Uses of Art Therapy for Adolescents With Personality Disorders

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  • Front Psychol
  • PMC7174707

Front Psychol. 2020; 11: 686.

Benefits of Art Therapy in People Diagnosed With Personality Disorders: A Quantitative Survey

Suzanne Haeyen

iGGNet Centre of Mental Wellness, Apeldoorn, Netherlands

iiKENVAK Research Centre for the Arts Therapies, Heerlen, Netherlands

3Department of the Arts & Psychomotor Therapies Education Programme, HAN University of Applied Sciences, Nijmegen, Netherlands

Farid Chakhssi

1GGNet Eye of Mental Health, Apeldoorn, Netherlands

4Section of Psychology, Health and Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, Netherlands

Susan Van Hooren

2KENVAK Research Centre for the Arts Therapies, Heerlen, Netherlands

fiveSection of the Arts Therapies Education Programme, Zuyd Academy of Applied Sciences, Heerlen, Netherlands

half dozenKinesthesia of Psychology, Open up Academy of kingdom of the netherlands, Heerlen, Netherlands

Received 2020 January 12; Accustomed 2020 Mar 20.

Abstract

Art therapy is widely used and effective in the treatment of patients diagnosed with Personality Disorders (PDs). Current psychotherapeutic approaches may benefit from this boosted therapy to better their efficacy. But what is the patient perspective upon this therapy? This study explored perceived benefits of art therapy for patients with PDs to allow the valuable perspective of patients be taken into business relationship. Using a quantitative survey study over 3 months (N = 528), GLM repeated measures and overall hierarchical regression analyses showed that the majority of the patients reported quite a lot of do good from art therapy (mean 3.70 on a 5-point Likert scale), primarily in emotional and social functioning. The improvements are concentrated in specific target goals of which the 5 highest scoring goals affected were: expression of emotions, improved (more stable/positive) self-epitome, making ain choices/autonomy, recognition of, insight in, and changing of personal patterns of feelings, behaviors and thoughts and dealing with own limitations and/or vulnerability. Patients fabricated information technology clear that they perceived these target areas as having been afflicted by art therapy and said so at both moments in fourth dimension, with a college score after three months. The extent of the perceived benefits is highly dependent for patients on factors such as a not-judgmental attitude on the part of the therapist, feeling that they are taken seriously, being given sufficient freedom of expression but at the same fourth dimension being offered sufficient structure and an adequate basis. Age, gender, and diagnosis cluster did not predict the magnitude of perceived benefits. Art therapy provides equal advantages to a wide target group, and then this form of therapy tin be broadly indicated. The experienced benefits and the increment over time was primarily associated with the degree to which patients perceive that they can give meaningful expression to feelings in their artwork. This provides an indication for the extent of the benefits a person can experience and tin can likewise serve every bit a clear guiding principle for interventions by the art therapist.

Keywords: fine art therapy, personality disorders cluster B and C, quantitative survey, treatment goals, indication, visual arts, benefits

Introduction

Personality disorders (PDs) are indelible and inflexible patterns of cognitions, emotions, interpersonal functioning or impulse command that lead to significant distress or impairments with an touch on a wide range of personal and social situations (American Psychiatric Association, 2013; World Health Organization, 2015). Recent meta-analyses have shown that psychotherapy is effective for reducing PD pathology, with significant just small to moderate effect sizes (Stoffers et al., 2012; Budge et al., 2013; Cristea et al., 2017), while psychosocial performance seems to remain severely impaired in individuals with PDs, and subsequently forms a substantial take a chance gene for relapse, occurrence or recurrence of symptoms (Zanarini et al., 2009, 2010; Keuroghlian et al., 2013; Chakhssi et al., 2019). Thus, electric current psychotherapeutic approaches may do good from additional therapies that may improve upon their efficacy.

Art therapy is one of the therapies that is widely used as an additional therapy in the treatment of patients with PDs 1 . Art therapy is an experiential form of handling that makes use of art media, creative processes, and the resulting artwork to improve a patient'due south symptomatic performance while enhancing their well-existence. Art therapy is aimed at artistic cocky-expression and reflection of problematic feelings or themes and guided by an art therapist. These feelings or themes tin be explored without being direct expressed in words [e.g., Moschini, 2005; Schweizer et al., 2009; Malchiodi, 2012; American Fine art Therapy Association, 2017; British Association of Art Therapists [BAAT]., 2017]. Difficulties with emotion-regulation are a central event for people diagnosed with a PD (Dixon-Gordon et al., 2017; Haeyen, 2018). Emotion regulation refers to the processes of how people influence experienced emotions: when we have emotions, how we feel them and how nosotros express them (Gross, 1998). The manner people express emotions plays an important role in social interactions (Gross, 2002). Art therapy may help patients to recognize hard emotions, to integrate conflicting thoughts, feelings or behaviors, and to observe a more constructive way of dealing with them (Eisdell, 2005; Simon, 2005; Haeyen, 2011b, 2018, 2019). Fine art therapy is an integrative health profession which has roots in the social sciences, medicine and art (Czamanski-Cohen and Weihs, 2016).

Art therapy for patients with PDs has shown to exist effective in a randomized controlled trial, in which fine art therapy was compared to wait list control showing large effects on PD pathology (N = 74) (Haeyen et al., 2018). Additional analyses showed that art therapy contributed equally to decreasing symptoms and improving well-being (Haeyen et al., 2017b). Also, in two pilot studies, art therapy among patients with primarily antisocial PDs was effective in provoking experiences and feelings (mental states) and promoting a healthy adult attitude to these feelings and experiences. It likewise improved cocky-esteem and social relations (Green et al., 1987; van den Broek et al., 2011). Several smaller non-comparative quatitative studies report positive results of art therapy regarding global functioning, treatment adherence (Franks and Whitaker, 2007; Eren et al., 2014), sense of confinement and self-centered isolation (Gatta et al., 2014), distress tolerance, service employ (Springham et al., 2012), and expression of emotions (Haeyen, 2011a).

Despite the scarce evidence, this course of therapy is named in some national care guidelines (Landelijke Stuurgroep Multidisciplinaire Richtlijn ontwikkeling in de GGZ, 2008; Alliantie Kwaliteit in de geestelijke gezondheidszorg. [Akwa GGZ], 2017). While it seems to be related to positive experiences in the do of professionals and service users, there has been little specific inquiry of this form of therapy. RCTs and other result studies are of import, but they mainly await at the degree of alter in complaints and coping. That is non the whole story. How do patients view the therapy? What do they think of it themselves? Then if we inquire them explicitly, we tin can map out the valuable perspective of the patients and let take their opinion taken into account. This could as well assist to facilitate a better indication for art therapy.

The experiences of patients with PDs are important, all the same, these have not been the subject field of many studies. Of the few studies performed in samples of patients with PDs, patients perceived relatively more benefits of art therapy than all other therapies (Group psychotherapy, cognitive group therapy, problem solving group, body-oriented group therapy, household group, and pharmaco therapy) and were given significantly higher scores. Also, the perceived benefits of fine art therapy correlated significantly with the perceived overall benefits of the therapeutic program [Karterud and Pedersen, 2004 (N = 319)]. More recently, 2 qualitative studies [Haeyen et al., 2015 (N = 29); Haeyen et al., 2017a (Northward = 11)], found that participants experienced more insight in their problematic patterns of feelings, thoughts, and behavior, which had not been addressed earlier and that this process went across a witting, cognitive level. Nevertheless, these studies exit questions unanswered regarding the more specific benefits of art therapy for patients with PDs, which specific therapeutic goals are perceived, which factors are of import for increasing the do good of the therapy, and for whom art therapy shows the largest benefits. To the best of our knowledge, no study has explored whether PD patients' demographic or clinical characteristics, also as fine art therapy elements, is associated with their perceived benefits of fine art therapy.

Therefore, the object of the present study is to focus in depth on studying the personal benefits experienced past patients as a result of art therapy. If we know how patients feel art therapy, then we can investigate whether the extent to which benefits are experienced is influenced by characteristics that have to do with the therapist's attitude or the extent to which patients felt they were able to express their feelings in the artwork. This study focuses on the questions: To what caste practise patients diagnosed with a PD experience benefits from art therapy, does this contribute to perceived improved daily, emotional and/or social operation and which handling goals are addressed? Is the experienced benefit related to the extent to which patients tin can express their feelings in making artwork? This question was added because emotion-regulation bug are a key outcome for people diagnosed with a PD. Furthermore, we wanted to explore if some factors or patient characteristics are predictive. Is the extent of benefits gained related to the attitude of the therapist, and what conditions he or she creates? And is art therapy more benign for certain persons than for others, looked at from the perspective of age, gender and diagnosis cluster?

Materials and Methods

This study is a practise-based, quantitative survey written report with two assessments covering a period of 3 months.

Participants

The participants were patients (xviii+) with at to the lowest degree ane DSM-5 PD (American Psychiatric Association, 2013), who were undergoing specialized treatment as usual, and where art therapy was offered as an boosted therapy. Exclusion criteria for the electric current study were the disability to read or speak the Dutch linguistic communication.

Data were collected from 539 patients with a PD at measurement points one and two. In this group, 27.1% were diagnosed with a Cluster B personality disorder (Borderline PD n = 116, Narcissistic PD north = 2), 30.one% were diagnosed with a Cluster C PD (Avoidant PD n = 95, Dependent PD north = 13, Obsessive compulsive PD due north = 23), and 34.5% with PD not otherwise specified. Most patients, 78.6%, were women. Age ranged from nineteen to 65 (mean: 35.67, SD: 10.12). In a number of cases (n = 104) diagnostic information was missing. These cases were still included in the analyses because the patients were in treatment in PD specialized intendance units, which always requires a PD diagnosis. Finally data from 528 of the 539 patients were analyzed based on the completion of the questionnaires at both T1 and T2.

Survey

The survey independent 8 questions and xiii statements almost perceived benefits from fine art therapy, associated factors and patient characteristics.

Benefits

The possible benefits from art therapy were evaluated with a question near the extent to which patients had benefited from the treatment (item: "Have you benefited from art therapy?") and 3 sub statements on improvement in their daily/emotional/social functioning during treatment cheers to fine art therapy (item example: "My daily functioning has improved through art therapy." The overall question was formulated post-obit the report of Karterud and Pedersen (2004). In this study every patient was asked "how much benefit did yous gain from therapy x?" We added the 3 sub statements focused on daily/emotional/social functioning based on the practice based classification of treatment goals used in a top clinical establish for PDs. The question and the statements were scored on a 5-bespeak Likert scale from "(1) none" to "(v) a lot." The Cronbach's alpha of this scale was 0.88, minimum ii.86, maximum 3.55, a range of ane.06, variance of 0.24 and a mean of 3.55. Test–retest reliability with boilerplate interval of 2 weeks showed a Pearson'southward correlation of r = 0.89 for the overall question, r = 0.79 for the detail virtually daily functioning, r = 0.79 for emotional, and r = 0.72 for social performance.

Perceived benefits related to treatment goals were and then examined using nine items which asked whether art therapy had contributed to a specific treatment goal such as a clearer self-image, increased self-confidence/self-esteem, or the expression of feelings/showing emotions ("Which personal areas have improved through art therapy?" Item examples: "Clearer self-paradigm (who I am, what I want, what I can exercise)" or "Making your own choices and cocky-conclusion"). This pick of specific treatment goals emerged in previous inquiry equally relevant for this target grouping (Haeyen et al., 2015). The various handling goals were evaluated by participants with a dichotomous scale request participants to indicate for each goal whether or not it had been achieved in art therapy. The internal consistency of these items was 0.82 measured with Cronbach's alpha. The test–retest reliability with boilerplate interval of two weeks of each particular/each treatment goal varied from 0.51 to 0.lxx measured with Spearman's rho (ρ). These items were analyzed on a single detail level and considering nosotros wanted to explore each goal by itself and therefore were not considered every bit a scale.

Associated Factors

The factors related to fine art therapy and the therapist's attitude were examined using five independent statements: – the relationship with the therapist, in which the therapist adopted a non-judgmental mental attitude (item: "The art therapist responds to me in a non-judgmental mode"); – the feeling that patients were taken seriously (particular: "I experience that I am taken seriously in art therapy"); – the caste of construction offered (particular: "I receive sufficient guidance to create artwork during the sessions"); – the level of freedom offered in the therapy (item: "I have sufficient freedom to express myself through working in art"). These aspects were scored on a 5-point Likert scale from "(1) never true" to "(5) most always true." 1 item asked about the extent to which a person could express his or her feelings in creating artwork in the art therapy sessions, for which the same Likert scale was used (item: "I am able to limited my feelings through the process of making art"). These items were analyzed on a single item level because we wanted to have a specific await at the content of each item. Test–retest results showed a Pearson's correlation in the range of r = 0.l to 0.85. More specifically: Non-judgmental therapist r = 0.60, Experience taken seriously r = 0.80, Sufficient freedom for expression r = 0.50, Sufficient guidance r = 0.70 and Expression of feelings in the art work r = 0.85.

Patient Characteristics as Predictors

In order to investigate which participant reported more than benefits than for others, the following aspects were examined: age (continuous), gender (male/female), and diagnosis cluster. Diagnosis cluster was divided into the subgroups of cluster B, cluster C, and PD (not otherwise specified), since these were the most frequent diagnoses within the unabridged grouping. The sectionalization in clusters was also based on meaningful clinical groups with a large enough sample to be looked at separately. These aspects were variables on a single particular level.

Procedure

The participants were recruited by 18 art therapists working in specialized departments for PD treatment at vi large mental health intendance institutions in Netherlands in order to obtain a nationwide representative sample. All treatments were multidisciplinary, with a group form of art therapy (and to a much bottom extent, individual therapy) every bit boosted therapy. Participants agreed to their participation by means of an informed consent course and and then completed the questionnaire at the first measurement point (later at to the lowest degree three sessions) and at a second measurement point, after 3 months. The first and second author are working in one of these health intendance institutions. Since the data collection was performed in six institutions, we consider at that place was no conflict of interest. In that location seems to be no question of furnishings of social desirability bias considering data drove was performed in six institutions and the questionnaire was handed out past the therapist or by colleagues, but in any example by persons other than the researchers.

The procedure for data handling was equally follows: we prevented as much every bit possible missing data past collecting a large part of the survey digitally and missing data were not accepted to the completion of the questionnaire. For the other part, the survey was offered newspaper and pencil wise. If only very few missing data occurred in a questionnaire, the mean value of a variable was used in identify of the missing information value for that aforementioned variable (mean substitution). The mean is a reasonable estimate for a randomly selected observation from a normal distribution. The sample seems large enough and ability does not seem an issue.

Data Analysis

Information were analyzed with IBM SPSS 24 (International Business organisation Machines [IBM], 2013). Firstly, we investigated the level of reported do good from art therapy (research question 1) (overall and in the instance of daily, emotional and social performance) and change over time using GLM repeated measures procedure with time as a within-subject gene. The nine items referring to specific handling goals and whether these inverse over fourth dimension were examined based on chi square tests.

In order to examine the research question ii, we correlated the associated factors with the overall perceived benefits and iii sub questions: benefits for daily, emotional, and social functioning.

For inquiry question iii "to examine whether differences in patient characteristics could predict the magnitude of perceived benefits" (patient characteristics as predictor), we used Pearson correlations for historic period and chi square for gender and diagnosis. In overall hierarchical regression analyses nosotros also tested whether benefits after three months could be predicted past benefits experienced at T1, the specific treatment goals, associated factors, historic period and gender, and PD diagnosis cluster. This model (see Effigy 1) was tested for overall benefits and for the three domains, i.e., daily, emotional, and social functioning. It was tested in 5 steps using the enter method, i.e., footstep 1, perceived benefits at T1; step 2, specific treatment goals at T1; stride 3, associated factors; step 4, historic period and gender; and step 5, cluster of PD diagnosis. This model was tested for overall benefits equally well equally the three domains of daily, emotional, and social performance.

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Frequencies of specified benefits of art therapy (%) (N = 528).

Results

Inquiry Question 1: Reported Benefits of Art Therapy

The bulk of patients reported that they had quite a lot of benefits from art therapy in general with a mean of iii.70 (SD = 0.99) on T2 (T1: 50.three%; T2: 56.4%). Simply 2.2% (T1) and 1.5% (T2) of patients reported that they perceived no benefits in general. For benefits relating to emotional operation, 25.2% of the patients reported these benefits at T1 and 31.8% reported this at T2. For daily and social functioning the percentages were lower (daily functioning, T1: 14.3% and T2: xvi.5%; social functioning T1: 12.1% and T2: 16.ix%). The results of the GLM repeated measures showed that the reported overall benefits increased later 3 months of art therapy F(ane,527) = thirteen.05, p < 0.001. This was also the case for benefits in emotional functioning F(1,526) = half dozen.262, p < 0.05 and in social functioning F(i,527) = five.73, p < 0.05, see Table ane.

Table ane

Benefits of art therapy, GLM repeated measures analyses (N = 528).

T1 mean (SD) T2 mean (SD) Df* T1, T2 F Sig. Partial eta squared ηii
Do good – overall 3.56 (1.04) 3.70 (0.99) 1, 527 13.05 0.00 0.024
Daily functioning 2.57 (1) 2.57 (1.02) i, 526 0.008 0.93 0.000
Emotional functioning ii.88 (one.06) 3.00 (i.06) 1, 526 6.262 0.01 0.012
Social performance 2.50 (0.97) ii.sixty (0.99) i, 527 5.73 0.02 0.011

Equally to whether art therapy contributed to specific treatment goals, a similar pattern over time was seen, see Effigy 1. At both points, the about oft reported specific treatment goals were expression of emotions (T1: 71.5%; T2: 76.1%), improved (more stable/positive) cocky-prototype (T1: 69.2%; T2: 73.1%), making own choices/autonomy (T1: 68.3%; T2: 72.7%), recognition of, insight in and irresolute of personal patterns of feelings, behaviors, and thoughts (T1: 62.seven%; T2: 71.two%) and dealing with ain limitations and/or vulnerability (T1: 62%; T2: 67.v%). Using chi foursquare, it was shown for each specific treatment goal that it was more than often reported at T2 than at T1 (p < 0.01).

Research Question 2: Associated Factors

Pearson'southward correlation coefficient (r) was used to examine whether the reported benefits were associated with specific factors relating to the therapist's attitude or the extent to which patients were able to experience expressing their feelings in the artwork in the art therapy sessions (meet Table 2). The diverse aspects proved to correlate with the caste of perceived benefits. Peculiarly the extent to which a person can express his or her feelings in the artwork showed a high correlation (ranging from r = 0.47 for social functioning to r = 0.72 for overall benefit).

TABLE 2

Pearson correlation (r) between benefits and a number of variables at T2 (Due north = 528).

Items Did you do good from art therapy? My daily functioning improved cheers to art therapy My emotional functioning improved cheers to art therapy My social functioning improved thanks to art therapy
Non-judgmental therapist 0.eighteen** 0.16** 0.14** 0.07
Being taken seriously 0.39** 0.29** 0.29** 0.24**
Sufficient freedom of expression 0.32** 0.27** 0.27** 0.22**
Sufficient construction/adequate basis 0.33** 0.22** 0.26** 0.23**
Extent to which feelings could be expressed in the artwork in AT 0.72** 0.51** 0.60** 0.47**

Research Question 3: Patient Characteristics equally Predictor

Diagnosis, age, and gender were not related to the reported benefits in general, nor to the benefits reported on daily, emotional, or social functioning; meet Table 3. Only on the item "my social functioning improved thanks to art therapy" did 16.i% of the women indicate more than often than men (half-dozen.1%) that their social functioning had not improved thanks to art therapy. And 18.three% of the men stated more often than the women (12.5%) that their social operation had improved thanks to art therapy.

Tabular array 3

Chi-foursquare test on benefits and several variables on T2 (North = 528).

Items Did you benefit from art therapy? My daily functioning improved thanks to fine art therapy My emotional operation improved cheers to fine art therapy My social operation improved thanks to art therapy
Gender 0.72 0.12 0.84 0.03a
Diagnosis cluster B, C, UPDb 0.24 0.89 0.88 0.74

Testing the overall model using hierarchical regression analyses, information technology was shown that the increase in reported overall benefits at T2 is associated with the extent to which the patient experienced beingness able to express his or her feelings in the artwork during the fine art therapy. The baseline values were predictive for increase in reported benefits of art therapy. No other specific benefit, therapeutic or patient characteristic was found to be associated with this increase. A similar pattern was shown for the effect of reported benefits on emotional functioning. But for social functioning, the increment in reported benefits was associated with whether art therapy focused on coping with limitations and/or vulnerability. Table 4 shows the results of these hierarchical regression analyses.

TABLE 4

Hierarchical regression analysis between perceived benefits at T2 and variables at T1 (Due north = 528).

Overall benefits Daily performance Emotional performance Social functioning

Δ R 2 B SE β Δ R2 B SE β Δ R2 B SE β Δ R2 B SE β
Footstep 1: Experienced benefits on T1 0.49∗∗ 0.52 0.07 0.54∗∗ 0.32∗∗ 0.45 0.07 0.44∗∗ 0.30∗∗ 0.39 0.07 0.39∗∗ 0.39∗∗ 0.49 0.07 0.50∗∗
Step 2: Specific benefits on T1 0.01 0.05 0.03 0.04
 Expression of emotions 0.11 0.13 0.05 0.08 0.14 0.03 0.11 0.sixteen 0.05 0.xviii 0.xiii 0.08
 Self image –0.fifteen 0.21 –0.07 0.07 0.13 0.03 –0.29 0.15 –0.12 –0.12 0.xiii 0.03
 Ain choices/autonomy 0.16 0.12 0.07 0.00 0.14 0.00 0.thirteen 0.15 0.05 0.07 0.thirteen 0.03
 Recognition, insight and changing patterns –0.03 0.11 –0.02 –0.ten 0.12 –0.05 –0.03 0.xiv –0.01 0.09 0.12 0.05
 Dealing with limitations/vulnerability –0.10 0.11 –0.05 –0.28 0.12 –0.14 –0.17 0.14 –0.08 –0.27 0.12 −0.13
 Self-confidence –0.02 0.12 –0.01 –0.22 0.13 –0.11 –0.xiii 0.15 –0.06 –0.22 0.13 –0.11
 Focused attending to ain bodily signals 0.16 0.10 0.08 –0.01 0.11 –0.01 0.07 0.12 0.03 –0.07 0.11 –0.03
 Addressed traumatic experiences 0.13 0.11 –0.06 0.03 0.12 0.02 0.xiv 0.xiii 0.06 0.01 0.eleven –0.00
 Improved social functioning 0.06 0.ten 0.03 –0.14 0.11 –0.07 –0.03 0.12 –0.02 0.02 0.11 0.01
Step 3: Associated factors 0.02 0.01 0.03 0.01
 Not-judgmental therapist –0.03 0.08 –0.02 –0.04 0.09 –0.03 –0.fourteen 0.10 –0.08 –0.05 0.08 –0.03
 Being taken seriously 0.07 0.08 0.05 0.14 0.09 0.10 0.04 0.10 0.03 –0.03 0.08 –0.02
 Liberty of expression –0.05 0.07 –0.04 –0.xiii 0.08 –0.x –0.01 0.08 –0.01 –0.05 0.07 –0.04
 Structure/adequate basis 0.04 –0.05 0.04 0.03 –0.06 0.02 –0.01 –0.06 –0.01 0.06 –0.05 0.05
 Extent to which feelings could be expressed in the artwork in AT 0.21 0.06 0.21∗∗ 0.03 0.07 0.03 0.23 0.08 0.21 0.12 0.06 0.xiii
Footstep 4: Gender/age 0.00 0.00 0.00 0.00
 Gender –0.01 0.10 –0.01 –0.xiii 0.12 –0.05 –0.12 0.thirteen –0.05 –0.05 0.11 –0.02
 Historic period –0.00 0.01 –0.04 –0.00 0.01 –0.02 –0.00 0.01 –0.03 0.00 0.01 0.03
Step v: Diagnosis cluster 0.00 0.07 0.05 0.06 0.00 0.08 0.06 0.07 0.00 0.05 0.06 0.04 0.00 0.02 0.05 0.02

Discussion

This report investigated the extent to which patients who accept been diagnosed with a PD experienced benefits from art therapy, and whether it contributed to the comeback of their daily, emotional, and/or social functioning. It also looked at the correlation with the extent to which people tin express their feelings in making artwork, with the conditions created by the therapist, and whether some persons reported more benefits from art therapy than others.

The majority of patients in the group studied (mainly Borderline, Avoidant, and PDs non otherwise specified) reported that they had gained quite a lot of benefits from art therapy in general with a hateful of 3.70 (SD = 0.99) on T2 (T1: 50.iii%; T2: 56.4%). The greatest positive change could be seen in reply to the overarching question as to overall benefit. Benefits in emotional functioning and social functioning also showed pregnant improvements, whereas any benefit to daily functioning did non involve a meaning modify. This fits the expectation that art therapy is focused on emotional aspects and because fine art therapy is more often than not in a group, information technology besides affects social functioning. The improvements are concentrated in specific target goals of which the five highest scoring goals affected were: expression of emotions, improved (more than stable/positive) self-image, making own choices/autonomy, recognition of, insight in and changing of personal patterns of feelings, behaviors and thoughts and dealing with ain limitations and/or vulnerability. Patients fabricated it articulate that they perceived these target areas as having been affected by fine art therapy and said so at both moments in time, with a higher score after iii months.

These findings are in correspondence with previous studies in which art therapy came forrad as highly suitable for and appropriate to the primal problems of patients with PDs, that it offers a well-defined route to a stronger emotional sensation and contributes to constructive emotion regulation (Green et al., 1987; Franks and Whitaker, 2007; Eren et al., 2014; Haeyen et al., 2015, 2017a,b, 2018). Likewise, the present study looked into the interplay between the caste of benefit and various factors: the specific treatment goals, associated factors, age and gender, and PD diagnosis cluster.

A potent correlation was found betwixt the level of benefit reported and factors such as a not-judgmental attitude on the part of the therapist, feeling that one was taken seriously, having sufficient freedom of expression, while at the same time offering sufficient structure and an adequate basis. Particularly, the extent to which patients can express their feelings in their artwork shows a strong correlation with social functioning, and is highest for overall do good. Then, when patients feel they tin express themselves in the art work, they also experience they can share this experience with others. Doing so, it likewise affects social aspects, which fits the thought that making meaningful art in the presence of others can function as a bridge for advice about emotion related themes between the patient and others, including therapists.

Factors that did not show whatsoever meaning correlation were age and gender. Fine art therapy in this written report came forward equally not primarily beneficial for men or for women, for younger or older people. Simply the aspect "improved social functioning" scored somewhat higher for men than for women. This might indicate that the women run across this less as a goal for themselves, whereas the group of men finds just the contrary. There was no departure betwixt extent of do good and the diverse diagnostic clusters. Then in this study it made no difference whether a person had a diagnosis in the categories cluster B, cluster C, or PDs not otherwise specified. For each of these diagnostic clusters, fine art therapy was every bit beneficial.

What ultimately came forward is that the increase in reported overall benefits is associated with the extent to which a patient has experienced that he or she can express his or her feelings in the artwork during the art therapy. No other specific benefit, therapeutic feature or patient feature was found to be associated with this increase. A like design was shown for reported benefits on emotional functioning. For daily and social operation, the increment in reported benefits was associated with coping with disability and/or vulnerability. This does non hateful that only patients are indicated for art therapy who have previous experience with expressing themselves in fine art or have the expectation that they will be able to express their feelings in art. Being able to express feelings in art is a skill that can be stimulated in art therapy, for which coming out of their condolement zone is therapeutic and triggering this possibility for self-expression in culling way next to verbal expression.

This study has a number of limitations. Firstly, the dropouts from art therapy were not included in the analyses since no data were known at the fourth dimension of measurement ii. This may have affected the results. Notwithstanding, the sample involved was large plenty to be concerned representative. A second limitation is that the period of iii months was a catamenia in the course of an ongoing handling. A clearly defined starting point might yield a clearer image or clearer results. However, the kickoff of a specialized treatment is seldom a clear starting point in the assistance and support programs of the patients in this target group, who have oft had to deal with issues in various fields of life for many years, and accept ofttimes been through numerous therapy processes, often resulting in few, temporary or variable furnishings. After all, their problems ofttimes consist of persistent patterns that have long existed and are typical of this diagnosis.

A 3rd limitation is that art therapy is not isolated in this study. Information technology was more often than not offered as role of a broader treatment plan, so that changes in benefits might be dependent on several factors, and not only on fine art therapy. An argument against this is that this survey posed specific questions with a focus on art therapy. Yet, this study does not accept a control group then cause and consequence conclusions are not possible and the repeated measures analyses yielded results with small outcome sizes. A fourth limitation is that this study did not expect at the relationship between the experienced benefits and aspects such every bit culture or IQ. These aspects might also be of influence, and information technology is recommended that they be included in subsequent studies. Lastly, this written report gives no insight into how benefit from fine art therapy is achieved, what factors are operative in art therapy and what interventions are decisive in this regard. This study primarily looked at secondary factors.

The strengths of this study are that it was conducted in the target group concerned, information technology was close to daily practice and involved a large group of participants, meaning that a sample of sufficient size could be assumed as the starting point. Equally far equally we know, a study of art therapy of this scope inside this specific target group was not conducted previously. In addition, often the participants in this report could not specifically cull art therapy, just it was a standard office of a broader, multidisciplinary treatment plan. This does not mean that simply participants with an analogousness for art therapy took part, but that a considerable number of participants may have had little or no affinity with fine art therapy or artwork. In practice, patients often say that art therapy is outside their condolement zone. Because the report did not involve only participants with leanings toward artwork, the results would probably give a more objective motion-picture show if this had been the case.

Conclusion

Patients diagnosed with a PD indicated that they experienced quite some benefit from art therapy. This is primarily shown in learning to express emotions, reinforcing and stabilizing their self-epitome, learning to make their ain choices and strengthen their autonomy, recognizing, gaining insight into and changing their own patterns in feeling, thinking and interim. They likewise regarded learning to deal with their own limitations and/or their ain vulnerability every bit an important goal of therapy. These target areas are perceived at the outset by patients every bit applicable in art therapy, and after a while it is seen even more strongly in this low-cal.

The extent of the perceived benefits is highly dependent for patients on factors such as a non-judgmental attitude on the role of the therapist, feeling that they are taken seriously, being given sufficient freedom of expression but at the same time being offered sufficient construction and an adequate ground. Historic period, gender, and diagnosis cluster brand no divergence for the extent of the benefits experienced by a person. Art therapy provides equal advantages to a wide target grouping, and so this grade of therapy tin can be broadly indicated. What does come forward is that the extent to which people perceive that they can give meaningful expression to feelings in their artwork is decisive. This provides an indication for the extent of the benefits a person tin can feel and tin can likewise serve as a clear guiding principle for interventions past the fine art therapist.

Data Availability Statement

The datasets generated for this written report are bachelor on request to the respective author.

Ethics Statement

Ethical review and approving was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

SH developed the research pattern, conducted the research, and first authored this article. SH and SV performed the statistical analysis. SV supervised the development of the research design and research process. SV and FC co-authored this article.

Disharmonize of Interest

The authors declare that the enquiry was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of involvement.

Acknowledgments

The authors would similar to thank all participating patients, art therapists, and mental health intendance institutions for their cooperation. Thanks are as well due to Arjan Doolaar for the APA check, and Carol Stennes for the translation.

Footnotes

oneArt therapy is an integral role of the handling for personality disorders in many larger national healthcare institutes in Netherlands, e.thousand., GGNet/Scelta, De Viersprong, Mediant, GGZ Friesland, Mondriaan, ProPersona, Synaeda, University Medical Center Groningen, GGZ Noord Kingdom of the netherlands Noord, GGZ Drenthe, GGZ Oost Brabant, Dimence and Lentis.

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