IntroductionThe National Institute of Mental Health defines schizophrenia as “a chronic, severe, and disabling mental disorder characterized by deficits in thought processes, perceptions, and emotional responsiveness.” Patients suffering from schizophrenia exhibit a diverse range of symptoms which are categorized under positive and negative.
The positive symptoms of Schizophrenia include delusions, thought disorders, and hallucinations. Negative symptoms include avolition (a lack of desire or motivation to accomplish goals) and lack of desire to form social relationships.Although schizophrenia cannot be fully cured, it is usually treated with pharmacotherapy as the primary treatment to stabilize the prominent symptoms caused due to the disorder. However, a lot of schizophrenic patients also tend to experience residual symptoms in spite of medication. To counter these residual symptoms, therapists use alternate psychotherapies. Art TherapyArt therapy is a form of expressive psychotherapy that involves the use of art making as a creative process to improve a person’s physical, mental, and emotional well-being. Art therapy allows insight into the patient’s inner psyche in a non?threatening way through a therapeutic relationship and the use of art materials. Margaret Naumburg and Edith Kramer are recognised as the premier founders of the Art Therapy during the mid 20th Century.
It was mainly developed in adult psychiatric inpatient units and was designed for use with people for whom verbal psychotherapy would be impossible which is seen in the case of schizophrenic patients.The creative process carried out by the patient to express themselves artistically can help them resolve their inner psychological issues as well as develop and stabilize their behaviours and feelings, reduce stress, and improve self-esteem and awareness.Psychologists or counsellors who use this therapy can interpret the underlying messages communicated through the art produced by the patient, which will aid in the healing process.Art therapy can achieve different results for different types of patients. It can be used for counselling by therapists, healing, rehabilitation, psychotherapy and can provide a deeper understanding of the patient’s psychology.Art therapy has been shown to benefit people of all ages. Research indicates art therapy can improve communication and concentration and can help reduce feelings of isolation and alienation. This type of therapy has also been shown to lead to increases in self-esteem, confidence, and self-awareness.
Certified art therapists will typically have a comprehensive understanding of the powerful effect that the creative process can have on those in therapy. Art therapists often use psychological, spiritual, and artistic theories in conjunction with clinical techniques to achieve the desired therapeutic outcome. The approach has proven to be beneficial even for non-verbal individuals and professional artists. The common techniques used in art therapy include Painting, Finger painting, Doodling, Scribbling, Sculpting, Carving, Making pottery, Making cards, Using textiles and Making collages.Because art therapy allows people to express feelings on any subject through creative work rather than with speech, it is believed to be particularly helpful for inherently shy people and people who feel out of touch with their emotions or feelings. Individuals experiencing difficulty discussing or remembering painful experiences may also find art therapy especially beneficial. Green and colleagues conducted a randomised trial of 10 weekly sessions of group Art Therapy plus standard care versus standard care alone among 47 people with ‘chronic psychiatric disorders’ of whom half had a clinical diagnosis of schizophrenia. At 10-week follow-up of those allocated to group Art Therapy reported improved self-esteem.
More recently, Meng and colleagues randomised 86 in-patients to twice weekly group Art Therapy sessions delivered over 15 weeks and reported improved health and social functioning at the end of this period. Richardson and colleagues compared the addition of 12 weekly sessions of group Art Therapy to standard care among people with chronic schizophrenia being treated in outpatient settings. Among 40 (45%) participants who were followed up at six months, statistically significant reductions in negative symptoms were found.However, in their systematic review of the effectiveness of Art Therapy for people with schizophrenia, Ruddy and Milnes concluded that because of small sample sizes, short follow-up periods, and high rates of loss to follow-up, the benefits and potential harms of Art Therapy for people with schizophrenia are still unclear. Moreover, because previous studies have not incorporated attention control groups there is no evidence regarding the relative contribution of non-specific components and ‘active ingredients’ of the intervention to observed outcomes. Nor has previous research examined the costs or cost-effectiveness of this intervention.Psychodynamic art therapy shows promise in helping in-patients with schizophrenia, according to a study by German psychiatric researchers in PLOS One. In a randomized controlled trial involving 58 hospitalized patients diagnosed with schizophrenia who were given treatment as usual and twice-weekly art classes over 12 weeks or just treatment as usual, the researchers found that those who took the art therapy showed “a significantly greater mean reduction of positive symptoms and improved psychosocial functioning at post-treatment and follow-up” and “a greater mean reduction of negative symptoms at follow-up compared to standard treatment.
” “Of secondary outcome parameters, patients in the art therapy group showed a significant improvement in levels of emotional awareness, and particularly in their ability to reflect about others’ emotional mental states,” they added, suggesting that the “results prove the feasibility of trials on art therapy during acute psychotic episodes and justify further research to substantiate preliminary positive results regarding symptom reduction and the recovery of mentalizing function.” The MATISSE (Multicenter Study of Art Therapy in Schizophrenia: Systematic Evaluation) study conducted by Crawford et al in 2012 aimed to examine the impact of adding art group therapy to the treatment of people diagnosed with schizophrenia compared to an active control treatment and standard care alone. The trial had 417 participants from across the UK who were all diagnosed with schizophrenia. Treatment lasted 12 months and the primary outcome measures were the Global Assessment of Functioning scale and the positive and negative symptoms Scale (PANSS) measured at 24 months after randomisation. The results of the study showed the mental health and global functioning of people with schizophrenia did not improve for patients who had art therapy group in addition to their standard carte. Those randomised to weekly group art therapy had similar levels of global functioning and mental health as those randomised to an activity control group over a two year period, except that the activity control group had a greater reduction in positive symptoms of schizophrenia at 24 months. People offered a place in an art therapy group were more likely to attend sessions than those offered a place in an activity group, but levels of attendance at both types of the group were low.
The primary and secondary outcomes between the three study arms did not differ.The main strengths of the study are that it was adequately powered, used a rigorous approach to minimising bias, and used broad inclusion criteria to assess whether the intervention would help most people with schizophrenia. Data from a national survey of art therapists working throughout England and carried out in parallel with this trial suggested that the approach used to deliver art therapy in the study is the same as that used more widely across the country.
However, this study did have several limitations, primarily being the level of engagement with the intervention. The researchers had deliberately set out to test the effectiveness of group art therapy among most people with schizophrenia who expressed a willingness to use this form of treatment. Almost 40% of participants randomised to group art therapy did not attend any sessions. Among those who did, few attended regularly. Possible explanations for the low level of attendance are that the interventions may not have been acceptable to participants or that participants lacked the motivation and organisational skills to attend. However, the average effect of attendance at art therapy among the compliant population was estimated in a two-stage least squares estimation, which suggested that even in those willing to participate in art therapy, attendance was not related to study outcomes.Many groups had only one or two regular attendees, with an average of two or three people attending art therapy groups. Although this meant that therapists may have been able to pay greater attention to each participant than would have been possible in a larger group, opportunities for group members to interact with each other were more limited.
Outcome data during the intervention phase of the study was also not collected, potentially precluding observation of short-term benefits. However, the absence of statistically or clinically significant differences in outcomes between participants in the three intervention arms at 12 months suggests that the short-term benefits of this art therapy could not last beyond a year. Previous accounts of the potential benefits of group art therapy suggest that it may help people in ways that are difficult to quantify. This study did not verify the findings of other small smaller scale trials of creative therapies that have shown improvements in symptoms of schizophrenia.Although the possibility that group art therapy benefits people with schizophrenia who are motivated to use this treatment cannot be ruled out, the findings suggest that it does not lead to improved patient outcomes when offered to most people suffering from schizophrenia Cognitive Behavioural TherapyCognitive-behavioral therapy (CBT) in schizophrenia was originally developed to provide additional treatment for residual symptoms, drawing on the principles and intervention strategies previously developed for anxiety and depression. In the 1950s, Aaron Beck had already treated a psychotic patient with a cognitive approach, but thereafter the research in this specific area lay dormant for decades. Only after cognitive therapy had been firmly established for depression and anxiety, in the 1990s, did the research into psychological treatments for psychotic conditions gather force—again, with Beck in the forefront.
Pharmacologic therapy can leave as many as 60% of psychotic patients with persistent positive and negative symptoms, even when the patients are compliant with their medication instructions. Furthermore, medication compliance remains a major problem despite the introduction of modern atypical antipsychotics. Studies have shown treatment discontinuation in an estimated 74% of patients in both outpatient and inpatient settings.
The evidence for the efficacy of CBT in treating patients with persistent symptoms of schizophrenia has progressed from case studies, case series, and uncontrolled trials to methodologically rigorous, randomized, controlled trials that include patients from both the acute and the chronic end of the schizophrenia spectrum. Subsequent meta-analysis and systematic reviews have further strengthened the evidence base. CBT is now recognized as an effective intervention for schizophrenia in clinical guidelines developed in the United States and in Europe. In spite of the evidence base and absence of side effects, however, the general availability of this treatment approach within community settings is still low. Lewis S, Tarrier N, Haddock G, et al. (2002) conducted a study to test the effectiveness of added CBT in accelerating remission from acute psychotic symptoms in early schizophrenia. As part of the study, a 5-week CBT programme plus routine care was compared with supportive counselling plus routine care and routine care alone in a multi-centre trial randomising 315 people with DSM-IV schizophrenia and related disorders in their first (83%) or second acute admission. Outcome assessments were blinded.
Linear regression over 70 days showed predicted trends towards faster improvement in the CBT group. Uncorrected univariate comparisons showed significant benefits at 4 but not 6 weeks for CBT routine care alone on Positive and Negative Syndrome Scale total and positive subscale scores and delusion score and benefits v. supportive counselling for auditory hallucinations score. They concluded that CBT shows transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early schizophrenia.Over the past decade, CBT has emerged as an evidence-based intervention that provides a long-needed integrative approach to schizophrenia.
The emergence of CBT for schizophrenia has added new optimism to the treatment of a highly stigmatized condition and may, in the long term, contribute to a change in the way the general public views people with schizophrenia. As the news about an effective talking therapy penetrates a wider audience, schizophrenia may no longer be seen as an essentially untreatable, incomprehensible, biologic condition beyond the reach of reasoning.All psychiatrists should therefore at least be acquainted with the basic principles of CBT for schizophrenia in order to incorporate this knowledge into the daily management of severely mentally ill patients and to be able to appropriately refer patients for specialist therapy. Although the existing evidence base for CBT in schizophrenia shares some of the same limitations that exist for other psychotherapies, research has firmly established the evidence for reduction of symptomatology, low dropout rates, and cost-effectiveness.
Despite this, widespread availability of CBT for psychotic patients is currently lacking, and providing sufficient availability of this method is one of the greatest challenges facing mental health services today.EvaluationAs seen from the evidence provided above, the research conducted to investigate the effect of art therapy on Schizophrenia has not been sufficient with barely minimal studies conducted on this topic. Of the studies conducted, most of the studies did not have sufficient sample size which shows that the results can be generalized.