In this scholarly paper the authors, who are experienced clinicians and researchers, focus on the mechanisms of change in the arts-based and altered state of consciousness based psychotherapy methods. First, a theoretical conceptualization of the arts-based therapy methods’ potential to introduce positive change is presented. The effectiveness of the arts-based psychotherapy methods is considered. Here the development of preverbal, implicit processing tools, especially in work with traumatized clients, is highlighted. Secondly, the clinical usefulness of these methods is reflected in written statements given by five traumatized clients. These statements concern which part of the therapeutic process the clients considered most beneficial. One of the statements has previously been published. It is finally discussed how the arts in psychotherapy can enhance clients’ self-soothing capacities, and change capability. This is considered achieved through the activation of intersubjectivity and the innate human ability to express and experience creativity, including beauty and awe. This, together with flow experiences in line with positive psychology may offer a creative space of play where a new reality may be constructed and shared. The conclusion is drawn that the potentially effective mechanisms in the arts-based psychotherapies ought to be further investigated through both objective and subjective lenses in clinical work and research processes.
List of abbreviations: ASC altered state of consciousness; AT art therapy; BMGIM Bonny Method of Guided Imagery and Music; CBT cognitive behavioral therapy; DMN default mode network; EMDR eye movement desensitization and reprocessing; GrpMI group music and imagery; MT music therapy; PDT psychodynamic psychotherapy; PTSD posttraumatic stress disorder; RCT randomized controlled trial; RMT receptive music therapy; WoT Window of Tolerance.
Date received: 20 September 2018
Date accepted: 19 June 2019
Publication date: 1 July 2019
The mechanisms of change in arts-based psychotherapy that we propose in this article are hypothetical, due to the current relatively low level of evidence for the arts and ASC-based therapies. How aesthetics and the arts can play a part in effective mental health practices, is an emerging field (Backos, 2018). Despite this, substantial clinical research is still lacking. There is a need for in depth studies of the mechanisms for change in the arts-based psychotherapies (Haeyen, 2018; Samaritter, 2018). In lieu of such studies, we can at least begin to sketch a theory-based evaluation of these methods (Gerge, 2018a).
Several of the agents for potential change in these interventions can be generalized to other types of treatments as well, including PDT and CBT, and can be measured. Clients` evaluations of change mechanisms might be better predictors of outcome than the corresponding therapists` evaluations (Mander, Wittorf, & Schlarb et al., 2012). Change capability in psychotherapy is considered consisting of a) resource activation, b) problem actualization, c) mastery through learning to cope, d) clarification of meaning through realization of (un)conscious goals and motives, and finally, e) the quality of the therapeutic alliance (Grawe, 1997).
The effect sizes for different aspects of psychotherapy are both reassuring and humbling. Wampold and Imel (2015) stated that psychotherapy was more effective than no treatment (d = 0.80), with average differences of effectivity between the specific practices small; d < 0.20. A relatively large impact on the therapies researched was due to common factors such as alliance (d = 0.57), empathy (d = 0.63), and congruence (d = 0.49). We consider it is important to note that the therapeutic relationship can be further reinforced and concretized in the arts-based interventions (Gerge, 2018c).
Here, we will reflect upon the proposed change mechanisms of art and arts-based therapy, with a certain focus on art therapy (AT) and receptive music therapy (RMT) in treatment of posttraumatic conditions. Deriving evidence from our clinical experience using AT and MT, sometimes together with clinical hypnosis and EMDR, we will share both our own and our clients’ impressions regarding the therapeutic process. We believe that the herein proposed mechanisms of change in the arts-based psychotherapies can offer a heightened understanding of what promotes decreased suffering and dysfunction, and heightened wellbeing in clients with posttraumatic conditions. Finally, we will discuss characteristics that the arts-based interventions share with other therapeutic specializations, specifically psychodynamic psychotherapy. We acknowledge that this is an ambitious undertaking and that maybe much of what we are trying to describe can be considered abstract and difficult to concretize and measure. Although, in defense of this enterprise, we can cite Daniel Stern (2004) “one can not get to the lived experience and stay there while talking about it. But that does not stop me from thinking about it and approaching as close as I can” (p. xiii). The predominant reason for this paper is to inspire further research.
Ten years ago Bradt and Dileo (2009) put forth the heightened evidence of the effects of MT for individuals with coronary heart disease. Their findings indicated that listening to music reduced heart rate, respiratory rate and blood pressure. In an update (Bradt et al., 2013) they summed the findings and added that MT may have a beneficial effect on anxiety in persons with coronary heart disease. They asked for more research on the effects of music offered by trained music therapists. The experiential quality of the AT in psychotherapy has been established (Binson & Lev-Wiesel, 2018; Gerge, 2015) and proven effective (Haeyen, 2018). As Gilroy et al. (2012, p.12) stated, in the art-based therapies there might be absence of evidence but presence of knowledge.
We know that music affects the whole brain and our systems for reward, motivation and well-being (Harvey, 2018), and Fachner, Gold, and Erkkilä (2013) specified the potent effects of MT. They found that MT significantly reduced depression and anxiety symptoms in an RCT with 79 depressed clients with comorbid anxiety. Landis-Shack et al. (2017) offered a theoretical review on MT for posttraumatic stress in adults. They found that music therapy for traumatized adults may be a useful therapeutic tool to reduce symptoms and improve functioning, though they ask for more rigorous empirical studies. Hass-Cohen and Clyde Findlay have given a thorough relational and neuro-affective explanation of the value of visual art in therapy (2015). Here too the need for more studies was noted.
Arts-based therapies are used in clinical programs to help patients express and explore emotions, but systematic outcome research is scarce (Haeyen, 2018). Very few nation-wide committees, for example NICE – National Institute for Health and Care Excellence (UK) or SBU/Socialstyrelsen (Sweden) give any notice at all to the arts-based psychotherapy methods, except in use for cancer rehabilitation and psychosis. In the nationwide (UK and Sweden) compilations of psychotherapy methods, that offer mainly a set of verbally based interventions, PDT and CBT are mentioned.
Internationally, in the field of psychotraumatology the evidence-level of the arts-based therapies is generally low (Drožđek, 2015; Gray, 2011). The systematic review of Schouten, De Niet, Knipscheer et al. (2015) found six controlled, comparative studies on AT for trauma in adult patients with significant decrease in symptoms for the treatment groups. Baker, Metcalf, and Varker et al. (2017) used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) in their systematic review on the efficacy of creative arts therapies in the treatment of PTSD. They found that the evidence for music therapy, art therapy, and drama therapy was ranked as low to very low, with no studies found for dance/movement therapy. Generally the quality of the trials was found to be very poor. Archer, Buxton, & Sheffield (2015) when researching the effects of creative psychological interventions, CPIs, on the psychological outcome for adult cancer patients, stated that, “because the limited number of homogeneous studies…, it was still inappropriate to conduct meta-analyses” (p. 4).
Despite documented low levels of evidence regarding the use of the arts-based psychotherapy in PTSD, multidisciplinary arts therapy (Droztek, 2015; Drožek, Kamperman, & Bolwerk, 2012) and MT (Beck et al., 2017; Maack, 2012; Rudstam et al., 2017) was found effective. AT in conjunction with cognitive processing therapy (Campbell et al., 2016), was found to improve trauma processing. In the study realized by Campbell et al. (2016), the veterans partaking in the RCT considered AT to be an important part of their treatment. They found that the therapy provided healthy distancing, enhanced trauma recall, and increased access to emotions. War veterans with PTSD partook in an intense AT program (three times per week for one month) with good results regarding depression, aggressiveness, and self-image (Kopytin & Lebedev, 2013). In treatment of children with PTSD (Felsenstein, 2013) pre-school children were offered post-trauma group music therapy with positive results.
When considering separate studies, several conditions do not necessarily fulfill criteria for PTSD though they can often be considered trauma-related including psychosis, personality disorders, depression, and post-cancer conditions. This is due to the fact that PTSD is strongly comorbid with other Diagnostic and Statistical Manual of Mental Disorders (DSM) disorders (Kessler et al., 1995; Flory & Yehuda, 2015; Allen et al., 2019). Taking this into consideration, we will also cite studies which show the arts-based therapy methods’ efficacy in regards to common comorbidities of post-traumatic conditions.
Erkkilä et al. (2011) found in their RCT involving individual MT that music improvisation used with a psychodynamic ground combined with standard care is effective for depression amongst working-age people with depression. The participants receiving music therapy plus standard care showed a greater reduction in depression symptoms than those receiving standard care only. AT has been used to make mentalization manageable without loss of affect in treatment of persons with borderline personality disorders (Springham et al., 2012). Similar results were also found in an RCT using psychodynamic group AT for clients with acute psychotic episodes (Montag et al., 2014). Here the clients were found to mentalize emotions better after partaking in AT. Haeyen et al., (2017) found very large effect sizes in reduced personality disorder pathology and the development of adaptive modes, self-regulation, and mentalization in their RCT involving short-term AT in a group setting with patients with personality disorders cluster B and C. Haeyen (2018) found AT to be an effective treatment in itself and recommended health care to invest in more AT for patients with personality disorders. A study from the USA showed that both women and men in prison reported reduced depression and increased experience of internal control (locus of control) after 15 weeks of group therapy with AT (Gussak, 2009).
Uggla (2019) in four studies found music therapy clinically effective as complementary therapy during and after the hematopoietic stem cell transplantation treatment of children with leukemia. It was found to enhance their coping capacity during the hospital treatment period. It was also noted that their evening heart rate decreased significantly in the music therapy group compared to the control group (p < 0.001). This could potentially indicate prevention of PTSD, because the medical treatment undergone was very demanding. Uggla (2019) stated that MT prevented development of posttraumatic conditions and enhanced life quality.
When evaluating arts interventions in recovery, King (2016) stated that the evidence for MT was strong (Gold et al., 2005; Mössler et al., 2011; Geretsegger et al., 2017), and for AT quite strong (Edwards, O’Brien, & King, 2016). Bradt et al. (2016) in their Cochrane review found that music interventions improved psychological and physical outcomes in cancer patients, where the results suggested a large effect of music interventions on patients’ quality of life (QoL). Unfortunately here, the concepts music in medicine and MT were generally mixed and the studies were often of low quality.
There is confusion concerning which methods should be considered. Part of the evidence for MT is based on studies of music used in medicine, not MT (Gold, Heldal, & Dahle et al., 2005; Bradt et al 2016), and supportive therapy might not have been distinguished from psychotherapy. The length of the interventions varies to a large extent. The terminology is complex and the studies can involve interventions conducted by formally trained arts therapists doing arts-based psychotherapy, psychotherapists or other health care professionals adding arts-based methods to their therapy practices.
Creative arts therapies are defined from a psychodynamic stance by Bullington, Sjöström-Flanagan, Nordemar and Nordemar (2005) as those which use non-verbal communication through primary process expressions, aiming at helping change from chaos to meaning. Haeyen (2018, p. 133) defined AT as a treatment based on the experience and use of art materials, aiming to target emotional functioning, self-expression and well-being for patients. Archer, Buxton, & Sheffield (2015) used the concept creative psychological interventions (CPIs), defined as forms of psychotherapy that use the expressive qualities of the creative arts. AT is conceived as an emotion-based therapy promoting improved comprehension of thoughts and behaviors based on the expression and increased understanding of emotions through making art (Lock, Fitzpatrick, Agras et al., 2018). The relational adaptations from psychodynamic psychotherapy in music and AT, also offer a complex labyrinth. Belkofer and Nolan (2016) encouraged art therapists to envision “an interpersonally influenced mind/body holistic experience” (pp. 160). Hence, we can underline that the methods used in art and the arts-based therapies are in the best of cases encompassed by the therapeutic relationship.
The arts are an effective system for the communication of implicit information (Gerge & Pedersen, 2017). With this in mind, we want to first present proposed mechanisms of change in the arts-based psychotherapies before we present more overall proposed changes in psychotherapy. According to Malchiodi (2006) art making consists of creation, observation, reflection, and meaning making. Such experiences lead to change and insight through the arts-based psychotherapies offering an imaginative sphere for containing the implicit.
We propose that experiencing arts, for example in RMT or active music therapy, where the client is relationally held and relaxed when listening to or playing music, can also have the same change-creating potential as AT. Both inner images and created pictures supposedly represent processes in the implicit realm (Belkofer & Nolan, 2016; Gerge, 2017,, 2018a,, b; Hass-Cohen & Findlay, 2015), and correspond in multifaceted ways with affects and arousal levels of the body.
Clients in RMT are encouraged to engage in spontaneous imagination in an altered state of consciousness (ASC) when listening to pre-recorded sequences of classical music. The method was initially inspired by existential and psychoanalytic theories, including guided affective imagery (Leuner, 1966/1969) and the therapeutic induction of altered states of consciousness. In the Bonny Method of Guided Imagery and Music (BMGIM), after suggestions for relaxation, selected sequences of classical music are used to support the generation and movement of inner experiences (Bonny, 1978; Bruscia & Grocke, 2002; Summer, 2002). Such therapeutic experience usually ends with the client creating a picture.
This method has been used in a continuum form among MI (Music Imagery) and GIM therapists, when treating military sexual trauma (MST) with returning veterans, where MST has a high occurrence of PTSD causing a significant amount of distress (Story & Beck, 2017). Developments of RMT into trauma-focused GIM (Beck, Messel, Meyer et al. 2017) and Group Music and Imagery (GrpMI) (Goldberg, 1994; Blake & Bishop, 1994) has evolved into trauma-focused GrpMI (Rudstam et al., 2017). In the adapted methods the music used is shorter, more structured and supportive, than in ordinary BMGIM or GrpMI. These methods most commonly include a shorter period of relaxation to introduce the music listening phase. Throughout the music listening the participants remain seated and can draw during or after the experience.
In active music therapy the emotional state of the patient can be influenced and regulated by the music the patient conducts, the coregulation and co-playing of the therapist, and the music’s temporal rhythms. This is based on the premise that music is felt just as emotions are felt. This also impacts the brain and regulative functions, both in healthy and in burdened populations (Kučikienė & Praninskienė, 2018). In this manner, conditions beneficial for healing and integration, can be induced and enhanced in the patient, due to the co-regulative experience of making music together with the therapist. Making sounds and music can be used for outflow of tension and for stabilization.
An adaptation of active music therapy together with Eye Movement Desensitization and Reprocessing (EMDR; Shapiro & Maxfield 2002) is described by Eklöf (2015). In this variation of MT, stabilization is induced with the help of the therapeutic relationship together with drumming. Expressive psychodynamic or analytical MT as an operative treatment, focusing on healing attachment deficits and abuse, is described by Austin (2006) and Pedersen (2006).
AT is defined as an integrative mental health and human service profession in which active art-making and creative processing is held within a psychotherapeutic relationship (American Art Therapy Association; AATA, 2018). AATA further professes AT’s potential to improve cognitive and sensorimotor functions, foster healthy self-consciousness, resilience, insight, social skills, and reduce and resolve conflicts and distress, all common goals of psychodynamic psychotherapy (PDT; Luyten, Lowyck & Blatt, 2017). In addition, the perspective of AT as a catalyst for social and ecological change, is proposed (AATA, 2018; Harrison, 2018; Hogan, 2012,, 2016). AT is commonly used in many clinical programs to help patients express and explore emotions. Unfortunately it has not been systematically researched.
Although AT initially developed from a psychodynamic or a psychoanalytic stance, today integrative adaptations are abundant (King, 2016). Cognitive behavioral therapy (CBT) oriented approaches in AT exist (Haeyen, 2018). Even though AT and CBT stem from different theories (Sarid & Huss, 2010), in practice, these methods have similarities. This is not surprising since they have the same goal as do all forms of psychotherapy – to help the client to improve well-being and mental health.
It is common that a psychodynamic oriented or integrative AT is incorporated into CBT or mindfulness-oriented therapy approaches. We can see examples of this in the treatment of eating disorders (Lock, Fitzpatrick, & Agras et al., 2018), and women experiencing perinatal mood and anxiety disorders (formerly referred to as postpartum depression) (Sarid, Cwikel, Czamanski-Cohen, & Huss, 2017). These conditions have a heightened prevalence of traumatic experiences.
Such pragmatic adaptations (Giacomini, 2010) can be clinically meaningful, though they make the answer to the question, What works for whom? (Norcross & Wampold, 2011, 2019) even more evasive, and this is definitely a question we as clinicians should consider. It also occurs that, conglomerates of theories are incorporated into developed methods. One example of this is the expressive therapy continuum (ETC; Hinz, 2009; Lusebrink, 1990,, 2004), where the resourcing potential of the art experience is presented in relationship to the brain’s activation during the integrative art activity, including choice of art materials (Chapman, 2014; Hinz, 2009).
In the field of AT for trauma and dissociation some plausible theories have been developed (Hass Cohen, 2016; Talwar, 2007; Gerge & Pedersen, 2017) which are in concordance with the findings of Van der Kolk (1994,, 2014; 2016) and Van der Kolk, McFarlane, & Weisaeth (1996), which emphasize the importance of integrating non-verbal memories of fragmented sensory and emotional elements from traumatic experiences. Such experiences generate traumatic memories that are experienced in the form of vivid fragments of images, sounds, smells, and bodily sensations (Ogden, Minton, & Pain, 2006). The essence of pathological dissociation is described as a break in attention and consciousness (Liotti, 1999,, 2009). Since the reorganization of attention and consciousness can be enhanced through AT (Hass-Cohen & Carr, 2008; Sarid & Huss, 2010; Talwar, 2007), the conclusion is that AT can help relieve dissociative symptoms. A consequence of complex trauma is a breakdown of self-regulation, expressed as trance-like conditions and unintegrated states. Subsequently overcoming trauma will be featured by a restored integrative capacity and a potential to experience states and affects without dissociation (Van der Hart, Steele, & Nijenhuis, 2006). Parts of contemporary AT is inspired from neuro-affective science and relational psychodynamic theory (Hass-Cohen & Carr, 2008), and the perspective of trauma and dissociation (Gantt & Tinnin, 2009; Gantt & Tripp, 2016). Sarid and Huss (2010) and Gerge (2018b) stated the importance of modifying stress levels to enable the restructuring of more positive memories. This is also asked for in regards to vicarious trauma (Downs, 2019) where the potential benefit of art therapy for over-burdened clinicians is proposed.
Sarid and Huss (2010) pointed to the similarities of cognitive behavioral interventions and AT, both offering a holistic approach that helps to re-integrate the overwhelming and fragmenting experience of trauma. Further theoretical developments on how art and brain functions impact each other have been undertaken (Hass-Cohen, 2016; King, 2016), and protocols for PTSD treatment have been developed (Chapman, 2014; Hass-Cohen, Clyde Findlay, Carr et al., 2014). Also, compilations of motifs presumed to induce a neuroception of safety (Porges, 2011) have been developed (Gerge, 2018c). These security-inducing themes co-variate with four stated AT goals (Spiegel et al., 2006); lowered arousal, heightened positive affects, self-efficacy, and heightened self-esteem. The induction of signs and symbols of potential security can be conceptualized in line with flow experiences and positive psychology (Kok & Fredrickson, 2013; Seligman & Csikszentmihalyi, 2000,, Wilkinson & Chilton, 2013).
The arts-based psychotherapy experience partly takes place on a non-verbal plane and thus constitutes our lived story gathered at preverbal levels (Gerge, Wärja, & Pedersen, 2017; Hass-Cohen & Clyde Findlay, 2015; Maack, 2012; van der Kolk, 1994,, 2014). Such lived stories have great impact upon body image (Schilder, 1978; Ogden et al., 2006). According to Spring (2004), AT enhances symbolization of sensory-perceptual elements and in the case of traumatised clients, stimulates integration of the traumatic event through image conversion.
Belkofer and Nolan (2016) stated that our contemporary understanding of the brain ought to draw mental health clinicians’ attention to the body, and we would add, to the arts. Thus, the client, through artistic endeavor, can experience an embodied sensation and integrate this information into that which can be said and thought – a narrative. Such a narrative is a lived embodiment of the phenomenal self. What is then made visible, or heard, or felt through interoception has the potential to initiate health promoting change. Interoception is defined as the sense of the internal state of the body (Khalsa & Lapidus, 2016; Vaitl, 1996). The arts-based psychotherapy experience can offer semiotic “statements” of what cannot be said otherwise – where the “unthought experienced” can take form and become lived experience – an embodied endeavor. Such experiences include our body image. Arts-based psychotherapy interventions can potentially add to these retaken embodied functions and to the client’s wellbeing, reaching levels beneath mere cognitive reflection.
What constitutes change in psychotherapy needs to be reflected upon (Castonguay & Beutler, 2006). In this section we will outline and discuss issues in the healing process of PTSD and how these issues can be changed through the arts-based psychotherapies. The general processes of communication described in AT (Luzzatto, 2010,, Hass-Cohen, & Clyde Findlay, 2015; Skov, 2013) are: (a) the direct communication between therapist and patient; (b) a silent creative communication between patient and image, and finally; (c) the therapist trying to understand and elaborate the image together with the patient, an undertaking based on joint attention, according to Hawes (2016). Such relationally held art-making, is supposed to heighten the self-soothing capacity (Krystal, 1988). Thus, such methods have the potential for helping clients connect with the self and its narrative potential through contact with implicit material while inside their Window of Tolerance (WoT; Siegel, 1999). The WoT can be defined as the state of mind and body where the persons’ arousal levels permit them to be awake, calm and sufficiently safe, enabling the potential for curiosity, sociability and learning in a social context. This constitutes an important prerequisite for the change mechanisms in psychotherapy (Fonagy & Luyten, 2015; Gerge, 2015).
Hass Cohen (2016), Talwar (2007) and Gerge & Pedersen, (2017) stated that in the arts-based trauma therapies it is not the verbal account of the event that is important to address. This is in line with Van der Kolk (1994,, 2014; 2016) and Van der Kolk, McFarlane, & Weisaeth (1996). One of the final goals of AT interventions is the integration of the non-verbal memory of fragmented sensory and emotional elements from traumatic experiences (Corrigan & Hull, 2015). Our knowledge about how these processes unfold is still preliminary, though findings of contemporary neuroscience give food for though (Hass-Cohen & Findlay, 2015; Siegel, 2010).
In the expressive therapy continuum, ETC, Lusebrink and Hinz (2016) have incorporated Csikszentmihalyi’s concept of flow (1989, 2014), as a proposed activated state where the left and right hemispheres of the brain are integrated. Although our understanding of the arts’ potential to facilitate integration through positive experience and eligible brain activity is still in the early stages of development (Carolan & Stafford, 2018), certain benefits are clear. We can see the results of interventions where positive affects and states that are expressed, experienced, and shared, ease affect-phobia and free healing potential (Gerge, 2017; Nijenhuis, 2017). Unfortunately, how the casual relationships work, and which feedback loops impacts change mechanisms and capability, is still unknown.
Such global activation patterns occur when the brain is at rest and is connected to inwardly oriented states, daydreaming, or hypnosis-like states (Deeley, Oakley, & Toone et al., 2012; Demertzi, Soddu, & Faymonville et al., 2011; McGeown, Mazzoni, & Vannucci et al., 2015), and presumably when we partake in art experiences (Hutton, 2014). Bluhm, Williamson, and Osuch et al. (2009) observed changes in the DMN, and self-referential processing in clients with chronic PTSD related to early-life trauma. When the untraumatized brain experiences the arts, the DMN is supposedly activated. Speculatively, such experiences can have a regulatory and soothing experience as well for traumatized persons.
Recently Gerge (2018b,, 2018c) stated the importance of co-regulation in ASC- and arts-based psychotherapies as a prerequisite for the soothing experience. Such co-regulation can be hypothesized to happen during ASC, induced by hypnosis (Watkins & Barabasz, 2008), guided affective imagery (Leuner, 1966/1969) and expressive and receptive arts-based psychotherapy interventions, for example music listening (Bonde, 2017; Rudstam et al., 2017). Engagement with the arts and imagination involve healing and ritual (Achterberg, 1985; Achterberg, Dossey, & Kolkmeier, 1994; Backos, 2018; McNiff, 1983). Such experiences, when relationally held, may be experienced as sufficiently safe, thus permitting change through benign neuroplasticity (LeDoux, 2002; Porges, 2000,, 2011) leading to reoccurring functions and flexibility (Siegel, 2003,, 2007,, 2010).
Hawes (2016) highlighted the soothing quality of the joint attention in AT, thus potentially leading to changed and deepened epistemic trust (Fonagy & Luyten, 2015). The Bottom-up perspective (Cozolino, 2002) refers to the way information is built up from sensory experience. Top-down processing, on the other hand, refers to perception that is driven by cognition. We propose that implicit experiences of the joint attention (Hawes, 2016) in the arts-based therapies give access to new embodied narratives, including more secure body images through Bottom-up processes. Such experiences can be theorized as especially valuable when aiming at implicit regulation, including inducing safety (Batty, Bonnington, & Tang et al., 2006; Deeley, Oakley, & Toone et al., 2012; Gerge, 2018b).
Imagery during music listening takes place in an altered state of consciousness (ASC), supposedly with the default mode network activated, which through embodied experiences enables the formation of meaning in line with clinical hypnosis (Hammond, 1990). The positive effect of arts-based psychotherapy may also be related to the possibility of dealing with painful emotions via imagery and metaphors. Thus, the client is held in an expanded WoT, due to the dual awareness offered by the arts-based therapy methods. Dual awareness is a concept originating from clinical hypnosis and describes the process of being able to pay attention to one or more experiences simultaneously (Nijenhuis, 2017). Through activating dual awareness via a conscious activation of the orienting response, we can offer a working through of traumatic material. This will potentially help contain overwhelming feelings, thoughts and body sensations, while experiencing, even when that experience is a traumatic memory.
Interventions which make use of dual awareness, create flexible pathways between the physical, emotional, and cognitive aspects of traumatic experiences, be it AT, CBT (Sarid & Huss, 2010), or in psychodynamic group AT (Montag, Haase, & Seidel et al., 2014). The latter stated that the creative space offered by AT gives clients in acute psychotic episodes the opportunity to express and communicate even extremely unusual experiences. This is especially valuable for those who are unable to express their inner life verbally. Such ’abnormal’ or ’unspeakable’ content can be shared through images.
In RMT music’s “remothering function” can hold painful experiences and states, thus making the ’unbearable, bearable’. Here the music can be seen as “speaking motherese”, aiming at a more secure attachment in line with an acquired safe attachment pattern (Schore, 2003a,, 2003b). Such processes can be enhanced through the hypnotic inner strength methodologies (Frederick & McNeal, 1999; Gerge, 2018b,, 2018c), and with the use of resource oriented talk-overs (Rudstam et al., 2017). In RMT, the music itself can be considered an image-evoking force, thus making this a multifaceted experience.
Imagery is both connected with and created by our reality, consisting of cognitions, affects, inner images and embodied states experienced through interoception, and the ongoing outer reality. We live in both the outer landscape and an inner scape – in the past, the present and our memory of an envisioned future. Images have the potential for giving us directions into the future, for better or for worse. In AT images are given a gestalt and can change through the creative process. According to Gerge (2018c), the positive effects of AT can be said to rely on: (a) a relationally held arts-based induction to a favorable altered state of consciousness; (b) the drawing or painting experience offering a concrete transition area providing the opportunity to move between primary and secondary processes in a resource-activating mode (Gerge, 2018b), and; (c) the general common factors of psychotherapy (Lindgren, Folkesson, & Almqvist, 2010; Wampold, 2010).
Memory processes are indeed creative. Each time we remember a memory it will in part be a new memory (Ecker, Ticic, & Hulley, 2012; Lane, Ryan, & Nadel et al., 2015; Nader, Schafe, & LeDoux, 2000). Through reactivation of old memories in a non-threatening and holding therapeutic environment, clients are able to contact previously overwhelming states, affects and memories, as a new experience of togetherness is offered. This can be achieved by offering the “third hand” (Carr, 2014; Kramer, 1972), namely the helpful and non-intrusive support given by the therapist.
In line with the bilateral stimulation of EMDR (Mansfield, Lovett, & Engel, & Mansfield, 2017; Shapiro & Maxfield, 2002), AT creates a task that overextends the working memory. This apparently adds to a distancing attribute in both expressive and receptive arts-based psychotherapy. Presumably in this way, the arts in trauma informed arts-based therapy offer distancing and relief from intense emotions and the chance to give shape and containment to memories too difficult to put into words (Schwartz, 2017).
Through memory reconsolidation memories are activated, reprocessed and brought back into long-term memory. Because the arts have the potential to activate creativity, curiosity and joy, the traumatized client is offered a contradictory, resourcing experience – a necessity for changing a memory. In addition, the ability to access trauma material without being overwhelmed adds to clients’ sense of efficiency, and eliminates their traumatic memories (Elsey & Kindt, 2017). Through the addition of positive resources to a previously negatively associated autobiographical narrative, trauma memories that have been stored implicitly, can be integrated and brought into context (Gerge, 2018c; Hass-Cohen & Clyde Finlay, 2015; Hass-Cohen, Bokoch, & Findlay et al., 2018).
The study of aesthetics and beauty has a long tradition (Chatterjee, 2014; Eysenck, 1940,, Proyer, Gander, Wellenzohn, & Ruch, 2015). This may include the art experiences transformative potential in line with Maslow’s (1962) concept self-actualization, emphasizing the positive potential of human beings. Today we see a renewed interest in positive psychology (Haidt & Keltner, 2004; Peterson, Park & Seligman, 2004). The beauty offered by the arts can help us both to create and experience harmony, energy and/or meaning. By combining qualities, such as shape, color, form, sounds, and in a wider array, also verbal metaphors, that please the aesthetic senses, beauty is created, and meaning is anchored.
Our consideration is that to simply reduce the experience of the arts in psychotherapy to a series of positive psychological interventions – such as change in affect-equivalents, steps in the meaning-making process, or memory reconsolidation – brings us too deeply into the realm of reductionism. From humanistic and axiological view-points, the arts offer what is necessary for a human being torealize his or her potential. Beauty thus leads us into a realm where the experience is a matter of the phenomenal self, ”and at this point the music of the future begins”. (Kandinsky, 1911, p. 17). We thus want to highlight two aspects of beauty in arts-based therapy. The act of creating beauty and the joint act of sharing experiences of awe.
In 1982 Rollo May proposed that we may suffer from the fear of finding ourselves alone, and thus don't find ourselves at all. We propose that art experiences offer a possibility to share beauty, spirituality and moments of awe, thus overcoming the loneliness of a human being and for a short moment let us experience that we are not alone, isolated in our bodies. Since we as clinicians are touched by the presence of our clients and their sufferings, a certain felt sense of togetherness is attainable in the experience of creating or experiencing beauty, held by joint attention (Hawes, 2016). Such experiences may offer a shelter, both for clients and therapists, where they can be mutually embraced by the experience of beauty offered as an extended third hand. This can ease experiential avoidance, as exemplified with the dance therapy form Authentic Movement (García-Díaz, 2018). Empathy includes the experience of the other person, in the here-and-now, showing that someone exists and how she exists (Bornemark, 2014). The act of creating beauty, or put in other words, engender what is necessary for the soul (Kandinsky, 1911), potentially helps empathy and self-compassion grow.
In a found poem (Leavy, 2015; Faulkner, 2009) on the art making experience after AT group sessions for women with breast cancer, the beauty and the activation of a positive state is highlighted (Reilly, Lee, & Laux et al., 2018, p. 211): ”Painting has become part of my life, /As an inward journey. /Every time I explore my inner scape, /I learn more about my true self: /My inner peace, /My beauty, /And the joy of being myself- /Feeling connected as a whole being.” This exemplifies that when we are creating arts, we discover our capacity for phronesis, practical wisdom, for gaining knowledge about ourselves and the world.
The arts in therapy, through the processes of meaning making, make possible the representation of the lived experience in all its depth. In “The Praxis of Psychotherapy”, Berger (2000) refers to Aristotle’s three categories of ‘thought’: knowing (theoria), doing (praxis), and making in the sense of creating (poesis). They all come together in creating and relating to the arts, thus offering an internal place of being, which may transform the person both in the act of creating and sharing.
The arts-based psychotherapy interventions would seem to increase energy and coping capacity (Jacobi & Eisenberg, 2002). We propose that they, in line with Bandura’s (1986,, 1997) concepts agency and self-efficacy, can add to self-actualization, and freed potential.
Perry and Bond (2017) suggest that the changes caused by a functioning therapeutic relationship in psychodynamic psychotherapy, are found in the individuals’ defence mechanisms. First the client’s states are facilitated to change, then, over time their personality structure and traits are transformed. The use of newly found, mature defenses is a manifestation of this change. Holmqvist and Persson (2012) in their research concerning the change process in AT with depressed clients, highlighted vitality affects (Stern, 1985,, 2010) as transforming agents. Holmqvist (2017) also found that the therapeutic alliance, based on trust in both the therapist and the art process, was a necessity for positive change and this could more likely be a prerequisite for the described positive outcome. How the clients’ ability to change covariates with alliance, mentalization and psychotherapy methods is an expanding field of knowledge.
As clinicians we can and should consider what in our methodology is effective. We can consult with our colleagues and previous research in order to understand the effectiveness of our methods, but we can also ask our clients.
We invited clients with distinct posttraumatic diagnoses that had partaken in some form of long (more than a year) arts-based psychotherapy to give us written answers to the following questions: (a) what has been important in the therapy?; (b) what have the arts-based elements in the therapy added?, and finally; (c) if you think the artistic feature has been valuable, describe how it has been helpful. The interventions considered were: MT (Eklöf, 2015), relational AT in individual and group settings (Hawes, 2016), and phase specific relational psychodynamic therapy with integrated AT (Gerge, 2010, 2018c).
These clients were all diagnosed according to DSM-5 (American Psychiatric Association, 2013) and ICD-11 (2018). They have also signed informed consent regarding having their reflections published. Albeit unique individuals, they were chosen because they represent the client groups with complex PTSD and posttraumatic comorbidities we meet in our ordinary clinical work as psychotherapists and as supervisors. All of these individuals suffered from attachment wounds and intercurrent traumatic experiences. They were also selected because they were in therapy under the process of writing this article.
The following comments are somewhat shortened excerpts from the answers to our questionnaire.
Female client with complex PTSD, due to severe and long-lasting childhood physical abuse, threat, and neglect. She also fulfilled criteria for an unspecified dissociative disorder, and had had several previous suicidal attempts. She suffered severe somatic problems and diseases. Here follows her comments on MT:
(a) “The therapy has helped me to handle my feelings, express my feelings and understand how my traumatic background affected me. Through therapy I have also understood and worked with the dissociations created in my childhood. I have simply changed and become a more whole person; (b) The music has had three basic tasks in therapy. With music I have been able to express what I felt, even when the words were inaccessible or not enough. The music has also been used to create feelings and experiences through getting in touch with a feeling that I could expand with the help of music. The music has also been used to make imaginary journeys that have become stories that have influenced me a lot. I can say that we would not have reached as far as we did without the help of music; (c) When I was very worried we could get in touch with a sense of security that I did not feel, though I could express it musically. The music then influenced me to experience the peace or tranquility I needed. The music has also been helpful in bringing out my creativity without demanding perfection, and the music has led me, instead of the other way around. Of course, the music has also been a pure joy, and created the feeling that the work is done together with the therapist. When we have played together, a special community has emerged in the music sphere beyond everyday problems.”
Male client with complex PTSD and unspecified dissociative disorder due to severe childhood physical and sexual molestation in MT: (a)
“The most important, from my perspective, has been my own will to help myself and fully opening all of my Life-book to the therapist, letting myself be helped by her and the methods she offered. Since day one, my therapist’s methods were really effective including the musical part that let me express my self in my own artsy way, including her calmness at the moment of receiving me, even when my inside was burning. I would say that all of this can be resumed by her experience with others; (b) The eye of my therapist found the art sides of me and brought them to the therapy. This made me feel comfortable. Art is a whole language that helps people to communicate those things that can not be expressed by words. This helped me to show my feelings and myself better to my therapist, and this unwritten and unspoken communication was an important tool for her to help me fix my interior world; (c) We came from different worlds, we did not even speak the same language, and we agreed to meet in a middle language – English, yet no one of us have English as a first language. In this scenario, sometimes the only way I could express my thoughts or what I had in my head was through colours, light, shape, and music. This really helped me to say what I had to say. Somehow the therapist understood that this kind of art comes from the deepest sides of my inner world, so that she focused the therapy in this imaginary world helped so much. I could use art for heal myself, as inside me everything appears in those languages.”
Male client with complex PTSD, autistic features and attachment wounds in MT highlighting the artmaking and drumming experience:
(a) “The trustful cooperation between patient and psychotherapist, working their way to find the reasons for the client’s emotional situation. This includes finding and establishing a diagnosis, providing insight, understanding and safety in the client-therapist relation and in future treatment. To work on the client’s self-esteem and confidence before initiating deeper therapy. Continuous work on establishing the ability to feel more calmness through relaxation exercises and changed mindsets; (b) Painting with colours (task to describe how I felt and what I felt) gave visual overview of myself and how I felt and gave me more understanding and insight. This enabled another way of looking and activated other parts of the brain when using colours and the brain’s artistic side. I could express feelings in colour and how to paint (force in brush strokes, size of painting, etc.) in a clearer and more powerful way than "just" talking about them. The combination of painting and discussing gave more effect on expressing feelings than just discussions. To share with the therapist (and myself) how I felt – not just in words (which can be difficult if you are unable to express yourself). Drumming together with the therapist freed inner aggressions and frustration, helped feelings like sadness, aggression, and joy to come through. The drumming also restored peace in body and soul. When the body and the head were emptied of negative energy by aggressive drumming, there was room for positive energy in the form of peace and calmness. I compare this with the effect of physical activity – where the body is emptied of the stress and tension originating from internal aggression and frustration, one gets tired, the body tension disappears. I gained more control and insight into how one of the body's main functions, the breathing, worked. Respiratory therapy together with drumming can quickly and efficiently affect me and my emotional state.”
Client with complex PTSD due to childhood trauma and sexual assault in relational AT:
(a) “For me it has been important to be able to feel that I own my process. In the beginning you (the therapist) said that the therapy had a relational foundation and I have really felt that, maybe because I compare it with when I was seeing a psychologist and I felt that I was being observed more like an object for diagnosis or treatment. Trust and knowing that it is my space, where I can control much of what is going to happen and how it will happen, I think this has made me take responsibility for my own process and dare to confront much of what has arisen during therapy without feeling pressure regarding what will happen; (b, c) This has permeated all the work, the opportunity and accessibility that allowed for the expression of and/or focus on something concrete that has been created in front of me. In part the art-making has been a pleasant way of focusing energy while we talked and in part, I have even (after a pretty long time with you – the therapist) understood that the way I make art says a great deal about the way I am in the world, in my relationships and so on. In this way, I have been amazed by the concrete and visible result of our work together, in my paintings and pictures. The fact that I can look back at these pictures also makes clear and tangible to me the reality of the work I have done.”
Client with complex PTSD and dissociative identity disorder (DID) due to severe childhood sexual and physical abuse in phase specific relational psychodynamic therapy with integrated AT (parts of this text has previously been published (Gerge, 2018d):
(a) “Central and absolutely most important is the therapeutic relationship…. Instead of destructiveness, self-hatred and phobic avoidance of all of me, slowly and gradually a more tolerant and forgiving attitude toward myself and my own system has developed. This has made me to more and more dare to approach traumatic events and explore my parts with consideration, and through that positive changes have occurred; (b) From the beginning fear and avoidance. It was too scary for me to even think about using artistic expressions when I had so long wanted to create distance to inner materials to manage to stabilize myself and my mood in the therapeutic relationship. However, there have been parts of me that liked it and used it without me being able to control their acts. It has, when it happened, often filled me with horror and perhaps most of all shame as we often conveyed different needs existing in various parts, and mostly in the small parts of me. As I now start daring to use mostly drawing and painting, I experience that I can approach memories, feelings, and thoughts in my various parts and aspects of myself relatively safely. It is sometimes as if the pen and paper become an extra protection between my experiences of myself now and what feels and exists inside and in my dissociative states and traumatic experiences. It has similarities to how I previously used writing to somehow "leave away" material. … Though, even in this, the relationship to you is a prerequisite for daring!”
Gerge (2018c) proposed that the arts in therapy could be of help when therapists need to introduce; (a) safer self-other relationships; (b) change patterns of dysregulation and, finally; (c) increase their clients’ joy, pleasure and experience of triumph. This seems to be emphasized in the answers of our clients.
As can be seen the clients highlight both the relational aspects of the therapies and the art experience, and clients in music therapy appreciate the incorporated drawing/painting experience. In the pilot study (N = 31) of Hass-Cohen et al. (2018) with graduate therapy students, 67% rated the drawing activity as the strongest contributing factor adding to their capacity to access resources, when processing a potentially traumatic experience. In our examples with severely traumatized clients, they all put forward the relational components of the arts-based methods.
Using the literature studied and the first-person experiences of PTSD clients who have undergone arts-based psychotherapy, we want in this section to discuss how the arts in therapy offer a transformational function. In a recent paper on RMT, Bonde (2017) proposed theoretical perspectives of imagery, embodiment, metaphors, and schemas. These elements were seen to be grounded in the music’s capacity to foster embodied therapeutic change and growth. This was achieved through sensory stimulation, relaxation, verbal guiding, multi-modal imagery, and music’s emotional and evocative capacity (Horowitz, 1983; Juslin & Sloboda, 2010; Summer, 2002). In essence, this makes it possible to regard music as a “co-therapist” in working for change.
This parallels in part, the art therapist’s view of the creative processes of both the client and the therapist as a co-therapist and “something third” (Hawes, 2016). This, together with the art therapist’s “third hand” (Kramer, 1972), can add to a transformation of the implicit, potentially leading to integration and synthesis (Malchiodi, 2006). In line with relational psychodynamic theories (BCPSG, 2010; Gaensbauer, 2016), Holmqvist (2017) put forward AT’s potential for therapeutic change. This change includes, heightened (a) affect-consciousness, (b) ego-strength, (c) self-awareness, and (d) creative capability.
In RMT the embodied music cognition theory (Leman & Maes, 2014), and how metaphorical processing (Johnson, 2007; Lakoff & Johnson, 2003,, 1999) happen, can, hypothetically, explain how change happens – in the session and in the lives of clients. Here the active element is the, so called, image schema which is grounded in bodily experiences and at its endpoint, cognitive restructuring. The image schema establishes patterns of understanding and reasoning and stems from our bodily interactions (Johnson, 2007), and of course from our historical context. This potent catalyst for change, can be one explanation for the effects of the arts-based psychotherapies, for cognitive behavior interventions (Sarid & Huss, 2010), and psychodynamic psychotherapy (Schore, 2014). These described processes are most likely present in several psychotherapy interventions, if the relational holding is experienced as safe enough (Gerge, 2018b; Hawes, 2016).
At this point in time, we don’t know if the changes seen in arts-based experiential and resonant learning processes (Gerge, 2015; Lindvang, 2010,, 2013) are qualitatively different, or not, compared with the mechanisms of relational PDT (Roth & Fonagy, 2005), where the importance of the relationship and the induction of hope and a resource-oriented attitude is considered of upmost importance.
Summarizing the contemporary understanding, neuronal circuits for rebuilding behavior, images, emotions and cognitions are activated during AT (Hass-Cohen & Carr et al., 2008; Hass-Cohen and Clyde Findlay, 2015; Schore, 2012), and in arts-based therapy, where methods steeped in aesthetics and ASC are used. Then tacit knowledge (Polanyi, 1958,, 1966,, Vedfelt, 2017) can be brought into context and consciousness, and broken narratives can be told and heard.
Currently it is not possible to specify if the efficacy of the arts-based psychotherapy methods is grounded on offering the client the opportunity to: (a) reclaim their self-soothing capacity (Krystal, 1988,, Gerge, 2018a,, 2018b); (b) activate flow experiences in line with positive psychology (Seligman & Csikszentmihalyi, 2000,, Wilkinson & Chilton, 2013), or; (c) change inner working models (Bowlby, 1969) through memory reconsolidation, including reworking earlier hardships. It would seem that the arts-based interventions offer more than plain cognitive restructuring and behavior activation (although they may lead to additional changes in these parameters).
A successful psychodynamic treatment will not only relieve defined symptoms but also promote abilities and resources – well-being. The arts-based psychotherapies may be especially effective, due to; (a) offering an expanded Window of Tolerance (WoT; Siegel, 1999), through dual awareness; (b) concretizing the psychotherapist’s care in the therapeutic relationship which thus becomes more “real”; (c) offering tools for preverbal implicit processing, and; (d) activating the innate human ability to express and experience creativity (Gerge, 2018c), including beauty. Finally, we would add that the arts in therapy offer a creative space of play (Winnicott, 2005) where a new reality may be constructed and shared.
We do not know to which extent the results of the arts-based psychotherapy methods can be contributed to factors other than the art and arts experiences, such as the intrinsic therapeutic factors of group psychotherapy (Anderson & Winkler, 2007; Yalom & Leszcz, 2005), or general working alliance factors (Falkenström, Granström, & Holmqvist, 2014). Though, we propose that the mechanisms described here are relevant for different categories of the arts-based therapies, and that the processes of change found in these therapies have more similarities than is usually thought. There may be more that unites than that which separates arts-based and ASC-based psychotherapy methods, including methods using expressive means for image making via concrete ways and methods steeped in imagination (Gerge, 2018b). From an integrative approach, what is effective in different psychotherapy methods supposedly has more common denominators than usually indicated (Kirsch, Wampold, & Kelley, 2016; Falkenström & Larsson, 2017; Gerge, 2018a; Luyten, Lowyck & Blatt, 2017:, Norcross & Wampold, 2019).
Our emerging understanding of the functional networks of the brain, and how we are influenced when we partake in art experiences (Hutton, 2014), suggest the strong value of the arts-based psychotherapies. Potentially, the use and induction of multi-layered metaphors in other therapeutic processes in combination with induced ASC might offer privileged opportunities for change. This can include both the therapeutically held creating and experiencing of the arts. As human beings we are hardwired for, and have a need to experience, share, be moved and reflect (Hoffmeyer, 2012). We consider the arts-based psychotherapy interventions especially valuable in such undertakings. Thus offering a rich array of the change promoting mechanisms in psychotherapy (Grawe, 1997).
When combining relational aspects of PDT and arts-based psychotherapy methods in clinical work, our understanding of the arts-based contributions to the field of psychotherapy can grow. This will hopefully promote the status of these methods and consequently their capacity to enhance clients’ well-being and competence for change. Healing in psychotherapy occurs in relationships, that is why and how psychotherapy works (Grecucci, Frederickson, & Job, 2017). From such a perspective we can further develop the arts-based psychotherapy methods based on relational psychodynamic research and affective neuroscience, tailored to specific client populations. Maybe we ought not to discuss AT or arts-based psychotherapy as singular concepts, but, instead reflect upon different clinical needs and how our methods best be adapted to these needs.
According to Schnyder et al. (2015), psychoeducation; emotion regulation and coping skills; imaginal exposure; cognitive processing, restructuring, and/or meaning making; emotions; and memory processes are considered important aspects of the empirically supported psychotherapies for trauma-related disorders. From our compilation of the theoretical understanding of change agents present in the arts-based psychotherapy methods, and our clients’ reflections, we propose that these agents are abundant in these treatments. It might even be that the evidence-based methods for treating PTSD: EMDR (Shapiro & Silk Forrest, 1997; Shapiro & Maxfield, 2002) and trauma focused CBT (tf-CBT; Friedman, Keane & Resick, 2007) are effective, in part, due to the use of imagery and imaginative (and thus ASC-based) work (McNeal & Frederick, 1999; Ranch & Gerge, 2013). Though we propose that the arts-based therapy methods also offer something more – aesthetic values, creativity, and change processes made concrete.
We look forward to further discussions and solid research on how the arts can enrich contemporary psychotherapy traditions with psychotherapy methods immersed in implicit regulation, and arts-based methodology. The arts-based and ASC-based psychotherapies first came from traditional psychodynamic psychotherapy as an aid to reach and help traumatized clients. Maybe now is the time to offer a revitalizing reunion?
Anna Gerge, PhD, is a lic. psychotherapist, expressive art therapist, and recognized supervisor in private practice. Anna is guest researcher at Aalborg University and supervises on complex trauma and pathological dissociation throughout Sweden.
Jane Hawes, has a master’s degree in disability studies, is a lic. psychotherapist and art therapist. Jane practices relational art therapy in her private practice and conducts workshops as an artist and creative facilitator.
Lotti Eklöf, has a master of arts, and is a reg. occupational therapist, lic. psychotherapist and music therapist in private practice. Lotti is also a recognized supervisor and is highly specialized in complex trauma in her clinical work.
Inge N. Pedersen, Ass Professor, PhD Aalborg University. DK. Head of The Music Therapy Research Clinic, Aalborg University Hospital, Department of Psychiatry and Aalborg University. Recognized supervisor. GIM Fellow. Private practice, GIM, psychodynamic movement and supervision.
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