Magyar művészetterapeutákkal és művészekkel készült interjú a művészetterápia pszichiátriai ellátásban való felhasználásáról, az MHM (Mental Health Matter through Restorative Art) Erasmus + projekt keretében

ERASMUS+ Program 2019-1-UK01- KA204-97CBFC43-EN

2020.április 28.

The use of restorative art in mental health structures (Hungary)

Valachiné Geréb Zs., Fonagy J., Oriold K.,

Two types of qualitative research were done to investigate the usage of art in mental health system in Hungary. One was a focus group held at the Debrecen Psychiatric institute. The second was five private interviews and questionnaires with artists, art therapists working in different areas Budapest. All findings show close relatedness with patients well-being, supportive factors of art, diagnostic framework and collaboration with mental health professionals.

Introduction

Mental Health Matters through Restorative Art (MHM) Erasmus+ program was called alive to bring awareness to the benefits of art practices from restorative perspective in the healing and rehabilitation of mental health patients.

Six organizations of five European countries tried to investigate current situation of art application in the national mental health systems.

In Hungary art professionals connect to the health System in two different ways. Either they are art therapists with a certificate in the profession (it exists since 2007, registered in the occupation registration list since 2011), or as an artist in training in psychiatric nursery. Artists without training are not permitted to work in health care system. Post graduated art therapists are either artists or has an MA diploma in humanities. In our research we tried to make interviews equally in all fields. Art therapy and artistic therapy trainings are offered several public universities.

Methods

H1. Focus group was called in Debrecen Psychiatry. Recruiting was voluntary with no financial compensation. 12 members of the Kenézy Gy. County Hospital Psychiatry participated. 6 psychiatrists, 3 psychologists, 1 mental-hygienic assistant, 2 artist psychiatric nurse

H2. Interviews and questioners were made with five artists-art therapists in concerned with their experience in art therapy in the mental health care.

Gathered data was analyzed to find key themes and topics relevant in the questionnaires and narratives.

Findings

H1. The Kenézy Gy. Debrecen County Hospital provides various mental health programs for clients. It is an interdisciplinary institute with psychiatrists, psychologists, nurses and art therapists working in a team. They have four departments Addictionology, Rehabilitation, Innovative Psychiatry, Psychiatric Daycare. All departments employ artists or art therapists for the benefit of the patients. The psychiatry holds a cognitive psychology approach, and offers various types of therapies. Other than art therapy there is encounter group, cognitive therapy, schema-therapy, tale group, sensory group, animal assisted therapy, music therapy, folk dance, biblio (literature)- therapy, drama therapy, psychodrama, relaxation group, film group, sewing group are existing.

Art or artistic therapies available are: complex art therapy, year-circle group, arts and crafts group.

Complex Art Therapy analytic approach, based on Jung’s theories. Analytic art therapy would be 1-3 year long process. On psychiatric care only elements of the methods are used. Requires self-reflection, art works reflects to myths, symbols, fairy tales, archaic images (architypes), poems.
Year circle Group: Reflects to the basic Hungarian traditions, holidays and anniversaries of the year. Creative process and free group interaction are combined.
Arts and crafts group: painting for music, free creating, clay and ceramics work, basketry.
Other art modalities such as music, drama, or dance combine drawing, painting or other creative elements of art therapy.
Artists reflection on the benefits of art in the mental health program: the art therapy sessions, and creative groups are sceneries of self-reflection and community development. People meet each other with their creative and healthy self-part. They can open up toward each other, share feelings, emotions, and often explore inner material that was unconscious before. Mentally ill people often have difficulties in emotional and self-expression, but through non-verbal images they can identify with the inner states and feelings that help them to realize and verbalize. This self-expression may foster increase in mental health state.

Art and the creative process is activity and helps to energize and enhance confidence and feelings of competence. Clients can try imaginary and thought in a pretend mode through forming images and create pictures. Also because art therapy sessions are not achievement –orientated they can ease anxiety and get familiar with working with a relaxed mind.

Making art can aid the diagnostic process as well, or can be a feedback in betterment. Traumas that can be pre- or post-verbal can show up in the image and client may be able to reflect on it, or get a new perspective or narrative of the event. Clients may empathize and identify with characters of films, short stories, tales that help them to learn about themselves and life strategies.

The creative process, recreating, or changing the image gives a feedback to clients that everything is in a change, and everything is changeable (not just the images but personality and life as well), which provides hope and self-esteem for many clients. The process of change, improvement is visible jet it is an evidence of betterment for the client which is not just beneficial for the patient but the therapists and the team as well. Improved self-esteem contributes to better coping strategies, new chances some risking in life. Rehabilitation is challenge that has to help the clients to reintegrate into society and find their place and responsibilities again. So art making can be a bridge between illness and future health and work opportunities.

Mental health professionals saw art as a supportive occupation of the clients with its benefits to emotion regulation and self-competence. They realized during the focus group the possible and additional diagnostic source of art-making, and the detection of the healing process. It seemed that more case studies and team group (case supervision) would be necessary to combine health profession with art as therapy.

H2 The interviews

The interviews form artists and (or) art therapists revealed the similar findings than above. Three of the therapists work at psychiatric department of hospital, one in addictology department and another one in social service for orphanage of public care. All of them had first MA degree and studied in postgraduate program to be an art therapist. Initially 3 of them are an artist, 2 of them are psychologists. All their clients struggle with mental health issues, many of them have severe symptoms of personality disorders or psychosis. Average age of clients is between 25-55.

Psychiatric and Addictology Departments provide many other forms of therapy including art therapy. Art therapy in all cases is part of the clients weekly routine. Art therapists in general are running 2-3 small groups in the institute. Clients may enroll to the art therapy group with the aid of their psychiatrist or in the rehabilitation phase they may continue on individual initiative.

In the children’s home the artist have three small group a week. Children are sometimes delegated by the caregivers, teenagers and young adults came voluntarily. Groups are divided by age groups.

Therapists summarize the effect of art on clients in the following ways. Art helps to communicate those emotions, feelings that are hard to put into words. The materialization of the inner content gives opportunity of distancing from it that provides safety and chance of examination. The introspection of creative process changes focus form performance to the course of action, and symbolically speaks about the pathology that might bring a relief.

Visibility and re-composition of problems, tensions, feelings in another- the visual, imaginary- modality improves clients condition. The safety environment of the art therapy group with the feedbacks of the group members and the therapist help mentalization capacity, expression and comprehension of own feelings and the emotions of others. The group serves as a container of suffer and heavy feelings, (and of course hopes and joys).

Beyond the effect of group dynamics (such as belonging to a community, acceptance, connectedness, mutual respect) art activates symbol creating which may hold unspeakable contents. Unconscious may represent itself, but comprehension depends on the client, which gives feelings of control and competence, and transformation of old patterns.

Expressing our inner world though arts strengthening the sense of individuality, gives self-competence. Imaginary is connected to preverbal development and for this reason many especially traumatic memories can be reached only by image making.

Most art therapist uses techniques of free or themed semi structured drawing, painting, oil of soft pastel works, montage, collage, clay-work, textile work. The focus may vary from content to method and material or specific technique. Many of them connects the art making to movements or dance, music, literature, film experiences brought by clients or therapist. Multimodality is well applicable. Most artist art therapists prefer techniques that are non-figurative and does not require any specific skill or knowledge, artistic trends such as gesture painting, reliefs, monotypes, figurines or ink techniques is adequate to this kind of approach.

Most art therapist combine individual work in group with group work. Where shared canvases or common creating is in front.

Most art therapists questioned in H1 or H2 works in a team with close collaboration with mental health practitioner’s. Although most of them would require more team meetings when they can share experiences about the clients. Little information change happens between the psychiatrists and artists, and especially in the focus group I turned out that specific knowledge and perspective of the artists could serve as a very useful source in the healing process. Those who worked in pairs with an art therapist, or psychologist colleague reported weekly regular meetings and caseload.

Discussion

Both focus group and interviews confirm the positive effect of art in mental health care. They emphasize three basic element of curative effects of art making which we have found resonate to the theory of Expressive Therapies Continuum-ETC- (Lusenbrick, Kagin 1978) which postulates that art as therapy effect three levels of the individual in accordance with the three levels neuropsychological information processing. It is the kinesthetic- sensory level where client experiences and reaches preverbal experiences such as rhythm, texture, sensation. Interaction with various art media stimulates primal areas of the brain and meets basic expressive needs such as scents, tactile information or movement. Engaging with the art modality and choice of medium refers to these primary needs. Since traumatic events – even if we consider PTSD events, or continuous traumatization which both are very frequent phenomenon in mental health pathologies (Turner 2004, Thoits, Kessler1985) causes dissociation (Bessel1995) we might see the correlation of art materials and expression of preverbal or post-verbal experiences. We need to highlight those current art therapy researches that tries to reveal the connection of art mediums and the level of stress relief (Iskovitz, Czamansky 2018) which emphasizes the fluidity and control factors of the material to be key components of stress relief. More recent studies were made also on the effectiveness of clay as a medium that hold possibilities of emotional regulation through the effect of manipulation of the material to the sensomotor system

The second level is perceptual- affective level, where focus is on the self-expression, visualization and materialization of emotions and feelings, it may combine with verbal thoughts, but it can remain of the level of gestures, and intensity of feelings. The image or creation is usually brings satisfaction or relief to the client, because an inner reality has been shared with the other being presence. The emotion regulative component of art making and art therapy is studied in recent years especially in concerned with anxiety (Chambla 2008), stress (Kaimal 2018) ad personality disorders(S. Haeyen 2015).

Third level is the cognitive symbolic level a way of expression when creation and planning are combined. Although it is a process of symbolizing, finding meanings and association to the image that has been made. The mentalization based art therapy approach (Harvesteen,2015) just investigates this approach. Where reflection to the process and the image is equally important. And clients may focus on working mechanisms through the creative phase. Also those art therapy techniques which combine visualization, relaxation or symbol creation may operate on this level. The material, and method is secondary for clients functioning this level, rather the expressed content is in the front.

The fourth is the creative level of functioning which integrates previous levels.

Limitations:

In further investigation we aimed a question if art is used to build bride between the clients and society (team of health care institute or relatives, family members). Unfortunately, there were no examples for any of these forms. We saw it as a limitation as the restorative element of art could be broaden if co-creation of the mental health clients and their environment may occur. It would be a new form of dialog and instructiveness and relation.