Art Therapy, Research and Evidence-Based Practice

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Andrea Gilroy

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    Dedication

    For Joyce and Jock

    Biography

    Andrea Gilroy, PhD, is an experienced art therapy educator and researcher. She trained originally as a painter, then qualified as an art therapist in the mid 1970s and worked in acute psychiatry and with people who have learning disabilities. She gained her PhD in 1991 for research into the occupational choice and career development of art therapists that focused on the evolution of their art practice. She has taught at Goldsmiths College, University of London since 1979 and is currently Reader in Art Psychotherapy and the Programme Area Coordinator for Art Psychotherapy and Dance Movement Therapy, teaching across a range of programmes and short courses. She is involved in the development of art therapy in Australia through her continuing involvement as an educator and researcher at the University of Western Sydney, NSW. Her research interests include the development of an evidence base for art therapy and the interface between the theories and practices of visual art/visual culture and the theory and practice of art therapy. Her publications include Pictures at an Exhibition: Selected Essays on Art and Art Therapy (Routledge, 1989) with Tessa Dalley; Art Therapy: A Handbook (Open University Press, 1992) with Diane Waller; Art and Music: Therapy and Research (Routledge, 1995) with Colin Lee; and The Changing Shape of Art Therapy: New Developments in Theory and Practice (Jessica Kingsley, 2000) with Gerry McNeilly.

    Foreword

    It seems to me that Andy Gilroy has almost single-handedly taken on the research mantle for the art therapy profession. Having completed her doctorate on ‘Art therapists and their art: from the origins of an interest in art to occasionally being able to paint’, as Programme Area Director for Arts Psychotherapies at Goldsmiths College, she has taught and developed post-qualification, research-based programmes. In this way, Andy has driven forward the research agenda when many of us may have been somewhat reluctant to acknowledge its significance and importance, particularly in the current climate of waiting-list pressures and shrinking resources within the public sector.

    The reality is that we are living and working in a new culture. Since the 1990s, government policies have required practice to be research based and practitioners to prove their clinical and cost effectiveness. There is ‘evidence’ that art therapy as a profession has progressed sufficiently to be granted State Registration in 1997 by the Council of Professions Supplementary to Medicine (now the Health Professions Council). However Andy argues that this is not enough – indeed she turns the question around suggesting that research has much to offer art therapy. Providing an evidence base for our discipline can develop theory and practice, and progress the recognition of art therapy as an effective and innovative treatment for a wide range of clients. Subjecting one's practice to research seems challenging but can be hugely helpful. This book goes a long way to help us understand how and why this is the case.

    I remember discussing the idea of this book many years ago. It has long been an ambition of Andy's to bring these issues to the profession in a meaningful and manageable way. We now have the privilege of this book to help us all through the quagmire of the different research methodologies that are pertinent to our practice. In her paper written in 1992, Andy acknowledged the ambivalence of art therapists to research. The word ‘evidence’ elicits various responses ranging from alarm, anxiety and despondency to thoughtful engagement with the rigours of the research endeavour producing a growing body of empirical and qualitative evidence. Pointing out tensions in the process of art therapy becoming evidence based and the idea that research may demand conformity and prescriptive practice, she describes how art therapy can develop its own appropriate evidence base. This involves new work and different work. Essentially Andy is inviting us to think about research, open up the debate and produce a range of evidence tailored to our needs, that is, make our own evidence base that informs our discipline so that we can judge this for ourselves.

    The argument is persuasive and is approached with optimism and enthusiasm. The thrust of this book is that art therapists certainly cannot afford to fall behind as evidence for all practices across all sectors is being developed. ‘It is all about language, all about audience. Art Therapists have to think, act and write with a political purpose in mind’ (p. 37). The challenge is to research the effectiveness of art therapy through both quantitative and qualitative means. In her personable and very readable style, Andy has certainly helped us rise to this challenge and this book will equip us to the task.

    When mulling over these ideas, two main thoughts came to my mind. First, if we are to provide our own evidence base, do we need to provide the necessary ‘evidence’ that it is the ‘art’ in art therapy that is the worthwhile and effective component. Andy argues that the alternativeness of art therapy makes it unique and especially helpful for those who find it hard to engage with routine services. I would go further by suggesting that it is in the very nature of the non-verbal processes at the preconscious and unconscious level that are made manifest in the image which can give rise to significant intrapersonal and interpersonal change. All of us, like Andy, who work with images in a therapeutic process fully understand this. The problem is how to show it. As someone who embarked on a research project in 1975 with exactly this problem in mind, I know how difficult it is to measure change and the efficacy of any type of treatment modality. In those days Rank Xerox funded research into art therapy and supplied a research grant for one year. The study was to evaluate art therapy with particular interest on creativity and its potential effects in therapy by comparing art therapy groups and verbal psychotherapy groups for psychiatric patients on an acute admission ward. In particular I was looking at measures of change in self-esteem, creativity and anxiety levels. Two papers, published from my thesis (Dalley 1979, 1980), identified changes in individual patients as measured on their own self-reporting rating scale. I also demonstrated how changes in their artwork reflected changes in mental state as reported by them on completion of the image. Although this study produced ‘hard evidence’, with changes that were statistically significant, I think I was left with more questions than answers. For example, what is being measured – the therapeutic relationship, the art process or the combination of the two. It seems to me that empirical research in dynamically oriented therapies is complicated by the nature of the relationship with the therapist and for this reason lends itself better to a qualitative or descriptive approach. Andy does not align herself to one particular research methodology, but explains in detail and depth the various approaches that are possible and desirable according to the approach of the practitioner. Her overall message, however, is emphatic. Not to engage in this process is not an option.

    Following on from this, I found myself thinking about change. Change is the essence of any therapeutic endeavour. Art therapy offers a particular opportunity to engage with making art forms in the context of a therapeutic relationship to work towards some significant change. We work to help understand the meaning of this change. How then is it possible to translate this sensitive and delicate process, which involves internal shifts and unconscious processes, into an external body of evidence? In healthy infant development Winnicott (1971) described how the ‘good enough’ mother enables the child to move forward in his or her development. The mother's interventions are sometimes experienced as impingements by her infant. These impingements are however necessary for the infant to develop a robust sense of self with an internal world that is integrated and not fragmented. This helps the infant's ego development, helps s/he relate to the external world and all the potential demands that are experienced in becoming independent and a viable person in his/her own right. For me, Andy's encouragement and commanding approach to her subject resonates with this process as we have to develop through the impingements of Evidence-Based Practice to ensure our professional growth to stand on our own. The burgeoning of empirical research into other psychotherapies (e.g. Fonagy et al., 2002) and also in neurobiology (Schore, 1994) is playing a central part in our overall understanding of change and is a world in which we must continue to engage.

    Dalley, TessaJune 2006.
  • Endnote

    Art therapists can tow the EBP line and use its methods to demonstrate what we know to be true: that art therapy is an effective treatment. We need to do the particular kind of research that EBP requires, and we need to do so soon. We need much more inductive, research – both quantitative and qualitative – to build towards the critical mass of hypothetico-deductive research that will demonstrate the effectiveness of different art therapy approaches in particular settings with specific client populations. We need to engage with the whole paradigm and meet the challenges it represents through strategic research and quality assurance initiatives.

    But we also need to take risks with the construction of art therapy's evidence base. When the aim is to effect policy there needs to be hard data and rigorous, robust literature, but we should resist exclusively ‘scientific’ notions of research, difficult though it is to change canonical beliefs about what research and the ‘best’ evidence are and what it therefore means for disciplines to become evidence based. We need to do research that goes beyond the orthodox hierarchies of medicine and into the social and the visual. We also need to present art therapy's differing forms of evidence and argue that it be judged according to the values and norms of the discipline. We can make some risky representations too. We can disseminate our evidence and differing researches in different venues to different audiences: through visual display, narrative and performance as well as through text. Visual and oral languages are not incompatible practices; they run in parallel with and complement each other. Why then must we always translate from the visual to the oral, and to text? Display and the performative allow a social inclusion that invites in a wider audience who can become immersed in the material and find meaning as forms of evidence and its dissemination are extended and enlivened.

    Using non-EBP-conformist research methodologies may, of course, have consequences. It may mean that content is ignored. Art therapists must make sure that we maintain a politically aware engagement with the paradigm and its practices. EBP is embedded in the systems and organisations where art therapists work but it is sustained through our attitudes towards it. EBP is in our working worlds, in our minds and in our hands. We can challenge the paradigm and add our voice to those who contest its fundamental assumptions. We can trouble both the edges and the heart of EBP's territory. To engage solely with the research and governance procedures of orthodox EBP or to limit art therapy research to social and visual methods, would result in a partial evidence base – either way something would be lost. We can generate the evidence that EBP requires, but we can do so in ways that make it our own.

    We need the facts, we need the figures, but we need the stories and the pictures too.

    Initial Appraisal Checklist

    Critical Appraisal Checklist

    Critical Appraisal Checklist

    Critical Appraisal Checklist

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