The use of creative media in psychotherapy is increasing and research in the area is evolving. An investigation of the current literature outlined the differences cross culturally regarding creative media in therapy, in writing this piece the term “creative media” is used intermittently with the terms “play therapy”, “creative media”, “creative therapy” and “expressive therapy” are used intermittently.
This article will outline and review creative media in psychotherapy and its uses in a therapeutic session. Following this, a brief overview of better-known therapies will be introduced to provide some context to the menu of options that make up creative media in therapeutic environment, noting and exploring the importance of the therapist, and their own creativity in the effectiveness of this intervention.
The term Creative Media is used throughout this piece as an umbrella term to include miniatures, puppets, dolls, art therapy, psychodrama and role play etcetera. The aim of utilising creative activities in psychotherapy is to assist clients transforming their lived experiences into words, it is postulated that the use of creative activities may provide valuable data that can potentially further explain what is happening for the client and allow them to articulate their experiences and feelings (Carver, 2017). In current and past writings on human development, it has been suggested that creativity is an inherent drive and a major goal within the psyche (Wilson, 2008). Creative interventions might include play, allowing clients to see and act out things differently by facilitating access to their own creativity to evoke creative problem solving as a tool of empowerment (Carver, 2017). Assisting the client to identify creative resources is a prerequisite to effective therapy (Carson and Becker, 2004). Creative media can include guided meditation, artistic impression, stories, poems, pictures, marbles, stones and humour, all of which incorporating an emotional and spiritual connection to the sharing healing energy (Carson and Becker, 2004). A creative approach also includes the use of play therapy, thus, using positive-association, can help foster a relationship of trust and positive attachment. It provides a non-threatening medium of communication (Carey, 2006). Creative arts therapies provide an avenue of acceptance and value for individual self-expression (Aldridge, 1993).
Hermine Hug-Hellmuth was credited as being the first psychoanalyst of children. She was the foundation of the work of both Melanie Klein and Anna Freud despite the lack of acknowledgement (Plastow, 2011). Play therapy is recognised as “the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients resolve psychological difficulties” (Association for play therapy, 2019). Hug-Hellmuth was the first to use the interpretation of play therapy with children, although a psychoanalyst she saw the limitations of this approach, and wrote, somewhat frugally, about the technique and benefits of utilising play therapy with younger clients. We can accept Hug-Hellmuth as the forerunner to two divergent streams of psychoanalysis of children (Schmidt, 1989). On the one hand, psychoeducational and child-raising aspect of her work was elaborated by Anna Freud. On the other hand, we can see the more analytical approach having been taken up initially by Melanie Klein, which includes her conceptualisation of the Childs’ transference and the use of play (Plastow, 2011).
The sand tray was developed in 1929 by Margaret Lowenfeld and was referred to as the “world technique” (Monakes, Garza, Wiesner III and Watts, 2011). The technique encourages clients to access their inner self through symbolic expression. Typically, the tray is rectangular with a blue painted interior, it is filled half way with sand and clients choose miniature figurines to place into the sand and create a scene, these miniatures are used as metaphors to symbolically tell a story (Monakes, Garza, Wiesner III and Watts, 2011). Fantasy play can assist clients in imagining a future, expressing emotions and proving relief. It can also, with the utilisation of narrative therapy facilitate re-writing the past (White, 2015). Whist there is no actual media used, the medium of fantasy can be beneficial in the therapeutic setting (Ennis, 1999). The sand tray is utilised across several orientations and is generally regarded as an effective therapeutic technique (Boik, 2000). The technique was then expanded by Kalff who was heavily influenced by Jungian practice in order to further explore the work of the conscious and unconscious (Monakes, Garza, Wiesner III and Watts, 2011).
Puppets and Miniatures
Puppets were introduced to assist in the externalising of a concern, it has been proved to be a safe comfortable medium using the same principles as play therapy (Pitre, Stewart, Adams, Bedard and Landry 2007). Butler, Guterman and Rudes (2009) demonstrated that puppetry has many advantages to offer, especially when communicating sensitive material, this can assist clients to distance themselves from the story which can offer protection from re-traumatisation. Puppets have been used in family, narrative and clinical therapies. Puppets and the use of these type of creative media has been equated to that of psychodrama, which is another avenue of expression that offers release to clients (Kellerman and Hudgins, 2000).
Out of all creative medias Art therapy has been written about most extensively, this may be due to it being academized and accredited (Regev & Cohen-Yatziv, 2018). Art therapy, which was theorised by Margaret Naumburg in the 1940’s, was closely linked to psychoanalytic therapy, with its roots of interaction in transference between the client and the therapist and the encouragement of free association. Naumburg noted that introducing clay and art into psychotherapy permitted the direct expression of dreams fantasies and inner experiences of clients which quickened the pace of the therapeutic process (Ulman, 2001). Art therapy is used to improve cognitive and sensorimotor functions, it assists in the development of self-esteem, awareness and fosters resilience in clients, it works to reduce conflict and stress and can be a catalyst for positive change in clients (Scope, Uttley and Sutton 2017). Drawings and the stories they express can assist therapists understand what is significant to the artist in a way that is often not readily available from verbal expression (Klop, 2017).
Expressive therapy is psychotherapy with the inclusion of art, drama, music and literature with the aim of improving the physical, emotional and cognitive function of clients, this is indistinguishable to the inclusion of mixed media into psychotherapy which is why it has been included in this literature review. In Australia this process was formalised by Pearson and Nolan in 1987 and was initially referred to as Emotional Release Counselling (ERC) (Pearson & Nolan, 2004). This style of counselling and psychotherapy is psycho-dynamically orientated and includes Jungian influences alongside gestalt methods (Wilson, 2008). The similarities between expressive therapy and the use of creative media in a therapeutic setting are vast, both utilise different methods as a catalyst for talk therapy to assist the client with self-awareness, self-direction, mindfulness, spirituality and help develop a deeper understanding of self and as such cannot be looked at separately in this research (Pearson & Nolan, 2004).
“Artistic representations of mental illness can increase understanding and empathy for those who are ill” (Marlow and Johnstone, 2017).
Creative arts can be used successfully alongside talk therapies, the use of creative means may give a voice to clients’ emotions or memories and provide them with an outlet to process these (Carver, 2017; Rouse, Armstrong and McLeod, 2015). Expressive arts can help therapeutically by making clients aware of the happenings in their past, conscious, and unconsciousness and the impact each of these have on our here and now (Rogers, 1993). Creativity is central to the therapeutic process as psychotherapy is a moment-by-moment experience (Carson and Becker, 2004). It has been argued that working creatively allows us to express our unconscious thoughts through symbolic forms of expression, which we may potentially struggle to articulate (Monakes, Garza, Wiesner III and Watts, 2011). It may also facilitate clients to engage with subject matter that is too embarrassing, or shame filled. The use of creative media and play provides a metaphoric plain to help describe difficult stories and emotions, which facilities the client to find a resolution through therapeutic processing (Silverstone and Thorne, 1997).
Using creative media can put clients in tune with emotions that are generally kept hidden, for this reason the sessions can get quite deep relatively quickly (Rouse, Armstrong and McLeod, 2015). It will take time to process and explore the information after the emotion has been experienced, but this transformative journey is logged through reviewing the art or sand trays created, this means that along with the use of notes the client’s interpretations of their previous work can provide a clear assessment of change (Silverstone and Thorne, 1997). If the introduction of a creative media is deemed beneficial it needs to be carefully considered and tailored to the clients preference, it may be that some clients prefer something more artistic, others might have a preference for more guided meditation, or indeed some may prefer to use props as a catalyst to help them discover the roots of their psychological distress (Baker, 2006). Pluralism suggests that this can also be a collaborative process with the client, allow them the space to be part of the process and decision, this may increase buy in to the intervention and empower the client further in their healing (Cooper and McLeod, 2011; Cooper and Dryden, 2016).
The use of creative media in the therapy room is largely down to the therapist’s own knowledge, upskill and creative prowess and it has been suggested that the creativity of the therapist plays a significant part in the effectiveness of therapy (Winnicott, 1971). This may mean that creative therapy, or the use of creative media may not have a one-size-fits-all flexibility (Carson and Becker, 2004). Whilst counselling is seen as a co-creative process, attention needs to be paid to whose frustration has caused the creative surge, the emotions of the client should be the catalyst for the use of creative media, the therapist is simply the facilitator (Carson and Becker, 2004). It has been postulated that when therapists are focused on being creative with their clients this is when the least creative work is being done, this may be because trying to be creative in therapy can distract the client from their processing and may interrupt the natural flow of communication, to counter this it is suggested to involve the client in the full process, give them an outline of what to expect without overtly guiding them in their experience (Carson and Becker, 2004; Cooper and McLeod, 2011). Whilst the use of creative theory is seen as a process that allows clients to remove barriers to their own creativity and allow for deeper exploration, it is suggested that therapy does not always need to be creative to be effective or helpful and that an over reliance of the use of creative therapies may become obstructive as it may dilute some of the achieved understanding of the client if there is not adequate space to assimilate and review the learning (Carson and Becker, 2004).
Although the research suggests that psychotherapists need to be creative in their approach, they need to be ever present and willing to follow the client being mindful the interventions they assume best suit, this may be somewhat at odds with the academic teaching of Psychotherapy. Creativity should be viewed as integral to the foundation of psychotherapy, it’s the therapists role to assist in the discovery and development of creative talents (Carson and Becker, 2004; Rouse, Armstrong and McLeod, 2015). It is suggested, if moving into a creative therapeutic space, the therapist must know a great deal about the materials and their use and must have experience of the artistic process to ensure minimal interference with the client’s own goals (Ulman, 2001). A trainee therapist needs to recognise the importance of understanding the extent to which creativity invites intimacy, using creative media in therapy requires courage and the willingness to become more intimately involved with the lives of clients. To add, trainees must be alert in their practice, they need to become expert in the recognition of resistance and work within the supervisory framework to help overcome and surpass these obstacles (Carson and Becker, 2004).
During human development there is a neurological parallel process which occurs (Lorelle and Michel, 2017). Research has shown that if there has been any disruption to this neurobiological growth, such as trauma for example, talk therapy alone will not lead to a full recovery, instead there is a need to engage playfully with clients (Prendiville & Howard, 2017). Talk therapy cannot cause changes in the mid-brain, it is here that a host of psychological, behavioural hypervigilance and emotion are housed clients (Prendiville & Howard, 2017). It is important to remember that there are two sides to the brain, both are instrumental in healing, the right side is dominant in the early years of life and is based in creative experience, the left side, whilst more cognitive is essential in its role for processing (MacNeilage and Giorgio, 2009). There are several different theoretical approaches when it comes to play therapy and creative media. Child-centred play therapy is focused on providing a healing environment for the child, Filial therapy is a psycho-educational model which allows the therapist to educate and coach parents to conduct non-directive play sessions with their own children. Jungian play therapy is grounded in Jung’s theory of the ego and self-separation (Prendiville & Howard, 2017).
The main types of play therapy used with adults are Theraplay, Adlerian, Cognitive Behavioural, Gestalt, Narrative and Psychodynamic play therapy; Theraplay and Adlerian are most commonly used (Prendiville & Howard, 2017). Theraplay creates a therapeutic play environment matched to the developmental stage of the adult, in a hope of matching with the neuro-sequential timeline which the distress may have initially occurred and is heavily influenced by Bowlby’s attachment theory. Adlerian play therapy works to re-work self-perception and belief through the introduction of mixed media, it works to adjust clients thinking and behaviour, similar to that of Reality therapy (Prendiville & Howard, 2017). When using creative media with an adult client it is imperative to track the journey of the consciousness as this is a window to the subconscious, the therapist must be prepared to remain working at this unconscious level to ensure minimal disruption to the therapeutic flow (Fuss, 2010). The adult in the therapy room is directing the therapy, it is however, the therapist’s job to be so attuned to not only the client, but the process too that they are able to observe responses to the media and facilitate client exploration and growth (Prendiville & Howard, 2017).
There have been several literature reviews commenting on the use of Creative and Art therapy with specific cohorts of clients, for example, adult survivors of child sex abuse (Perryman, Blisard and Moss, 2019; Qiu, et al., 2017; Blomdahl, et al., 2016). There is limited research of the use of creative media and art therapies with the general adult population, the use of creativity in the psychotherapeutic process is underutilised, this is perhaps due to the lack of research and imperial evidence of its benefits (Regev & Cohen-Yatziv, 2018). It is important however, to remember that absence of evidence is not evidence of absence (Marlow and Johnstone, 2017). There have been several studies that show the benefits of utilising creative media in a therapeutic setting. In a study conducted by(Monakes, Garza, Wiesner III and Watts, 2011) which reviewed the use of the Sand Tray when working with male substance abuse offenders they found that it was a positive experience which was beneficial in allowing exploration of their choices, it was provocative and offered a reflective sobering rumination of the past. The participants noted that it was a safe non-judgemental space that allowed for individual acceptance and change (Monakes, Garza, Wiesner III and Watts, 2011).
The use of creative media has also been used when working with clients with psychiatric disturbances, one such study reviewed the effect of Art therapy on prison inmates with schizophrenia, this study proved that art therapy provided a unique platform for the inmates to express their distress, anger, fear and despair in a creative way that alleviated boredom and improved their quality of life and sense of value (Qiu, Ye, Liang, Huang, Liu, and Lu 2017). This is further supported in other writings which confirm there is evidence to show the benefits of using art in a therapeutic setting, “art-viewing can support relational processes, expression of emotionality and playfulness, in turn facilitating therapeutic engagement” ("Art and Work-Related Stress", 2019). It has also been found, in an alternate study that creative therapies, to include Art and Music, have been found non-beneficial when working with clients with schizophrenia. The conclusion of this study surmised that further studies in the use of creative media, and the impact on clients in the reduction of mental distress is warranted (Leurent, Killaspy, Osborn, Crawford, Hoadley, Waller, King, 2014).
Regarding clients that have been diagnosed with cancer art therapy was found to be a suitable method of distress management, likely because it provides a mind–body interaction (Lee, Choi, Kim, Sun, Park, Kim, Koom, 2017). This study worked on the stress and anxiety that a cancer diagnosis might cause, the art therapy took the form of art appreciation as a foundation and then a creative stage as intervention. Previous studies have reported that art therapy incorporating both visual art appreciation and hands-on creation of artwork was beneficial to patients with terminal cancer in hospice care, thus it can be argued that as an intervention creative therapies can assist clients with general stress and anxiety (Lee, Choi, Kim, Sun, Park, Kim and Koom, 2017).
Rao, Nainis, Williams, Langner, Eisin and Paice (2009) conducted a study to review the impact of art therapy on clients that were HIV positive. It was discussed and proved that Art therapy assisted with the alleviation of pain and other symptoms which were bore by the respondents. Overall it assisted coping skills by providing an alternative focus for the client. It has been argued that whilst art therapy can yield the result of positive change in clients the therapist must be aware of the importance of the selection of materials, it is not as simplistic as paint or a crayon, there is symbolic relevance in this which should be noted, basically, the material interaction as well as the art product are needed to gain information on the aspects of the clients psychological functioning (Pénzes, van Hooren, Dokter, Smeijsters & Hutschemaekers, 2015).
It can be argued that utilising creative media, such as play, miniatures or art is imperative when working in a family therapy setting, this is due to the recognition that almost all people in families will communicate differently, ergo, assuming all people have even a basic level of creativity, creative therapy is a common denominator (Klop, 2017). For therapy to be effective it needs to ensure that is a tailored experience. Children may be limited in vocabulary, even adolescents may not be as not be as articulate as the adults in the room, as a result, to combat the resistance of verbal communication the inclusion of a creative media is recommended (Klop, 2017). In a family system it is paramount that all voices are heard, and that it is encouraged that all hold a meaningful role in the therapy and by proxy, the family system. Family therapy should not be a layman’s adult therapy, it should be a fit that gives a voice to all that are present, as such alternative methods of psychotherapy should be explored (Klop, 2017). There is recognition in the family therapy literature that there needs to be greater inclusion of children in family therapy, how else can this be achieved but by fostering an environment of equal importance and ensuing that all mediums of communication are utilised (Klop, 2017).
Creative therapy has been proven to connect with the right side of the brain, this facilitates deeper exploration of our unconscious, the boundaries of speech will not be a filter, which means clients may delve deeper than they have previously, due to this there is an ethical responsibility of the therapist to provide psychological safety for the client to ensure they do not feel overly exposed (Andrew, 2003, as cited in Baker, 2006). For this reason, informed consent is paramount in this type of setting, there should be room for the client to explore the intervention and time set to debrief post intervention. This is ever more present when working with clients that have a history of trauma or abuse, it is imperative that the client’s safety is at the forefront of the therapists’ mind and there is no maleficence to the client (IACP, 2018). In the instance of triggering an emotional overwhelm within the client where traumatic material is brought to the forefront the therapist must be experienced enough and equipped in the frameworks of client containment, self-regulation and grounding before further exploration is advised (Baker, 2006).
In a creative media rich therapy session, the therapist is ever mindful of the client, this provides a level of safety, allowing them to explore and process at their own pace (Rogers, 1993). Using creative media in therapy allows for experiential learning, clients get closer to their feelings through experience rather than conversation, experiencing also allows for a client’s guards to be lowered which may assist them working though their own story (Carson and Becker, 2004). However, due to the potential depth the session can go to it is imperative that the therapist is competent in navigating this space. The therapist should only practice within their realm of expertise and experience. Supervision also an important part of this process as there may be residual trauma from the clients that needs to be appropriately dispersed to limit the possibility of counter transference or over-identification (Allen, Folger and Pehrsson, 2007)
Whilst play therapy, creative psychotherapy, creative media, expressive therapy all refer to the same phenomenon. Since the introduction of play therapy, it has seen its primary use in a therapeutic setting with children, however, there has been some work, lead by theoretical underpinnings in developmental psychology, that state the use of creative media with adults that have suffered psychological distress at different stages of development can be beneficial. There is room to move towards offering a more dynamic and inclusive psychotherapy if both therapists and their clients are open, however for this to happen there needs to be a shift in the assumption that play isn’t powerful, play can be for everyone, and as demonstrated in this article, can hugely help adult clients in coming to terms with potentially difficult experiences in a safe expressive way.
Using creative media, as with all therapeutic interventions, should be discussed and agreed with the client, they need to feel safe in this process to facilitate complete buy in. There are some creative therapies that are better known, such as Art therapy, Play Therapy, the use of sand tray, but there are more that can be used in a collaborative session with a client. This learner is anxious to include that it is not practical, or probably beneficial, to have all sessions of therapy with a creative underpinning but if we are to include some of these in to our practice we may be offering clients a bigger menu in which to experience growth and development. Through the research it has become apparent that the use of creative media in psychotherapy works, however, there is limited knowledge to the overall effect. Several qualitative studies have shown clients appreciation of the use of creative media, but it is difficult to quantify the long-term effects or impact for the client, as such there is much research to be done in this field.