15041611Voices: A World Forum for Music Therapy1504-1611GAMUT - Grieg Academy Music Therapy Research Centre (NORCE &
University of Bergen)10.15845/voices.v19i2.2564ResearchProposed Mechanisms of Change in the Arts-based
PsychotherapiesGergeAnnaanna@insidan.seHawesJaneEklöfLottiPedersenInge NygaardAalborg University, Department of Communication and Psychology, DKArt therapist in private practiceMusic therapist in private practiceDepartment of Communication and Psychology, Aalborg University, DKMusic Therapy Research Clinic, Aalborg University HospitalKimSeung-AWoodwardAlphaRioRobin17201919220920181962019Copyright: 2019 The Author(s)2019This is an open-access article distributed under the terms of the
http://creativecommons.org/licenses/by/4.0/, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.https://voices.no/index.php/voices/article/view/2564
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.
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.
The Contradictory Findings Regarding the Efficacy of the Arts-based
Therapies
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.
Evidence of the arts-based therapy methods’ efficacy
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).
Arts-based Therapies in Treatment of Posttraumatic Conditions
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.
Arts-based Therapies and Trauma-related Dysregulation
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.
Confusions in the Field
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.
Proposed Mechanisms of Change in the Arts-based Psychotherapies
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.
Music Therapy
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).
Art Therapy
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).
Elements in understanding PTSD that support the proposed mechanisms of change in
arts-based psychotherapies
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 Psychotherapies and Body Image
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.
Change in Psychotherapy
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).
Proposed Mechanisms of Change in The Arts-based Therapies for Clients with
Posttraumatic Disorders
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).
Activation of Flow and Positive Experiences in Arts-based Psychotherapies
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.
Soothing Experiences in Altered States of Consciousness Enables Changed and Retaken
Narratives
A compilation of some of the brain’s functional networks. Notice that
the default mode network encapsulates the midbrain and the limbic system (Gerge & Johansson Metso, 2018).
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
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 Reconsolidation through the Lens of the Arts in Therapy
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 Experience of Beauty in Therapy
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.
Overcoming Loneliness and the Impact of the Other
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.
Overcoming Avoidance and Inducing Proudness of Being
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.
Arts-based Therapies Offer a Global Process of States Turning into Traits
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.
What Do the Clients Say?
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 answers
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!”
What Adds to a Resourcing Experience?
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.
Bringing it All Together
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.
Conclusion
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).
Further Directions
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?
About the authors
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.
AchterbergJ1985Boston, MAShambalaAchterbergJDosseyBKolkmeierL1994New York, NYBantam BooksAllenM TMyersC EBeckK DPangK C HServatiusR J2019Inhibited Personality Temperaments Translated Through Enhanced
Avoidance and Associative Learning Increase Vulnerability for PTSD1049610.3389%2Ffpsyg.2019.00496American Art Therapy Association; AATA2018https://arttherapy.org/American Psychiatric Association20135Washington, D.C.American Psychiatric AssociationAndersonF JWinklerA E2007An integrated model of group psychotherapy for patients with
fibromyalgia5745174ArcherSBuxtonSSheffieldD2015The effect of creative psychological interventions on psychological
outcomes for adult cancer patients: a systematic review of Randomised Controlled
Trials24111010.1002%2Fpon.3607AustinD2006Songs of the self: Vocal psychotherapy for adults traumatized as
childrenCareyLLondon, UKJessica Kingsley PublishersBackosR2018New York, NYRoutledgeBakerFMetcalfOVarkerTO’DonnellM2017A systematic review of the efficacy of creative arts therapies in the
treatment of adults with PTSD10664365110.1037%2Ftra0000353BanduraA1986Englewood Cliffs, NJPrentice-HallBanduraA1997New YorkFreemanBattyM JBonningtonSTangB KHawkenM BGruzelierJ H2006Relaxation strategies and enhancement of hypnotic susceptibility: EEG
neurofeedback, progressive muscle relaxation and self-hypnosis711-38390BeckB DMesselCMeyerSCordtzTSøgaardUSimonsenEMoeT2017Feasibility of trauma-focused Guided Imagery and Music with adult
refugees diagnosed with PTSD – a pilot study10.1080/08098131.2017.1286368BelkoferC MNolanE2016Practical applications of neuroscience in art therapy: a holistic
approach to treating trauma in childrenKingJ L157172New York, NYRoutledgeBergerL S2000Praxis as a radical alternative to scientific frameworks for
psychotherapy5414354BinsonBLev-WieselR2018Promoting Personal Growth through Experiential Learning: The Case of
Expressive Arts Therapy for Lecturers in Thailand8227610.3389%2Ffpsyg.2017.02276BlakeRBishopS1994The Bonny Method of Guided Imagery and Music (GIM) in the treatment of
post-traumatic stress disorder (PTSD) with adults in the psychiatric
setting12125129BluhmR LWilliamsonP COsuchE AFrewenP AStevensT KBoksmanK et al2009Alterations in default network connectivity in posttraumatic stress
disorder related to early-life trauma34318794BondeL O2017Embodied Music ListeningLesaffreMLemanMMaesP-J269277London, UKRoutledge FalmerBonnyH L1978BaltimoreICM pressBornemarkJ2014The genesis of empathy in human development: a phenomenological
reconstruction1722596810.1007%2Fs11019-013-9508-yBowlbyJ1969London, UKBasic BooksBradtJDileoC2009Music for stress and anxiety reduction in coronary heart disease
patientsCD00657710.1002%2F14651858.CD006577.pub2BradtJDileoCPotvinN2013Music for stress and anxiety reduction in coronary heart disease
patientsCD00657710.1002%2F14651858.CD006577.pub3BradtJDileoCMagillLTeagueA2016Music interventions for improving psychological and physical outcomes
in cancer patientsCd006911BrusciaK EGrockeD E2002Gilsum, NHBarcelonaBullingtonJSjöström-FlanaganCNordemarKNordemarR2005From pain through chaos towards new meaning: Two case
studies32426127410.1016%2Fj.aip.2005.04.007CampbellMDeckerK PKrukKDeaverS P2016Art therapy and cognitive processing therapy for combat-related PTSD:
A Randomized Controlled Trial33416917710.1080%2F07421656.2016.1226643CarolanRStaffordK2018Theory and art therapyCarolanRBackosA1733New York, NYRoutledgeCarrS M D2014Revisioning self-identity: The role of portraits, neuroscience and the
art therapist’s ‘third hand.’192547010.1080%2F17454832.2014.906476CastonguayL GBeutlerL2006Oxford, UKUniversity PressChapmanL2014York, NYWW Norton & sonsChatterjeeA2014New York, NYOxford University PressCorriganF MHullA M2015Recognition of the neurobiological insults imposed by complex trauma
and the implications for psychotherapeutic interventions392798610.1192%2Fpb.bp.114.047134CozolinoL2002New York, NYWW Norton & sonsCsikszentmihalyiM1989Optimal experience in work and leisure56May 89815822CsikszentmihalyiM2014New York, NYHarper PerennialDownsM2019(Expressive Therapies Capstone Theses. 114.)Retrieved from
https://digitalcommons.lesley.edu/expressive_theses/114DeeleyQOakleyD ATooneBGiampietroVBrammerM JWilliamsS CHalliganP2012Modulating the default mode network using hypnosis6022062810.1080%2F00207144.2012.648070DemertziAFaymonvilleM AGosseriesOVanhaudenhuyseAPhillipsCMaquetPNoirhommeQLuxenALaureysS2011Hypnotic modulation of resting state fMRI default mode and extrinsic
network connectivity193309322DrožđekB2015Challenges in treatment of posttraumatic stress disorder in refugees:
towards integration of evidence-based treatments with contextual and
culture-sensitive perspectives610.3402/ejpt.v6.24750DrožekBKampermanA MBolwerkNTolW AKleberR J2012Group Therapy With Male Asylum Seekers and Refugees With Posttraumatic
Stress Disorder200975876510.1097%2FNMD.0b013e318266f860EckerBTicicRHulleyL2012New York, NYRoutledgeEdwardsCO’BrienTKingR2016Visual art: Principles and evidence base for art therapyNeilsenPKingRBakerF2847New York, NYSAGEhttps://uk.sagepub.com/en-gb/eur/author/phillip-m-neilsenEklöfL2015Hur metoder som musik- och bildterapi kan bidra till att lugna och
reglera för att möjliggöra bearbetningGergeA197206Stockholm, SwedenInsidanElseyJ WKindtM2017Tackling maladaptive memories through reconsolidation: From neural to
clinical science14210811710.1016%2Fj.nlm.2017.03.007ErkkiläJPunkanenMFachnerJAla-RuonaEPöntiöITervaniemiM2011Individual music therapy for depression: Randomised Controlled
Trial1992132910.1192%2Fbjp.bp.110.085431EysenckH J1940The general factor in aesthetic judgements3119410210.1111/j.2044-8295.%201940.tb00977.xFachner J.Fachner JGoldCErkkiläJJBT2013Music Therapy Modulates Fronto-Temporal Activity in Rest-EEG in
Depressed Clients26233854FalkenströmFGranströmFHolmqvistR2014Working alliance predicts psychotherapy outcome even while controlling
for prior symptom improvement2421465910.1080%2F10503307.2013.847985FalkenströmFLarssonM H2017The working alliance: From global outcome prediction to
micro-analyses of within session fluctuations37167178FaulknerS L2009Walnut Creek, CALeft Coast PressFelsenstein R2013From uprooting to replanting: on post-trauma group music therapy for
pre-school children2216985FloryJ DYehudaR2015Comorbidity between post-traumatic stress disorder and major
depressive disorder: alternative explanations and treatment
considerations172141150FonagyPLuytenP2015A multilevel perspective on the development of borderline personality
disorderCicchettiD3726792New York, NYJohn Wiley & SonsFriedmanM JKeaneT MResickP A2007New York, NYGuilford PressFrederickCMcNealS1999Mahwah, NJLawrence Erlbaum AssociatesGaensbauerT J2016Moments of meeting: The relevance of Lou Sander’s and Dan Stern’s
conceptual framework for understanding the development of pathological social
relatedness37217218810.1002%2Fimhj.21555GanttLTinninL W2009Support for a neurobiological view of trauma with implications for art
therapy3614815310.1016%2Fj.aip.2008.12.005GanttLTrippT2016 The image comes first : treating preverbal trauma with art therapyKingJ L6799New York, NYRoutledgeGarcía-DíazS2018The effect of the practice of Authentic Movement on the emotional
state58172610.1016%2Fj.aip.2018.03.004GeretseggerMMösslerK ABieleninikŁChenXHeldalTGoldC2017Music therapy for schizophrenia or schizophrenia-like disordersHoboken, NJJohn Wiley & Sons, Ltd.GergeA2015Fokusering, affektregulering och kreativt gestaltande terapi som
länkar mellan kroppsligt upplevande och hur vi registrerar det och tillskriver
upplevelsen mening. (Focusing, affect-regulation, and creatively gestalting
therapies as links between embodied experience, our registration of the moment and
how we create meaning)GergeA7190StockholmInsidanGergeA2017What does safety look like? Implications for a preliminary resource
and regulation-focused art therapy assessment tool5410512110.1016%2Fj.aip.2017.04.003GergeA2018aAalborgAalborg University PressGergeA2018bRevisting the Safe Place: Method and Regulatory Aspects in
Psychotherapy when Easing Allostatic Overload in Traumatized
Patients66214717310.1080%2F00207144.2018.1421356GergeA2018cSome Reasons for Adding Art therapy to Trauma-informed
Psychotherapies73GergeA2018dArt Therapy as Part of the Treatment of a Patient with Dissociative
Identity Disorder (DID)74GergeAPedersenI N2017Analyzing pictorial artifacts from psychotherapy and art therapy when
overcoming stress and trauma54566810.1016%2Fj.aip.2017.02.001GergeAWärjaMPedersenI N2017Using aesthetic response, a poetic inquiry to expand knowing. Part II:
Some theoretical perspectives on arts-based research17110.15845%2Fvoices.v17i1.913GergeAJohansson MetsoF2018StockholmInsidanGiacominiM2010Theory Matters in Qualitative HealthBourgeaultIDingwallRDe VriesR7London, UKSage Publications10.4135/9781446268247.n8GilroyATippleRBrownC2012New York, NYRoutledgeGoldCHeldalT ODahleT2005Music therapy for schizophrenia or schizophrenia-like
illnesses210.1002%2F14651858.CD004025.pub2GoldbergF1994The Bonny Method of Guided Imagery and Music as individual and group
treatment in a short-term acute psychiatric hospital31834GrayA E L2011Expressive arts therapies: Working with survivors of
torture2113947GraweK1997Research-informed psychotherapy71GrecucciAFredericksonJJobR2017Editorial: Advances in Emotion Regulation: From Neuroscience to
Psychotherapy898510.3389%2Ffpsyg.2017.00985GussakD2009The effects of art therapy on male and female inmates: Advancing the
research base36151210.1016%2Fj.aip.2008.10.002HaeyenS2018(Dissertation)Radboud University.HaeyenSvan HoorenSDehueFHutschemaekersG2017Development of an art-therapy intervention for patients with
personality disorders: an intervention mapping study111110.1080%2F17454832.2017.1403458HaidtJKeltnerD2004Appreciation of beauty and excellence [awe, wonder, elevation]PetersonCSeligmanM E P537551New York, NYOxford University PressHammondC1990New York, NYWW Norton & CompanyHarrisonJ2018Art therapy and social changeCarolanRBackosA123133New York, NYRoutledgeHarveyA R2018Music and the Meeting of Human Minds976210.3389%2Ffpsyg.2018.00762Hass-CohenN2016Secure resiliency: Art therapy relational neuroscience trauma treatment principals and guidelines100138London, UKRoutledge PublishersHass-CohenNCarrR2008London, EnglandJessica Kingsley PublishersHass-CohenNClyde FindlayJCarrRVanderlanJ2014“Check, Change What You Need To Change and/or Keep What You Want”: An
Art Therapy Neurobiological-Based Trauma Protocol312697810.1080%2F07421656.2014.903825Hass-CohenNClyde FindlayJ2015Adaptive responding: Secure remembranceHass-CohenNClyde FindlayJ300357New York, NYW.W. Norton PublishersHass-CohenNBokochRFindlayJ CWittingA B2018A Four-Drawing Art Therapy Trauma and Resiliency Protocol
Study10.1016%2Fj.aip.2018.02.003HawesJ2016(Unpublished thesis)LinköpingLinköpings Universitet, Institutionen för Beteendevetenskap, Steg 2
Relationell PsykoterapiHinzL2009New York, NYRoutledgeHoffmeyerJ2012The natural history of intentionality. A biosemiotic
approachSchilhabTStjernfeltFDeaconT97116The NetherlandsSpringerHoganS2012London/New York, NYBerghahn BooksHoganS2016London, UKRoutledgeHolmqvistG2017(Avhandling)Art therapy – A path to inner change and improved health(Dissertation)Högskolan i Halmstad, Akademin för Hälsa och Välfärd, Centrum för
Forskning om Välfärd, Hälsa och Idrott (CVHI).HolmqvistGPerssonC L2012Is there evidence for the use of art therapy in treatment of
psychosomatic disorders, eating disorders and crisis? A comparative study of two
different systems for evaluation531475310.1111%2Fj.1467-9450.2011.00923.xHorowitzM1983New York, NYJason AronsonHuttonN2014Visited on Februari 17, 2014/ 2018-07-10http://thebeautifulbrain.com/2014/02/art-and-the-default-mode-networkWorld Health Organization2018WHO, World Health Organization.Jacobi, E. &
Eisenberg, G. (2001–2002). The efficacy of the Bonny Method of Guided Imagery and
Music in the treatment of rheumatoid arthritis. Journal of the Association
for Music and Imagery, 8, 57–74.JohnsonM2007ChicagoUniversity of Chicago PressJuslinP NSlobodaJ2010Oxford, UKOUP OxfordKandinskyV1911New YorkDoverKesslerR CSonnegaABrometEHughesMNelsonC B1995Posttraumatic stress disorder in the National Comorbidity
Survey5210481060KhalsaS SLapidusR C2016Can Interoception Improve the Pragmatic Search for Biomarkers in
Psychiatry?712110.3389%2Ffpsyt.2016.00121KingJ L2016New York, NYRoutledgeKirschIWampoldBKelleyJ M2016Controlling for the placebo effect in psychotherapy: Noble quest or tilting at windmills?32121131KokB EFredricksonB L2013Positive emotion: How positive emotions broaden and buildFrohJ JParksA C6163Washington, DCAmerican Psychological Association10.1037%2F14042-010KopytinALebedevA2013Humor, self-attitude, emotions, and cognitions in group art therapy
with war veterans301202910.1080%2F07421656.2013.757758KramerE1972Oxford, UKSchockenKrystalH1988Jersey, NJAnalytic PressKučikienėDPraninskienėR2018The impact of music on the bioelectrical oscillations of the
brain25210110610.6001%2Factamedica.v25i2.3763LakoffGJohnsonM2003Chicago, IlUniv. of Chicago PressLakoffGJohnsonM1999New York, NYBasic BooksLaneR DRyanLNadelLGreenbergL2015Memory reconsolidation, emotional arousal, and the process of change
in psychotherapy: New insights from brain science3810.1017%2FS0140525X14000041Landis-ShackNHeinzA JBonn-MillerM O2017Music Therapy for Posttraumatic Stress in Adults: A Theoretical
Review27433442LeavyP2015York, NYGuilford PressLeDouxJ E2002New York, NYPenguinLemanMMaesP J2014The Role of Embodiment in the Perception of Music9(3–4)236246Leuner, H.
(1966/1969). Guided Affective Imagery. (GAI) A Method of Intensive Psychotherapy:
Abbreviation of a lecture given at the New Jersey Neuropsychiatric Institute,
Princeton, N. J., May 16, 1966. Reprinted from American Journal of
Psychotherapy, 23(1), 4–22.LindgrenOFolkessonPAlmqvistK2010On the Importance of the Therapist in Psychotherapy. A Summary of
Current Research22419224229LindvangC2010(Thesis)Aalborg UniversityLindvangC2013Resonant learning – a qualitative inquiry into music therapy student´s self-experiential learning processes8130GilsumBarcelona PublishersLiottiG1999Understanding the dissociative processes: The contribution of
attachment theory19575778310.1080%2F07351699909534275LiottiG2009Attachment and DissociationDellP FO´NeilJ A5365New York, NYRoutledgeLockJFitzpatrickK KAgrasW SWeinbachNJoB2018Feasibility study combining art therapy or cognitive remediation
therapy with family-based treatment for adolescent anorexia
nervosa261626810.1002%2Ferv.2571LusebrinkV B1990New York, NYPlenum PressLusebrinkV B2004Art therapy and the brain: An attempt to understand the underlying
processes of art expression in therapy21125135LusebrinkV BHinzL D2016The expressive therapies continuum as a framework in treatment of
traumaKingJ L4266New York, NYRoutledgeLuytenPLowyckBBlattS J2017, Mechanisms of change through the lens of two-polarities models of
personality development: State of the art and new directions37179190LuzzattoP2010Art TherapyHollandJ C422424Oxford, NY, USAOxford University PressMaackC2012(Doctoral dissertation)Aalborg UniversityRetrieved from http://www.mt-phd.aau.dk/phd-theses/ManderJ VWittorfASchlarbAHautzingerMZipfelSSammetI2012Change mechanisms in psychotherapy: Multiperspective assessment and relation to outcomeMalchiodiC2006New York, NYMcGraw-HillMansfieldLMansfieldD2017Use of the flash technique in EMDR therapy: Four case
examples11419520510.1891/1933-3196.11.4.195MaslowA19621New York, NYVan NostrandMayR1982New York, NYWW Norton CoMcNealSFrederickC1999New York, NYRoutledgeMcNiffS1983Review of clinical art therapy: A comprehensive guide53237010.1037%2Fh0098803McGeownW JMazzoniGVannucciMVenneriA2015Structural and functional correlates of hypnotic depth and
suggestibility231215115910.1016%2Fj.pscychresns.2014.11.015MontagCHaaseLSeidelDBayerlMGallinatJHerrmannU2014A pilot RCT of psychodynamic group art therapy for patients in acute
psychotic episodes: Feasibility, impact on symptoms and mentalising
capacity911e11234810.1371/journal.pone.0112348MösslerKChenXHeldalT OGoldC2011Music Therapy for people with schizophrenia and schizophrenia-like disordersCD004025John Wiley & SonsNaderKSchafeG ELeDouxJ E2000The labile nature of consolidation theory13216910.1038%2F35044580NijenhuisE2017Bristol CTVandenhoeck & RuprechtNorcrossJ CWampoldB E2011What works for whom: Tailoring psychotherapy to the
person6721273210.1002%2Fjclp.20764Norcross, J. C., &
Wampold, B. E. (2019, April 22). Relationships and Responsiveness in the
Psychological Treatment of Trauma: The Tragedy of the APA Clinical Practice
Guideline. Psychotherapy. Advance online publication.
http://dx.doi.org/10.1037/pst0000228OgdenPMintonKPainC2006New York, NYNortonPedersenI N2006AalborgAalborg UniversitetsforlagPerryJ CBondM2017Addressing defenses in psychotherapy to improve
adaptation37153166PetersonCParkNSeligmanM E P2004Strengths of character and well–being23560361910.1521%2Fjscp.23.5.603.50748PolanyiM1958ChicagoUniversity of Chicago PressPolanyiM1966Chicago, IlUniversity of Chicago PressPorgesS W2000The polyvagal theory: Phylogenetic substrates of a social nervous
system42212346PorgesS2011New YorkWW NortonProyerR TGanderFWellenzohnSRuchW2015Strengths-based positive psychology interventions: a randomized
placebo-controlled online trial on long-term effects for a signature strengths –
vs. a lesser strengths-intervention645610.3389/fpsyg.2015.00456RaichleM EMacLeodA MSnyderA ZPowersW JGusnardD AShulmanG L2001A default mode of brain function9867668210.1073%2Fpnas.98.2.676RanchMGergeA2013Symboldramaterapi med
ungdomarGuided Affective Imagery with adolescentsGergeAWhat have you been up to? PTSD and dissociation in
children and adolescents. Occurrence, diagnostics and treatment205232StockholmInsidanReillyR CLeeVLauxKRobitailleA2018Using found poetry to illuminate the existential and posttraumatic
growth of women with breast cancer engaging in art therapy152 1963 21710.1080%2F14780887.2018.1429863RothAFonagyP2005New York, NYGuilfordRudstamGElofssonUSöndergaardL OBeckB D2017Trauma-focused Group Music and Imagery with women suffering from
PTSD/Complex PTSD – a feasibility study92147161SamaritterR2018The aesthetic turn in mental health: Reflections on an explorative
study into practices in the arts therapies8410.3390%2Fbs8040041SaridOHussE2010Trauma and acute stress disorder: A comparison between cognitive
behavioral intervention and art therapy37181210.1016%2Fj.aip.2009.11.004SaridOCwikelJCzamanski-CohenJHussE2017Treating women with perinatal mood and anxiety disorders (PMADs) with
a hybrid cognitive behavioural and art therapy treatment (CB-ART)20122923110.1007%2Fs00737-016-0668-7SBU/Socialstyrelsen2013SBU/Socialstyrelsen, Authority of Social Wellfare, SwedenSchilderP1978New York, NYInternational Universities Press. (Original work published
1935)SchnyderUEhlersAElbertTFoaE BGersonsB PResickP A et al2015Psychotherapies for PTSD: what do they have in common?6110.3402%2Fejpt.v6.28186%3BSchoreA N2003aNew York, NYW. W. NortonSchoreA N2003bNew York, NYW. W. NortonSchoreA N2012New York, NYWW Norton & Co.SchoreA N2014The right brain is dominant in psychotherapy51338839710.1037/a0037083SchoutenK Ade NietG JKnipscheerJ WKleberR JHutschemaekersG M2015The effectiveness of art therapy in the treatment of traumatized
adults: A systematic review on art therapy and trauma16222022810.1177%2F1524838014555032SchwartzA2017Berkeley, CAAlthea PressSeligmanM E PCsikszentmihalyiM2000Positive psychology: An introduction55514ShapiroFSilk ForrestM1997New York, NYBasic BooksShapiroFMaxfieldL2002Eye Movement Desensitization and Reprocessing (EMDR): Information
processing in the treatment of trauma58893394610.1002%2Fjclp.10068SiegelD J1999New York, NYThe Guilford PressSiegelD J2003An interpersonal neurobiology of psychotherapy: The developing mind
and the resolution of traumaSolomonM FSiegelD JNew York, NYNortonSiegelD J2007New York, NYNortonSiegelD J2010New York, NYNortonSkovV2013(PhD-dissertation)AalborgAalborg UniversitySpiegelDMalchiodiCBackosACollieK Art therapy for combat-related PTSD: Recommendations for research and practice200623157–164SpringD2004Thirty-year study links neuroscience, specific trauma, PTSD, image
conversion, and language translation21200209SpringhamNFindlayDWoodsAHarrisJ2012How can art therapy contribute to mentalization in borderline
personality disorder?173115130SternD1985New York, NYBasic BooksSternD2004New York, NYBasic BooksSternD2010Oxford, UKOxford University PressStoryK MBeckB D2017Guided Imagery and Music with female military veterans: An
intervention development study5593102SummerL2002Gilsum, NHBarcelonaTalwarS2007Accessing traumatic memory through art making: An art therapy trauma
protocol (ATTP)341223510.1016%2Fj.aip.2006.09.001UgglaL2019(Thesis)StockholmKarolinska InstituteVaitlD1996Interoception421-212710.1016%2F0301-0511%2895%2905144-9van der HartONijenhuisE R SSteeleK2006New York, NYNortonvan der KolkB A1994The body keeps the score: Memory and the evolving psychobiology of
posttraumatic stress1253265van der KolkB2014New York, NYViking Booksvan der KolkB2016Commentary: The devastating effects of ignoring child maltreatment in
psychiatry - a commentary on Teicher and Samson 20165732677010.1111%2Fjcpp.12540van der KolkBMcFarlaneAWeisaethL1996York, NYGuilfordVedfeltO2017York, NYRoutledgeWampoldB E2010The research evidence for common factors models. A historically
situated perspectiveDuncanB LMillerS DWampoldB EHubbleM A24982Washington, DC.American Psychological AssociationWampoldB EImelZ2015New York, NYRoutledgeWatkinsJ GBarabaszA F2008York, NYRoutledgeWilkinsonR AChiltonG2013Positive art therapy: Linking positive psychology to art therapy theory, practice, and research301411WinnicottD W2005New York, NYRoutledgeYalomILeszczM20055New York, NYIUP