Art therapy from around the world: school-based and trauma-focused approaches

It is with great honour to start the new year as the Deputy Editor for the International Journal of Art Therapy (IJAT), stepping up from my previous role as an Early Career Research Editor. In line with IJAT’s new aims and scopes (IJAT Aims & Scope), I am committed to contribute to the timely and rigorous peer-reviewed publication of original, ethical, and high quality research, practice and opinion articles. I am also especially interested in the review and publication of co-designed research and practice, the inclusion of service user and lived experience perspectives in all aspects of the journal’s work.

The first issue of 2022 is focused on two key areas of research and practice: working with service users with experiences of trauma, and school-based art therapy. Two of these studies were conducted in Israel (Kaspy et al., 2021; Regev, 2021), one in Tanzania (Luzzatto et al., 2021) and one was a systematic review which included 44 international studies (Bowen-Salter et al., 2021). The four articles are summarised below, highlighting the key implications for future research, policy, and practice.

Art therapy approaches for people with lived experience of trauma

Bowen-Salter et al. (2021) conducted a systematic review to determine what constitutes good practice when working with service users who have experienced trauma. They identified substantial gaps in the studies’ reporting of the art therapists’ training and the treatment delivery guidelines. Due to reporting inconsistency, and often absence of treatment guidelines, identifying the elements of good practice was not feasible. The authors recommended that better reporting mechanisms are needed in future studies that would allow replication with larger samples. Better reporting mechanisms would also enable comparisons between similarities and differences in art therapy practices and identifying the elements of good practice. This gap in current literature has commonly been discussed in previous systematic reviews (Cohen-Yatziv & Regev, 2019; McDonald & Drey, 2018; Moula, 2020), including one specifically focusing on post-traumatic stress disorder (Schnitzer et al., 2021).

This gap in literature aims to address the second study that is focused on trauma from Luzzatto, Ndagabwene, Fugusa et al. (2021). Based at Muhimbili National Hospital in Tanzania, art therapy was delivered in a group of four women who had experienced traumatic events. The authors developed a protocol of practice which can be used for future replication and for the investigation of its effectiveness in future research. Following the sessions, service users felt better able to contain their emotions, to appreciate positive memories while also sharing negative memories, to accept the trauma that been part of their life history and to make plans for the future. Their findings echo other similar studies focused on children with experiences of trauma (Carr & Hancock, 2017; Mills & Kellington, 2012), and veterans (Jones et al., 2017; Lobban & Murphy, 2017, 2020). The authors also addressed another key gap in the literature, the need for follow-up procedures (Moula et al., 2020; Uttely et al., 2015). Participants reported sustained benefits up to at least 9 weeks after the end of art therapy. The authors recommended that future art therapy practices should focus more closely on emotional strengthening and understand how group cohesion affects the healing process.

School-based art therapy

Regev (2021) aimed to address the gap in literature relating to the lack of links between process and outcome variables of art therapy practice. This study involved 32 art therapists and 44 clients aged 7–13 in Israel. The art therapy process was assessed through the art therapists’ ratings of the clients’ degree of involvement in therapy, productive behaviours, and resistance to therapy. The Child Behaviour Checklist was used to evaluate the outcomes of art therapy, specifically changes in children’s behaviour and functioning over time. Children and young people who were referred to art therapy had experiences of social difficulties, emotional difficulties, low self-esteem, behavioural disorders or Attention Deficit Hyperactivity Disorders (ADHD) that impaired their ability to learn.

The findings suggested that cognitive–behavioural exploration was the most influential process variable, showing that children and young people explored their thoughts or behaviours, even if they did not have all the answers they were looking for. The art therapists’ assessment of the improvement in cognitive– behavioural exploration was positively correlated with teachers’ assessment of improvement in internalising problems. However, there was no significant change in client involvement; in contrast, resistance was increased in some cases. This was potentially because children and young people did not seek out therapy themselves and as such, there could be fluctuations in the extent of their involvement in art therapy. Interestingly, resistance did not negatively affect the outcomes of art therapy. Regev (2021) suggested that future studies should examine the processes underpinning clients’ feelings of acceptance in therapy in relation to their involvement in the therapeutic process.

In a second school-based study from Israel, Kaspy et al. (2021) investigated the impact of replacement in the educational system (e.g. when art therapists go on maternity leave), and the substitute art therapist’s role. Art therapists, supervisors, and school counsellors were interviewed on issues related to the art therapist’s substitution. Authors found that there are conflicts surrounding the definition of the art therapist’s role, and a lack of consensus regarding the conditions and environment needed for art therapy, findings that come in agreement with current literature (Snir et al.,2018). The substitute art therapists’ needs were also not fully understood, and handover was expected to take place during the replacement’s own time. Substitute therapists also had to compromise on the room, equipment, storage and privacy requirements since they were often perceived as ‘momentary guests’. The participants recommended that the departing art therapists should prepare therapy summaries, complete client sessions files, and meet with the substitute before leaving. At least one joint session with the client and both art therapists should be held where possible, to prepare the clients for the transition and support them in coping better with the termination of sessions with the former art therapist. In terms of future research and practice, the authors recommend that a framework for guidance needs to be defined that is responsive to the substitute’s needs. Repeated interviews at different time points would also be valuable to better understand the substitution process and the impact on the clients, as well as in different contexts, such as in hospitals or treatment centres. In terms of policy implications, the authors suggested that the Ministry of Education should allow more time for the replacement to take place. Cooperation between the supervisor, the departing therapist, and the substitute before departure would be crucial to diminish the feelings of uncertainty and frustration that are commonly experienced by both substitutes and clients.

Concluding remarks

In conclusion, the articles included in this issue call for (a) improved reporting mechanisms, specifically regarding the art therapists’ training and treatment guidelines; (b) better follow-up procedures; (c) understanding of how group cohesion affects emotional strengthening and the healing process; (d) exploration of the links between feelings of acceptance in therapy and involvement in the therapeutic process; (e) clear consensus regarding the conditions and environment needed for art therapy; and (f) a framework for substitution guidance, including more time for substitution to take place.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Zoe Moula

Zoe Moula is a research fellow at Imperial College London and University College London, Institute of Education. Her research is focused on the impact of arts in nature for children's mental health, wellbeing and environmental sustainability. She is also the EDI co-lead at the Imperial Medical Education Innovation and Research Centre (MEdIC), where she leading studies related to authenticity, belonging, and the inclusion of arts and humanities in the medical curriculum. She has currently completed her PhD in arts psychotherapies as a tool for the prevention of health difficulties in childhood. Zoe is a Fellow of Higher Education Academy (FHEA) and she holds a MRes in Health Research, MSc in Therapeutic Play, and BEd in Primary Education. Her previous work has included research and teaching at schools and universities in Greece, China, and the UK. Zoe is also the Deputy Editor at the International Journal of Art Therapy.