the creative arts therapies as 'real' therapies (zwerling)

8/13/2019 The Creative Arts Therapies as 'Real' Therapies (Zwerling)

1/8

The Creative Arts Therapies asReal Therapies

Israel Zwerling M.D. Ph.D.

Elements of a standard definition of psychotherapy are used tosupport the argument that the creative arts therapies should not becharacterized as adjunctive therapies, or discredited as not being ~realtherapies. Two concepts widely acknowledged as important in theapplication of the creative arts therapies are discussed: first, that thenonverbal media employed by creative arts therapists tap emotionalrather than cognitive processes and evoke responses more directlyand immediately than traditional verbal therapies, and, second, thatcreative arts therapies are reality-based and provide a more immedi-ate and real link to a patient's experience than something he canportray only verbally.hen drawings, painting s, or move ments were used only as diagnos-ic tools in the mental health field, there was little concern withwhether they were therapies or merely adjuncts. In the 1940s, whenMargare t Nau mberg began writing about the application of art to treat-

ment, not just to diagnosis, it seemed most convenient to lump the newtherapy with the essentially diversionary activities tha t had been found

useful adjuncts in treatin g the mentall y ill. Thus the creative arts thera-

Reprinted by permission from Hospital and Community Psychiatry December, 1979.Dr. Zwerling s address at Hahnemann is 17th Floor, New College Building, 230 Nor thBroad Street, Philadelphia, Pennsylvania 19102. This paper is based on a presentation atthe Conference on Creative Arts Therapies, held Ju ne 28-30, 1979, in Washington, D. C.American Journal of Dance Therapy 1989 American DanceVol. 11, No. 1, Spring/Summer 1989 1 9 Therapy Association


2/8


3/8

The Creat ive Arts Therapies as Real Therapies 21

reti red from the practice of a range of medical and surgical specialties,except tha t none have practiced psychiatry. One of the patients I exam-ined was receiving 20 different medications daily.My point is that the medical staff were trained physicians, and somewere indeed well trained, but it would stretch credulity to argue thattheir training in any significant way prepared them to be therapists forthis menta lly ill population. If tha t seems a terribly exaggerated picture,or an isolated or unique instance, I would urge tha t you visit your neareststate hospital.This situation is of course in sharp contrast to the t raining and creden-tialing of creative arts therapists, whose preparation is specifically andexclusively for the treatment of the mentally ill and emotionally dis-turbed. In the programs I know for the t rain ing of creative arts thera-pists, there is a careful balancing of content between basic and appliedareas, including personality theory, psychopathology, psychodynamics,and individual, family, and group psychotherapy-in addition to thecontent related to the application of the particular creative art form tothe therapeutic process. Thus lack of training of the practitioners plainlycannot serve to disqualify the creative arts therapies as '~real therapies,"so we must look further along in the definition.A psychotherapist ~deliberately establishes a professional relationshipwith a patient." It hard ly seems worth stopping even for a momen t tostudy this point, but I would share two images tha t come to mind. One isof the medication clinic of a menta l healt h center I recently visited: a lineof patients came for the monthly r enewal of thei r psychotropic medica-tion, greeted in each instance by the psychiatr ist with '~And you ar e . . . ?"then responding with their names, and feeling validated when the psychi-atr ist picked out their char t with a reassuring '~Here you are " A review ofthe symptoms and side-effects, last ing no more than five to ten minutes,followed, and the patients were given a renewal prescription and anappointment for the following month. Not much of a deliberate effort toestablish a relationship on the part of the %ompleat therapist," thepsychiatrist.Again, please do not draw solace from the happy fantasy tha t this is anexaggera ted picture, or an atypical scene: it comes much closer to describ-ing the actual ~'relationship" tha t exists between psychiatrists and manythousands of patients in and out of hospitals th an the relationships mostcreative arts the rapists have deliberately established with thei r patients.The other image, a contrasting one, is of a very poignant momen t whenan autistic boy with whom a movement therapist had worked for manyhours finally allowed her to put her arms around him, and he cuddled inclose to her. Clearly enough, practitioners of the creative arts therapiescannot be fairly accused of failing to deliberately establish relationshipswith thei r patients.


4/8

Zwer l ing

W e c o m e f i n a l l y to t h e r e a l l y s i g n i f i c a n t i s s u e , to t h e q u e s t i o n o f t h ep u r p o s e o f t h e r a p y : r e m o v i n g , m o d i f y i n g , o r r e t a r d i n g e x i s t i n g s y m p -t o m s , ~ a t t e n u a t i n g o r r e v e r s i n g d i s t u r b e d p a t t e r n s o f b e h a v i o r , a n d'~ p ro m o ti ng p o si t iv e p e r s o n a l i t y g r o w t h a n d d e v e l o p m e n t . W h a t i s i t w eh o p e to a c co m p l is h , a n d h o w a r e w e t o u n d e r s t a n d t h e c h a n g e t h a t o u re f f o rt is t o b r i n g a b o u t ? T h e s e t w o c o m p o n e n t s c a n n o t r e a l l y b e s e p a -r a t e d .

A c o l l ea g u e , a c h i l d a n a l y s t , r e f e r r e d t o m e f o r f a m i l y t h e r a p y a c a s ei n v o l v i n g a n l l - y e a r - o l d g i rl w i t h a s c h o ol p h o b i a . A f t e r a y e a r o f t r e a t -m e n t b y a c h i ld a n a l y s t , s h e h a d r e m a i n e d p h o b i c a b o u t l e a v i n g h o m e f o rs c h oo l . H o w e v e r , a f t e r tw o m o n t h s o f o n c e - a- w e e k f a m i l y t h e r a p y , s h er e t u r n e d t o s c ho o l. T h e a n a l y s t h a s n o t r e f e r re d a n y m o r e c a s e s to m e ,a n d h e p e r i o d i c a l l y c h e c k s u p o n t h e s t a t u s o f t h e g i rl ; h e i s s u r e s h e i s ina ~ Tlig ht i n t o h e a l t h a n d w i l l a t a n y m o m e n t c o m e d o w n w i t h a r e c u r -r e n c e o f s y m p t o m s o r w i t h s o m e n e w s y m p t o m s . W h a t i s a t i s su e h e r e i st h e t r u s t w e p l a c e i n o u r t h e o r y - o r b e l i e f s y s t e m , i f y o u w i ll .

A s s o o n a s w e o f fe r t o e x p l a i n w h a t w e d o , w e t h e r a p i s t s , w h o u p t o t h a tp o i n t h a v e b e e n m a r c h i n g s id e b y s i de , e s c h e w o u r s o l i d a r i ty a n d b r e a ku p i n t o a l m o s t c o u n t l e s s c l u s t e r s u n d e r s e p a r a t e b a n n e r s ( n e u r o b i o l o g i c ,b e h a v i o r a l , p s y c h o d y n a m i c , f a m i l y s y s t e m s , a n d s o o n), a n d w i t h i n e a c hc l u s t e r i n t o n u m e r o u s f i l e s ( fo r e x a m p l e , t h e f a m i l y s y s t e m s c l u s t e r h a si t s s tr u c t u r a l , a n a l y t i c, m u l t i g e n e r a t i o n a l , a n d o t h e r fi le s) . E a c h c l u s t e ra n d e a c h f il e h a s a n a d v e r s a r y r e l a t i o n s h i p t o a ll o th e r s . W e a r e g e n e r -a l l y p o l it e , a n d w e th e r e f o r e g e n e r a l l y a g r e e , v e r b a l l y , t h a t w e w o u l db e t t e r s p e n d o u r t im e s e a r c h i n g f o r c o m m o n a l i t i e s a n d f o r a r t i c u l a t io n sb e t w e e n s y s t e m s l e v el s. S o m e f e w go b e y o n d v e r b a l a g r e e m e n t a n d a c tu -a l l y m a k e s u c h e f f or ts . B u t f or t h e m o s t p a r t , w e c a r p a t o n e a n o t h e r ' st h e r a p i e s a s t o o s h a l lo w , o r t o o i m p r a c t i c a l, o r a s u n p r o v e n o r e m p i r i c a lo r m y s t i c a l o r w h a t e v e r .

Operational onceptsW h e r e d o t h e c r e a t i v e a r t s t h e r a p i e s f i t i n t h i s r a t h e r c h a o t ic a n d u n s e t -t l i n g s c e n e ? I s ee t h e m a s s h a r i n g a n u m b e r o f o p e r a t i o n a l c o n c e p ts , b u tw i t h o u t a s i n g le d e f i n e d t h e o r y u n i q u e a n d s p e c i fi c t o t h e a r t s . T h e r e a r eo f c o u r s e e n d l e s s m y t h s , o r s p e c u l a t i o n s , a b o u t m e n t a l i l ln e s s a n d c r e -a t i v i ty , u t t e r l y u n s u p p o r t e d , m o s t s u g g e s t i n g t h a t y o u h a v e t o b e a li t tl ec r a z y , b u t n o t t o o c r a z y , t o b e c r e a t i v e .A r i e t i h a s o f f e re d a t h e o r y o f c r e a t i v i ty , 2 a s h a v e m a n y o t h e r s f r o m aw i d e r a n g e o f d i sc i pl in e s . P s y c h o l o g i s t s h a v e l o n g s t u d i e d p e r c e p t i o n , a n da n u m b e r - R u d o l f A r n h e i m 3 i s p e r h ap s t h e b e s t k n o w n - h a v e e l a b o ra t e dt h e o r i e s o f a e s t h e t i c s . I k n o w o f n o a t t e m p t , h o w e v e r , to f o r m u l a t e a


5/8

T h e C r e a ti v e A r t s T h e r a p i e s a s R e a l T h e r a p i e s 2 3

comprehensive theory of mental wellness and illness and the creativearts.Two operational concepts are widely acknowledged as having para-mount importance in the clinical application of the creative arts thera-pies. First, and almost universally accepted, is the concept that thenonverbal media employed by creative arts therapists more directly tapemotional rathe r tha n cognitive processes in patients. A number of exper-imental studies, recently reviewed by Daniel Schubert, 4 support thehypothesis tha t the crea tive arts the rapists deal closer to primary processtha n do verbal therapists. Her man Belmont ranks art closest to second-ary process, movement next, and music furthes t from secondary process. 5Others have put it that the creative arts therapist deals with the idra the r t han the ego. It has occurred to me that a case can be made for thecreative arts therapies being addressed to the right brain, while theverbal therapies primarily engage the left brain.The point, however conceptualized, is that the creative arts therapiesevoke responses, precisely at the level at which psychotherapists seek toengage the patients, more directly and more immediately than do any ofthe more traditiona l verbal therapies. The feelings tha t are aroused andexpressed while singing, or playing an instrument, or listening to music,or moving to a rhythm, or drawing, or painting, become available to thetherapist to identify, to develop, and to change. Whether one attributesthe heal ing effect to the clarification of the evoked feelings much asmight occur in the interpretation of a dream), or directly to the creativeexperience-or to both, or to neither-is not an issue I wish to join; thecreative arts t herapist s are as busy organizing and campaigning for thei rparti cular theoretical schools as are the therapists in all other modalities.Rather, I would like to illustrate with a brief vignette the use of musictherapy with a patient in our prison unit.I should interject that when the Hahnemann department of mentalhea lth sciences was offered the opportunity to organize and operate amajor unit in the Philadelphia County prison system, an art therapist, amovement therapist, and a music therapi st were among the first mentalhealth professionals I hired. There were raised eyebrows at the time;after a few months, the three creative art s therapists on the staff were asfully accepted on their treatment teams as the psychiatrists, psycholo-gists, social workers, and nurses.The patient was a 27-year-old black male, incarcerated on the charge ofaggravated assault on the woman with whom he lived. Following asuicide threat, he was transferred to the Hahn eman n psychiatric unit atthe Philadelphia prisons. He was diagnosed as having a borderline per-sonality disorder, with hys terical and destructive traits.Abandoned by his mother at birth, the pa tient was raised by his grand-mother until the age of 13, when she died. His relationships with foster


6/8

4 Z w e r l in g

parents were poor, and he felt alone. His adult relationships with womenwere failures, due to his overwhelming dependency needs. Each relation-ship was an attempt at replacing his grandmother; anger from the loss ofhis grandmother was displaced onto current relationships, surfacingwhen the women would attempt to break the relationship with him.The pati ent was g radua ted from high school and a ttended college fortwo years. He had a number of jobs, none of which las ted longer th an sixmonths. He was in the army from 1967 until 1969 and received a psychi-atric discharge; the details were not available.His psychiatric history included a hospitalization at Philadelphia Gen-eral Hospital for six weeks in 1974, where he was given unknown medica-tion. He stated that he was admit ted because he tried to kill himself bytak ing Valium, drinking alcoholic beverages, and jumping into the Dela-ware River. He was admitt ed to the Institut e of the Pennsylvania Hospi-tal for six weeks in 1975 because he was ~'falling apart, anxious-likelosing something. I wanted to love people but I couldn't.The patient's arrest for assaultive behavior was his second. The firstoccurred in 1974 after another woman te rmin ated a three-year relation-ship with him. He spent 30 days in the House of Correction, and he nowfeared that a recurring pattern was developing.During the initial four weeks of therapy, which included a weeklysession with a psychiatrist and another with a social worker, as well asthe administra tion of both tranquilizing and antidepressant medication(Serax, 15 mg. q.d., Tofranil, 100 mg. q.d.), no change was observed. Thepatient was assigned to the team music therapist. The following is anexcerpt from the music therapist's segment of the discharge summary:~After the fourth week of treatment, guided imagery and music wasemployed because the patient was motivated to deal with his emotionalconflict. Guided imagery and music is a technique that involves listeningto music in a relaxed state for the purpose of allowing imagery, symbols,and deep feelings to arise from the inner self. This process facilitatestherapeutic intervention and self-understanding. The goals of this ther-apy were for him to experience his inner self and s trengthen his ability tohave control of his own life, not to be so dependent on others, and to beable to understand his destructive behavior.~Each session included an initial conversation to determine his mentalstatus; then he was induced into an altered state of consciousnessthrough re laxation techniques. This was followed by a music listeningsession in which the guide (the therapist) encouraged a dialogue, askingthe pa tient to report the images, feeling states, and thought pat terns tha twere aroused by music. The role of the guide was to offer supportive anddirective reactions to the imagery, and to maintain a position betweeninvolvement and objectivity. Each session was closed by a t alk ing sessionfor the integration of the experienced elements. Supportive group music


7/8

The Creat ive Arts Therapies as Re al Therapies 25

t h e r a p y s e s s i o n s a ll o w e d fo r h i s d e f e n s e s t o s t r e n g t h e n a s h e d e v e l o p e dr e l a t io n s h i p s . T h e g r o u p s m e t t h r e e t i m e s p e r w e e k fo r o n e h o u r .

~ 'D u r in g t h e f i f t h s e s s i o n , t h e p a t i e n t r e p o r t e d t h a t h e a c t u a l l y f e l t t h ep h y s i c a l p a i n i n h is a b d o m e n t h a t h e h a d e x p e r i e n c e d w h e n h e l o s t h i sg r a n d m o t h e r . H e r e a l i z e d t h a t i t w a s t h e s a m e p a i n h e f e l t a f t e r h ea s s a u l t e d h i s g i r l fr i en d s . T h i s l e d t o a n u n d e r s t a n d i n g o f h o w h e u s e dw o m e n t o t a k e t h e p l a c e o f h i s g r a n d m o t h e r .

T h e m u s i c t h e r a p i s t t o l d m e t h a t t h e l a t e s t r e p o r t s i n d i c a t e d t h a t t h ep a t i e n t w a s s u c c e s s f u l l y l i v i n g o n h i s o w n , h a d e n r o l l e d i n c o ll e g e , a n dw a s c o n t i n u i n g w i t h o u t p a t i e n t t h e r a p y a t a l o c a l c l i n i c .

T h e s e c o n d w i d e l y a c k n o w l e d g e d c o n c e p t r e l a t e d t o t h e c l i n ic a l a p p l ic a -t i o n o f t h e c r e a t i v e a r t s t h e r a p i e s i s t h e i r i n t r i n s i c s o c i a l o r r e a l i t y - b a s e dc h a r a c t e r . T h e r e a r e, o f c o u r s e, d y a d i c i n t e r a c t i o n s b e t w e e n t h e r a p i s t a n dp a t i e n t i n a rt , m u s i c , a n d m o v e m e n t t h e r a p y ; t h e m u s i c t h e r a p i s t ' s t r e a t -m e n t o f t h e p r i s o n e r - p a t i e n t j u s t d e s c r i b e d is a n e x a m p l e . B u t g r o u pm u r a l s , g r o u p d a n c e s e s s i o n s, a n d g r o u p m u s i c s e s s i o n s a r e c h a r a c t e r i s t i ct e c h n i q u e s , a n d t h e y a r e o b v i o u s i n s t a n c e s o f t h e s o ci al c h a r a c t e r o f t h e s em o d a l i ti e s . H o w e v e r , I m e a n s o m e t h i n g b e y o n d t h e n u m b e r s o f p e r s o n si n t h e t r e a t m e n t s e ss io n . T h e r e i s a v i si b l e o r a u d i b l e o r t a n g i b l e l i n k t os o c i e ty in a s e s s io n i n v o l v i n g a c r e a ti v e a r t s t h e r a p i s t a n d a p a t ie n t , a n di t h a s a q u a l i t a t i v e l y m o r e i m m e d i a t e , m o r e r e a l p re s e n c e t h a n d o e s t h ep e r s o n o r t h e t h i n g a p a t i e n t m a y t a l k a b o u t .

I m a k e a k i n d o f i n t u i t iv e , a n d e x p e r i m e n t a l l y u n s u p p o r t a b l e , c o m p a r i -s o n b e t w e e n t h i s q u a l i t y o f t h e c r e a t i v e a r t s t h e r a p i e s a n d t h e e x p e r i e n c eo f d e a l i n g w i t h t h e a c t u a l p a r e n t s i n a f a m i l y t h e r a p y s e s s i o n i n s t e a d o fd e a l i n g w i t h p a r e n t a l t r a n s f e r e n c e . A b o d y i m a g e p r o b l e m v e r b a l i z e d isj u s t n o t t h e s a m e a s a b o d y i m a g e p r o b l e m l i v ed o u t in m o v e m e n t . Av e r b a l d e s c r i p ti o n o f o n e 's h o m e , o r o f o n e 's f a m i l y , is j u s t n o t t h e s a m e a sa d r a w i n g - e v e n a s t ic k - fi g u re d r a w i n g - o f o n e 's f a m i ly . N o v e r b a l s t at e -m e n t a b o u t f e e l in g s c a p e g o a t e d i s a s p o w e r f u l a n d p o i g n a n t a s a d r a w i n gi n w h i c h o n e u n w i t t i n g l y , w i t h o u t d e l i b e r a t e n e s s , p i c t u r e s o n e s e l f a l o n e ,s e p a r a t e d f r o m o n e 's f a m i l y g r o u p .

T h e q u e s t i o n ~ T o w h i c h c a t e g o r y o f t h e r a p y d o t h e c r e a t i v e a r t s t h e r a -p i e s b e l o n g ? p l a i n l y c a n b e a n s w e r e d o n l y b y t h e c o n t e x t in w h i c h t h e ya r e u s e d . I n th e c a s e I d e s c r ib e d , t h e a n t i a n x i e t y m e d i c a t i o n w a s a d j un c -t i v e t o t h e m u s i c t h e r a p y ; o n e c a n o f c o u r s e re a d i l y b r i n g t o m i n d i n-s t a n c e s i n w h i c h t h e r e v e r s e w a s tr u e . A t d i f f e r e n t p o i n t s i n a p r o g r a m o ft r e a t m e n t , d i ff e re n t t h e r a p i e s m a y t a k e c e n t e r s ta g e , a n d o t h er s m a ym o v e f ro m c e n t r a l t o a d j u n c t i v e p o s it io n s . S p u r g e o n E n g l i s h , i n t h ef o r e w o r d to h i s r e m a r k a b l e c o m p i l a ti o n o f e s s a y s o n a c o m b i n e d v e r b a la n d m o v e m e n t a n a l y s i s o f a p s y c h o t h e r a p y s e s si o n , s t a t e s ~ E v e n t s a r ei n c o m p r e h e n s i b l e e x c e p t i n t e r m s o f t h e c o n t e x t i n w h i c h t h e y o c c ur . '~M e n t a l h e a l t h p r o f e s s i o n a ls w h o s e t o u t t o ~ c ur e d i s e a se s , a n d e s p e -c i a ll y t h o s e w h o ~k n ow t h a t t h e d i s e a s e t h e y a r e t r e a t i n g w i l l b e c u r e d


8/8

6 Z w e r l in g

o n c e t h e y h a v e b a l a n c e d s e r o t o n i n l e v e ls o r w h e n th e y h a v e m a d e t h eu n c o n s c i o u s c o n f li c t c o n s c io u s o r w h e n t h e y h a v e i n d i v i d u a t e d a f a m i l ym e m b e r f r o m t h e u n d i f f e r e n t ia t e d f a m i l y e g o m a s s w i l l a t b e s t m a k every per i pher a l use o f the creat i ve ar t s therapi es . T h ose who orga ni zep r o g r a m s d e s i g n e d t o t r e a t p e o p le r a t h e r t h a n t o c u re d i s e a s e w i l l f in dcreat i ve ar t s therapi s t s i nva l uabl e .

R e f e r e n c e o t e s1 . L . E . H i n s i e a n d R . J . C a m p b e l l , Psychiatric Dictionary 4 t h e d i ti o n , O x f o rd U n i v e r s i t y

P r e s s , N e w Y or k C i ty , 1970 .2 . S . A r ie t i , Creativity: The Magic Synthesis B a s ic B ooks , N e w Y or k C i ty , 1976 .3 . R . A r nh e in~ A rt a nd Visual Perceptior~ U n ive r s i t y o f C a l i f o r n i a P r e s s , B e r ke l e y , 1954 .4 . D . S . S c hube r t , ~ 'C r ea t iv i ty a nd th e A b i l i t y t o C ope, Creative Psychiatry N o. 5 , G e igyP ha r m a c e u t i c a l s , 1975 .5 . H . B e lm o n t , A r t T h e r a p y : A n O u t s i d e r ' s V i e w , Forum H a h n e m a n n M e d i c a l C o l le g ea n d H o s p i t a l , V o l . 4 , A u t u m n - W i n t e r 1 9 7 4 - 75 .6 . O. S . En gl ish , ed i to r , Strategy and Structure in Psychotherapy E a s t e r n P e n n s y l v a n i aP s y c h i a t r i c I n s t i t u t e , P h i l a d e l p h i a , 1 96 5.

the creative arts therapies as 'real' therapies (zwerling)

Documents