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Art therapy for individuals with severe mental illness

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Art therapy for individuals with severe mental illness

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Content ART THERAPY FOR INDIVIDUALS WITH SEVERE MENTAL ILLNESS

by

Ryan J. Rivera

A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(JOURNALISM)

May 2008

Copyright 2008 Ryan J. Rivera

ii
TABLE OF CONTENTS

Abstract iii
Main Body 1
What is art therapy? 4
Priorities within the field and an emerging evidence base 7
Limits on prevalence 12
Wellness and Recovery 17
Where empiricism and recovery collide 20
Three Case Studies 23
Bibliography 32

iii
ABSTRACT

Art therapy can most easily be understood as the marriage between psychology
and art. A participant in an art therapy program is able to enter a dialogue with an art
therapist by using artistic expression, a process art therapists say is especially
advantageous for people unable to communicate verbally.
The discipline is at least 50 years old, and while the ranks of art therapists
continue to grow, it has not become part of establishment mental healthcare treatment
regimens. Research into the efficacy of art therapy is ongoing, but many believe art
therapy is nothing more than an enjoyable diversion and not a “real” therapy that
achieves meaningful results.
Since a substantial part of the burden of financing mental healthcare falls on
taxpayers – and since what constitutes improvement in matters of mental health can be
viewed as somewhat subjective – people should be aware of how art therapy and other
alternatives are being investigated and implemented.
If art therapy is demonstrably effective, common sense policy should dictate it
become more readily available. Yet if efficacy remains questionable, compelling
arguments exist on both sides of the debate with respect to how art therapy should be
treated.
1
Wandering through one section of Sherman Oaks Hospital, you would think you
had stepped into the halls of an elementary school.
Walls and bulletin boards are covered with simple art – crayon drawings,
collages, paintings. Crayola markers, watercolors, and cutout images from magazines are
scattered across the large table in the center of the room. The familiar but forgotten
Elmer’s glue cow stares back at you, and for a split second you remember that kid in
kindergarten who’d snack on the milky white goo when the teacher wasn’t looking.
Even though it’s after hours and the students you’re imagining have all gone
home, you start to picture boys and girls sitting around the table, drawing and painting,
perhaps getting their hands and arms dirty in the process.
But then you remember you’re in a hospital, so your mind jumps to the only
logical conclusion: you’ve stumbled upon a pediatric ward. Wrong again.
The “partial hospitalization” program that fills this section of Sherman Oaks
Hospital serves people with psychiatric diagnoses whose conditions fall just shy of
warranting full time hospitalization but whose symptoms and limited functioning require
constant attention during the day. Schizophrenia, bipolar disorder, and borderline
personality disorder diagnoses are all part of the mix, and post-traumatic stress, sexual
abuse, and dementia can also lead to a referral to the program. Symptom management,
counseling, social skills training, and traditional case management services are all
provided here, but it’s the fruits of art therapy that leave their mark on the walls.
Art making in mental healthcare is not new, nor is the specific discipline of art
therapy. But art therapy as it is perceived today – an intervention popular with many
2
participants but whose scientifically proven efficacy remains questionable
1
– offers a
window into two competing trends shaping mental healthcare: the push for evidence-
based practices and the embrace of the wellness and recovery models.
2

Simply put, the ongoing debate centers on how mental healthcare service
providers should allocate their time and money. Should scarce resources go only to those
treatments that have passed scientific, quantitative tests of efficacy? Or should patients be
given wider options, including some that may be more appealing but that are not based on
the same kind of statistical research?
Evidence-based practices – interventions, drug treatments, and services vetted
through rigorous scientific research – are touted as offering the most reliable bang for the
buck. Proponents of these practices argue that funds should primarily be allocated to
treatments with proven efficacy in order to maximize limited budgets.
Supporters of the recovery model start with the assumption that people can
recover from mental illness, and believe the process is unique to each individual. Rather
than just treating symptoms in the most expedient fashion, mental wellness should be the
goal of mental healthcare policy. Whether helping someone through recovery or offering
the tools one needs to prevent a psychological or psychotic break in the first place,
everyone should be afforded the freedom to choose the services that they believe work
best or are most meaningful to them. Further, those in recovery should be offered hope
that they can lead meaningful lives.

1
Crawford, Mike. J and Sue Patterson. “Arts therapies for people with schizophrenia: an emerging evidence base.”
Evidence Based Mental Health 10 (2007): 69-70.
2
Frese, Frederick J., Jonathan Stanley, Ken Kress and Suzanne Vogel-Smith. “Integrating Evidence-Based Practices
and the Recovery Model.” Psychiatric Services 52, no. 11 (2002): 1462-1468.
3
Supporters of the wellness and recovery models generally do not take a position
on which types of treatments or therapies are most effective, and there need not be an
inherent conflict with supporters of evidence-based practices. Yet they remain concerned
that an emphasis on evidence-based practices could limit alternatives when budgets are
tight. If options are not offered and treatment not personalized, what happens to those
people outside the bell curve for whom the evidence-based practice is ineffective?
Furthermore, critics claim that the label “evidence-based” does not necessarily translate
into workable solutions, as many studies rely on homogeneous groups that do not
accurately reflect the population at large or account for people with multiple disorders.
3

Since these two sometimes-conflicting ideologies are largely shaping policy
today, including prioritization of the $121-plus-billion in public funds spent on mental
healthcare and substance abuse programs each year,
4
figuring where art therapy fits in
against this backdrop could help determine its long-term viability. The extent to which art
therapy is seen as a scientifically proven approach that benefits patients on their path to
recovery will largely drive the speed and vigorousness with which art therapy is
embraced or rejected.

3
Goldman, Howard H., Vijay Ganju, Robert E. Drake, Paul Gorman, Michael Hogan, Pamela S. Hyde and Oscar
Morgan. “Policy Implications for Implementing Evidence-Based Practices.” Psychiatric Services 52, no. 12 (2001):
1591-1597.
4
National Expenditures for Mental Health Services and Substance Abuse Treatment: 1993–2003. SAMHSA
Publication No. SMA 07-4227. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2007.
4
What is art therapy?

Art’s connection to mental health probably dates back to the beginning of human
society. The belief in a link between madness and creativity is expressed in the works of
Plato,
5
and analysis and interpretation of art produced within asylums or by people with
perceived mental illnesses began at least several centuries ago.
6

Published histories of the practice and memoirs by practitioners suggest that the
notion that art can be used as a bridge to connect therapist and patient began to coalesce
into something resembling modern art therapy sometime in the late 1940s and 1950s.
American art therapy pioneers like Margaret Naumburg were heavily influenced by
Freudian and Jungian psychoanalysis, but in somewhat of a departure, mostly left
interpretation up to the patient.
78
Contemporaries in Australia, the United Kingdom,
9
and
Brazil
10
were coming to many of the same conclusions about the power of art.
Art therapy, as it is used at Sherman Oaks, does not have specific outcome
objectives. Rather, the process aims to give people who have difficulty expressing
themselves with words an avenue to let out their thoughts and emotions, fears and
fantasies.

5
Spaniol, Susan. “Art and mental illness: where is the link?” The Arts in Psychotherapy 28 (2001): 221-231.
6
Staricoff, Rosalia Lelchuk. “Arts in health: the value of evaluation.” Journal of the Royal Society for the Promotion of
Health 126, no. 2 (2006): 116-120.
7
Zwerling, Israel. “The Creative Arts Therapies as ‘Real Therapies.’” Hospital & Community Psychiatry 30, no. 12
(December 1979): 841-844.
8
Hogan, Susan. Healing Arts: The History of Art Therapy. London and Philadelphia: Jessica Kingsley Publishers,
2001.
9
Henzell, John. “Art, madness and anti-psychiatry: a memoir.” In Art, Psychotherapy and Psychosis, edited by
Katherine Killick and Joy Schaverien, 176-197. London: Routledge, 1997.
10
Holston, Mark. “Paintings of the psyche.”Americas 56, no. 2 (Mar/Apr 2004): 6-13.
5
“Words don’t come close to expressing their inner world,” said Paige Asawa,
author of A History of Art Therapy in the United States and an instructor in the art
therapy program at Loyola Marymount University.
“Art can be a way to really shout out what’s deep inside,” said Judene Shelley of
the National Empowerment Center, an organization that advocates for a recovery-
oriented approach to mental healthcare.
Proponents of art therapy say it can serve as a reprieve from the living nightmare
experienced by people with severe mental illnesses, including the 2.4 million Americans
with schizophrenia according to the latest estimate by the National Institute of Mental
Health.
11

The general public associates schizophrenia with the so-called “positive”
symptoms of the disorder, including delusions and hallucinations. But in addition to the
positive symptoms, the condition is exacerbated by “negative” symptoms such as lack of
pleasure or purpose and flat affect and cognitive deficit symptoms such as an inability to
interpret or absorb new information.
“It was just very healing to be able to tap into a safe place…[and] to know that I
wasn’t alone because I felt very alone, very isolated,” said Lauren Spiro, 51, who took
part in art therapy after being hospitalized following a schizophrenia diagnosis when she
was 16 years old. She credits art with helping her through the recovery process.

11
National Institute of Mental Health. “The Numbers Count: Mental Disorders in America.”
http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml#Schizophrenia
(accessed 20 Mar 2008).
6
Introducing people to any new therapy or treatment and keeping them engaged
enough to stick with a new routine can be difficult, and art therapy is no exception to this
rule. But proponents of art therapy claim high retention, even if things start off rocky.
“At first, they’re anxious or don’t get it or don’t like it – but then they love it,”
said Kate Loree, an art therapist in the partial hospitalization program.
According to Loree, a typical art therapy session at Sherman Oaks lasts just under
an hour and includes a group of 10 to 12 participants. A few minutes are spent explaining
the day’s project – a simple directive like drawing one’s family or more abstract like
“create a feeling monster” – and then the group members spend about 25 minutes
working on their art.
The remainder of the session is devoted to talking about the artwork and the
feelings and emotions that went into creating it or what the art represents.
“One of the misconceptions is that art therapists are walking dream dictionaries”
with stock interpretations for any art produced or feeling expressed by participants, said
Loree. But she stressed that the art therapist’s role is to facilitate a discussion whereby
participants express their own thoughts on what they produced, not to impose a preset
interpretation such as red equals passion or blue means sadness.
In environments where art therapists are treated as an equal member of the
treatment team, the insights of an art therapist can prove invaluable, according to Ronald
Lay, an art therapist at the Napa State Hospital who works primarily with forensically
committed geriatric patients. Lay said he is often dispatched to the most difficult cases
where individuals can’t or won’t communicate with other mental health workers. Based
7
on the artwork created by the patient and the discourse that typically follows the art
making process, Lay said he is able to offer insight into the patient’s state of mind and
collaborate with other team members on devising the best treatment plan.

Priorities within the field and an emerging evidence base

Art therapists – as well as traditional psychotherapists, recreation therapists, social
workers, and others in a variety of mental health professions – strive to improve the
quality of care and quality of life of people with mental illnesses. Art therapists say their
approach differs from that of many psychiatrists, neurologists, and researchers who they
believe emphasize the disease more than the whole person by focusing on symptoms,
attempting to understand the mechanisms of disorders, and looking for cures.
The question is one of priorities. Some researchers believe art therapy has some
role to play in mental healthcare, but to them understanding disease and finding cures is
as important – if not more so – than caring for people currently afflicted.
“Do I think it [art therapy] is going to cure anyone from schizophrenia? No,” said
Anissa Abi-Dargham, a clinical psychiatrist at Columbia University whose research on
schizophrenia involves neuroimaging techniques.
Art therapists say finding a “cure” is not the point.
12

12
Zwerling, Israel. “The Creative Arts Therapies as ‘Real Therapies.’” Hospital & Community Psychiatry 30, no. 12
(December 1979): 841-844.
8
The most common positive effects witnessed at Sherman Oaks are in line with
research studies
1314
done on art therapy: increased self esteem, personal satisfaction, and
improved interpersonal skills, according to art therapist Einat Metzl.
Though art therapy was largely born in psychiatric institutions, the research
literature shows it has also been used with cancer patients to improve self esteem,
15

children to overcome trauma or engage the participant into a more traditional counseling
relationship,
16
and prison inmates to elevate moods and improve interpersonal
interactions.
17

“My gut reaction is it probably is effective in certain cases,” said James Herbert,
Associate Dean of the College of Arts and Sciences at Drexel University, “[but] there is
very little good scientific research to support it.”
The consensus among psychiatrists, psychologists, and other mental health
professionals outside the art therapy world is that not enough research has been
conducted to accurately assess the efficacy of art therapy.
18

Art therapists remain split on the question of whether the current body of research
is significant, but most would argue that more research would only serve to strengthen
the field’s standing within the larger mental healthcare community. A common refrain

13
Richardson, Phil, Kevin Jones, Chris Evans, Peter Stevens and Anna Rowe. “Exploratory RCT of art therapy as an
adjunctive treatment in schizophrenia.” Journal of Mental Health 16, no. 4 (2007): 483-491.
14
Green, Bonnie L., Christina Wehling and Gerald J. Talsky. “Group Art Therapy as an Adjunct Treatment for Chronic
Outpatients.” Hospital and Community Psychiatry 38, no. 9 (1987): 988-981.
15
Bar-Sela, Gil, Lily Atid, Sara Danos, Naomi Gabay and Ron Epelbaum. “Art therapy improved depression and
influenced fatigue levels in cancer patients on chemotherapy.” Psycho-Oncology 16 (2007): 980-984.
16
Saunders, Edward J. and Jeanne A. Saunders. “Evaluating the Effectiveness of Art Therapy Through a Quantitative,
Outcomes-Focused Study.” The Arts in Psychotherapy 27, no. 2 (2000): 99-106.
17
Gussak, David. “The Effectiveness of Art Therapy in Reducing Depression in Prison Populations.” International
Journal of Offender Therapy and Comparative Criminology 51, no. 4 (2007): 444-460.
18
Brandsma, Lynn and James D. Herbert. “The Use of Creative Arts Therapies in Counseling and Psychotherapy.”
Counseling and Human Development 30, no. 3 (1997): 1-10.
9
from art therapists – including Metzl and Asawa – is that the field is still relatively young
and more research is coming in every day.
But Scott Lilienfeld, professor of psychology at Emory University and the
founding editor of the journal The Scientific Review of Mental Health Practice remains
skeptical, noting that art therapy has been practiced for fifty years but has failed to
produce substantial research evidence to back up anecdotal claims. “It only takes half a
century [to determine efficacy] if no one wants to look at it,” he said. “[Art therapy]
emerged in an ethos where research isn’t highly valued.”
Indeed, most art therapists come from an arts rather than research background.
Admission requirements to the 33 master of arts programs accredited by the American
Art Therapy Association (AATA) include completion of studio art courses and
submission of a portfolio of original artwork. Research methods are covered in graduate
art therapy programs, but the emphasis is placed on practical application of the skills
learned, not research.
“You’re going to get more people who are interested in practice than in research,”
said Lynn Kapitan, editor of Art Therapy: Journal of the American Art Therapy
Association and a former AATA president.
Researchers in other fields could study art therapy, but there appears to be little
interest. Many art therapists and researchers in other mental health fields acknowledge
that at least the initial spark needs to come from within the art therapy community, and
research will beget more research. In an editorial on the value of research, Kapitan argued
10
that even one well-constructed empirical study can have a huge influence on perceptions
of art therapy.
19

Until recently – and to this day for most practitioners – the master of arts has been
the terminal degree in art therapy and “research is typically done at the doctoral level,”
said Audra Moran, director of scientific affairs and research grants at NARSAD, the
largest non-profit donor to mental health research
Research supported by NARSAD and the publicly funded National Institute of
Mental Health is concentrated on genetic, neurological, and drug studies.
“People that apply to NARSAD know what types of projects we fund,” said
Moran. Though not opposed to considering art therapy projects, the organization simply
does not receive applications from art therapists, according to Moran.
Kapitan argues that people who criticize art therapy for lacking a robust research
base often unfairly equate the field to other established disciplines with doctorate level
programs at every major university. “The two or three doctoral programs we have in art
therapy are fairly new,” she said. “We’re producing only a dozen or so researchers a
year.”
Systematic reviews of the available literature confirm that only a handful of
empirical studies have been conducted on art therapy and most journal articles consist of
case studies or anecdotal reports.
20

19
Kapitan, Lynn. “The ‘Multiplier Effect’: Art Therapy Research That Benefits All.” Art Therapy: The Journal of the
American Art Therapy Association 23, no. 4 (2006): 154-155.
20
Ruddy, R. and D. Milnes. “Art therapy for schizophrenia or schizophrenia-like illnesses.” Cochrane
Database of Systematic Reviews. Issue 4 (2005): Art. No. CD003728. DOI: 10.1002/14651858.CD003728.pub2.
11
Some art therapists would argue that developing standard outcome measurements
is difficult and might be counterproductive given the often-subjective nature of art
therapy. They insist available research suggests that participants value and can articulate
a preference for art therapy even if objective measures show little or no tangible effect.
21

“It’s hard to show solid proof that it works or is helpful,” said Amy Pfenning, an
art therapist at Coalinga State Hospital.
Supporters of art therapy and critics of the narrow scope and rigidity of some
aspects of the research community criticize the notion that scientifically rigorous research
is the only valid type of evidence. They argue that the “practice wisdom” borne by
working in the field in a scientifically imperfect setting is just as, if not more, valuable
than the results gathered in a controlled research environment, and evidence-based
practices should not wholly supplant working therapies that lack scientific evidence.
22

“Just because you can’t test art therapy doesn’t mean that it doesn’t work,” said
Loree.
Lilienfeld, presenting a view common in the research community, counters that
anything can be tested, and one would simply have to have one group complete art
therapy and one abstain with all other elements of the treatment plan identical. These and
similar types of studies are slowly being adopted by art therapy researchers.
“In just the last 3 or 4 years… we’re starting to see better and more sophisticated
research,” said Kapitan whose role as editor of Art Therapy keeps her abreast of the latest

21
Odell-Miller, H., P. Hughes and M. Westacott. “An investigation into the effectiveness of the arts therapies for adults
with continuing mental health problems.” Psychotherapy Research 16, no. 1 (Jan 2006): 122-139.
22
Zayas, Luis H., Manny J. Gonzales and Meredith Hanson. “‘What Do I Do Now?’: On Teaching Evidence-Based
Interventions in Social Work Practice.” Journal of Teaching in Social Work 23, no. 3 (2003): 59-72.
12
trends. One paper she highlighted was a randomized controlled study – “the gold standard
in science,” she said – that showed art therapy reduced acute stress with adolescents
suffering from post traumatic stress disorder.
23

However, a study published in the journal Mental Health in 2007, billed as the
first randomized control trial of art therapy used with schizophrenic patients, proved
inconclusive in terms of assessing the efficacy of art therapy while showing that such
studies are possible.
24

“That kind of research is an opening for having the field be taken a little more
seriously,” said Kapitan. “More and more people sit up a little bit.”
Of course, this “sit up” effect largely presupposes that outcomes will be positive.
Negative or inconclusive research could serve to marginalize art therapy as a novelty.

Limits on prevalence

Three primary factors are seen as limiting the use and acceptance of art therapy:
familiarity with the discipline, perceived legitimacy of art therapists, and budgetary
constraints.
At Sherman Oaks, Loree and Metzl said they are fortunate to have administrators
who believe in the value of art therapy and include them with psychiatrists, rehabilitation

23
Chapman, L. M., D. Morabito, C. Ladakakos, H. Schreier and M.M. Knudson. “The effectiveness of art therapy
interventions in reducing Post Traumatic Stress Disorder (PTSD) symptoms in pediatric trauma patients.” Art Therapy:
The Journal of the American Art Therapy Association 18, no. 2 (2001): 100-104.
24
Richardson, Phil, Kevin Jones, Chris Evans, Peter Stevens and Anna Rowe. “Exploratory RCT of art therapy as an
adjunctive treatment in schizophrenia.” Journal of Mental Health 16, no. 4 (2007): 483-491.
13
therapists, and social workers on the treatment team. But perhaps it goes without saying
that a facility with an art therapy program would believe in it.
Different types of evidence can be shown to support or deride art therapy, and
there is room to debate the legitimacy of the practice as an effective intervention. But on
a more basic level, simple awareness of art therapy as a distinct practice remains low in
the mental health field and even lower among the general public, according to Loree.
Metzl argues that firsthand exposure typically leads to a positive opinion of art
therapy, and its use, acceptance, and embrace tends to spread anecdotally. But even as
more people are becoming aware of art therapy, art therapists remain concerned that their
specialized training is undervalued.
Art therapists say the danger to the their discipline arises when people conflate art
making with art therapy. Though most art therapists think art is inherently therapeutic and
that art should be stressed more in society at large, they are quick to point out that they
offer more than an art class.
Art therapy represents the union of psychotherapy and artistic expression, and art
therapists stress that someone skilled in only one of the disciplines cannot – and should
not – claim they are offering art therapy. An artist is not trained in aspects of psychology
any more than a psychologist is trained in different art mediums or practices, they argue.
“I can change a light bulb, but I’m not going to go out and say I’m an electrician,”
said Lay, who has worked as an art therapist at Napa State Hospital since 1999.
All three California schools offering graduate degrees in art therapy – Loyola
Marymount University in Los Angeles, Phillips Graduate Institute in Encino, and Notre
14
Dame de Namur University in Belmont – include traditional marriage and family therapy
training side by side with art therapy since the state licenses marriage and family
therapists but not art therapists. When it comes to government funding of mental health
services, state licensure can convey a level of legitimacy not offered by the board
certification of the AATA-affiliated Art Therapy Credentials Board.
In California, one can be a marriage and family therapist without being an art
therapist, but any art therapist hoping to land a job better have a marriage and family
therapy license on top of their AATA certification, according to Metzl and Loree, both
graduates of the LMU program.
AATA encourages its 4900 members to monitor legislative action in their states
that could affect the profession, and actively petitions for licensure as “it is often believed
to be an automatic steeping stone to reimbursement of one’s services as a mental health
professional.”
25
New York, Tennessee, and Kentucky are among the handful of states that
currently license art therapists outright.
Services that are reimbursed by public or private insurance are most likely to be
offered, but service providers also have access to grants, state or local government
programs, donations, and other funds that allow them to support more novel treatments.
Yet art therapy has not risen to a “must offer” status, and budget constraints often limit
service providers’ ability to offer art therapy even in climates where administrators and
staff are enthusiastic about it.

25
American Art Therapy Association. AATA Government Affair 2006-2007 Sourcebook.
http://www.arttherapy.org/pdf/GACsourcebook2006_07.pdf (accessed 10 Feb 2008).
15
“When budgets are tight, it gets cut,” said Spiro, who has worked as an advocate
for consumer-oriented therapies for more than two decades following her own recovery
from schizophrenia.
“You have to be creative in terms of billing,” said Kristi Rangel, program
manager at the Alcott Center in Los Angeles, a community-based organization offering
psychosocial and residential services to people with mental illnesses since 1979.
Participants have responded well to art therapy programs in the past, but the
Alcott Center does not currently offer it among its services due in part to an inability to
get reimbursed for the service by Medi-Cal, California’s Medicaid program. Art
therapists have to be skilled at writing progress notes, emphasizing the talk therapy
component and downplaying the art elements, according to Rangel.
At Sherman Oaks, the art component is intentionally downplayed or left off notes,
according to Loree, in favor of emphasizing the talk-therapy elements of art therapy.
Though it is not impossible to get art therapy reimbursed under Medicaid
guidelines, “they often put people through fairly rigorous hoops in terms of making the
determination of what is medically necessary,” said Rusty Selix, executive director of the
California Council of Community Mental Health Agencies.
Unlike most community-based service providers, where Medicaid reimbursement
often makes up the bulk of funding – 52.5 percent of all government funding for mental
16
health care in California in 2004,
26
the last year for which complete figures are available
– the state hospital system operates on its own budget at its own discretion.
All five state hospitals include robust art therapy programs, according to Nancy
Kincaid, spokeswoman for the California Department of Mental Health.
“In our hospitals, [art therapy] is viewed as very important,” Kincaid said, noting
that art therapy has been used in the hospitals for decades.
Though the state hospitals are far from perfect and not without their critics, the
fact that hospital administrators are not beholden to Medicaid opens up the possibilities
of services that can be offered. Only 2.1 percent of the state hospitals’ $700 million
budget came from Medicaid in 2004,
27
with the rest coming from the state’s general fund.
“Our door is always open to art therapists,” said Karen Zanetell, chief of
rehabilitation at Napa State Hospital, which currently employs 17 art therapists.
Coalinga State Hospital is the newest state-run facility and currently employs 11
art therapists, according to Pfenning, who has worked there since it opened in 2005. As
the hospital adds patients, it continues to expand its art therapy program.
As for art therapy’s efficacy, Kincaid said if CDMH didn’t have confidence that it
achieved positive results, it wouldn’t allow for it in the hospitals’ budgets.
The problem with relying on Medicaid for mental health funding is mental health
encompasses more than just a medical component, and Medicaid is explicitly rooted in
medicine, according to Bill Emmet, director of the Campaign for Mental Health Reform.

26
2006 Center for Mental Health Studies Uniform Reporting, California.
http://download.ncadi.samhsa.gov/ken/pdf/URS_Data06/CA.pdf (accessed 1 Feb 2008).
27
Ibid.
17
“[Medicaid] seems impervious to the idea that a broad range of rehabilitation
services offer some benefit,” said Emmet. “Services that aren’t perceived as medical are
being denied for reimbursement.”

Wellness and Recovery

But the greater budgetary discretion does not entirely account for the increased
emphasis on art therapy at the California state hospitals. Like many institutions both
public and private, the California Department of Mental Health is embarking on a
philosophical restructuring.
“We’re transitioning from a biopsychosocial model into the wellness and recovery
model,” said Lay, of the Napa State Hospital. The former remains rooted in a top down,
doctor-knows-best approach to treatment while the latter prioritizes decision making by
the patient and collaboration with the doctor.
A central tenet of the wellness and recovery movement is the notion that recovery
is possible and services should be organized to treat the whole person, not just those
elements that pertain to psychiatric diagnoses. One size does not fit all and doctor does
not always know best.
Spiro, a self-described psychiatric survivor, said when she was diagnosed with
schizophrenia as a teen, she was told she’d never have a normal life. “The system says,
‘Oh, schizophrenia. Lock her up, put her on drugs.’”
18
But Spiro was able to transition back to a “normal” life. She earned both her
bachelor’s and master’s degrees in psychology after her diagnosis, served in the Peace
Corps for three years, and became an advocate for reforming mental healthcare.
Currently, she serves as director of public policy for the National Coalition of Mental
Health Consumer/Survivor Organizations.
Critics of the biomedical and biopsychosoical models – approaches that give the
greatest weight to the biological component of mental illness – argue that focusing on one
aspect of mental illness ignores or masks other factors.
28
They note that aspects generally
associated with a healthy life – exercise, a healthy diet, meaningful relationships,
spirituality, to name but a few – are too often disregarded to focus solely on a disease-
oriented approach to mental illness.
In contrast, the wellness and recovery model says “each person knows what’s
right for them,” said Shelley, the consumer rights advocate affiliated with the National
Empowerment Center. For some, it may be sticking to drug treatments, counseling, and
symptom management classes, but for others it could include going to church with
friends, yoga, and hiking.
For people who view art therapy as an important part of their recovery process,
the idea that art therapy shouldn’t be a choice for them is absurd.
“[Art] is the one thing in my life I haven’t wanted anyone to tamper with,” said
Sharon Wise, who was diagnosed with schizoaffective disorder, a condition featuring

28
Jacobson, Nora and Dianne Greenley. “A Conceptual Model of Recovery.” Letters. Psychiatric Services 52, no. 5
(2001): 688.
19
symptoms of schizophrenia and a mood disorder, when she was in her teens. Wise said
that her recovery was “99 percent because of art.”
Elements of recovery and wellness, including granting greater autonomy to
consumers and broadening the focus beyond the biological component of mental illness,
have gradually been embraced over the past two decades, with the pace increasing in the
past few years as evidenced by recent policy decisions.
The New Freedom Commission on Mental Health, created by executive order of
President George. W. Bush and tasked with providing ways to improve and revamp
mental healthcare in the United States made recovery a top priority. “We envision a
future when everyone with a mental illness will recover… [and have] access to effective
treatment and support – essentials for living, working, learning, and participating fully in
the community,”
29
the commission’s 2003 final report stated.
The California Mental Health Services Act, passed by popular vote in November
2004 that created a new tax on people with incomes over $1 million to fund new and
innovative programs, was largely seen by reform advocates as an endorsement of
consumer-focused programs.
“The consumer voice at the legislative level has become much more powerful and
has been noticed… [and money to fund recovery-oriented programs] is starting to trickle
in,” said Dori Hutchinson, services director at the Center for Psychiatric Rehabilitation at
Boston University.

29
New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in
America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, Maryland: 2003.
20
Many proponents of recovery would like to see systems that are already in place –
such as Medicaid and government grant programs – reconstructed in such a way that
allows funding of any service a mental health consumer sees as beneficial rather than
only funding programs and services approved by committee. Our public health system
shouldn’t discriminate among services, said Emmett.
Alternative approaches to treatment, such as art therapy, yoga, meditation,
acupuncture, “need to be accessible and affordable, and they’re not today,” said Spiro.

Where empiricism and recovery collide

One of the logical outgrowths of the freedom to choose which services to use is
the potential or likelihood of making choices that don’t maximize efficacy.
Mental health consumers can and should be able to “choose things that don’t
necessarily have scientific evidence behind them if they want to,” said Frederick Frese, a
psychologist and National Alliance on Mental Illness board member.
But the very nature of mental illness leaves some questioning the practicality of
such a mindset.
“If you think about it philosophically, it has to do with the definition of freedom,”
said Herbert Peyser, a psychiatrist and sometimes critic of aspects of the recovery model.
For people afflicted with mental illness, rational thought is often compromised and rather
than being free, people’s minds are trapped by the disease, according to Peyser.
30

30
Peyser, Herbert. “What is Recovery? A Commentary.” Psychiatric Services 52, no. 4 (2003): 486-487.
21
Peyser sees value in many elements of the recovery model – such as empowering
patients to make decisions about their treatment and looking at the whole person and not
just the symptoms of the illness – but he said recovery advocates too often take an
extreme approach that completely dismisses the biological component of mental illness.
Too an extent, and especially with the most debilitated individuals, he argued the doctor
really does know best.
Some advocates for consumer choice and autonomy are opposed to any
treatments initiated against the will of people with mental illness – for example, forced
medications or use of restraints – even if such treatments are evidence-based.
But others take a more nuanced view and acknowledge that there is a spectrum of
disability and should be a corresponding sliding scale in terms of granting autonomy over
treatment decisions.
31

As society shapes its mental health policy, especially with respect to funding, the
question becomes knowing where to draw the line. Supporters of evidence-based
practices advocate pouring the most money into the most effective programs as
determined by quantitative research. Recovery proponents stress treating the whole
person and personalizing services, even if what is most popular is not scientifically
proven to be most effective.
The two philosophies are not entirely at odds. Proponents of evidence-based
practices are committed to alleviating the burdens brought on by mental illness and are
supportive of including patients in decisions to the extent that such choices are based on

31
Frese, Frederick J., Jonathan Stanley, Ken Kress and Suzanne Vogel-Smith. “Integrating Evidence-Based Practices
and the Recovery Model.” Psychiatric Services 52, no. 11 (2002): 1462-1468.
22
evidence. Wellness and recovery supporters would like to build support for those
treatments that are most effective, but their standards of research and evidence extend to
non-scientific proof, including the personal experience of clinicians and individuals
diagnosed with mental illness.
The ongoing debate about how mental healthcare policy and practice should be
structured will continue to influence the role art therapy can play within the system. If the
emphasis on scientific evidence persists – and technological advances such as new brain
scanning techniques and quick and inexpensive gene sequencing suggest that it will – art
therapists will need to conduct more extensive and rigorous research if they hope to keep
the field afloat. And if wellness and recovery come to dominate the discussion, art
therapy will face the marketplace of consumer choice and be viable so long as patients
and clinicians value the practice.

23

Three Stories of Recovery that Included Art

The following stories represent personal experiences of recovery from mental
illness. The three women profiled each availed themselves of services including
psychological counseling, social services, and antipsychotic medication regimens at
various points in their lives, and it cannot be known for certain which factors are most
responsible for their progress. But since each stressed the value of art in her life, the
stories primarily focus on the role art played in the recovery process.
All three women currently work as advocates for mental healthcare reform and
have established careers that draw on their own experiences as mental healthcare
consumers.

Jan Kobe

A few years after earning her bachelor of fine arts degree from the University of
Kansas, Jan Kobe had already made it big. She was living in San Francisco illustrating
greeting cards for Hallmark and traveling the country networking with other young
artists. Kobe earned a good living, worked for a respected art studio, and was generally
pretty happy with her lot in life.
24
Yet in the back of her mind comments old friends made in her days back at KU
persisted – “The arts are never going to be as important as math or science,” these
engineering students would say – and Kobe began looking for a more meaningful use of
her talents.
“I saw people exiting the hospitals of San Francisco without any support and I
thought, ‘Wow, what better way to help people using art than to help people with mental
illness,’” Kobe recalled.
Kobe had heard that art could be used as bridge to help people who couldn’t
communicate verbally and thought that as an art therapist she could make a difference in
people’s lives and prove to herself and her friends that art mattered.
But in a cruel twist of fate, Kobe would have to wait two decades before using her
art to help others recover from mental illness. At 27, Kobe suffered a psychotic break,
was diagnosed with schizophrenia, and was hospitalized.
“I had a bright, bright mind and then after my onset it took 20 years to come back
and rebuild my life,” said Kobe, now 54 and once again a practicing artist. “I could not
paint, I couldn’t read, I couldn’t watch TV because my functioning was shot.”
Kobe was hospitalized off and on for several years following her diagnosis before
antipsychotic medications began to kick in and quiet some of the delusions and
hallucinations she experienced. Through medication and therapy, she gradually rebuilt
her life.
25
Like many suffering with the deficits of a mental illness, the loss of skills that
once defined her – in Kobe’s case her talent as an artist – was devastating. “It was like I
had lost my sight,” she recalled.
Kobe can’t say for certain whether her recovery followed her art or the return of
her art skills followed her recovery, but she believed they went hand in hand. Though she
never took part in formal art therapy sessions, case managers, recreational therapists, and
other mental health professionals encouraged her artwork.
“Even in the hospital, I illustrated and designed their newsletter,” she said.
One therapist had Kobe and other patients paint murals on the walls of common
areas, changing them every few months, a project that everyone in the group enjoyed
working on together.
In the mid-1990s following the introduction of a new generation of antipsychotic
medications, Kobe experienced what she calls an awakening. Skills she had lost flooded
back, and she decided to pursue her original goal of helping others with art.
Six years ago, Kobe helped found an art studio at the Wyandot Center, a
community-based mental health center in her native Kansas City, Kansas. She and her
coworkers wrote up a grant proposal and received $1900 from the Kansas Department of
Social and Rehabilitation Services. A modest sum, perhaps, but enough to start up an art
studio.
The people Kobe helps are mostly diagnosed with schizophrenia, bipolar disorder,
autism, and major depression. “They are some of the most creative artists,” she said.
26
Kobe is not an art therapist, but her background in art allows her to help people
express themselves creatively and her own history with a psychiatric diagnosis enables
her to relate to consumers in a way that someone who hasn’t been through the mental
health system can’t.
“I hope that there will be outcomes in the future, research-wise, that show art
helps people with recovery,” she said. “I’m a living example.”

Lauren Spiro

Lauren Spiro, 51, believes her psychiatric hospitalization at 16 was neither
medically necessary nor appropriate.
“It took me 25 years to realize that what was labeled as schizophrenia, for me,
was actually a spiritual breakthrough. My mind was reaching out – screaming out – for
what it needed,” Spiro said.
Her parents provided her with the trappings of the nouveau middle class – ballet
lessons just after learning to walk, formal oil painting instruction in a neighborhood
artist’s basement – but she said her childhood was full of little criticisms that chipped
away at her self esteem and lead Spiro to bottle up her thoughts and emotions. She had no
sense of who she was, nor the confidence to express herself to other people.
When she was 14, her father was killed in a random act of violence, and two years
later came the voices. The form Spiro’s delusions – or, in her terms, “breakthrough” –
took was an unyielding belief that she had to seek out and talk to the president of the
27
United States and advise him on domestic policy. God was telling Spiro to do something
about the drugs and crime wreaking havoc on the country, and she didn’t even believe in
God.
“At the time I was very, very confused. I mean confused enough to be put in a
mental hospital,” she said.
What Spiro said she needed, more than anything else, was someone to listen to
her and talk her through the confusing way her brain was choosing to express her
thoughts. What she got instead was a life sentence.
“My family was told that there was no chance of my recovery, of having a
meaningful life. That I would be in a mental institution most of my life, that I would be
on psychiatric medication all of my life,” Spiro recalls.
As the only teen in a psychiatric hospital full of adults, Spiro felt more and more
isolated. Group art therapy was the only place she connected with the heavily medicated
“zombies” she called neighbors.
“They were 30, 40, 50 [years old]… but when we did the artwork, it cut across the
boundaries,” said Spiro. “I didn’t bond with anyone doing anything else.”
Through the growth achieved in art therapy, the help of a handful of counselors
who would actually listen to her, and the sheer determination to get out of the hospital
and on with her life, “I decided that I had to stop listening to the voices in my head, that I
could no longer go on living that way,” she said.
Spiro went on to earn her bachelor’s and master’s degrees in psychology and
serve in the Peace Corps for 3 years. While in Dakar, Senegal, she introduced art and
28
movement therapy to the staff and patients of the largest psychiatric hospital in the
country.
As the director of public policy for the National Coalition of Mental Health
Consumer/Survivor Organizations, Spiro advocates for reform that allows people with
mental illnesses to take greater control of their treatment decisions.
“We need people who’ve been through the system and who are still in the system
to be involved in every level of decision making,” she said.
She believes mental healthcare should be about offering options and hope, not
forcing compliance and engendering a sense of hopelessness.
“No matter what the world tells you, and no matter how you’re treated, there is
that beautiful, exquisite part of you that no one can take away,” Spiro said.

Sharon Wise

Sharon Wise, 43, believes in the healing power of art. She tours the country
setting up drama, dance, creative writing, and visual arts programs for abused and
neglected kids, addicts, adults with chronic mental illnesses, and people just looking for a
creative outlet.
“Some people feel science and math is all you need,” she said. “But some people
can’t [verbally] tell you what’s going on, and for them art is priceless.”
29
Though Wise holds a master’s degree in psychology and is currently working
toward a doctorate, she does not approach the people she’s trying to help from a textbook
point of view.
Diagnosed with schizoaffective disorder – a psychiatric condition marked by
symptoms of schizophrenia including delusions or hallucinations coupled with a mood
disorder such as major depression or manic episodes – Wise has been hospitalized more
than 30 times since she was 9 years old. Like many left confused and isolated by mental
illness, Wise began to self-medicate in her teens. Drugs and alcohol drowned out the
voices in her head, and Wise was incarcerated multiple times for minor offenses.
In the long, slow process toward recovery, she said she turned to art to “unleash
my creative energy.”
Her family didn’t understand what she was expressing with her art and would ask,
“Why you draw these monsters?” or say “There’s something wrong with you, you’re a
devil child.” In contrast, the art therapists she encountered while hospitalized offered
support, understanding, and a safe place for her to express herself. “There’s nothing
wrong with you, you’re an artist,” she remembered them saying.
“[Art] has been the one thing in my life I haven’t wanted anyone to tamper with,”
Wise said. She believes being allowed to explore whatever ideas were in her head
through creative expression in a non-verbal and non-judgmental way is “99 percent”
responsible for her healing. In addition to the psychotic symptoms she was trying to
manage, Wise had to overcome verbal, physical, and sexual abuse.
30
Sober 19 years and last hospitalized in 1998, Wise decided to stop taking her
antipsychotic medication a year ago. “I draw and I dance and I sing and I paint,” Wise
said, rattling off her preferred methods of maintaining her sanity.
No matter what may be going on inside someone’s head – be it hallucinations and
delusions or just the stress of everyday life – letting it out through art is “never as painful
as keeping it in,” she said.
A self-described psychiatric survivor and activist, Wise pushes for mental health
agencies to place a greater emphasis on art because of its therapeutic value. More broadly
speaking, Wise believes American culture as a whole undervalues art and artists, and this
thinking ultimately influences policymakers’ willingness to consider art as a serious
endeavor.
Wise takes a less is more approach to art therapy. She appreciates the role trained
art therapists can play in guiding people through the talk-therapy element art creation can
inspire, but she believes the process of art making – absent direction or post-analysis – is
the true epicenter for healing. In her experience, some art therapists interfere with
creative expression by placing limits on the form art must take or attempting to interpret
work themselves rather than letting the consumer guide the conversation.
A program with an art therapist who lets the participants take the lead may be
ideal, but Wise insists you don’t need an art therapist or expensive supplies to implement
an arts program.
31
Though she acknowledges art programs can run into funding difficulties, Wise
thinks lack of money is a weak excuse for healthcare providers to exclude art from the
services offered.
“If they don’t have money, do they have old socks we can make sock puppets out
of?” Wise said.

32
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Abstract (if available)

Abstract Art therapy can most easily be understood as the marriage between psychology and art. A participant in an art therapy program is able to enter a dialogue with an art therapist by using artistic expression, a process art therapists say is especially advantageous for people unable to communicate verbally.

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Asset Metadata

Creator Rivera, Ryan J. (author)

Core Title Art therapy for individuals with severe mental illness

School Annenberg School for Communication

Degree Master of Arts

Degree Program Journalism (Print Journalism)

Publication Date 04/24/2008

Defense Date 04/01/2008

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag art therapy,journalism,Mental Health,OAI-PMH Harvest,revocery,schizophrenia,wellness

Language English

Advisor Suro, Roberto (committee chair), Cole, K.C. (committee member), Land, Helen (committee member)

Creator Email riveraryanj@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m1189

Unique identifier UC1311454

Identifier etd-Rivera-20080424 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-60436 (legacy record id),usctheses-m1189 (legacy record id)

Legacy Identifier etd-Rivera-20080424.pdf

Dmrecord 60436

Document Type Thesis

Rights Rivera, Ryan J.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu