A Structured Observation Framework for Evaluating Clients’ Inner Change During and After Art Therapy

Abstract

In order to provide clinical utility for research of how art therapists perceive clients’ inner change, the authors created a structured observational framework. This note-taking and assessment consist of five themes and sub-themes: Therapeutic Alliance, Creating, Affect-Awareness, Self-Awareness, and Ego-Strength. The framework was designed to be clinically-friendly, adaptable to various settings, and assist communication with both patients and relevant healthcare professionals.

Keywords:

• Art therapy
• observational framework
• inner change
• emotional development

Since the introduction of evidence-based medicine in the 1990s in Sweden, there is a requirement to clearly communicate the results of art therapy. Much has already been written about the client’s change through art therapy based on different theoretical perspectives, and a large number of different assessment instruments and tests have been constructed to confirm its usefulness (Pénzes et al., 2014). However, to the best of our knowledge, there is no practical, observational framework for assessing the development of inner change during and after art therapy.

In our earlier qualitative study, we defined the concept of inner change as a deeper psychological structural change, which is permanent and differs from a more superficial, transitory change (Holmqvist et al., 2017). The art therapists who participated answered two open-ended questions in their own words: Can you describe how you perceive inner change in a client, and can you describe one or more situations when you perceived an inner change in a client? We discovered five themes and associated sub-themes: Attachment, Creating, Affect-awareness, Self-awareness, and Ego-strength (Figure 1). The purpose of this paper is to make use of our findings in order to present a practical observational framework for assessing the development of the client’s inner change during and after art therapy.

Figure 1 The Five Themes with Subthemes

Construction of the Observational Framework

Art therapists in Sweden are influenced by various theories but most of them have knowledge of psychodynamic theory and use psychodynamic concepts in describing clients’ psychological inner change. This was also the case with the art therapists who participated in the above-mentioned study. In addition, they were familiar with the triangular relationship theory, i.e., the client, the therapist, and the image, as well as the creative process (Schaverien, 2000). In order to adapt our research into a practical note-taking tool, we chose to expand on the five themes in relation to theories of psychodynamic emotional development and art therapy.

Attachment refers to the emotional relationship, which is based on the early relation between caregiver and child (Bowlby, 1988). The individual attachment style can be secure, insecure-ambivalent, insecure-avoidant, or insecure-disorganized (Ainsworth et al., 1978; Main & Solomon, 1993), which often becomes visible in art therapy through the way the art material is used (Corem et al., 2015; Snir et al., 2017). Clients with a secure attachment style often find art creation joyful and stimulating, while those with an insecure attachment pattern exhibit a tendency to resist and react negatively to the art material (Corem et al., 2015). Haeyen and Hinz (2020) claim that the individual attachment style can be observed within the first 15 minutes of an art therapy session, as the client soon exhibits emotional regulation strategies and favored components in accordance with the Expressive Therapies Continuum (ETC), namely cognitive/symbolic, perceptual/affective, and kinesthetic/sensory levels, linked at the creative level. A therapeutic alliance built on trust and security is established as the client and the art therapist together formulate the tasks, framework, and individual goals of the therapy (Haeyen et al., 2018; Hinz, 2019). De Witte et al. (2021) underlined the importance of both a strong therapeutic alliance and a safe environment for clients’ processes of change. As the client and the therapist subjectively share an experience and feeling that is usually implicit and nonverbal, it enables a very specific in-depth relationship, called intersubjectivity (Skaife, 2001). Rankanen (2021) believes that the therapeutic working alliance is based on intersubjective actions that change from attunement to misattunement and reattunemnt.

Creating refers to the creative process where the client uses different art materials to transfer thoughts, feelings, and experiences into an image. Expressing their inner life non-verbally in an image enables the client to exhibit feelings that may not be easily verbalized (De Witte et al., 2021). Hinz (2019) pays particular attention to the aha moments of self-realization in which surprised clients understand something new about themselves that was previously unknown. Playful experimentation and playfulness are a state of spontaneous and carefree creation, which is not primarily focused on producing a product. Playfulness is an important ingredient of art therapy, as it can help the client befriend different artistic materials, overcome barriers to creativity, and avoid being overwhelmed by affects and feelings (Hinz, 2019). Rankanen (2021) stresses the importance of playing together with the image in the triangular relationship to counteract compliance or resistance. Winnicott (1971) has suggested that play is a means of reaching the authentic, creative, less defended part of a person’s personality, what he calls the true self. In the therapeutic relationship the art material can be raised from its concrete materiality and obtain a symbolic meaning in an image, which can be explored and understood (Isserow, 2013). Exploration implies looking together, which is more or less a matter of course in art therapy (Isserow, 2008). Betensky (1995) emphasized the significance of the question: what do you see? to emphasize that the art therapist must help the client to understand and communicate through the image.

Affect-awareness means that clients are aware and observant of their bodily reactions, the affects, and are able to identify them as emotions or feelings. It is crucial to understand oneself and to be understood that the emotions are experienced consciously, that one can tolerate them and communicate them non-verbally and verbally (Monsen et al., 1996). As Shouse (2005) pointed out, feelings are subjective either consciously or subconsciously. According to Tomkins (1984), the basic affects are interest, joy, surprise, disgust, anger, grief, fear, and shame. Emotions and feelings constitute the basis for thoughts, decisions, and actions and are the primary system of motivation. In art therapy, sharing an affect in an image may promote clients’ awareness of emotions (Isserow, 2008). Increased awareness of emotions may in turn promote affect-tolerance and affect-regulation (Haeyen et al., 2015). The vitality affect differs from the basic affects in that it is an inner psychological movement that emerges in the individual’s meeting with dynamic, stimulating events (Stern, 2010). According to Stern, creative activities like art, music, and dance can set the patient’s inner life in motion and may evoke vitality affects that lead to revitalization, which provides energy, meaning, and a sense of being alive. An important part of affect-awareness is the verbal expression of feelings, which requires the client to translate body sensations into an image and then into words (Czamanski-Cohen & Weihs, 2016). The client has to discover the movement between non-verbal and verbal levels and understand that communication can appear in many different ways (Hinz, 2019). Non-verbal expression of feelings and verbally sharing the creative experience in art therapy will counteract depression and alexithymia, a condition characterized by an inability to recognize, understand, and describe emotions (Nan & Ho, 2014).

Self-awareness means being aware of one’s own way of being and how one is perceived by others. As the image in art therapy is seen as visualization of the client´s inner life (Case & Dalley, 2014), self-awareness will increase in a process from implicit to explicit self-expression (Czamanski-Cohen & Weihs, 2016). Increased insight and all changes in art therapy are dependent on the client’s ability to achieve a reflective distance to the image and the creative process (Kagin & Lusebrink, 1978). This means the client has to achieve a cognitive distance from the emotions that occur as a result of art creating, thereby making it possible to think about and reflect on the deeper meaning of the creative expression (Hinz, 2019). Insight into one’s own emotions, the emotions of others, and distinguishing between them is called mentalization (Fonagy & Target, 1997), where art therapy has particularly been highlighted as a method that seems to promote mentalization processes (Springham et al., 2012). Springham et al. (2012) state that mentalization processes are promoted by creating images at a slow pace, as thoughts and feelings can be organized, after which the images can gradually be transformed into words and shared with a therapist or group members. In art therapy is it possible to see things more clearly through an image, which leads to questioning a typical way of looking as well as discovering new ways of looking at a situation or at one’s own person (Hinz, 2019). Clients have reported that art therapy started a process of change that promoted improved self-image, which means increased acceptance and a more realistic view of oneself (Rankanen, 2016). In the same way artistic self-expression and reflection on problematic feelings stabilized the self-image of clients diagnosed with Personality Disorders (Haeyen et al., 2020). Widening perspectives is possible in art therapy by creating an image and then changing it, which can give clients the opportunity to look at the reality from different perspectives and accept a more adaptive point of view (Czamanski-Cohen & Weihs, 2016). However, Isserow (2013) underlines the fact that in the end, it is the client´s ability to take another standpoint that enables therapeutic changes to occur.

Ego-strength consists of mental functions and processes that help the individual to manage life experiences (Guntrip, 2018). Examples of ego-functions are impulse regulation, self-knowledge, thinking ability, and perception of reality that involves separating the internal life from the external. In art therapy ego-functions may be strengthened by overcoming difficulties and postponing needs by, for example, finishing an artwork (Case & Dalley, 2014). When clients are strong enough to be true to their own personality, values, and spirit, regardless of their situation, they will show greater authenticity, which in Winnicott’s (1971) words can be described as having a true self. Winnicott argued that the individual will develop a true or false self, depending on the relationships experienced when growing up and that repairing and changing imply going from a false self to a true self. A false self is associated with shame, which in art therapy can be reduced through the creative experience, reflections on the self-image, and changes toward a more authentic and true self (Hinz, 2019). Increased autonomy is not always described specifically in art therapy but can hide behind concepts such as coping ability, manageability (Shafir et al., 2020) or ability to make decisions (Blomdahl et al., 2022). One exception is a group of clients diagnosed with Personality Disorders in the study by Haeyen et al.(2020). They described the ability to make own choices and increased autonomy as one of several areas positively affected by art therapy. On a general level, creating seems to maintain and strengthen autonomy, promote coping resources, and help the individual to find a sense of control in a situation experienced as chaotic (Braus & Morton, 2020).

Observational Framework

From our review of how the five themes of inner change may present in art therapy, we designed an observational framework note-taking form (Table 1). One alteration we made pertained to the theme of attachment. We broadened the area by re-naming it as therapeutic alliance, based on the sub-themes of attachment, trust, and interactive relationship (Holmqvist et al. 2017).

Table 1. Observational Framework of Developmental Inner Change

Therapeutic Alliance
Sub-theme	First Observation	Developmental Stage 1	Developmental Stage 2	Developmental Stage 3
Attachment secure, insecure-ambivalent, insecure avoidant or insecure-disorganized	………………. ………………. ……………….	Unsure in the contact Example: Pays attention to the reactions of the therapist. Tests the trustworthiness of the therapist. Date … … …	Contact making Example: Shows interest in the therapist. Discusses what is happening in the therapy room and dares to express dissent. Date … … …	Attached to the therapist Example: Shows joy, playfulness, and engagement. Gives an impression of confidence. Date … … …
Trust in the therapist and situation	………………. ………………. ……………….	Carefully begins to build a relationship Example: Asks for advice. Shares parts of her/his life. Seeks affirmation. Shows some controlling behavior. Date … … …	Showing incipient trust Example: Is active and sometimes spontaneous. Shares parts of her/his private life. Date… … …	Exhibiting trust Example: Is calmer and more relaxed. Is more proactive and interactive. Shares difficult emotional experiences. Date … … …

Table

Creating
Sub-theme	First Observation	Developmental Stage 1	Developmental Stage 2	Developmental Stage 3
Experimentation Playfulness, creativity	………………. ………………. ……………….	Investigating Example: Tries different materials, tools, colors, and shades. Tests forms and movements. Discovers possibilities and limitations. Date … … …	Risk-taking Examples: Challenging oneself and usual patterns. Changes choice of material, technique, and symbolic language. Date … … …	Changing creation Example: Enjoys sensory experiences. Changes the image, cuts out, paints over, adds, removes. Playful and spontaneous creation. Date … … …
Exploration Explores the content of the image	………………. ………………. ……………….	Interested in the content of the image Example: Discovers that the image has a personal content and meaning. Is surprised by own images. Date … … …	Beginning of reflecting Example: Shows signs of reflective distance. Is attracted to the symbolic language. Date … … …	Shows reflective distance Example: Associates freely. Is amused by exploring the image. Can see her/himself from the outside and others from their inside (Mentalization). Date … … …

Table 1. Continued

Affect-Awareness
Sub-theme	First Observation	Developmental Stage 1	Developmental Stage 2	Developmental Stage 3
Bodily expression of feelings Nonverbal expressions in image	………………. ………………. ……………….	Access to affects Example: Shows awareness of bodily reactions and behaviors during creation. Sometimes exhibits discomfort. Date … … …	Tolerance of emotions and feelings Examples: Shows tolerance of affects. Continues creation despite evoked affects. Seems to understand them as emotions and feelings. Date … … …	Non-verbal expressions Example: Creates freely, evokes affects and shares emotions and feelings in the image. Reflects on these experiences. Date … … …
Verbal expressions of feelings Identifying and describing feelings	………………. ………………. ……………….	Pays attention to emotions and feelings Example: Observes emotions and feelings, identifies them, and can see them in the image. Date … … …	Reflects on emotions and feelings Example: Interprets and understands feelings aroused during the image-creation process. Starts to put words to them. Talks about different feelings. Date … … …	Handles strong emotions and feelings Example: Is able to harbor strong emotions. Understands the importance of communicating emotions and feelings. Reflects freely on feelings in the past and present. Seems revitalized. Date … … …

Table

Self-Awareness
Sub-theme	First Observation	Developmental Stage 1	Developmental Stage 2	Developmental Stage 3
Insight In-depth knowledge of own inner life	………………. ………………. ……………….	Surprise Example: Becomes surprised that the image reveals unknown material. Unexpected emotional memories appear in the image. Date … … …	Insight Examples: Starts to understand the image’s mirroring of the inner life, relationships, and life situations. Expresses self-empathy. Date … … …	Recognizes connections between image and inner life Example: Consciously uses the image to express emotions and feelings. Improved awareness of inner processes and impact on own external life and behaviors. Date … … …
Sub-theme	First Observation	Developmental Stage 1	Developmental Stage 2	Developmental Stage 3
Self-image A more realistic image of oneself	………………. ………………. ……………….	Reframing oneself Example: Begins to use other words when describing her/himself. Can see opportunities to make positive changes in her/himself. Date … … …	Accepting oneself Example: Expresses change in self-image. Can identify resources in her/himself. Can see both strengths and weaknesses. Date … … …	Improved self-image Example: Shows understanding and tolerance of her/himself. Affirms the meaning of own art creation. Can joke about her/himself. Date … … …
Wider perspective Changing perspective on own life in the past, present, and future	………………. ………………. ……………….	Attentive to changes Example: Can feel and see changes appearing and see them confirmed in the image. Starts to become aware of reasons for own behavior. Date … … …	Reshaping the image Example: Creates change through reformulating the image using color and shape. Revaluates and expresses understanding of why changes are necessary. Date … … …	Changed behavior Example: Sees new perspectives in the image and different aspects of her/himself. Transfers the content of the therapy process to everyday life. Date … … …

Table

Ego-Strength
Sub-theme	First Observation	Developmental Stage 1	Developmental Stage 2	Developmental Stage 3
Authenticity Changes toward an authentic self	………………. ………………. ……………….	Reflective Example: Starts to reflect on the images and on several sides of her/himself. Seeks confirmation of own personality in the images. Date … … …	Coherence Example: Increased coherence of image and narratives. The image is more integrated, colors and elements are associated. Date … … …	Openness Example: Expresses honesty and genuineness. Has confidence in her/his own personality, values, and spirit. Recognizes her/himself in the image. Date … … …
Autonomy, e.g., independence Trust in oneself, acting from own values and interests	………………. ………………. ……………….	Responsibility for own process Example: Less reserved. Talks about choices of art materials and the emerging image. Is sensitive to own feelings and to the art process. Date … … …	Interested in other’s opinion Example: Explores own values and opinions. Open to the therapist´s comments. Date … … …	Hopes for the future Example: Expresses faith in the future. Trust’s own ability has the strength to make decisions. Sees new opportunities. Is revitalized, and harmonious. Date … … …

Each theme is presented as a chart that includes sub-theme definition, blank space for an initial general observation of the client, and three developmental stages. In these boxes, examples of changes are presented, with space for the therapist’s notes and date. The developmental stages were organized based on the authors’ knowledge and experience of psychodynamic psychotherapy and art therapy. Therefore, to use this framework effectively, it should be used by a properly trained art therapist who is familiar with the theories of psychodynamic emotional development.

Reference Groups

During the development of the observational framework, seven trained art therapists in Sweden were asked to review the framework on two occasions. First, all seven were asked to give their views on the initial version. Six perceived the framework positively but pointed out the need for clarification of the different levels and one therapist was doubtful about an ongoing evaluation. When the framework had been revised in accordance with the suggestions, four of the most experienced art therapists reviewed it again to evaluate usability. They assessed the framework as user-friendly. One also mentioned that it may even lead to a better understanding of the clients’ problems.

Instructions for Using the Observational Framework

After the first two or three therapy sessions the art therapist assesses the client’s behavior and psychological status in relation to each area and to the vertically presented sub-themes. These initial observations can be briefly noted in the first observation box for each sub-theme. At the following evaluation, it may be appropriate to share the first evaluation with the client and at the same time make a preliminary plan with a timeframe and goals for continued art therapy. Furthermore, the client and the art therapist can decide together how often the follow-up with the framework should take place and whether they should complete it together. The decision can be reviewed and changed during the therapy. The time between follow-ups may vary, depending on whether the client is undergoing a crisis, has deeper psychological problems or severe mental illness with disabilities. The following follow-up intervals are suggested but may be changed depending on the client’s status and situation:

1. Short treatment time with evaluation every few weeks, for example due to a crisis in connection with grief, less complicated trauma, or physical problems.

2. Longer treatment time with evaluation every few months, for example due to the need for behavioral change, increased self-awareness, or mild depression.

3. Several years of treatment with evaluation at 6-month intervals, for example in cases of severe mental illness such as affective disorder or psychosis, deep trauma, or severe crisis.

Usability of the Observational Framework

This observational framework is intended for individual art therapy but not delimited to a specific art therapeutic institution or for a special group of clients. It is intended for use in different organizations, where art therapists want to obtain a structured evaluation of the clients’ inner change. It intentionally does not contain any descriptions of reduced symptoms or behavioral changes in everyday life, as the focus is on the lasting inner change that takes place on a psychologically deeper level over time. However, in the case of a successful therapy outcome, both symptoms and everyday activities will probably be affected in a positive direction.

This framework describes an ongoing process where the client moves from one stage to another, characterized by an elusive dynamic interaction between the areas and sub-themes. Therefore, the client’s inner change cannot be described solely based on the areas of affect-awareness, self-awareness, and ego-strength, because change is also manifested in attachment and creation, where the quality of attachment has an impact on creation. It can also be assumed that a positive therapeutic working alliance is linked to a better relationship between the client and the art medium, or vice versa, where creating may give a positive therapeutic alliance (Bat Or & Zilcha-Mano, 2019).

The framework is intended to show a client’s development in three steps. It is not intended to describe the natural back-and-forth movement in a client’s progress, only the achievement of a lasting developmental step. It is also not realistic to expect that all clients will reach the third step. But it is possible to use the framework to determine an optimal development for the client based on, for example, background, level of function or length of therapy. This way of using the framework can be seen as positive as it helps the art therapist to set realistic goals or, if necessary, assist the client in finding a more suitable contact, for example, counseling or support in everyday life.

Implications

Like other therapies, a prerequisite for art therapy is being able to capture, describe, and communicate the client’s change in a structured and clear manner. This observational framework offers one possibility. The framework aims to help art therapists to follow the client’s progress toward inner change in their practical work. It can be used as a reflective tool for assessing the efficacy of the treatment and while the outcome is mainly discussed with the client, it can also be communicated to e.g., relevant healthcare professionals (Haeyen & Noorthoorn, 2021). One of the difficulties involved in designing this qualitative observational framework was the need to formulate areas and sub-themes in a static way, which is very much in contrast to the dynamic, creative art therapy process. However, there was no indication that the art therapists who tested it experienced it as a problem.

Translating art therapy research in such a way that it can be used by practitioners is an important and delicate task. In our initial study, the art therapists described a quite similar perception of the clients’ change despite varying educational backgrounds (Holmqvist et al., 2017). The completed framework can therefore be considered to reproduce what this group of art therapists had seen, heard, observed, experienced, and reflected on during clients’ art therapy. The fact that the triangular relationship and the knowledge of psychodynamic theory seem to bind these art therapists together despite different art therapeutic training agrees well with earlier findings about art therapy and the triangular working alliance (De Witte et al., 2021).

Conclusion

We hope this observational framework will stimulate art therapists to identify and describe the patient’s progress from the outset, facilitate communication with the patient, and contribute to improved dialogue between patients, healthcare professionals, and researchers. We encourage art therapists to use it in their work. For further follow-up, we encourage experienced art therapists in health and social care to clinically test, research, and evaluate the observational framework’s clinical usefulness.

Acknowledgments

Thank you to all art therapists in Sweden who participated in the research by Holmqvist et al. (2017) on which this observational framework is built. Without your experience and knowledge this work would not have been possible.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Skaraborg Institute for Research and Development, Regions House, Stationsgatan 3, SE-54130 Skövde, Sweden under Grant [number 18/1025].

Notes on contributors

Gärd Holmqvist

Gärd Holmqvist, PhD, is art therapist and occupational therapist, Skaraborg Institute for Research and Development in Skövde, Sweden. Cristina Lundqvist-Persson is Associate Professor of Psychology, Department of Psychology, Lund University, Sweden, and Research Leader at Skaraborg Institute for Research and Development in Skövde, Sweden.