In today's nosology we might diagnose a major depressive episode with melancholic features in Mill. Feeling that he could not confide in his friends or family, Mill turned at last to the poetry of William Wordsworth. To his surprise, Mill found Wordsworth's poetry to be an elixir for his depression. "What made Wordsworth's poems a medicine for my state of mind," Mill wrote, "was that they expressed not mere outward beauty, but states of feeling, and of thought colored by feeling under the excitement of beauty." 1
This vignette highlights one of the earliest recorded instances of what we would now term "poetry therapy"--the subject of Dr Jack Leedy's comprehensive volume, Poetry as Healer. Poetry therapy is just one example, however, of how the arts have enriched and informed psychotherapeutic practice. In an age sometimes given over to purely "biological" approaches, it is important for psychiatrists to appreciate how the arts can enhance our approach to even the most seriously disturbed patients.
The use of literature, drama, painting, music, dance, and related modalities for psychotherapeutic purposes is conveniently referred to as expressive arts therapy. As the Web site for the American Art Therapy Association explains:
Art therapy is an established mental health profession that uses the creative process of art making to improve and enhance the physical, mental and emotional well-being of individuals of all ages. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce stress, increase self-esteem and self-awareness, and achieve insight.2
Although this description is from an organization that emphasizes the visual arts, the principles articulated may also be applied to expressive arts therapy in general. And while "art making" is sometimes the focus of expressive arts therapy, treatment frequently centers on the patient's reaction to existing texts, music, films, or related artistic media. For example, in poetry therapy, a patient may be asked to read a poem by a published poet, and to reflect on how the poem might capture the patient's own mood, experience, or fears.3
Similarly, in dance therapy, the therapeutic aim is not primarily choreographic. Rather,
Dance therapists help people develop a nonverbal language that offers information about what is going on in their bodies. The therapist observes a person's movements to make an assessment and then designs a program to help the specific condition. The frequency and level of difficulty of the therapy is usually tailored to meet the needs of the participants. Dance therapy is used in a variety of settings with people who have social, emotional, cognitive, or physical concerns. It is often used as a part of the recovery process for people with chronic illness.4
Although dance has been a mode of emotional expression for untold millennia, dance therapy actually originated in the workaday world of inpatient psychiatry. In the 1940s, psy- chiatrists at St Elizabeth's Hospital in Washington, DC, noticed that some of their patients--many traumatized by World War II--improved after attending the "dance classes" of Marian Chace, a dancer and choreographer who was influenced by psychiatrist Carl Jung.4
Psychodrama is closely related to dance therapy and is perhaps most closely associated with the work of Dr J. L. Moreno and Zerka T. Moreno.5 In essence, psychodrama--also known as psychodramatic psychotherapy--holds that professionally supervised "role playing" can lead patients to perceive new solutions to psychological conflicts and problems. Psychodramatic psychotherapy has been used since the 1930s to treat a variety of psychiatric problems, and in the past 15 years, has undergone more systematic evaluation.6
Hussey and Layman7 reviewed music therapy in a past issue of Psychiatric Times. They noted that music therapy offers the patient a "safe haven from which to explore feelings, behaviors and issues ranging from self-esteem to severe emotional dysregulation."
Music therapy techniques used to treat children who are emotionally disturbed include live music production, improvisation, guided imagery (eg, pairing of visualization with music), creative songwriting, and lyric analysis. The precise approach is based on a careful assessment of the child's needs and capabilities, after which music therapists formulate an individualized treatment plan, goals, and measurable objectives.7
Finally, in recent years we have seen the emergence of "cinema therapy" (or "movie therapy") as an innovative treatment modality.8-10 Psychiatrist Fuat Ulus, drawing on the principles of transactional analysis, hypothesizes that movies may reach the viewer on 1 or more of 3 psycho-developmental levels: parental, adult, and child.8 For example, a movie heavily laden with music and fantasy may speak to the more primitive, childlike, or emotive realm of the psyche. The judicious use of films as part of the broader therapeutic process is thought to promote growth and healing.
Indeed, Wolz,9 drawing on Jungian principles, suggests that films, "like myths, tap into patterns of the collective unconscious . . . [and] help us in our personal process of healing and transformation." Alan Stone, MD (personal communication, August 28, 2007) has observed, "Movies can be used like dreams in psychodynamic psychotherapy: as a bridge to conflicts the patient has trouble confronting in his own life or sharing with the therapist." Ulus has found specific types of movies that are useful in the group setting. For example, a movie in which 2 characters forgive each other might help group members to "open up" and discuss their own experiences and difficulties with forgiveness.10Does expressive arts therapy work?
At a time when evidence-based medicine exhorts us to hold our treatments up to the light of systematic investigation, it seems appropriate to ask: What is the evidence for believing that expressive arts therapy actually works for our patients? How many controlled studies show that any art therapy is more effective than, say, a waiting list or another control condition? In truth, there is a paucity of randomized, controlled studies of expressive arts therapy--perhaps reflecting the "humanistic" orientation of most early art therapy practitioners. Much of the expressive arts literature seems to consist of single case reports or small uncontrolled studies. Furthermore, there is very little information on contraindications to various types of creative arts therapy, although adverse reactions have occasionally been reported.11
On the other hand, a trend toward more systematic investigation is suggested by several recent studies. A Brazilian study examined psychodramatic psychotherapy combined with pharmacotherapy in patients with major depressive disorder.6 Twenty patients with major depressive disorder receiving antidepressant treatment were divided into 2 groups: the experimental group received 4 individual and 24 structured psychodramatic group sessions, whereas subjects in the control group did not receive psychodramatic psychotherapy. Both groups were evaluated with the Social Adjustment Scale-Self-Report and the Hamilton Rating Scale for Depression. Those who had received psychodramatic psychotherapy showed significantly greater improvement than those in the control group.
Another recent study examined the effects of art therapy on the coping skills of women with primary breast cancer.12 Patients were randomized to a study group (n = 20) that received individual art therapy 1 hour per week during postoperative radiotherapy or to a control group (n = 21). There was an overall greater increase in coping resources among patients taking part in the art therapy intervention than among those in the control group. Of course, larger-scale randomized studies will be needed to confirm the results of both studies.
It is difficult to find controlled studies in the poetry therapy and movie therapy literature. However, there appears to be growing interest in the role of poetry therapy in palliative care, both with regard to treating patients and their (often very stressed) caregivers.13 One hopes this will lead to systematic investigation of poetry therapy in this and other settings. Similarly, Ulus is applying for grants to study the efficacy of group-based movie therapy in patients with specific disorders, such as borderline personality disorder, obsessive-compulsive disorder, and posttraumatic stress disorder.10Conclusion
There is growing evidence that music, poetry, film, painting, and other artistic media may be used adjunctively in psychotherapy to good effect--at least in some patients. However, we need much more systematic research to learn the specific indications, contraindications, and appropriate candidates for expressive arts therapy. Still, when William Congreve observed, "Music hath charms to soothe a savage breast," he may have anticipated the beneficial effects of expressive arts therapy.