Development of an art-therapy intervention for patients with personality disorders: an intervention mapping study

Figures & data

Table 1. Specific determinants of ineffective PD behaviour per diagnostic group (APA, 2013).

Diagnostic group (prevalence in general population)		Specific determinant
Cluster B	Antisocial personality disorder (0.2–3.3%^a)	Pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour
	Borderline personality disorder (1.6–5.9%^b)	Pervasive pattern of instability in relationships, self-image, identity, behaviour, and affects often leading to self-harm and impulsivity
	Histrionic personality disorder (1.84%)	Pervasive pattern of attention-seeking behaviour and excessive emotions
	Narcissistic personality disorder (0–6.2%)	Pervasive pattern of grandiosity, need for admiration, and a lack of empathy
Cluster C	Avoidant personality disorder (2.4%)	Pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation
	Dependent personality disorder (0.49%/0.6%)	Pervasive psychological need to be cared for by other people
	Obsessive-compulsive personality disorder (2.1–7.9%)	Characterised by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (not the same as and quite different from obsessive-compulsive disorder)

^aIn rehabilitation clinics, jail, and forensic institutes >70%.

^bIn mental health institutions up to 20%.

Table 2. Matrix of general change objectives and performance objectives in art therapy for PD patients cluster B/C.

Target group and determinant (selected)	General change objectives	Performance objectives in art therapy
Cluster B – Lack of empathy – Instability in relationships – Instability of self-image, identity – Instability of behaviour (impulsivity) and affects (excessive emotions)	Experiences a (more) stable and positive sense of self Is able to express and regulate emotions Understands own emotions, thoughts, and behaviours Uses improved social skills Uses improved problem-solving skills	Patient tries to understand other patient’s actions and expressions in art work Patient integrates feeling, acting, and thinking on the level of individual and group art processes Patient develops observation skills and positive thinking about own and other’s actions and art products Patient experiments with self-expression and structuring art processes Patient becomes aware, reveals identity in a situation of felt control Patient develops a new perspective on his self-image (more positive) Patient frames/integrates the experiences by reflective verbalisation Patient dares to participate and experiment with behaviour on the level of individual and group art processes Patient experiments with self-expression and spontaneous art processes Patient becomes aware, reveals identity in a situation of reduced control
Cluster C – Feelings of social inhibition and inadequacy – Dependent or avoidant behaviour and anxiousness (suppressed/avoided emotions) – Extreme sensitivity to negative evaluation – Psychological need to be cared for by other people – Rigid conformity to rules, perfectionism, and excessive control

Table 3. The art-therapy 10-session intervention protocol based on theoretical models and empirically validated methods.

Number	Art assignments	Change objectives	Performance objectives
1	Warming up: verbal exploration of emotions Assignment 1: exploring basic emotions (fear, angry, happy, sad) in abstract using sensory/motoric vs. symbolic art using pastels Assignment 2: ‘Three sheets of paper working towards each other’ (autonomy vs. collaboration, with paint; interpersonal effectiveness) Evaluation: reflection	1, 2, 3, 4	1, 2, 3, 7, 8, 9
2	Warming up: exploring present emotions with pastels (‘What & How skills’; observe, describe, participate & non-judgementally, one-mindfully, effectively) Assignment: ‘Above and below surface’ with coloured ink (emotion regulation, dialectic theme) Evaluation: reflection	1, 2, 3, 4	1, 2, 3, 4, 5, 7
3	Warming up: relaxation and ‘Personal weather message’ with drawing materials Assignment: ‘Life line’, displayed in line, form, and colour (emotion regulation) Evaluation: reflection	1, 2, 3	1, 2, 3, 4, 5, 7
4	Warming up: exploring clay; sensory, motoric and affective (mindfulness skills) Assignment: two clay figures; ‘Big self & little self’, what does the child need? (exploring own schema modes) Evaluation: dialogue between clay figures; exploring internal dialogue, reflection	1, 2, 3, 5	1, 2, 3, 4, 5, 6, 7, 9, 10
5	Warming up: material experiment (‘What & How skills’) Assignment: ‘Emerging painting’ (improving the moment) Evaluation: titles for each other’s work, reflection	1, 2, 3, 4	1, 3, 4, 6, 7, 8, 9, 10
6	Assignment: ‘The tormentor’ (exploring negative feelings and thoughts/ helping symbol; opposite action) Evaluation: reflection	1, 2, 3, 5	1, 2, 3, 4, 5, 6, 7
7	Warming up: imagination (improve the moment) Assignment: ‘Clay monsters’ (exploring anger and fear; emotion regulation) Evaluation: putting the monsters together, making up sounds and texts, reflection	1, 2, 3, 5	1, 2, 3, 4, 5, 7, 10
8	Assignment: ‘Group painting’ and role-play (interpersonal effectiveness, active schema modes) Evaluation: reflection	1, 2, 3, 4	1, 2, 3, 7, 8, 9
9	Warming up: mindfulness exercise Assignment: ‘Image of emotional pain’ and soothing reaction; distress tolerance, opposite action to painful emotions, self-soothing Evaluation: reflection	2, 3, 5	1,3,4,5,6,7
10	Assignment: ‘Emotion in clay and other material’ (emotion and experience acceptance) Evaluation: reflection	1, 2, 3	1, 2, 3, 4, 7, 8, 9, 10

Extra assignment 1: ‘Introduction collage’, for a starting group member.

Extra assignment 2: ‘Choose your most important art work’, for a leaving group member.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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