The Creative Arts Therapies as "Real Therapies"

Israel Zwerling, M.D., Ph.D.

Elements of a standard definition of psychotherapy are used to support the argument that the creative arts therapies should not be characterized as adjunctive therapies, or discredited as not being ~real therapies." Two concepts widely acknowledged as important in the application of the creative arts therapies are discussed: first, that the nonverbal media employed by creative arts therapists tap emotional rather than cognitive processes and evoke responses more directly and immediately than traditional verbal therapies, and, second, that creative arts therapies are reality-based and provide a more immediate and real link to a patient's experience than something he can portray only verbally. hen drawings, paintings, or movements were used only as diagnosic tools in the mental health field, there was little concern with whether they were therapies or merely adjuncts. In the 1940s, when Margaret Naumberg began writing about the application of art to treatment, not just to diagnosis, it seemed most convenient to lump the new "therapy" with the essentially diversionary activities t h a t had been found useful adjuncts in treating the mentally ill. Thus the creative arts thera-

Reprinted by permission from Hospital and Community Psychiatry, December, 1979. Dr. Zwerling's address at Hahnemann is 17th Floor, New College Building, 230 North Broad Street, Philadelphia, Pennsylvania 19102. This paper is based on a presentation at the Conference on Creative Arts Therapies, held June 28-30, 1979, in Washington, D. C. American Journal of Dance Therapy Vol. 11, No. 1, Spring/Summer 1989 1989 American Dance Therapy Association

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pies were identified as ~adjunctive therapies," a characterization I will argue against. My Random House dictionary defines "adjunct" as %omething added to another thing but not essentially a part of it"; it goes on to say ~joined or associated, especially in an auxiliary or subordinate relationship" and, further, '~attached or belonging without full or permanent status." By the term 'creative arts therapies" I refer to art, movement, and music therapy; others, like psychodrama and poetry therapy, belong generally to the creative arts therapies, but I have not used them or observed their use. Now if the creative arts therapies are ~adjunctive" to psychotherapy, we obviously need to inquire about the nature of the process to which they are impermanently attached and subordinate. My first step was to consult Hinsie and Campbell. 1 There are other medical and psychiatric dictionaries, but I am enough of a traditionalist to feel really secure with a dictionary published by the Oxford University Press. They propose that psychotherapy is ~any form of treatment for mental illnesses, behavioral maladaptations, and/or other problems that are assumed to be of an emotional nature, in which a trained person deliberately establishes a professional relationship with a patient for the purpose of removing, modifying, or retarding existing symptoms, of attenuating or reversing disturbed patterns of behavior, and of promoting positive personality growth and development." Now the prefatory phrase in this definition-'~any form of treatment"-patently leaves room for the creative arts therapies to be real therapies and not merely adjunctive subordinates, and we are therefore driven further into the definition of psychotherapy if we are to establish the adjunctiveness of the creative arts therapies in the treatment of '~mental illness, behavioral adaptations, and/or other problems that are assumed to be of an emotional nature." We next encounter the requirement that the real therapist be ~'a trained person." Here again the creative arts therapists would seem to qualify as real therapists, though it is a tricky point. I say so because I had the unhappy chore recently of participating in a survey of the patients in a state maximum-security institution for the criminally insane. The press had conducted a series of exposes about the inhumane treatment of patients there, culminating in the trial of some staff members who were charged with beating patients to death, and a panel of forensic psychiatrists was invited to examine the patients. The institution is located in a remote rural area, and, for white, middleclass therapists, it houses some of the least attractive patients imaginable-both mad and bad, many black and Hispanic, all poor, and several with rather violent tempers. As a result, it cannot hope to attract qualified psychiatrists, and the %eam leaders" of the ward units, to whom the creative arts therapists are presumably adjunctive, are all physicians

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retired from the practice of a range of medical and surgical specialties, except that none have practiced psychiatry. One of the patients I examined was receiving 20 different medications daily. My point is that the medical staff were trained physicians, and some were indeed well trained, but it would stretch credulity to argue that their training in any significant way prepared them to be therapists for this mentally ill population. If that seems a terribly exaggerated picture, or an isolated or unique instance, I would urge that you visit your nearest state hospital. This situation is of course in sharp contrast to the training and credentialing of creative arts therapists, whose preparation is specifically and exclusively for the treatment of the mentally ill and emotionally disturbed. In the programs I know for the training of creative arts therapists, there is a careful balancing of content between basic and applied areas, including personality theory, psychopathology, psychodynamics, and individual, family, and group psychotherapy-in addition to the content related to the application of the particular creative art form to the therapeutic process. Thus lack of training of the practitioners plainly cannot serve to disqualify the creative arts therapies as '~real therapies," so we must look further along in the definition. A psychotherapist ~deliberately establishes a professional relationship with a patient." It hardly seems worth stopping even for a moment to study this point, but I would share two images that come to mind. One is of the medication clinic of a mental health center I recently visited: a line of patients came for the monthly renewal of their psychotropic medication, greeted in each instance by the psychiatrist with '~And you a r e . . . ? " then responding with their names, and feeling validated when the psychiatrist picked out their chart with a reassuring '~Here you are!" A review of the symptoms and side-effects, lasting no more than five to ten minutes, followed, and the patients were given a renewal prescription and an appointment for the following month. Not much of a deliberate effort to establish a relationship on the part of the %ompleat therapist," the psychiatrist. Again, please do not draw solace from the happy fantasy that this is an exaggerated picture, or an atypical scene: it comes much closer to describing the actual ~'relationship" that exists between psychiatrists and many thousands of patients in and out of hospitals than the relationships most creative arts therapists have deliberately established with their patients. The other image, a contrasting one, is of a very poignant moment when an autistic boy with whom a movement therapist had worked for many hours finally allowed her to put her arms around him, and he cuddled in close to her. Clearly enough, practitioners of the creative arts therapies cannot be fairly accused of failing to deliberately establish relationships with their patients.

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We come finally to the really significant issue, to the question of the purpose of therapy: "removing, modifying, or retarding existing symptoms," ~attenuating or reversing disturbed patterns of behavior," and '~promoting positive personality growth and development." What is it we hope to accomplish, and how are we to understand the change that our effort is to bring about? These two components cannot really be separated. A colleague, a child analyst, referred to me for family therapy a case involving an ll-year-old girl with a school phobia. After a year of treatment by a child analyst, she had remained phobic about leaving home for school. However, after two months of once-a-week family therapy, she returned to school. The analyst has not referred any more cases to me, and he periodically checks up on the status of the girl; he is sure she is in a ~Tlight into health" and will at any moment come down with a recurrence of symptoms or with some new symptoms. What is at issue here is the trust we place in our t h e o r y - o r belief system, if you will. As soon as we offer to explain what we do, we therapists, who up to that point have been marching side by side, eschew our solidarity and break up into almost countless clusters under separate banners (neurobiologic, behavioral, psychodynamic, family systems, and so on), and within each cluster into numerous files (for example, the family systems cluster has its structural, analytic, multigenerational, and other files). Each cluster and each file has an adversary relationship to all others. We are generally polite, and we therefore generally agree, verbally, that we would better spend our time searching for commonalities and for articulations between systems levels. Some few go beyond verbal agreement and actually make such efforts. But for the most part, we carp at one another's therapies as too shallow, or too impractical, or as unproven or empirical or mystical or whatever.

Operational Concepts
Where do the creative arts therapies fit in this rather chaotic and unsettling scene? I see them as sharing a number of operational concepts, b u t without a single defined theory unique and specific to the arts. There are of course endless myths, or speculations, about mental illness and creativity, utterly unsupported, most suggesting that you have to be a little crazy, b u t not too crazy, to be creative. Arieti has offered a theory of creativity, 2 as have many others from a wide range of disciplines. Psychologists have long studied perception, and a n u m b e r - R u d o l f Arnheim 3 is perhaps the best k n o w n - h a v e elaborated theories of aesthetics. I know of no attempt, however, to formulate a

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comprehensive theory of mental wellness and illness and the creative arts. Two operational concepts are widely acknowledged as having paramount importance in the clinical application of the creative arts therapies. First, and almost universally accepted, is the concept that the nonverbal media employed by creative arts therapists more directly tap emotional rather than cognitive processes in patients. A number of experimental studies, recently reviewed by Daniel Schubert, 4 support the hypothesis that the creative arts therapists deal closer to primary process than do verbal therapists. Herman Belmont ranks art closest to secondary process, movement next, and music furthest from secondary process. 5 Others have put it that the creative arts therapist deals with the id rather than the ego. It has occurred to me that a case can be made for the creative arts therapies being addressed to the right brain, while the verbal therapies primarily engage the left brain. The point, however conceptualized, is that the creative arts therapies evoke responses, precisely at the level at which psychotherapists seek to engage the patients, more directly and more immediately than do any of the more traditional verbal therapies. The feelings that are aroused and expressed while singing, or playing an instrument, or listening to music, or moving to a rhythm, or drawing, or painting, become available to the therapist to identify, to develop, and to change. Whether one attributes the healing effect to the clarification of the evoked feelings (much as might occur in the interpretation of a dream), or directly to the creative experience-or to both, or to n e i t h e r - i s not an issue I wish to join; the creative arts therapists are as busy organizing and campaigning for their particular theoretical schools as are the therapists in all other modalities. Rather, I would like to illustrate with a brief vignette the use of music therapy with a patient in our prison unit. I should interject that when the Hahnemann department of mental health sciences was offered the opportunity to organize and operate a major unit in the Philadelphia County prison system, an art therapist, a movement therapist, and a music therapist were among the first mental health professionals I hired. There were raised eyebrows at the time; after a few months, the three creative arts therapists on the staff were as fully accepted on their treatment teams as the psychiatrists, psychologists, social workers, and nurses. The patient was a 27-year-old black male, incarcerated on the charge of aggravated assault on the woman with whom he lived. Following a suicide threat, he was transferred to the Hahnemann psychiatric unit at the Philadelphia prisons. He was diagnosed as having a borderline personality disorder, with hysterical and destructive traits. Abandoned by his mother at birth, the patient was raised by his grandmother until the age of 13, when she died. His relationships with foster

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parents were poor, and he felt alone. His adult relationships with women were failures, due to his overwhelming dependency needs. Each relationship was an attempt at replacing his grandmother; anger from the loss of his grandmother was displaced onto current relationships, surfacing when the women would attempt to break the relationship with him. The patient was graduated from high school and attended college for two years. He had a number of jobs, none of which lasted longer than six months. He was in the army from 1967 until 1969 and received a psychiatric discharge; the details were not available. His psychiatric history included a hospitalization at Philadelphia General Hospital for six weeks in 1974, where he was given unknown medication. He stated that he was admitted because he tried to kill himself by taking Valium, drinking alcoholic beverages, and jumping into the Delaware River. He was admitted to the Institute of the Pennsylvania Hospital for six weeks in 1975 because he was ~'falling apart, anxious-like losing something. I wanted to love people but I couldn't." The patient's arrest for assaultive behavior was his second. The first occurred in 1974 after another woman terminated a three-year relationship with him. He spent 30 days in the House of Correction, and he now feared that a recurring pattern was developing. During the initial four weeks of therapy, which included a weekly session with a psychiatrist and another with a social worker, as well as the administration of both tranquilizing and antidepressant medication (Serax, 15 mg. q.d., Tofranil, 100 mg. q.d.), no change was observed. The patient was assigned to the team music therapist. The following is an excerpt from the music therapist's segment of the discharge summary: ~After the fourth week of treatment, guided imagery and music was employed because the patient was motivated to deal with his emotional conflict. Guided imagery and music is a technique that involves listening to music in a relaxed state for the purpose of allowing imagery, symbols, and deep feelings to arise from the inner self. This process facilitates therapeutic intervention and self-understanding. The goals of this therapy were for him to experience his inner self and strengthen his ability to have control of his own life, not to be so dependent on others, and to be able to understand his destructive behavior. ~Each session included an initial conversation to determine his mental status; then he was induced into an altered state of consciousness through relaxation techniques. This was followed by a music listening session in which the guide (the therapist) encouraged a dialogue, asking the patient to report the images, feeling states, and thought patterns that were aroused by music. The role of the guide was to offer supportive and directive reactions to the imagery, and to maintain a position between involvement and objectivity. Each session was closed by a talking session for the integration of the experienced elements. Supportive group music

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therapy sessions allowed for his defenses to strengthen as he developed relationships. The groups met three times per week for one hour. ~'During the fifth session, the patient reported that he actually felt the physical pain in his abdomen that he had experienced when he lost his grandmother. He realized that it was the same pain he felt after he assaulted his girlfriends. This led to an understanding of how he used women to take the place of his grandmother." The music therapist told me that the latest reports indicated that the patient was successfully living on his own, had enrolled in college, and was continuing with outpatient therapy at a local clinic. The second widely acknowledged concept related to the clinical application of the creative arts therapies is their intrinsic social or reality-based character. There are, of course, dyadic interactions between therapist and patient in art, music, and movement therapy; the music therapist's treatment of the prisoner-patient just described is an example. But group murals, group dance sessions, and group music sessions are characteristic techniques, and they are obvious instances of the social character of these modalities. However, I mean something beyond the numbers of persons in the treatment session. There is a visible or audible or tangible link to society in a session involving a creative arts therapist and a patient, and it has a qualitatively more immediate, more real presence than does the person or the thing a patient may talk about. I make a kind of intuitive, and experimentally unsupportable, comparison between this quality of the creative arts therapies and the experience of dealing with the actual parents in a family therapy session instead of dealing with parental transference. A body image problem verbalized is just not the same as a body image problem lived out in movement. A verbal description of one's home, or of one's family, is just not the same as a d r a w i n g - e v e n a stick-figure d r a w i n g - o f one's family. No verbal statement about feeling scapegoated is as powerful and poignant as a drawing in which one unwittingly, without deliberateness, pictures oneself alone, separated from one's family group. The question ~To which category of therapy do the creative arts therapies belong?" plainly can be answered only by the context in which they are used. In the case I described, the antianxiety medication was adjunctive to the music therapy; one can of course readily bring to mind instances in which the reverse was true. At different points in a program of treatment, different therapies m a y take center stage, and others may move from central to adjunctive positions. Spurgeon English, in the foreword to his remarkable compilation of essays on a combined verbal and movement analysis of a psychotherapy session, states ~Events are incomprehensible except in terms of the context in which they occur. ''~ Mental health professionals who set out to ~cure" diseases, and especially those who ~know" that the disease they are treating will be cured

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once they have balanced serotonin levels, or when they have made the unconscious conflict conscious, or when they have individuated a family member from the undifferentiated family ego mass, will at best make very peripheral use of the creative arts therapies. Those who organize programs designed to treat people rather than to cure disease will find creative arts therapists invaluable.

Reference Notes
1. L.E. Hinsie and R. J. Campbell, Psychiatric Dictionary, 4th edition, Oxford University Press, New York City, 1970. 2. S. Arieti, Creativity: The Magic Synthesis, Basic Books, New York City, 1976. 3. R. Arnhein~ Art and Visual Perceptior~ University of California Press, Berkeley, 1954. 4. D. S. Schubert, ~'Creativity and the Ability to Cope," Creative Psychiatry, No. 5, Geigy Pharmaceuticals, 1975. 5. H. Belmont, "Art Therapy: An Outsider's View," Forum, Hahnemann Medical College and Hospital, Vol. 4, Autumn-Winter 1974-75. 6. O. S. English, editor, Strategy and Structure in Psychotherapy, Eastern Pennsylvania Psychiatric Institute, Philadelphia, 1965.