Mindfulness-Based Art Therapy: A Review of the Literature

The concept of mindfulness, which originated from early Buddhist practices, historically encouraged an enlightening meditation that focused on awareness of one’s emotions, sensations, and consciousness (Smalley & Winston, 2010). Today, mindfulness practice continues to be defined as “an awareness of self and a capacity to reflect” (Smalley & Winston, 2010), but has branched out from its roots as a Buddhist meditation method to become integrated into psychology as a means of coping with a variety of conditions including anxiety, eating disorders, substance abuse, and other mental, emotional, and physical issues (Smalley & Winston, 2010). Concurrently, as mindfulness continues to progress as a therapeutic treatment, a dual therapeutic modality has also been gaining momentum.

Since its beginnings in the late 1940s, art therapy has become a rapidly developing field, its application spreading everywhere from hospitals to prisons, in addition to many individual practices. A typical art therapy session will generally include either the art as therapy approach, in which the act of creating serves as a means of releasing emotions, or the art psychotherapy approach, in which the completed art is analyzed by the therapist and client to develop insight into their emotions (Coleman & Farris-Dufrene, 1996). Recently, several progressive figures in the field, including psychologist and writer Laury Rappaport, have proposed Mindfulness-Based Art Therapy, or MBAT, as a method of combining the philosophies of mindfulness practices with the existing art therapy setting (Rappaport, 2009). While Mindfulness-Based Stress Reduction has long been used to help clients approach themselves and the world around them with an open, accepting mindset and an awareness that allows them to reflect on what they find, leading to a greater understanding of one’s emotions and inner self, Mindfulness-Based Art Therapy aims to include the creative process of art-making in this self exploration. Much has been accomplished in this field to date, and practitioners of MBAT are of the opinion that this method will greatly benefit patients participating in therapy, in addition to becoming a successful asset to the field of art therapy in the future (Rappaport, 2009). While more research is necessary to determine exactly how effective Mindfulness-Based Art Therapy is compared to traditional art therapy, the practice has already begun to demonstrate its value as a healing tool in the field of psychology, where variety in methods is essential to accommodate for the variety present in human beings.

The following historical review will explore the effectiveness of mindfulness-based art therapy as a treatment method, including an examination of the two modalities used separately, as well as simultaneously. Research has shown that because the brain accesses similar states during both treatment modalities, it is not mentally difficult for clients to combine them and receive the benefits of these two methods at once (Smalley & Winston, 2010). According to Susan L. Smalley, a researcher and writer on the subject, long-term mindfulness practices can change brain patterns, “moving towards patterns that coincide with calm yet focused states of attention,” as well as brain structure, contributing to thicker and more developed areas of gray matter (Smalley & Winston, 2010). In similar ways, art making engages and develops neural pathways in the brain that foster the skills needed for creating (e.g. focus) (Englebright Fox & Schirrmacher, 2009).

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The following chapter will include a historical review of the use of art therapy with adults, the effectiveness of mindfulness-based therapies on their own, and the relatively new theory of mindfulness-based art therapy. As there has not been a great deal of research done on mindfulness-based art therapy, a historical review may not have been considered comprehensive if it were to only focus on that topic. Therefore, the review was expanded to include research conducted on the two separate modalities as well, in order to offer a more complete examination of the subject.

Literature Review

The Wayne State University online library was used as the primary source of research conducted to date, related to the topic of mindfulness-based art therapy for adults. The entirety of the research was limited to peer-reviewed articles, in order to ensure that professionals in the field had authorized all information included. Initially, the terms “mindfulness,” “art therapy,” and “adults,” were searched simultaneously in the PsychInfo database, followed by combinations of one or more of the topics. The search of all three terms yielded only eight results, but when using only “art therapy” and “mindfulness,” the results broadened to 55 articles. A book reference, titled “Focusing-Oriented Art Therapy,” and written by Laury Rappaport, was also included (Rappaport, 2009). To widen the search further, the terms “mindfulness,” and “therapy” were searched together, and yielded 1,682 results in the PsychInfo database. The purpose of this particular search was to compare and contrast the effects of mindfulness therapy used alone with the effects of mindfulness-based art therapy.

To present the research in an orderly manner, the review will be broken down into the following categories: mental and emotional concerns, physical illnesses, self-acceptance/self-esteem, and personal relationships. Though the focus of this review remains on mindfulness-based art therapy, drama and music therapies combined with mindfulness will also be discussed, as they are forms of creative therapies, and researchers of mindfulness-based art therapy could gain information from these studies as well. Most of the literature offers information on therapies utilized with adults as opposed to children, so this distinction will not affect the organization of the review.

Mental and Emotional Concerns

Several studies yielded by the search discussed the effects of mindfulness or MBAT as a treatment method for individuals with mental and/or emotional concerns. For example, several mindfulness practices have been utilized in relapse prevention programs for people with substance abuse disorders. One study explores the idea of combining mindfulness techniques with cognitive behavioral therapy for this population, as CBT has already shown to be effective in changing the ways in which people view lapses after recovery (Witkiewitz, Marlatt, & Walker, 2005). For instance, if a lapse is viewed as something uncontrollable, the person is more likely to continue these behaviors and potentially begin an actual relapse. However, if the lapse is viewed as a behavior that can be worked through and prevented in the future, they are more likely to be able to overcome it (Witkiewitz, Marlatt, & Walker, 2005). This increase in the ability to self-regulate has been extremely useful for people in recovery from substance abuse, and the addition of mindfulness-based techniques into treatment can aid immensely in this pursuit. These methods can also help people escape “cognitive avoidance,” which can cause even more harm, as clients become less aware of their thoughts and actions (Witkiewitz, Marlatt, & Walker, 2005, p. 215). Overall, this study found that mindfulness based cognitive therapies were at least as effective as CBT on it’s own, but could actually be less expensive, as meditation does not require the client to be in session or have any special supervision (Witkiewitz, Marlatt, & Walker, 2005).

These results are corroborated by art therapist and writer Laury Rappaport, who discussed MBAT in her book, “Focusing-Oriented Art Therapy” (Rappaport, 2009). Referring to her way of working as focusing-oriented art therapy, another name for MBAT, Rappaport combined psychotherapist Eugene Gendlin’s theories on focusing with her own art therapy background. In the early 1980s, Gendlin developed his method of focusing as a result of his discovery that the clients who showed the most signs of success in therapy were those who were able to connect with their inner selves, or “felt-sense,” as he called it, in a bodily rather than cognitive sense only (Gendlin, 1982). His method encouraged patients to do so by offering a series of steps that they could follow to access this felt-sense and, consequently, be able to identify and communicate those feelings more readily. During this process, his clients took part in a practice similar to meditation, in which they paid close attention to their body’s physical responses to their emotions, then used what they discovered to aid them in understanding and coping with what they were feeling (Gendlin, 1982). When Laury Rappaport adopted these ideas to create her own Mindfulness-Based Art Therapy practice, she pieced together two modalities that have since proven to be quite compatible. Her theory stated that mindfulness practices could “[add] a dimension of connecting the imaginal realm with the bodily felt experience” to traditional art therapy, while the act of creating could offer a means of expressing the inner felt-sense when verbal expression proved inadequate or too difficult (Rappaport, 2009, p. 17).

Rappaport illustrated this idea through several case studies, one of which involved a 52-year-old woman presenting with a depressive state brought on by her husband’s ill health. By participating in MBAT, the client was able to more fully understand where her feelings originated from and how to cope with them (Rappaport, 2009). Through a method of working back and forth between focusing on her felt-sense and expressing what she discovered with oil pastels, the client was able to retrieve the sensations she experienced in her body and lay them out concretely for herself and Rappaport to consider. While at the beginning of therapy the woman was unaware of this particular emotion, she realized that underneath her care and worry for her husband was a great deal of anger at not being able to address her own needs. This sense of want was so buried by thoughts of taking care of her husband and her duties as a spouse, that only by looking to her body could she become conscious of it. By allowing these abstract physical feelings to be expressed freely through art, as opposed to translating them into verbal communication, the client was able to stay as true to her bodily sensations as possible, while still expressing them accurately (Rappaport, 2009). These positive results are similar to those found in another study by Rappaport, conducted on children experiencing trauma (Rappaport, 2015). MBAT was shown to be beneficial for use with children, as it emphasized building trust, empathy, feelings of safety, and self-compassion (Rappaport, 2015). Rappaport reported using three steps when working with children and adolescents: “establish a safe environment, process trauma and access inner wisdom, and integrate [the] healing process and move forward with life” (Rappaport, 2015, p. 311). She moved through these stages by using techniques such as meditation, yoga, drawing people or animals in a way that shows that they are “okay,” and using imagery to picture the future (Rappaport, 2015, p. 316).

In MBAT work with clients dealing with mental or emotional concerns, the concepts of intuition and trust in one’s body contributed to the compatibility of mindfulness and art therapy. While both forms of therapy put those ideas to use in unique ways, the combination resulted in a method that allowed for both internal and external applications of trust in the self.

Physical Illnesses

Much of the research collected in this historical review also explored the use of MBAT and related methods as a treatment for individuals with physical illnesses. The beginnings of MBAT were rooted in Mindfulness-Based Stress Reduction (MBSR), an approach that has been effective for many populations, including individuals with PTSD, anxiety, or depression. A recent review regarding MBSR took an alternative angle, and examined how this method affects people living with HIV/AIDS. Psychological stress has been shown to stimulate the HIV virus to replicate, so this type of research is crucial for improving quality of life and survival rates for this population (Riley & Kalichman, 2015). Additionally, the use of denial is correlated with greater impairment to the immune system, so researchers predicted that cultivating awareness and mindfulness of their condition would help this population both mentally and physically. While cognitive-behavioral techniques have been useful for some aspects of coping with HIV/AIDS and other conditions, these methods focus on changing cognitions rather than accepting them, so MBSR may be more effective when combatting denial (Riley & Kalichman, 2015). By using MBSR, individuals with HIV/AIDS may be able to better assess which emotions and physical symptoms must be accepted, and which can be changed. The opportunity to regain control in these ways allowed patients to benefit both emotionally and physically from mindfulness-based techniques (Riley & Kalichman, 2015).

In addition to the use of MBSR with clients dealing with physical illnesses, several studies have been conducted that focus specifically on mindfulness-based art therapy as well. A recent study examined the effects of MBAT for women with cancer, particulary on their distress levels and quality of life (Monti, Peterson, Kunkel, Hauck, Pequignot, Rhodes, & Brainard, 2006). For this study, 111 women of various ages and types of cancer diagnoses were randomly placed into either an 8-week MBAT program, or placed on a waitlist as a control group (Monti et al., 2006). The MBAT group focused on combining mindfulness and meditation techniques with different art therapy exercises, to encourage expression and healthy coping methods. Participants were taught body scanning, walking meditation, and gentle yoga, and given homework to meditation daily for at least 30 minutes (Monti et al., 2006, p. 367). The art-based activities focused on developing a sense of control, and on sharing inner thoughts in a social environment. Compared to the waitlist control group, participants in the MBAT group showed significantly greater decreases in stress levels, and reported improvements in overall quality of life as well. This study had considerable limitations, as its control group had no therapy of any kind, so the MBAT results could not be compared to any other therapeutic methods. Researchers suggest a control group in future studies that includes a talk therapy group, so that data can be collected on how MBAT affects people as opposed to talk therapy in a social setting (Monti et al., 2006).

Another recent study, conducted with adult women with breast cancer, also reported success with MBAT techniques, especially used in a group setting. This research used functional magnetic resonance imaging to monitor cerebral blood flow and changes in stress levels during a MBAT program (Monti, Kash, Kunkel, Brainard, Wintering, Moss, &…Newberg, 2012). Specifically, researchers measured these changes when the women were resting, participating in a MBAT activity, and during a stressful activity (Monti et al., 2012). They set up a control group and a MBAT group, where they taught meditation, yoga, emotional awareness, and incorporated art-based activities including painting representations of their emotions, body mapping, and open studio time (Monti et al., 2012). Overall, researchers found that those who had been part of the MBAT group activities had lower increases in cerebral blood flow when exposed to stressful situations than members of the control group. This represented lower stress levels, and supported the hypothesis that the MBAT group would help women with breast cancer deal with the stresses in their daily lives (Monti et al., 2012).

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In addition to these visual arts-based mindfulness practices, other creative therapies have also been researched to determine their effectiveness with clients. For example, drama therapy has been combined with mindfulness and yielded positive results. Researchers have found that a wide range of populations can benefit from these techniques, whether they involve dance, theater, music, or a combination of these methods (Williams, 2014). They can be used particularly when attempting to “transform feelings” or change how clients respond to their emotions (Williams, 2014). One study involved bringing theater performances to children’s bedsides in hospitals, and provided an example of drama-based mindfulness therapy. This investigation focused on children from 5 to 12 years old and their parents, in the cardiac, oncology, and general pathology wards of a hospital (Sextou & Monk, 2013). Before the performances began, a Mindful Behavioral Cognitive therapist taught breathing and imagery techniques to the actors, so that they could incorporate them into interactive experiences for the children (Sextou & Monk, 2013). When the actors performed at the children’s bedsides, they worked these techniques into their story lines in order to have the children participate in these mindfulness-based activities. In this way, they were able to help the children escape from the hospital environment through imagery, and increase their relaxation levels through mindful breathing (Sextou & Monk, 2013). Children reported that the performance helped them calm down and forget about being in the hospital for a while (Sextou & Monk, 2013).

A related study, also in a hospital setting, focused on mindfulness-based music therapy for women in the oncology ward, particularly on the treatment’s effect on their attention and mood (Lesiuk, 2015). As these women were participating in chemotherapy, which can have negative effects on attention, short-term memory, and mood, researchers hypothesized that they could reverse some of these affects with therapy (Lesiuk, 2015). Previous studies had shown that mindfulness alone can improve these cognitive functions, but there was no research to date on whether or not traditional mindfulness-based stress reduction therapy has a significant impact on attention or memory. Therefore, researchers chose to incorporate music-based therapy as well, which can help clients increase their focus (Lesiuk, 2015). The researchers performed a four-week long study during which participants engaged in activities such as “music-assisted relaxation,” listening to familiar songs with unfamiliar instruments, and suspending judgments (Lesiuk, 2015, p. 278). At the end of the program, mindfulness-based music therapy had improved their attention spans, reduced stress, and decreased confusion levels (Lesiuk, 2015). However, this study only involved 15 women, so a larger sample size would be necessary to draw more significant conclusions (Lesiuk, 2015).

Self-Esteem and Self-Acceptance

A further area in which research has shown the effectiveness of MBAT and related therapies involves increasing self-esteem and self-acceptance for clients. One study focused on MBAT used with children ages 8 to 15, and hypothesized that this method could increase both self-awareness and resiliency (Coholic, 2011). This study defined mindfulness practice as “an activity that encourages awareness to emerge through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment (Coholic, 2011, p. 303). While there was already evidence that these practices could be of use for people with anxiety, depression, chronic pain, stress, and other issues, the researchers decided to explore how MBAT could affect a group of children and adolescents; specifically, the study focused on their views of both themselves and life’s meaning (Coholic, 2011). They included an art-based aspect of the program to encourage children who may be reluctant to participate, and to increase their comfort levels. The participants included 50 children and adolescents who had issues with self-esteem and/or aggression (Coholic, 2011). Using creative activities such as the “jar of thoughts” experiential, where colored balls were dropped into a jar of water and shaken to represent thoughts running wild, the group discussed the differences between calm states of mind and stressed or scattered states of mind (Coholic, 2011, p. 309). Participants also completed activities that involved painting their emotions and then discussing them, to promote self-awareness and appropriate social skills with other members of the group (Coholic, 2011). At the end of the study, several parents reported that their children smiled more, acted with more confidence, and exhibited more awareness of their emotions. When asked about the group, the children participating reported that they had an opportunity to meet new people and gained self-esteem (Coholic, 2011). According to this study, the MBAT group was a success for the children, and achieved the goals it had set (Coholic, 2011).

Another study that investigated issues of self-esteem and self-acceptance focused on nature as therapy, and studied the influence of gardening practices (Corazon, Stigsdotter, Moeller, & Rasmussen, 2012). Though not technically defined as MBAT, this research combined creativity and mindfulness, and so it was included in this review. Researchers conducting this study hypothesized that gardening could be a useful technique, as many cultures believe that nature can be healing and have relied on natural spaces for “spiritual and personal guidance” (Corazon, Stigsdotter, Moeller, & Rasmussen, 2012, p. 336). For this study, researchers taught the participants several techniques to focus on the present moment, and combined these with an outdoor gardening practice (Corazon, Stigsdotter, Moeller, & Rasmussen, 2012). Focus was placed on the sensory experiences of nature, in order to reduce stress and remain aware of the present moment. Participants reported that the experience helped them feel more balanced and connected to nature, which led to an increase in self-acceptance (Corazon, Stigsdotter, Moeller, & Rasmussen, 2012).

Personal Relationships

The final section of this review will examine how mindfulness and/or MBAT practices can impact how individuals experience their personal relationships with others. Differing from the research previously discussed, the following will explore not only how mindfulness impacts clients, but it’s benefits for clinicians as well.

One such study explored the effects of therapeutic mindfulness techniques on relationship and sexual satisfaction for dating couples (Khaddouma, Gordon, & Bolden, 2015). This study defined mindfulness as “a concept originating in Buddhist spiritual systems and presently defined by Western researchers as the ability of the individual to purposefully bring his or her attention and awareness to the experiences of the present moment and relate to them in a non-reflexive, non-judgmental way” (Khaddouma, Gordon, & Bolden, 2015, p. 269) They created their hypothesis based on previous research which suggested that greater levels of mindfulness could increase empathy, acceptance, and emotional security in romantic relationships (Khaddouma, Gordon, & Bolden, 2015). However, no studies had previously tested this theory directly. To accomplish this, researchers recruited 322 undergraduate students, ages 18-25, who were currently in a dating relationship, and examined the affects that five different aspects of mindfulness had on their sexual and relationship satisfaction (Khaddouma, Gordon, & Bolden, 2015). Researchers used a 25-question survey to assess participants’ levels of sexual satisfaction, and a 16-question survey to gather data on their relationship satisfaction (Khaddouma, Gordon, & Bolden, 2015, p. 278). After surveying the volunteers and analyzing the data, they found that the “observing” and “nonjudging of inner experience” facets of mindfulness had the greatest impact on both areas of satisfaction, while the other three facets, “describing,” “acting with awareness,” and “nonreactivity to inner experience,” had no correlation to satisfaction levels (Khaddouma, Gordon, & Bolden, 2015, p. 268). This corroborated earlier research that had suggested that mindfulness may increase sexual satisfaction, but provided empirical evidence, which previous researchers had not discovered (Khaddouma, Gordon, & Bolden, 2015). Limitations of this study included the fact that it was conducted on young adults and did not include any married or older couples, and that it relied only on self-reported data. In the future, studies that include interviewing or physiological measurements were recommended (Khaddouma, Gordon, & Bolden, 2015).

Another related study pertained to the effects that a therapist’s personal mindfulness practice has on their work with clients. Using a phenomenological analysis, this study explored how these practitioners use MBSR with clients, including yoga techniques, meditation, body scans, and other methods (Cigolla & Brown, 2011). For this study, six therapists were recruited, by emailing those who expressed an interest in mindfulness-based practices on their professional online profiles. They all participated in a personal mindfulness practice and used MBSR with their clients (Cigolla & Brown, 2011). The participants were then interviewed, and the results were analyzed through detailed note taking which led to the development of several main themes (Cigolla & Brown, 2011). The final analysis resulted in an over-arching theme of mindfulness as “a way of being” (Cigolla & Brown, 2011, p. 8), and that one has to experience it to understand it. Participants stressed that mindfulness gives them a greater understanding of their clients, and increases their listening capabilities (Cigolla & Brown, 2011). They also reported that by understanding mindfulness themselves, they were able to help clients become more aware of their own emotions and thoughts, and teach them techniques such as meditation and body scanning (Cigolla & Brown, 2011). The study concluded that it would be beneficial if mindfulness were to be included in therapists’ curriculums to allow them to build even stronger therapeutic relationships with their clients, and to have the ability to increase self-awareness in their own lives as well (Cigolla & Brown, 2011).

A similar article also discussed the personal mindfulness practices of therapists, but in an arts-based therapy setting. The study stated that this practice allows art therapists to increase their compassion and empathy, not only for their clients, but for themselves as well (Franklin, 2010). Maintaining a mindfulness practice can help therapists stay in the present moment while working with clients, and remain nonjudgmental as well. Furthermore, mindfulness allows the therapist to “[surrender] the need to reject suffering,” so that they can monitor any countertransference that they may experience, and prevent it from getting in the way of their work (Franklin, 2010, p. 166).

According to these research studies, MBAT has had a positive impact on several types of interpersonal relationships.

Summary

Research to date has shown significant potential for MBAT as a combined treatment modality, especially in areas such as stress reduction, social support, and emotional wellbeing. As discussed in this review, mindfulness and art-based therapies activate the same areas of the brain, so combining the two methods into one experience can come naturally for the human mind (Smalley & Winston, 2010). However, further investigations that specifically compare MBAT to a control treatment, such as MBSR or traditional art therapy, are necessary to draw conclusions about its effectiveness as opposed to other therapeutic methods. This type of research could continue to reveal the ways in which participants could gain the advantages of art therapy and mindfulness simultaneously, and receive the many benefits that these methods could provide.

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Acknowledgements

The author would like to sincerely thank Dr. Holly Feen-Calligan from Wayne State University for serving as an advisor during the course of this review.

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References

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