Art Therapy Assessment Research Articles

Exploring artificial intelligence approach to art therapy assessment: A case study on the classification and the estimation of psychological state based on a drawing

The art therapy assessment involves the classification of the psychological state of the drawer into several groups (e.g., normal or abnormal) and the estimation of it in numeric (e.g., psychological examination score) based on the interpretation of his or her drawing. Based on a qualitative approach to these tasks, a statistical approach relying various quantitative features of drawings has broadened the scope and methods in the analysis of the psychological states through drawings. In this paper, we explore an artificial intelligence approach and discuss its superiority over the statistical approach and also identify its limitations. The synergistic effects of the interdisciplinary framework combining qualitative, statistical, and artificial intelligence approaches is expected to make a critical contribution to the development of art therapy assessment.

Use of Bridge with Path Drawings with Military Service Members Experiencing Traumatic Brain Injury and Post-Traumatic Stress Disorder

This article introduces the use of an art therapy assessment, the Bridge with Path Drawing, for service members experiencing effects of Traumatic Brain Injury (TBI) and/or Post-Traumatic Stress Disorder (PTSD) during treatment at an outpatient clinic. Brief clinical vignettes describe the processes and outcomes of Bridge with Path Drawing Assessment for two service members. Bridge to Path Drawing aided service members with TBI/PTSD in discovering and disclosing thoughts and feelings through symbolic and metaphorical associations to their drawings. Service members shared meanings related to their senses of identity, their futures, the transitions to civilian lives, strategies to overcome obstacles, and purposes and meanings in their lives. Providers working with service members experiencing effects of TBI/PTSD and military-to-civilian transition found an art therapy assessment, the Bridge with Path Drawing, useful to explore patients’ meaning in life at an outpatient medical clinic on a military base.

Attachment Representations of Female Child Sexual Abuse Survivors Reflected in the Bird’s Nest Drawing Assessment

The study examined the Bird’s Nest Drawing (BND) of 14 adults who experienced child sexual abuse perpetrated by females, primarily their mothers. Descriptive analysis revealed the prevalence of insecure attachment and mainly an ambivalent representation. The drawings reflected vulnerability and under-protectiveness. Almost one-third of the drawings did not include caregiving and were suggestive of loneliness, abandonment, and rejection. When maternal caregiving was depicted, it was intrusive and characterized by a lack of separation, abandonment, or unsatisfying caregiving. The survivors’ narratives (n = 4) revealed themes of sadness, lack of protection, and vulnerability related to their mothers’ lack of competence. These findings suggest that the BND can serve as a valuable art therapy assessment tool to better understand attachment representations.

THE ROLE OF EXPRESSIVE ART THERAPY AND NEUROFEEDBACK ASSESSMENTS IN IMPROVING CLINICAL HYPNOSIS ADHERENCE AMONG ANXIETY SUFFERERS

Despite worldwide concern on anxiety, preventive measures in public health industries remained scarce. Previous studies found that therapeutic adherence is vital for the treatment efficacy of anxiety sufferers; polyvagal theory may address adherence issues by considering biopsychosocial perspectives. As such, this research intends to generate polyvagal-focused therapeutic guidance in line with anxiety sufferers. This study examines the effectiveness of the Creative Brain Health Intervention (CBHI), which includes expressive art therapy and neurofeedback assessments, as well as clinical hypnosis for anxiety sufferers. The study utilizes a qualitative method with a grounded theory approach to explore helpful and unhelpful factors of CBHI. The study samples were found to have minimal scores at a mild level (on anxiety or stress subscales) of eight (for the anxiety subscale) and 15 (for the stress counterpart) under DASS-21 following a screening procedure. Particularly, the samples were analyzed after CBHI through in-depth interviews for data collection. A total of 45 participants were recruited to generate the outcomes of this study, and the results show that mental healthcare can be enhanced by addressing adherence, stigma, and support through a public system and education, backed by six domains for anxiety treatment and innovative therapeutic approaches. The study recommends early intervention and prevention phases in future research to address stigmas and prevent mental disorder. Resultantly, therapeutic adherence could be enhanced with a polyvagal-focused framework CBHI established for this study. Consequently, the study suggests insights for developing therapeutic guidance to enhance adherence and prevent full-fledged anxiety complexities.

Development of the Expressive Therapies Continuum: The Lifework of Vija B. Lusebrink, PhD, ATR-BC, HLM

This Viewpoint essay serves three purposes: (1) revealing the life experiences of Vija Lusebrink that shaped what would become the pantheoretical art therapy assessment and treatment model known as the Expressive Therapies Continuum; (2) clarifying the broad and deep scope of this model; and (3) encouraging the art therapy audience to recognize this model as a complex marriage of information processing and agents of change. The Expressive Therapies Continuum (ETC) lends itself to outcome-informed treatment in art therapy as a systems-oriented means of gauging client responses to multidimensional interventive inputs and modifying the therapist’s approach accordingly. It is important for art therapists to share a unified understanding of the ETC that is consistent with the ideas of its co-creators.

Communicating Scope of Practice: An Outpatient Group Art Therapy Documentation Initiative (Communiquer le champ de pratique : une initiative de documentation sur l’art-thérapie ambulatoire de groupe)

In medical settings, art therapists face challenges of communicating their therapeutic practices to clinicians who are unfamiliar with the vernacular of art therapy. Despite growing evidence, the field of art therapy lacks a common language “scope of practice” that easily translates across fields. In this study, we piloted a novel documentation tool, The Progress Note for Group Art Therapy (PN-GAT), which aggregated frequencies of assessments and interventions within the Addiction Institute at Mount Sinai Beth Israel Hospital in New York, while identifying common practices of outpatient art therapy groups that may contribute to the development of a more communicable “scope of practice.” Our interdisciplinary documentation initiative was implemented during 18 adult outpatient art therapy groups conducted by one art therapist from August 2018 through February 2019. Analysis showed that insight-development (38.6%) and social-relational (35.9%) interventions were recorded more frequently than art-making (25.5%) interventions. The most frequently logged art therapy assessments included assessments of client response (88.9% of sessions) and mental status examinations (72.2%). The growth of art therapy within medical practices necessitates a rethinking of treatment collaboration. Our findings identified frequently used components of art therapy based in a medical setting, as well as the need for future medical education initiatives. While improving standards of collaborative care, the development of a well-defined “scope of practice” may serve to enhance interdisciplinary communication.

OBAS-ATT: observation-based instrument for assessment in art therapy with traumatised women

ABSTRACT Background Art therapists need specific instruments to measure treatment outcomes. The development of assessment instruments for special purposes, such as measuring key elements of the therapeutic process, is a growing and important area of research. Standardised instruments can help to compare and contrast data, and this may contribute to the development of the discipline. Aims The aim of this research was to design a new, process-oriented instrument that can help art therapists assess the therapeutic progress of the treatment for women who have suffered traumatic experiences. The instrument was called Observation-based Assessment Art Therapy Trauma Tool (OBAS-ATT). Methods The preliminary design of the tool was based on observation instruments and the analysis of the psychological scales commonly used with the target group. The first version of the tool was submitted to a panel of experts as part of a Delphi study to reach consensus on the content of the tool. Then, a focus group was held to improve tool usefulness. Results The final result is a structured template composed of 50 items organised in 11 dimensions that helps to collect qualitative and quantitative data. Conclusions The designed tool is an interesting starting point for developing useful and standardised tools. Experts participating in the study highlighted the importance of combining qualitative and quantitative data. Implications for practice/policy/future research This tool can help art therapists gather organised information and evaluate the patient therapeutic process, which should improve practice in the field. Further research is required to determine inter-rater reliability and the psychometric properties of the scales. Plain-language summary This article proposes a new observation tool in the art therapy field that can help to assess the therapeutic progress of patients who have experienced traumatic situations. Research into art therapy assessment is a growing area of knowledge, as art therapists need tools designed specifically for art therapy. Tried and tested forms of assessment can help to demonstrate the effectiveness of art therapy. They can lead to art therapy being considered an optimal approach for trauma treatment. The designed tool is a template to help art therapists gather key information related to what happens during the art therapy session. The art therapist rates observation items expressed on a scale of 1–6 and has the option of adding observations. Two different groups of individuals with expertise in this field were consulted about the content of the tool. The Delphi method and focus group technique were used. Although further research is required to validate the tool, this instrument can help art therapists to organise information and assess therapeutic progress. Also, it is a potentially interesting starting point for developing effective assessment.

Using neuroscience to explore creative media in art therapy: a systematic narrative review

ABSTRACT Background Few studies have investigated brain responses to different art media. Investigations into brain processes during art making have highlighted important structures. Neuroimaging tools have been used to investigate activation of brain areas whilst artmaking, but not in a therapeutic setting. This review highlights recent advancements in this area and encourages researchers to be the first to apply this in the UK. Aim To understand how the principles of neuroscience are currently informing the literature to explain the effects of art media in art therapy practice. Methods Review of published peer-reviewed research between years 2000 and 2020 on neuroscience and art therapy. Results Findings were summarised into categories discussing psychological/neurobiological issues, art media, neuroimaging technology, and models posited. Forty-six studies were found; majority discussed the structure and function of the brain to explain art therapy processes. The Expressive Therapies Continuum (ETC) model theorised that media properties stimulate different levels of visual and cognitive processing. The novel Mobile Brain/Body Imaging (MoBI) neuroimaging technology may be used as a means of quantifying data. Conclusion Significant progress has been made in attempting to explain brain responses during the art therapy process. However empirical data is needed to prove theoretical models. The use of neuroimaging has started this process to lead research into evidence-based practice. Implications for practice/further research Evidencing the ground-breaking ETC model, using neuroimaging and MoBI technology is needed through close collaboration between transdisciplinary departments. Art therapists should be encouraged to use the ETC to inform art therapy assessment, planning and treatment. Plain-language summary Neuroscience is the study of the brain and its processes, and recently technology has been available to researchers to examine brain processes in detail. This systematic narrative review explores recent literature that uses the principles of neuroscience to investigate the effects of art therapy, with a specific interest in art media. A systematic narrative review is when the findings of the study rely on the use of words to summarise the data. Art media is an important part of art therapy, as it is through artistic expressions that the client communicates their inner troubles. Different art media has been shown to elicit different feelings and behavioural responses in clients. However, research showing brain responses to different art media is limited. This study highlights ways in which further research in this field can take place. Results show that significant advancements have already been made that identify important structures and functions of the brain accessed during art therapy. Important models which incorporate neuroscience principles and theorise the art therapy process are highlighted. A significant model is the Expressive Therapies Continuum. This model explains how the brain processes information when different art media is used. However empirical data is needed to substantiate the theory behind this model. The use of neuroimaging technology is one way to achieve this. Therefore, this paper encourages transdisciplinary research to further investigate the effects different art media has on the brain during the art therapy process.

Formal Elements of Art Products Indicate Aspects of Mental Health.

Formal elements are often used in art therapy assessment. The assumption is that formal elements are observable aspects of the art product that allow reliable and valid assessment of clients’ mental health. Most of the existing art therapy assessment instruments are based on clinical expertise. Therefore, it is not clear to what degree these instruments are restricted to formal elements. Other aspects might also be included, such as clinical expertise of the therapist. This raises the question of whether and how formal elements as observable aspects of the art product are related to clients’ mental health. To answer this question, four studies are presented that look at: (1) a meta-theoretical description of formal elements; (2) operationalization of these formal elements so they can be analyzed reliably in clients’ art products; (3) establishment of reliable and clinically relevant formal elements; (4) the relationship between formal elements and adult clients’ mental health. Results show that the combination of the formal elements “movement,” “dynamic,” and “contour” are significantly interrelated and related to clients’ mental health, i.e., psychopathology, psychological flexibility, experiential avoidance, and adaptability. These findings give insight in the diagnostic value of art products and how they may add to clients’ verbal expression and indicate their potential to benefit from therapy.

The Anthroposophic Art Therapy Assessment Paint (AART-ASSESS-P): A peer-report instrument to assess patients’ pictorial expression during Anthroposophic Painting Therapy

ObjectiveAnthroposophic painting therapy (APT) is a specific form of art therapy that aims to activate self-healing capacities through painting aquarelles. MethodsThe Anthroposophic Art Therapy Assessment-Paint’ (AART-ASSESS-P) was developed to measure pictorial expression and validated in the framework of a comprehensive cohort design study. The validation study examined 68 breast cancer patients with fatigue. Art therapists made pre- and post-assessments of spontaneously drawn water-color paintings with a preliminary version of the AART-ASSESS-P (58 items). Inter-rater reliability (IRR) for the items was examined with Cohen's weighted Kappa (κw). Additionally, a reliability- and factor analysis (FA) were conducted. Convergence criteria were patients’ self-report measures: the Satisfaction with Painting Therapy, Inner Correspondence with Painting Therapy and the Self-Regulation Questionnaire. ResultsIRR for the items was heterogeneous (κw= 0.09-0.89, Mean κw= 0.40, SD = 0.17). Thirty-six items were excluded due to insufficient IRR and item-total correlation (κw= < 0.30, ρitem-total< 0.30). A FA with 22 items revealed 5 subscales: Shape Development (6 items), Shape Arrangement (6 items), Order and Symmetry (5 items), Color Application (3 items), and Color Quality (2 items) explaining 61% of total variance. Psychometric properties for the AART-ASSESS-P were satisfying with Cronbach's alpha coefficients (rα = 0.60-0.81) across subscales. Due to weak inter-subscale correlations (r = 0.18-0.48, p < 0.05) and the ambiguity of face validity a sum-score was not formed. Correlations between subscales and self-reports were small (all p < 0.05). ConclusionThe AART-ASSESS-P is the first reliable instrument to measure pictorial expression during APT.

Children with epilepsy: assessing state anxiety through drawings and a self-report questionnaire

ABSTRACT Background Children and adolescents with epilepsy are at increased risk for anxiety disorder. The aim of this preliminary study was to examine children and adolescents’ self-report on state anxiety by utilizing drawings and a structured questionnaire. Method The sample consisted of 30 patients (7 - 13 years) diagnosed with epilepsy. Each participant was asked to complete self-report questionnaire and to draw two drawings: one depicting himself/herself today and one depicting himself/herself before the illness. Results The mean score of children and adolescents’ state anxiety on the structured questionnaire was moderate, and the administration of the projective Draw-A-Person method added nonverbal approval to this result. Conclusions The findings indicate that despite potential critiques and limitations of the use of figure drawings as a research tool, future studies can incorporate both art therapy assessments and psychometric measures to address psychosocial aspects of epilepsy in children and adolescent.

Assessing the Six-Member Collaborative Drawing Technique with the Collaborative Art Elements Scale

This research develops, validates, and applies a scale for evaluating the Six-Member Collaborative Drawing Technique (S-CDT) for measuring individual collaborative tendencies in pictorial expression; the Collaborative Art Elements Scale (CAES) comprises eight criteria for rating the S-CDT. The S-CDT involves structured art therapy assessment, wherein a group of six people draw together a community on a single sheet of large paper; the drawings’ formal elements are used to assess collaborative tendency. In this study, there were 437 participants (205 men, 215 women; age: 18–35 years). In the development of the rating scale, 20 initial items were examined and reviewed by experts over three sessions, to establish content validity; following factor analyses, the CAES was validated and eight items were derived to evaluate the S-CDT. The intra-class coefficient (ICC), at .89, and the intra-rater reliability, at .87–.93, were satisfactory, demonstrating reliability. Eight items were established as scoring criteria for pictorial expressions in the group-unit drawing assessment. Based on the evaluation, this research found that Factor 1 (energy) and Factor 2 (harmony) affect completion of the group task in the S-CDT. Overall, as scored by the CAES, the S-CDT is an effective group-unit assessment of participants’ collaboration in group artwork.

What does safety look like? Implications for a preliminary resource and regulation-focused art therapy assessment tool

In this article, the author discusses the identification of defining characteristics in pictorial artefacts based upon a pre-understanding of traumatization, dissociation and recovery, metaphorical processing, and pictorial semiotics. Signs of reduced arousal, increased positive affect and states, self-efficacy, and self-esteem, are considered important parameters when assessing pictorial artefacts conducted in therapy. These signs, related to overcoming traumatization and a re-established experience of safety, as well as the concept of neuroception, should be easily identifiable via the use of appropriately designed assessment tools. We tested this hypothesis on a series of non-clinical material consisting of drawings produced by 122 experienced clinicians. Through the identification of defining concepts in artwork, we developed a preliminary assessment tool with the aims of guiding clinicians in identifying perceptions of fright in relation to safety and in facilitating the nurturing of safe states in clients when conducting pictorial artefacts. This tool consists of plain observation and subjective appraisal combined with the identification of seven predefined perspectives; how is the picture made, colour utilization, depiction of states and body positions, which affects/emotions, symbols and secondary metaphors/symbols for the self can be recognized in relation to a neuroception of threat with respect to safety.

Implementation of a clinical practice guideline for schizophrenia in a specialist mental health center: an observational study.

BackgroundIn mental health settings, implementation of and adherence to clinical practice guidelines (CPGs) is low. Strategies are needed to overcome barriers and facilitate successful implementation of CPGs into standard care. The goals of this study were to develop a framework for the implementation of a CPG for schizophrenia for hospitalized service users in a mental health care facility, and to monitor adherence to the guideline.MethodsAn eight-step framework was developed based on project management principles: 1) the Appraisal Guideline for Research and Evaluation (AGREE) tool was used to rate and select a CPG; 2) an algorithm was created from the guideline; 3) a gap analysis identified clinical services and processes not conforming with the CPG recommendations; 4) a governance structure was created; 5) a modified Delphi process determined key outcome and process adherence metrics; 6) a project charter was developed; 7) clinical informatics ensured that systems and tools were in place to support the CPG; and 8) therapeutic services were realigned to match the requirements of the CPG within specified fiscal constraints. Percent adherence to the identified process adherence metrics was calculated before (March 2014) and for 12 months after implementation (April 2014-March 2015).ResultsThe National Institute of Health and Care Excellence guideline scored highest on AGREE and was used to develop the algorithm. Cognitive behavior therapy for psychosis (CBT-P), art therapy and carer assessments were identified as gaps in care. Clinical global impression – Schizophrenia score was identified as the primary service user outcome variable and antipsychotic polypharmacy, metabolic monitoring, CBT-P referral and supported employment/vocational services referral as the primary process adherence measures. Adherence to guidance for metabolic monitoring (March 2014, 76.7 %; March 2015, 81.6 %), CBT-P referral (March 2014, 6.5 %; March 2015, 11.4 %) and vocational rehabilitation referral (March 2014, 36.6 %; March 2015, 49.1 %) were increased after CPG implementation. There was an initial increase in adherence to antipsychotic monotherapy (March 2014, 53.4 %; November 2014, 62.7 %), which decreased back toward baseline (March 2015, 55.1 %).ConclusionsThe eight-step framework was used to implement a CPG process, though further quality improvements initiatives may be needed to improve adherence.

Material interaction and art product in art therapy assessment in adult mental health

Background: Art materials have a central role in art therapy. The way a client interacts with art materials – material interaction – is an important source of information in art therapy assessment in adult mental health. The aim of this study was to develop the categories of material interaction and examine the relationship between material interaction, the art product and clients’ psychological characteristics. Methods: Three sequential focus groups were conducted, in which 47 art therapists participated. Results: A large number of art therapists recognised that observing material interaction enabled them to gain a perspective on client’s psychological functioning. Styles of material interaction could be placed on a continuum from “affective” to “rational” and provided valuable information about a client’s affective and rational characteristics. Conclusions: Art therapists were able to describe clients’ material interaction and psychological characteristics based on the analysis of the formal elements of the clients’ art product. The results provided a preliminary theoretical base for art therapy assessment in adult mental health.

The Bird's Nest Drawing: A study of construct validity and interrater reliability

The Bird's Nest Drawing (BND; Kaiser, 1996) is a single drawing art therapy assessment developed as a projective measure of attachment security. This study examined the individual graphic indicators and overall impression ratings of 136 adult undergraduate BNDs using two rating scales to determine interrater reliability and construct validity. Participants completed the BND, the Inventory of Parent and Peer Attachment (IPPA), and the Experiences in Close Relationships Questionnaire (ECR). Chi-square analyses were conducted to assess the frequency distributions of graphic indicators and overall impression ratings in high and low ECR and IPPA groups. Two of 11 graphic indicators reached statistical significance when compared with attachment score groups. The inclusion of a family of birds was significantly associated with high IPPA scores (χ2=4.371, p=.037), and bottomless nests were associated with low ECR scores (χ2=7.253, p=.007). An association was also found between overall impression ratings and the ATM subscale of the IPPA (χ2=12.5733, p=.006). These results provide preliminary support for a growing trend in art-based assessment in which overall impression scoring systems are used with theory-based drawing assessments.

The symbolic content in adults’ PPAT as related to attachment styles and achievement motivation

The present study inquired into the symbolic content of PPAT (Gantt, 1990) in young adults aged 20–35 years as related to their attachment and achievement motivation. Symbolic contents in the drawings were measured by SC-PPAT/a: Symbolic Contents in PPAT/adults (Bat Or, Ishai, & Levi, 2014b), which codes content aspects of the drawn objects (person, tree, and person–tree relations). Attachment dimensions were measured by a self-reported questionnaire, experiences in close relationships scale (ECR) (Brennan, Clark, & Shaver, 1998); achievement motivation was measured by the achievement goals questionnaire (Elliot & Church, 1997). Although no significant correlations were found between SC-PPAT/a with the validating variables, meaningful associations were found after splitting the sample into attachment groups. For example, secure individuals tended to draw a coherent script of reciprocal relationships between person, tree, and apple/s that eased the picking task for the person, while insecure individuals tended to depict a mixed picture, containing contradicted contents with non-cooperating relations between the objects. Negative PPAT content aspects were found as related with performance goal and performance avoidance orientations within specific attachment groups. The results are discussed in light of attachment theory, projective drawings, and their implications to art therapy and art-based assessment research.

Material interaction in art therapy assessment

Diverse approaches to art therapy assessment agree that art materials should play a central role. However, relatively little research is done on the role of different art materials. This article describes the results of a qualitative study on the use of art materials by art therapists in art therapy assessments of adults with mental health problems in The Netherlands.Nine qualitative in-depth interviews were analyzed using Grounded Theory, which produced a theoretical framework of the use of art materials in art therapy assessments. This study showed that the way in which a client interacts with specific properties of art materials (i.e., the material interaction) reflects aspects of the client's mental health. Methodical application of specific properties of art materials enables art therapists to observe the client's material interaction and gain insight into the client's mental health. This observation helps art therapists with decisions to offer further treatment, formulate treatment goals and choose appropriate art interventions. Material interaction links art material properties to art making, art product and mental health, and it may connect the diverse approaches to art therapy assessment.

A computer system using a structured mandala to differentiate and identify psychological disorders

The Computer System for the Structured Mandala (CSSM) has been developed to quantitatively and automatically evaluate color-related elements in a structured mandala, find the statistically significant elements that differentiate the four groups of non-patients, anxious patients, depressed patients, and schizophrenic patients, and identify which of the four groups drew the mandala. A total of 495 samples of structured mandalas were obtained from the four groups. The system applied the statistical methods of factor analysis and regression analysis. The system found 67 statistically significant elements and successfully identified the group based on only a structured mandala without further information. The CSSM contributes to the automation and standardization of the structured mandala as an art therapy assessment with high reliability, validity, and usefulness. The system can be used as an assessment for other art therapy dealing with various psychological disorders.

A Review of the Principles for Culturally Appropriate Art Therapy Assessment Tools

In an increasingly diverse society, and with the broadening scope of art therapy, the duty of art therapists to ensure responsible and appropriate assessment is ever more important. This article discusses considerations that are necessary for the successful adaptation and use of drawing-based assessments in cross-cultural and multicultural contexts. Examples from the literature of art therapy instruments that conform to established principles for cross-cultural psychological assessment are examined, and recommendations are offered to provide direction for their ongoing development.