Schizophrenia affects up to one in a hundred people at some point and can cause hallucinations, delusions, and loss of energy and motivation. Creative psychological interventions such as art therapy are widely used in combination with drugs. But the effectiveness of art therapy is unclear.
Professor Mike Crawford of Imperial College London, UK, and his team examined the benefits of group art therapy among 417 adults with a diagnosis of schizophrenia. The patients received group art therapy or non-art group activities each week for a year, or standard care.
The art therapy involved a range of art materials which the patients were encouraged to use “to express themselves freely.” Non-art group activities included board games, watching and discussing DVDs, and visiting local cafes.
This study differs from previous trials of art therapy by focusing on clinically important differences in outcomes. It also provides detailed information about attendance rates, and offers art therapy of a duration that is more like that in real-life clinical practice.
When patients were assessed after two years, overall functioning, social functioning, and mental health symptoms were similar between the groups. Levels of social functioning and satisfaction with care were also similar.
Patients offered a place in an art therapy group were more likely to attend sessions than those offered a place in an activity group. However, the levels of attendance at both types of group was low, with 39 percent of those referred to art therapy and 48 percent of those referred to activity groups not attending any sessions.
Writing in the British Medical Journal, the researchers state, “While we cannot rule out the possibility that group art therapy benefits a minority of people who are highly motivated to use this treatment, we did not find evidence that it leads to improved patient outcomes when offered to most people with schizophrenia.”
They conclude that art therapy, as delivered in this trial, “did not improve global functioning, mental health, or other health related outcomes.” They point out that “[T]hese findings challenge current national treatment guidelines that clinicians should consider referring all people with schizophrenia for arts therapies.” The authors suggest that art therapy should not be offered on a broad basis to all patients, but targeted at those most likely to make use of it, based on an assessment of the patient’s interest and motivation to attend sessions.
Currently, the UK’s National Institute for Health and Clinical Excellence recommends that doctors “consider offering arts therapies to all people with schizophrenia, particularly for the alleviation of negative symptoms.” This should be provided by a registered therapist who has experience working with people with schizophrenia.
The guidelines describe arts therapies as “complex interventions that combine psychotherapeutic techniques with activities aimed at promoting creative expression. The aesthetic form is used to ‘contain’ and give meaning to the service user’s experience, and the artistic medium is used as a bridge to verbal dialogue and insight-based psychological development.
“The aim is to enable the patient to experience him/herself differently and develop new ways of relating to others,” the guidelines add.
Professor Crawford and his team think that the lack of clinical improvement in their trial may be due to “the high degree to which people with established schizophrenia are impaired in their clinical and social functioning.” They explain that these impairments are known to increase over time, and the participants had been diagnosed for around 17 years.
It may be that to benefit from group art therapy, “patients need a greater capacity for reflective and flexible thinking,” so targeting interventions at an earlier stage of the illness may be more effective.
Commenting on the study, Dr. Tim Kendall of the UK’s National Collaborating Centre for Mental Health believes that, while art therapy is unlikely to be of clinical benefit for schizophrenia, it “still has great potential for success in the treatment of negative symptoms.”
In an online response to the study, psychiatric hospital art therapist Betsy A. Shapiro, of Alvarado Parkway Institute, La Mesa, California, says the once-weekly nature of the art therapy sessions in the study is a potential problem.
She writes, “I work with patients with schizophrenia and see them 3-5 times a week. Patients not only enjoy group art therapy, they excel in it. Working with a variety of materials keeps them focused, encourages their creativity and appears to increase self-esteem.”
She adds that patients can “show their auditory or visual hallucinations, and express feelings which are difficult for them to do verbally. It provides for safe release of strong emotions such as rage and has prevented them from hurting themselves, others or property.”
Overall, she concludes, “It would be a great disservice to patients if this study influenced a cut-back in art therapy services.”
Group art therapy as an adjunctive treatment for people with schizophrenia: multi-centre pragmatic randomised trial. Crawford, M. J. et al. The British Medical Journal February 29, 2012 doi: 10.1136/bmj.e846