist Connection
Power of artmaking	Valuable activity Expressing and containing things through artwork Image starting a dialogue Changing experience of artwork and self
Challenges	Fragmented and chaotic group Impact of health, social issues and trauma backgrounds Access and funding Not for everyone
Supporting recovery	Linking up with community On-going art activity

Thematic summary

The power of artmaking appeared to be the central theme to service users’ experience, which allowed service users to express, contain and explore their non-verbal material. This theme was linked to other themes including connection (within safe space) and supporting recovery. Whilst most of the themes focus on positive perceived processes, it is important to acknowledge that some participants experienced challenges to engaging with art therapy. Through the analysis, service user and art therapist interviews were compared alongside one another at code and theme level. No discernable differences were found between the different perspectives and all main themes mapped onto both art therapist and service user perspectives. Table 2 shows the main themes and sub-themes.

Safe space

This theme was represented by feeling contained and having a supportive art therapist, which enabled people to connect with each other.

Containment. Participants described the importance of being held and grounded in therapy and not having an abrupt ending.

Sometimes they feel very lost and confused, so if we can provide that containment, if you like, and holding, grounding them back and somehow bringing the emotional arousal down, I think that that's a pretty good aim. (Alec)

Helping people think about going out again, so it’s not an abrupt ending and putting artwork away […] just sort of helps that containment, that feeling safe. (Becky)

Supportive art therapist. This included the art therapist being non-judgemental, client-led, which helped service users to feel understood and valued and aided the building of trust.

The person who runs the group is very warm, kind and non-judgemental, so she makes you feel very safe (Pauline*²)

Most people, by the time they come into a place like this, haven't felt very valued in their life, […]. So, I think just also having that curiosity about people, and encouraging them to have the curiosity about themselves can be really powerful. (Sarah)

I feel you know like he’s [art therapist] listening more, so maybe you can trust him more or you can see he has got some intelligence, like a sensitive intelligence. (Grace*)

Connection. Participants shared that connecting with their art therapist and others in the group, helped them realise that they were not alone, share their experiences and experience togetherness through the artmaking.

Being with other people who’ve been through similar experiences, it makes you feel like it’s not so odd, what you’ve been going through. (Pauline*)

The benefits are exponentially powerful because those moments when service users themselves connect with each other and realise that they're not alone. And you haven't had to do that. They've done that. (Katie)

Because we're in company, everyone gets busy. (David*)

Power of artmaking

All participants shared the power of artmaking.

Valuable activity. Participants reported how artmaking in itself was valuable, being engrossed in the experience, exploring and experimenting, which seemed to offer peace and respite from anxieties.

It’s lovely, because I lose myself from the whole world. I’m in another place, a peaceful place (Jade*)

So, the artmaking, in itself, I think is what he [service user] is seeing as valuable (Becky)

It was only in the last few years that I've grabbed some more styles out of it and experimented (David*)

Image starting a dialogue. Participants described an appreciation of artwork with the art therapists and others in the group, and exploration of feelings and relationships through the artwork.

To have the opportunity to focus on the artwork, together, though, jointly, I think, basically, this even enhances the therapeutic alliance, the therapeutic relationship. This is because of the art psychotherapy triangular relationship. (Alec)

While I did the art we would talk, about how I was feeling and what was happening, and how I’m coping, etc., etc. Then at the end he would look at my picture and then we’d discuss it. Through the art he could actually see how I was feeling (Jade*)

So, we’ve been quite actively working with his tendency to be very self-critical and this kind of very negative critical inner dialogue he has, telling him that he has not achieved anything, lots of shame. A lot of that comes from some very difficult family dynamics, so we’ve been really exploring a lot of that through the art. (Sarah)

Expressing and containing a wide range of things through artwork. This included non-verbal thoughts, experiences, feelings, emotions, wishes and fears.

I experience a lot of pain with my [physical] illness, and I guess it’s quite a good relief really. Relief to let something out on the page. (Harry*)

I find, a lot of the time … a lot of the time the processes are very unconscious (John*)

You can see what goes on in other people’s worlds, you know because sometimes people might be feeling down and it’s apparent in their work how they’re feeling (John*)

It is also then your transference and your projections and all of that projected into the image. So you've got some ability to notice them and look at them and think about them without them directly hurting you. (Katie)

Changing experience of artwork and self. Participants shared how art therapy provided a sense of freedom where they could experience a positive shift in view of artwork and self.

People just get to step out of it [illness] and show different parts of themselves, really. (Rachel)

He [service user] sat down and said, “It’s okay, isn't it? I like it.” And we just kind of acknowledged what a shift that had been, and how he wouldn’t have been able to say that. (Sarah)

It [art therapy] gave me the confidence to achieve goals that I wanted to achieve […] I’d just like to say thank you because I don’t believe I would’ve done it otherwise (John*)

Challenges

Challenges appeared to be a relatively small part of the data, but they appeared to fit more appropriately into one theme rather than being integrated into others. They included the group sometimes feeling fragmented and chaotic, the impact of health, social issues and trauma backgrounds, access and funding for services and art therapy not being right for everyone.

Fragmented and chaotic group. Some participants shared how fragmented and chaotic the group could sometimes feel, particularly inpatient open ward groups.

Referring to a specific session:

I’d say that the group itself, the group dynamics, I guess, felt quite fragmented. There was never a time when everybody was seated making artwork. (Laura)

Impact of health, social issues and trauma backgrounds. Individuals’ mental and physical health, social issues and trauma backgrounds appeared to impact their ability to attend and engage in art therapy. These included feeling unsafe, racism, poverty, social disadvantage, experiencing voices or visions, side effects of medication and physical illnesses.

This individual is on a lot of medication, really … is, kind of, struggling to get up with it, but finds it very hard to sleep because he experiences a lot of visual hallucinations and has had some very frightening experiences in the past, which means he feels very unsafe and has to do a lot of checking. (Becky)

The illness that I’ve got, my physical illness, stops me from really exploring the art side. So I didn’t really get what I wanted from it. (Harry*)

A lot of people have had poor education, grown up in care, lived in poverty, had a lot of disadvantage, a lot of stigma. A real lack of self-esteem and confidence, and people that really aren’t confident about using art materials at all, and need some help and support with that. (Sarah)

Access and funding. Participants shared that it can be difficult for some to access art therapy due to the service location and under-resourcing.

Just getting to the group, it’s a citywide group as well, so for some people they’ve got to get two buses to get here, so there’s all the, sort of, anxiety of just being in a public space and waiting at a bus stop (Becky)

Our arts therapies … I feel is really under-resourced. So there's a limitation for what they can do. (Rachel)

Not for everyone. Participants’ interviews illuminated the variety and variability of art therapy. If the timing of the intervention and non-directive approach of the art therapist did not fit, then it was likely services users would disengage from art therapy.

When I first came into hospital I was in a very strange place, mentally and I didn’t really know what to expect. I wasn’t interested in doing any art because I didn’t understand what was wrong with me, and art was the last thing that I wanted to do (John*)

Sometimes the non-directive sort of model can feel quite difficult. (Sarah)

Supporting recovery

This was represented by the idea of linking up with the community, through planting the seed of art therapy in inpatient settings and continuation of care, as well as on-going art activity.

Linking up with community. Participants shared that planting the seed of art therapy and linking up with the community helped support recovery. This involved referring on after inpatient stays, doing art-gallery visits and linking up with other services.

I think it's important to have a picture of that recovery journey and to think how you can possibly help them to understand what art therapy does and how they can benefit from it and basically to plant, if you like, the seed for the flower later on to come up. That's the difficulty here, that if you plant the seed throughout their stay here, possibly you won't be able to see any small flower coming out, but the seed is there and the seed is really important. (Alec)

There is something really positive about continuation of care that we can help feed into that to help somebody’s recovery beyond the hospital as well. (Laura)

A few times we went on trips, one to an art gallery and one to something else, a coffee and thingy. That was really good, and a few of us became quite good friends. (Jade*)

On-going art activity. Participants spoke of the importance of on-going art activity helping support recovery. This included continual artmaking at home and art becoming a leisure pursuit.

It keeps me more focused on something else than the bad things that are going on in my head that’s too much for me to cope with within the home environment. (Jade*)

They value it [artmaking] and there's a possibility that they may take it beyond the therapy into a leisure pursuit (Katie)

Discussion

A strength of this research includes its exploration of both service users’ and art therapists’ perspectives. There were no marked differences in themes produced by service users and art therapists, which suggests there is a shared understanding between the therapists and service users regarding the processes of art therapy.

Consistent with Czamanski-Cohen and Weihs’s (2016) bodymind model of art therapy, having a safe space, associated with a supportive art therapist, seemed key for therapeutic engagement and continued participation specifically here for people with a psychosis diagnosis. The power of artmaking as an enjoyable, non-verbal activity and a means for expressing and containing non-verbal and embodied experiences, alongside connecting with one another, could be suggested as important processes of art therapy that support service user recovery.

The findings suggest that through the ‘power of artmaking’, service users related to their artwork, themselves and others differently through art therapy, in keeping with the suggested potential benefits as stated in NICE guidelines (2014). Artmaking seemed to enable expression, containment and exploration of a range of experiences and feelings. These results broadly align with previous qualitative research from service user and therapist perspectives (Allan et al., 2015; Colbert et al., 2013; Holttum et al., 2021; Lynch et al., 2019; Patterson et al., 2013; Teglbjaerg, 2011), and with the comprehensive model and guidelines in Wright and Holttum (2020). However, this paper specifically highlights the importance of artmaking enabling the expression of non-verbal material, as hypothesized by Czamanski-Cohen and Weihs (2016) and as reported for group art therapy with various other client groups (Gabel & Robb, 2017). Our method also triangulated the perspectives of services users and art therapists, finding high convergence.

The current findings build upon former research by focusing specifically on the role of artmaking and in-session processes, triangulating responses of service users and art therapists using the same systematic qualitative method. The findings are largely consistent with the BAAT guidelines (Wright & Holttum, 2020), which drew on existing research and in-depth interviews with art therapists (Holttum et al., 2021) as well as unsystematic consultation with service users. Our findings corroborate the practice examples and service users’ experience of art therapy as presented in the BAAT guidelines.

Themes of expression and communication are in line with Lynch et al. (2019). They also cohere with Czamanski-Cohen and Weihs’s (2016) ‘bodymind model’ and Gabel and Robb’s (2017) thematic synthesis (neither of which were specific to psychosis), describing how the triangular relationship (relational aesthetics) enabled the expression and containment of emotional material into concrete (embodied) artwork. These experiences could then be engaged with and reflected upon. Participants in the current study shared the importance of having a supportive art therapist who helped them ‘express and contain a wide range of things through their artwork’. These findings are consistent with the art therapist’s supportive role in Holttum et al. (2021).

The present findings also support the idea that art therapy can enhance mentalisation (Montag et al., 2014; Springham et al., 2012) (Springham et al., 2012; Montag et al., 2014). Similar to Czamanski-Cohen and Weihs’s (2016) theorised meta-cognitive processes and Lynch et al.’s (2019, p. 1) ‘discovering other perspectives’, the findings propose that artmaking helped some service users discover new perspectives and acknowledge that different people think in different ways.

Support was found for several of Yalom’s (2005) group therapeutic factors, including universality. This concept signifies the idea that people are not alone in their experiences and difficulties. The sub theme in the current study of ‘realising you are not alone’ appears to also resonate with Lynch et al.’s (2019, p. 4) subcategory of ‘commonality’. Another therapeutic factor includes group cohesiveness (Yalom, 2005). This was found in Gabel and Robb’s (2017) relational aesthetics theme, whereby artmaking could unify the group, and in Lynch et al.’s (2019, p. 4) ‘connect with others’ category. The sub theme of ‘connection’ in the current study appears to parallel these ideas, whereby artmaking helped people connect with one another.

Although the challenges participants shared were a relatively small part of the data, they appeared to fit more appropriately under one theme. This resembles some of the barriers participants shared in Lynch et al.’s (2019) study, including ‘impact of mental health’, ‘not the right fit’, and ‘access and availability’. These were noted in the current research, with the addition of the impact of physical health, social issues, trauma backgrounds and under-funding issues for art therapy services.

The results from the current study support the new BAAT guidelines and evidence-based theory of art therapy in relation to psychosis (Wright & Holttum, 2020), particularly the themes around supporting recovery and the challenges service users can experience, including social issues and trauma backgrounds. Consistent with Lynch et al. (2019), who only included participants with first-episode psychosis diagnosis, both service users and art therapists in the present study shared how artmaking was a valuable activity in itself and helped support service users in their personal recovery journey, including by taking artmaking with them for home use.

Limitations of the study

Despite this study offering useful insights, there are limitations. One is the relatively small sample size. Although depth rather than breadth is the aim in research involving thematic analysis, more participants may have provided additional perspectives. Furthermore, most service user participants had used art therapy over several years, which could mean that some of the overlap in themes was due to their internalised ways of understanding art therapy processes from their therapists. Nevertheless, their longevity in use of art therapy could also be testament to its value to them.

Another limitation involved the reliance on art therapists to recruit service users. Service users with more positive experiences might have been promoted to participate, which may have biased the sample. It was considered ethically important for service users to be recruited through their art therapists, in order for them to be approached by someone they knew and to enable art therapists to clinically judge whether it would be appropriate for them to take part in the research. However, different recruitment methods may have provided a less biased sample. This limitation is pertinent to much of the qualitative research in this area.

Whilst this study recruited service users from community settings, art therapists were recruited from both community and inpatient settings. Although it was decided for service users from inpatient settings to not be recruited due to concerns regarding their vulnerability, this might be seen as making an unhelpful assumption regarding capacity to contribute to research. Some findings may have been different if service users in inpatient settings had also been recruited. This might mean that the study has less transferability to service users from inpatient settings. However, one service user recalled experiences from both inpatient and community art therapy sessions. Furthermore, the participant group was diverse in other areas (e.g. ethnicity, ‘race’ and geography).

Although quality assurance measures were put in place, involving the use of memos, a research diary, respondent validation and coding comparison, it is important to acknowledge the researchers’ positive stance on art therapy. For this reason, some interview questions specifically elicited experiences of art therapy that were less positive, as exemplified by one of the main themes presented.

Implications for policy, practice and further research

The results propose that for some adults experiencing psychosis, art therapy can be an engaging activity that helps their recovery. It also suggests clear roles for artmaking, including the ‘power of artmaking’, ‘expressing and containing a wide range of things through artwork’ and ‘image starting a dialogue’. Art therapy offers something that other therapies do not and engages service users who might find purely verbal interventions difficult. It provides a bridge from somatic and emotional experiences to verbally articulated content (Czamanski-Cohen & Weihs, 2016), which may be difficult for some people to do without the scaffolding of the artwork. Thus, it appears appropriate for service users who struggle with verbalising thoughts and feelings to be offered art therapy. This might help them explore non-verbal and embodied material through their artwork with the help of a supportive art therapist.

This research, alongside other qualitative studies, suggests that some of the art therapy processes and experiences are not captured in outcome measures or questionnaires. It would be useful for further research to create a service user process questionnaire for completion after an art therapy session using the current data and to test it with service users. This would enable researchers to investigate the degree to which the in-session processes described here can be rated and how meaningful and useful they may be to a wider range of service users and art therapists. It would also be helpful to consider the different types of art therapy and their potential differential impact on the service users’ recovery and different experiences known as ‘positive’ and ‘negative symptoms’.

Another strand would be to examine whether service users feel more able to use other and specifically more verbal psychological interventions after art therapy, given that it may enable service users to begin to verbalise difficult material in a relatively safe way.

Furthermore, it would be helpful for further research to investigate the transferability and validity of the current findings. Other observational methods, including videos of sessions (where feasible and with ethical consideration) may help to gather insights into the comprehensive processes of art therapy in relation to psychosis, and how these may lead to positive change for service users. This future research could build on the suggested processes from the current study. It may also highlight when it is appropriate for an art therapist to be more or less directive. This could help some service users who experience potential barriers to engaging with art therapy.

Conclusion

It appeared that within the safe space of art therapy with a supportive art therapist, some service users were able to experience powerful effects of artmaking and express and contain non-verbal and embodied thoughts and feelings in the artwork. The artwork seemed to help them explore their difficult feelings, connect with one another and experience a shift in how they see themselves and their work. Whilst participants shared the importance of art therapy sessions, some also described the significance of doing art outside the session in supporting their recovery. It is important to note that challenges were identified in engaging in art therapy.

Notwithstanding limitations, this research has contributed to the field of art therapy and psychosis. It has focused on the perspectives of both art therapists and service users and has explored change processes involved in a session. The findings build upon previous research, by highlighting how a lot of the work is embodied and non-verbal. Artmaking allows a space for people to express verbal and nonverbal material, which can facilitate a dialogue. This is a novel finding in the field of art therapy for people experiencing psychosis, from both art therapist and service user perspectives. Art therapy can be experienced as confidence building, unique, and valuable, particularly for those who struggle with verbal communication.

Acknowledgements

The authors would like to thank all the service users and art therapists who shared their rich experiences of art therapy, for which this project would not exist without them. In addition, thanks are due to a service user consultant who does not wish to be named.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The project was funded as a research project forming part of the first author’s clinical psychology doctorate training at Canterbury Christ Church University.

Notes on contributors

Helen Barrett

Helen Barrett, D.Clin.Psy., is a clinical psychologist who trained at Salomons Institute for Applied Psychology and qualified in 2020. This research formed part of her doctoral training and was supervised by the second and third authors.

Sue Holttum

Sue Holttum, C.Psychol., AFBPsS, is a senior lecturer at the Salomons Institute for Applied Psychology, and also works one day per week as the Research Officer at the British Association of Art Therapists (BAAT). She has carried out research on art therapy for several years and led the research components of the BAAT’s work developing evidence-based UK national guidelines on art therapy for people with a psychosis-related diagnosis, completed in 2020. She has lived experience of treatment for significant mental health difficulties and draws on this in her work. ORCID 0000-0003-2618-8518; https://www.researchgate.net/profile/Sue-Holttum; Twitter: @SlightOwl; https://www.linkedin.com/in/sue-holttum-30952033/

Tim Wright

Tim Wright: M.A. Art Psychotherapy is an art therapist and Head of Arts Therapies for Local Services, West London NHS Trust. He has published on a range of topics relating to art therapy and was co-author, with Sue Holttum, of the British Association of Art Therapists UK national guidelines on art therapy for people with a psychosis-related diagnosis.

Notes

1 Artwork and quote from a service user participant (pseudonymised).

2 Service user quotes are denoted by an asterisk.