Art therapy as a river with many streams: I think our time has come

My body is still reverberating with aliveness and excitement from watching the launch of the healing arts and wellbeing initiative at the Metropolitan Museum of Art in NYC (https://youtu.be/H65tUKHILj8), which is a collaborative effort between the WHO, the UN, NYU, and other local and global partners. I am inspired that my lifelong career and passion are receiving such recognition. This event emphasises our need to understand that the arts belong to all, and our theories, practice and training programmes must develop to reflect these changing times, as well as be a part of creating the change. Reflective of this intention, this issue features papers from around the globe with diverse methodologies and theoretical backgrounds, engaging different populations. The cover art, by Ceinwen Birrell (2021), depicts her child’s development and the adaptations of fantasies as he grows; similarly our profession is developing to meet the needs of the individuals we work with, in an ever-changing world. We practice art therapy in a multitude of settings, developing theories that attempt to explain why what we do works, and are confident in our practice in a way that enables us to work from diverse theoretical standpoints. While conducting traditional efficacy studies is still important, we are also conducting research that addresses the power dynamics inherent in the therapeutic relationship, and approach practice as a creative co-exploration.

One such example is a research paper that explores the experience of art therapists working in psychiatry (Holttum et al., 2021). The grounded theory approach enabled the authors to obtain an in-depth account, of the ways in which 18 art therapists in the UK experience their work. Aligned with the goal of grounded theory, this paper aims at developing theory and guidelines regarding work with individuals diagnosed with psychosis and emphasises the importance of obtaining supervision and further training. The authors call for developing a flexible approach to art therapy that relates to clients and meets them where they are. A major point is made for the importance of using artmaking for grounding, crucial in enabling safety and developing a relationship. The art therapist’s role of ‘swimming against the tide’ of the psychiatric establishment and being positioned in a fringe role that is not always understood is also discussed. As we keep our unique identities, that have their place both in the fringes as well as in mainstream, we need to learn how to talk about the work we do with each other, our students and trainees, and the multidisciplinary team members that we work with. This paper is a good example of how to do just that.

While the abovementioned paper examined the experiences of art therapists working with a specific population, the following paper examines work in a particular space. Our profession was born in asylums and hospitals, then expanded to clinics and schools and is now practiced also in community spaces, such as museums, and art galleries (Coles et al., 2019; Coles & Harrison, 2018; Lobban & Murphy, 2020). Community settings provide the opportunity to shift the power relationships between service recipients and providers. This study examines the experience of five art therapists working in museum settings and highlights how the museum enables the creation of a more equal space in which the power dynamics foster social inclusion and autonomy (Watson et al., 2021). Furthermore, the art therapists use the art in the museum as a platform for inspiration and the space was experienced as normalising and enabling informality.

While it is important to conduct qualitative research to explore new frontiers and obtain an in-depth view of the experience of service providers and recipients, we also need to conduct outcome studies to examine and measure the efficacy of our interventions. In the systematic review in this issue, 20 papers that pertain to the use of art therapy (both group and individual) for people with post-traumatic stress disorder (PTSD) were reviewed (Schnitzer et al., 2021). Most of the studies were qualitative, or case studies, four were mixed method and three were purely quantitative. Unfortunately, the overall quality of the studies was assessed as poor, not enabling generalisation of findings, and making it difficult to conclude regarding the efficacy of art therapy for PTSD symptoms. The authors recommend more funding, and better research training to enable the conduct of studies that will provide evidence of efficacy of our interventions.

IJAT recently added a new type of paper that enables clinicians to present their clinical work. This issue has three practice papers, which indicates that this new platform is being well accepted as a way to share clinical work and propose hypotheses which can then be tested in future research. As human and natural disasters are gaining prevalence, western art therapists are travelling to non-western countries to provide art therapy services and aid relief (Kalmanowitz, 2016; Lloyd & Usiskin, 2020; Usiskin & Lloyd, 2020). Thus, culturally sensitive practice is needed to ensure that we are practicing in ways that are respectful and culturally humble to safeguard against engaging in colonial practices or imposing western values on non-western cultures. One way of doing so is co-developing interventions. Gavron et al. (2020) describe co-developed interventions conducted in Japan, with local mental health professionals, following the earthquake and tsunami of 2011. The use of joint art making was found to be a way to express community trauma and used a variety of art materials encouraging corporal sensations and authentic expression. The art making was first personal and then shared and enabled a space for changing the art or adding to it to offer a non-verbal way to narratively process trauma. Participants were encouraged to share and engage in introspection and observe the work of others. The authors provide two case samples to demonstrate the interventions and their process. The participants were able to co-create and rebuild their city in the shared artwork, which has been seen in other trauma work, as a way of remembering lost places or express emotions (Czamanski-Cohen, 2010; Luzzatto et al., 2021). Since art is a culture-bound activity, co-development of interventions that are in line with and enable the development of culturally appropriate coping strategies are needed.

Practice papers provide us the opportunity for an in-depth exploration of clinical work from specific theoretical standpoints. In the following practice paper, Chaidemenaki (2021) offers us a look at one year of art therapy with an adult coping with a severe learning disability and mental illness, with limited verbal skills, in a residential unit. The use of plasticine as a tactile media that enables taking apart and being together again is described to communicate and modify challenging behaviour, using a Winnicottian framework, emphasising the creation of a holding environment and play. The need for the adaptation of our clinical work with service users that have diverse cognitive and verbal abilities is well exemplified in this paper.

While efficacy studies help us prove that our interventions work, mechanistic studies are focused on how our interventions work. That is, what are the active ingredients of our interventions that help create change. This is done by examining mediating and moderating variables in studies that have comparative conditions attempting to isolate these variables. The bodymind model was written to that end (Czamanski-Cohen & Weihs, 2016). An example of a mechanistic study of this sort is the REPAT study, that examines emotional processing as a mechanism to reduce symptoms of depression, pain, and fatigue in breast cancer survivors (Czamanski-Cohen et al., 2019, 2020). For a scoping review of mechanisms of change in creative arts therapies, see De Witte et al. (2021). In this issue, Czamanski-Cohen and Abato (2021) demonstrate how the mechanisms described in the bodymind model manifest in clinical work with a woman coping with problem substance use. In this case, artmaking was shown to serve a role of assisting in connecting with bodily and emotional pain rooted in childhood trauma, externalising, and obtaining a reflective stance that enabled the engagement in decision making and developing a sense of agency and hope.

The papers in this issue are reflective of where our profession is at this moment in time and can serve as inspiration for moving our clinical work and research forward. These past years of the Coronavirus pandemic have made the need for community and art evident. The expansion and development of our theories and practice make me feel hopeful that our time has come, and maybe instead of swimming against the stream, as mentioned in Holttum et al. (2021), it is time to change the course of the stream, create new tributaries and bring others along with us.