International Journal of Art Therapy

Formerly Inscape

ISSN: 1745-4832 (Print) 1745-4840 (Online) Journal homepage: http://www.tandfonline.com/loi/rart20

Exploring art therapy group practice in early

intervention psychosis

Sarah Parkinson & Claire Whiter

To cite this article: Sarah Parkinson & Claire Whiter (2016) Exploring art therapy group
practice in early intervention psychosis, International Journal of Art Therapy, 21:3, 116-127, DOI:
10.1080/17454832.2016.1175492

To link to this article: http://dx.doi.org/10.1080/17454832.2016.1175492

Published online: 19 May 2016.

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 INTERNATIONAL JOURNAL OF ART THERAPY, 2016
VOL. 21, NO. 3, 116127
http://dx.doi.org/10.1080/17454832.2016.1175492

Exploring art therapy group practice in early intervention psychosis

Sarah Parkinson and Claire Whiter

ABSTRACT ARTICLE HISTORY

This article aims to outline the process by which we set up an art psychotherapy group for Received 17 December 2015
young adults experiencing rst episode psychosis. Our reections on this process are Accepted 4 April 2016
discussed together with reections from the individuals accessing the group in its rst year.
KEYWORDS
Our writing, evidence and discussion are based on an earlier report which aimed to identify Art therapy; early
good art therapy practice in early intervention for psychosis by meeting guidelines set out intervention; group; joint
by the National Institute of Clinical Excellence and the Initiative to Reduce the Impact of attention; mentalising;
Schizophrenia. psychosis

Introduction Register of Control Led Trials (Central) in July 2013,

identifying no direct results.
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Our early intervention in psychosis Service specialises

Art psychotherapy literature has historically offered
in working with people who are experiencing a rst
a psychodynamic approach to working with psychosis
episode of psychosis, and with their families. The
underpinned by psychoanalytic theory (Killick &
team sees people from the age of 14 working in part-
Schaverian, 1997). Prior to the 1980s, however, the
nership with local Child and Adolescent Mental
focus rested more on the healing potential of art
Health Services (CAMHS). Individuals referred to the
making and the studio environment itself (Wood,
team have had no prior contact with mental health ser-
1997). The relevance of the social and political
vices and are offered support for up to three years.
context and a fundamental understanding of the
The rst three years of psychosis are seen as a critical
need for respect are also well documented through-
period, socially, psychologically and biologically; psy-
out the history of art therapy from the 1930s to the
chologically because the experience of psychosis is
1990s (Wood, 1997).
traumatic and the longer it persists the more pervasive
More recent developments (Bateman & Fonagy,
and enduring the effects will be (Reduce the Impact of
2012) have furthered our understanding of the
Schizophrenia [IRIS], 2012, p. 6).
impact of trauma and attachment systems on the
The early intervention (EI) team philosophy includes
development of neural pathways in the brain. This is
promoting a positive approach to mental health, indi-
understood to impact an individuals abilities in reec-
vidual choice and social inclusion, supporting friends
tive functioning and mentalising. Of particular interest
and family, and working collaboratively with service
to art therapists is the development of mentalisation-
users to make sense of their experiences. Tolerating
based therapy (MBT), which is specically focused on
diagnostic uncertainty (IRIS, 2012, p. 14) enables the
enhancing awareness of mental states in oneself and
team to move forward with offering medical, social,
others in explaining behaviour. A mentalising approach
vocational and psychological support for distressing
concerns the ability to feel and think, socially and
experiences, rather than delaying until a clearer
imaginatively.
picture of psychotic illness has developed.
When taking a mentalizing stance the mere contem-
plation of alternative possibilities may lead to a
change in beliefs. (Bateman & Fonagy, 2006, p. 1)
Evidence and guidelines
MBT was originally adopted in art psychotherapy prac-
Art therapy and psychosis literature
tice for people with a diagnosis of borderline personal-
There is a great deal of expertise and literature about ity disorder (BPD) (Fonagy, 2012; Franks & Whitaker,
using art therapy with people living with psychosis 2007; Karterud & Pederson, 2004; Springham, Findlay,
(Brooker et al., 2007; Greenwood, 2012; Killick & Scha- Woods, & Harris, 2012). In art therapy for psychotic
verian, 1997; Wood, 2013). However, we have found states, mentalising is now recognised as a key com-
no published material on the use of arts therapies ponent (Greenwood, 2012; Michaelides, 2012; Taylor
within EI services. A literature search was conducted Buck & Havsteen-Franklin, 2013; Wood, 2012). For
by using PsycInfo, Cinahl and Cochrane Central example, Greenwood (2012) identies her side by

CONTACT Sarah Parkinson sarah.parkinson4@nhs.net

2016 British Association of Art Therapists

side approach as directly related to the mentalising
stance.
inquisitive, active, empathic and at times challen-
ging but most importantly the therapist should
refrain from becoming an expert who knows.
(Bateman & Fonagy, 2006, p. 101, cited in Greenwood,
2012, p. 10)
A not knowing stance in mentalising is key to ensuring
that the therapist maintains an active and inquisitive
approach towards the service users experience rather
than making assumptions or interpretations about
what is going on in the other persons mind
(Bateman & Fonagy, 2012, p. 10).
Much art therapy practice can be recognised within
the mentalising framework. Mentalising involves con-
tinuous movement between different perspectives,
for example internal/external, self/other, cognitive/
affective. In a similar way, art therapy practice oscillates
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between art making, looking and reecting on the
marks made as well as sharing the artworks to
include your own and other peoples perspectives.
This continuous movement is recognised as a mechan-
ism of change by both service users and art therapists
working in MBT for borderline states (Springham et al.,
2012). The use of image making and non-verbal relat-
ing is also discussed as a key component in re-estab-
lishing epistemic trust, or the sort of trust needed to
allow social learning (Fonagy, 2013; Taylor Buck & Havs-
teen-Franklin, 2013).
Central to current practice is Isserows attachment-
based practice, in particular his extension and develop-
ment of the triangular relationship (Case, 1990; Scha-
verien, 1990; Wood, 1990) examining how the art
therapist and service user look together at the
artwork. Isserow (2008) relates this familiar occurrence
of looking together or joint attention to its roots in
attachment and the development of our capacity to
look and feel together. Isserow brings Baron-Cohens
(2004) Theory of Mind into his art therapy practice
with young children and adults on the autistic spec-
trum, noting that the ability to look together is not a
given, but a milestone developed in early infancy,
socially embedded and emerging before language
(Baron-Cohen, 2004; Isserow, 2008). He writes that
joint attention
is dependent on the infants understanding that other
people have minds separate to their own; that others
minds have thoughts of their own which can be
directed to objects and events in the world, as well
as the infant developing the capacity to orientate to
others point of view. (Isserow, 2008, p. 41)
This chimes with our understanding that the place of
looking together in the art therapy group is a key
area in which mentalising is being practised.
Despite the lack of published research in art psy-
chotherapy in EI for psychosis, there is evidence of
INTERNATIONAL JOURNAL OF ART THERAPY 117
using attachment-based models of verbal psychother-
apy for rst episode psychosis. Among other ndings,
Macbeth, Gumley, Schwannauer and Fisher support
the view that reective functioning is a trans-diagnostic
concept and therefore as relevant to individuals experi-
encing rst episode psychosis as to people with a diag-
nosis of BPD (Macbeth, Gumley, Schwannauer, & Fisher,
2011). Brent (2009) is curious as to whether MBT can be
used to help reduce vulnerability to psychosis. He
makes particular reference to the link between psycho-
sis and trauma in early childhood attachments and con-
cludes that a mentalising approach may be useful for
people experiencing disturbances in self-awareness
and awareness of others.
As an approach theoretically underpinned by
attachment theory and neuro-developmental under-
standings, MBT offers a way of understanding how
art therapy contributes to change as well as offering
guidelines for re-examining and developing art
therapy practice. We propose that a further advantage
of a mentalising approach is that it is in keeping with
the updated recommendations by the National Insti-
tute of Clinical Excellence (NICE) in 2014
to be more clearly dened, taking into consideration the
phase and symptomatology of the illness (Gilroy &
McNeilly, 2000; Jones, 1996). The arts therapies described
in the studies included in this review have predomi-
nantly emphasised expression, communication, social
connection and self-awareness through supportive and
interactive experiences, with less emphasis on the use
of uncovering psychoanalytic approaches (Green,
1987; Rohricht & Priebe, 2006; Talwar et al., 2006;
Ulrich, 2007; Yang et al., 1998). (NICE, 2014, p. 216)
Together with the development of cognitive behav-
ioural therapy (CBT) for psychosis and the rise in
service user informed practice outlined below, there
is currently a great deal of exciting new thinking to
integrate into current good practice.
NICE guidelines
NICE (2014) identies arts therapies as core interven-
tions in the treatment and management of schizo-
phrenia in adults in primary and secondary care.
Guidelines state that the arts therapies are currently
the only interventions (both psychological and
pharmacological) to demonstrate consistent efcacy
in the reduction of negative symptoms (NICE, 2014,
p. 220).
Nice guidelines (2014) recommend that arts thera-
pies be considered for people with psychosis or schizo-
phrenia, both for acute episodes and in recovery. NICE
guidelines (2013) have also recommended that arts
therapies are considered for children and young
people with psychosis or schizophrenia:
1.4.6 Consider arts therapies (for example, dance
movement, drama, music or art therapy) for all children
 118 S. PARKINSON AND C. WHITER
and young people with psychosis or schizophrenia,
particularly for the alleviation of negative symptoms.
This can be started either during the acute phase or
later, including in inpatient setting. (NICE, 2013, p. 28)
Both NICE guidelines for adults and children/young
people give further recommendations on the clinicians
training and regulation as well as the setup of the inter-
vention and the aims of therapy.
Arts therapies should be provided by a Health Pro-
fessions Council (HPC) registered arts therapist, with
previous experience of working with people with
schizophrenia. The intervention should be provided
in groups unless difculties with acceptability and
access and engagement indicate otherwise. Arts thera-
pies should combine psychotherapeutic techniques
with activity aimed at promoting creative expression,
which is often unstructured and led by the service
user. Aims of arts therapies should include:
. enabling people with schizophrenia to experience
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themselves differently and to develop new ways of
relating to others
. helping people to express themselves and to organise
their experience into a satisfying aesthetic form
. helping people to accept and understand feelings
that may have emerged during the creative process
(including, in some cases, how they came to have
these feelings) at a pace suited to the person
(NICE, 2014, p. 221).
Schizophrenia Commission
The Abandoned Illness Report (Schizophrenia Com-
mission, 2012) recommends increasing access to
psychological therapies in line with NICE guidelines.
A survey carried out by the commission among prac-
titioners, people using services and their families
placed [c]reative therapies (music and art) in
amongst the interventions they most valued along-
side medication (Schizophrenia Commission, 2012,
p. 33).
IRIS guidelines
There is no direct reference to arts therapies in the EI
declaration or the IRIS guidelines. However, IRIS rec-
ommends creative and assertive approaches to suit
the individual (IRIS, 2012, p. 17) in order to optimise
initial service experience and achieve the initial thera-
peutic goal of early engagement.
We found three of the vision statements from the
early psychosis declaration particularly important as
guidelines for setting up the group:
. Challenge stigmatising and discriminatory attitudes
so that young people are not disadvantaged by
their experiences and are truly included in their
local communities.
. Generate optimism and expectations of positive
outcomes and recovery so that all young people
with psychosis and their families achieve ordinary
lives.
. Raise wider societal awareness about psychosis and
the importance of early intervention. (IRIS, 2004).
Hearing Voices Movement (HVM)
The Hearing Voices Movement (HVM) is a socio-political
movement advocating for people who hear voices, see
visions or have other unusual perceptions (Hearing
Voices Network, 2016). The basic assumptions of HVM
are:
. Hearing voices is a normal though unusual and per-
sonal variation of human experience.
. Hearing voices makes sense in relation to personal
life experiences.
. The problem is not hearing voices but the difculty
to cope with the experience.
. People who hear voices can cope with these experi-
ences by accepting and owning their voices.
. A positive attitude by society and its members
towards people hearing voices increases acceptance
of voices and people who hear voices. Discrimi-
nation and excluding of people who hear voices
must stop (Intervoice, 2015).
Open dialogue
The open dialogue approach developed in Finland and
increasingly adopted internationally is a way of support-
ing people through mental health crisis by engaging with
the person and their social networks as much as possible
in their own home. The approach aims to open up the
dialogue between everyone involved (though mainly
those identied as signicant by the service user) giving
value to everyones perspective. This involves mental
health workers being able to sit with the persons distress
and listening to what is most important to the individual
rather than the priorities of the mental health service
(Open Dialogue Approach UK, 2015).
Setting up the group
Working together
Sarah and Claire worked over a period of weeks to look
at relevant research and guidelines and consider our
different personal and professional backgrounds.
Our overall aims were:
. To develop group art therapy as an option for the EI
service in accordance with best practice guidelines
(NICE, 2014).

. To nd out how best to meet EI service user needs in
terms of expression, communication, social connec-
tion and self-awareness (NICE, 2010, p. 252) within
the group.
. To evaluate changes in mental health and wellbeing.
A more detailed account of our objectives, of setting
up the group and outcome measures including
WarwickEdinburgh Mental Wellbeing Scale
(WEMWBS) scores is available in a separate report
(Parkinson & Whiter, 2014).
Introducing art and creativity into new working
relationships
An important part of engaging service users and
achieving appropriate referrals depended on the
teams understanding of what we were offering.
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We wanted to identify art therapy as a psychological
intervention that is both a psychotherapy and accessi-
ble, social and fun. This reected EI philosophy in using
a positive, socially inclusive and non-clinical approach.
Showing an Audio Image Recording or AIR (Spring-
ham & Brooker, 2013) during the weekly clinical
meeting and suggesting that care coordinators email
the link to those service users who expressed an inter-
est was seen as helpful by the team.
Once the group was established we were able to
make our own AIRs with members and, depending
on whether we had written consent, we could now
use these to inform our colleagues. We also included
video links on new information and leaets available.
Formalising the referral pathways to the group and
also what the process was should further psychological
therapy (e.g. CBT or individual trauma work) be con-
sidered helped to identify and integrate the individuals
art psychotherapy within their wider package of care.
Art therapy or CBT?
NICE guidelines (2013, 2014) identify both CBT and arts
therapies as effective treatments for psychosis. The
early intervention team offers individual CBT as a
matter of course for all service users on the caseload
and an understanding of cognitive behavioural
approaches for psychosis forms part of the training
for work in EI.
Initially, if an EI service user was referred for a
psychological therapy and both therapies were indi-
cated, CBT would be given preference in line with
NICE guidelines. However, as the art therapy group
has developed, and in line with IRIS guidelines, EI
service users are increasingly supported to make their
own informed choices about which psychological inter-
ventions best meet their needs.
Requests to access both CBT individual work and
the art therapy group alongside each other have
also been considered. NICE guidelines suggest that
INTERNATIONAL JOURNAL OF ART THERAPY 119
CBT be offered individually and that arts therapies
be offered in groups. The advantages and disadvan-
tages of offering a group therapy alongside individual
work have been discussed in terms of resources as
well as supporting an individuals therapeutic needs.
When both psychotherapies run concurrently, we
have since identied making time to review progress
together with both therapists and the service user as
best practice although this was not our practice
during the rst year.
Consideration of how CBT and art therapy group
work can complement each other, and also identifying
the counter-indications of doing both, will be a helpful
piece of work to develop further.
Referral rate
We had anticipated starting the group with a minimum
of ve members. However, referrals were slow to come
through and we decided to start the group on the
chosen date regardless of how many members there
were. This was due to the enthusiasm of service users
wanting to get started with the group. The group
started with three members.
Engaging with service users1
Bringing in the art
As well as introducing art as a psychological interven-
tion to colleagues, we needed to bring it into the
working relationship with new service users. We
found that using art during the individual assessment
was helpfulparticularly soft coloured modelling clay
which could be worked with while simultaneously
talking. This modelled the art therapy process that we
would be using in the group and allowed individuals
a tasterfor example the experience of moving
from talking to making and back to talking and reect-
ing on the clay models created.
Service users often reected upon their experiences
of art in the context of schoolfor example regret
about not taking up opportunities at school and now
feeling bored and wanting something creative to
take part in. Some found that teachers would focus
their attention on those who were good at art so
they would mess around instead. It was important
therefore that we demonstrated that art therapy is
non-judgemental.
Some service users expressed expectations for the
focus to be on the technical aspects of art with the
intention of improving skills and exploring different
techniques. While this wasnt our main focus, we recog-
nise that it has an important role to play, both practi-
cally and in keeping safe at the beginning and
taking the attention away from emotional content so
service users wouldnt feel exposed in front of a new
group of people they dont know.
 120 S. PARKINSON AND C. WHITER
Individuals expressed anxieties about being no
good at drawing and anxiety also raised questions
about what would happen to the work, including
whether the contents could be used as evidence
against the artist. It was important to understand the
anxieties and respond practically when needed, for
example in providing folders to enable individuals to
know that their work was safe in their own keeping if
necessary.
Warm ups: drawing games and exercises
A number of individuals asked for help in getting into
art making during their assessment. One service user
asked for a stimulation as a game or warm up at the
start of the group. This idea has been adopted and
developed in the groups with participants making up
their own ideas and becoming fully involved in which
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warm up is chosen each week. Warm ups vary from
the familiar squiggle game (Winnicott, 196468),
which is the most requested, to exercises and games
in observation drawing or more rarely reection on
feelings. One or both therapists join in.
These short exercises or games at the beginning of
each group played an important role in meeting indi-
vidual anxieties about skill and being with others:
[exercises] helped in being short and guidedit broke
down the barrier of who was most skilled because then
you know youre not going to create a masterpiece!
(Former group member)
In addition to helping members engage in art making,
the exercises allowed the group to notice small shifts
between different ways of looking, within their own
experience and between themselves and others. An
example might be the differences between looking at
the object and looking at each others drawings of
the object. Another example could be seeing an
image in a squiggle differently to the next person.
The squiggle game brought us together as a group and
built relationships up. I would see a chicken but they
drew a bicycle. It was fun but I thought why dont
people see what I see? (Former group member)
An element of fun was important to reduce anxieties
and the use of drawing games helped, for example
drawing from touch or from hidden objects, now you
see it, now you dont. These short exercises enabled
the group to reect on seeing and experiencing
things differently. They also opened up issues such as
whose experience is real?.
Texts
Text reminders proved helpful for people to attend the
group each week. Service users told us that they
struggled with remembering when the group was.
The text helps service users to remember and wake
up on time. Group members also used the text to let
us know they were coming, if they were late and if
they were unable to come.
We planned to follow up missed sessions with a
letter; in the event, this was increasingly done by text.
Social inclusion
Venue
When we rst advertised the group, there were a
number of service users who were put off by the
location of the group in the same building as an
acute inpatient unit. To support the vision to challenge
stigmatising and discriminatory attitudes, IRIS rec-
ommends the EI services avoid psychiatric outpatients
and engage in low stigma settings. Nine months after
the start of the group we moved to an arts community
setting. Once there, service users expressed their relief
and were more open about the difculties of coming to
a group on a hospital site. These included walking up
the path and returning to the building where they
had been acutely unwell. It could mean bumping into
other mental health staff involved in their care, which
distracted from the purpose of coming to an art
therapy group. The sense of space and freedom in
the new studio included freedom from electronic
noises and alarms typical of the hospital setting.
While working at the hospital site was less popular, it
did more easily enable us to meet a NICE guideline rec-
ommendation that when psychological treatments,
including arts therapies, are started in the acute
phase (including in inpatient settings), the full course
should be continued after discharge without unnecess-
ary interruption (NICE, 2010, 1.3.4.11).
A number of group members rst met Sarah and
Claire during an acute inpatient admission. However,
the venue is now a 20-minute walk or a bus ride away
from the ward, which has prevented us from working
with people when they are receiving inpatient care.
Session length
We set the group up to run for 90 minutes, but in line
with our aim to nd out more about best practice with
this group, we were open to adapting the time. After a
number of months, group members expressed that
there wasnt enough time to get into the artwork
and we agreed to trial increasing the time to two
hours. This worked well, felt less rushed and allowed
more adequate time to engage in the art making and
group process. We have continued at two hours.
Group structure
The two-hour group time was made up of making tea
and coffee, a ve- or ten-minute warm up exercise

and reection of the artwork. This was followed again
by a longer period of art making, usually free of direc-
tion and ending with a longer period of talking and
looking together at the work. We have put the
artwork on the wall when practically possible, which
makes it more available to the group as a whole to
see. One or usually both therapists join in with the
art-making process, depending on the demands of
the group, and share our work along with the group.
Involving friends and family
One new referral we met, Josh (name changed), came
for his initial meeting with a friend and said he would
like his friend to join him. This was helpful because
the two friends were able to talk about their experi-
ences of their social group. When Josh struggled to
nd the words to identify problems he wanted to
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change, his friend was able to reassure him that what
he was saying was relevant.
When Josh asked if he could bring his friend to the
sessions, we advised them that it wouldnt be appropri-
ate because the group is designed for service users
only so they can relate to their shared experiences of
rst episode psychosis. At the same time we encour-
aged his friend to continue to help him get to sessions.
Unfortunately, Josh did not make it to the group and
we were not able to re-engage him with the group or
the EI service. This led us to discuss what we could
have done differently in terms of friends and family
support for the members of the group.
Other service users expressed that they would like
friends and family to be involved and we proposed a
separate friends and family session once every 10
weeks.
These sessions are held on a different day of the
week and follow a similar format. Our experience is
that the service user group members take responsibil-
ity for the friends and family members spontaneously
explaining how the group works, making tea and
helping their friends feel comfortable.
In the rst year participants have chosen to ask their
friends, rather than family members.
Endings
There have been a number of unplanned endings over
the rst yearfor example two members left due to
changes in their college timetable, two members left
to start full-time work, others moved house or found
themselves unable to get to the group due to being
unwell. Our experience so far is that endings havent
been smooth and the uncertainty about who will be
there from week to week has been difcult for those
members remaining.
Members have tended to leave the group before
reaching a planned end session. Our understanding
INTERNATIONAL JOURNAL OF ART THERAPY 121
of this is that life can move on very quickly for this
age group and they go with it.
For remaining group members this degree of uncer-
tainty also left little opportunity for the group to say
goodbye to those leaving. We noticed, however, that
members who have left remain in the fabric of the
group via those still in the group who continue to
make references to them and particularly to their
artwork.
We invited two members who had come to the
group for 11 months and 6 months, respectively, to
return to make an AIR to reect on their art and learn-
ing from the group. Both have been enthusiastic to do
so and the results are included.
Audio Image Recordings (AIRs)
The format of making AIRs with service users has been
developed by the British Association of Art Therapists
(BAAT 2015; Springham & Brooker, 2013). The process
is based around a reect interview template, designed
to capture the individuals narrative of their experience
of art therapy as well as their perception of art therapy
agents of change .Questions include reection on other
therapies, which was helpful in this case as both indi-
viduals had also used CBTAmie used CBT with her
care coordinator prior to the art therapy group and
Jed started a short course of CBT towards the end of
his time in the group.
The end product of the AIR is a DVD using still
images and showing two pieces of the interviewees
chosen artwork, with a voiceover reect interview.
The DVD is the property of the service user and was
designed as a reective tool. Both service users have
given consent for the use of their interviews in this
report.
Service user reections: AIR transcripts
For the purposes of this report we refer to transcripts of
the two AIRs described above and made by the rst
two participants to end therapy.
We noticed that both our interviewees chose to use
their air time to encourage other young people to join
the group, though we have not included this in the
transcript below.
We have chosen passages from the AIRs that
comment on the three aims of practice recommended
by NICE (2014). Service user names are changed.
Experiencing yourself differently
1. Enabling people (who have experienced rst episode
psychosis) to experience themselves differently and to
develop new ways of relating to others. (NICE, 2014,
p. 221)
 122 S. PARKINSON AND C. WHITER

Jed talked about the benet of working in a small
group, and particularly how he is able to take in
what others are saying, which contrasts with his
former fears of what other peoples motives might
be. There are also examples of regulating emotion,
with reference to developing patience and
tolerance.
Having asked Jed about how he felt at the start of
therapy, Claire asks how he feels now:
Jed: I am a lot more relaxed about stuff and I dont
let things get to me and I think that denitely part
of the group has made me more condent in speak-
ing to people. Just having a general chat rather than
thinking about what is their intention with this con-
versation and all things like that other than think
what a nice person to talk to. It is just a bit more
easier and I have become a bit more condent
about showing my artwork to people outside of
art therapy.
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to them and share our artwork and what it meant
and everything like that, you have almost got a
sense of community and a back-up system. If you
were to do art on your own at home you would
draw your picture and that is it. You put it to one
side whereas in art therapy you can talk about
what you have done and you can almost learn
from other peoples experiences as well you
feel safe. You can express yourself how you wish
and that just stays in that room and you are not
afraid of people judging you because you are all in
the same boat.
Expressing yourself
2. Helping people to express themselves and to organ-
ise their experience into a satisfying aesthetic form.
(NICE, 2014, p. 221)

Claire: What have you got out of art therapy?

Jed: I learnt to be able to laugh at myself. In silly situ-
ations and stuff but also one of the big things was lis-
tening to people made a big difference because you
sort of understand it is not just you, it is everyone
else and you get a collective understanding I
suppose and patience develops which is quite nice. I
think it gives you that little bit of a spark of condence
to move on.
It makes you have a tolerance to everything and
understanding and know that it is not always about
you, it is about other people as well.

Jed goes on to talk about how making artwork within

the group enables him to take more risks with what
he takes in from others and with what he says.
Sarah: What is it about the artwork within that group?
Jed: The artwork helps you express yourself and
being around creative people makes you more crea-
tive and also relaxes you because you are around
people who are in a similar mind set but just
doing the artwork and being able to concentrate
on something and having the structure of the
artwork I think is a really big factor of the group
and then being able to talk about the artwork after-
wards with each other and get everyones opinions
and constructive criticisms and being open and
knowing that you have done it together so you
have got rights togetherlike doing the workto
tell someone that is rubbish or that is good and
stuff like that because you have done it as a group
which is quite nice.
Amie also talked about the importance of working in a
group, which helped her feel part of a community:
Sarah: What is it about art therapy that has made those
changes happen?
Amie: I felt really alienated by the condition that I
had and did not feel that I could share that with other
people because of obviously the stigma and every-
thing with mental health. Whereas being in a room
with people with similar experiences you can talk
Figure 1. Jeds selected image. Ink and paper frame on paper.
42cm 29cm.
Jed talked about coming to the group on a difcult
day and using his artwork to try and alter or manage his
feelings. He also describes a slight shift towards a differ-
ent way of organising his emotional and aesthetic
experienceputting a frame around it:
Jed: I dont fully remember doing it (the painting). I
remember the day, I remember I went to the job inter-
view and it didnt go very well and I was stressed out. I
was on a bit of a low with my mood and how I was
feeling and I just wanted something nice to look at
to cheer myself up. Basically I think that is what the
feeling I get from looking at it now is the sort of
thing I do when I am very low, I make bright happy
things to adjust my mood as such everything just
got a bit much at that time .
The only thing I remember really doing about it
was putting the frame around it, even though it is
just another piece of paper but just so it is nished,
you know, it was sort of like I am doing that, that is
done, thats that sort of moment over really.
Putting a full stop if you like, just nishing it and
leaving it alone.

Asking what it was like making an earlier image Jed
makes clear that alongside thinking about his feelings
he enjoys the aesthetic pleasure of making something.
Figure 2. Jeds selected image. Graphite and ink on paper.
Downloaded by [Lancaster University] at 01:18 06 September 2017
42cm 29cm.
Sarah: What was it like making it?
Jed: I really enjoyed it actually making it because it is
just the thought behind it and trying to put the per-
spective in there and changing a black and white
drawing and then adding colour to it that was nice
even though it was the idea that I was trying to get
across but it was still nice to add that little bit of
colour to something.
Amie talked about a shift between bottling things up,
putting things in boxes to help her feel safe, and
placing things in piles to make some sense of her
thinking and to help her address issues that she had
otherwise ignored.
Claire: What did it feel like when you were creating this
piece?
Amie: Well I tend to sort of zone out I think and I see
what comes out I had a frame and I put something
in the frame and it was almost as though you are
looking through a window at how I feel and as the
art therapy weeks went on that frame seemed to disap-
pear, and I think it was almost like a safety thing and
the more sessions I did and the more comfortable I
felt the more freehand stuff I was able to do rather
than do it within the safety frame.
Claire: The frame was sort of containing it in the
beginning?
Amie: Yes. It was sort of almost putting it in a box.
Later Amie expands:
Well it is almost like if you bottle things up and you
ignore them then they are going to come back to you
eventually and bite you on the ass anyway but you can
almost if you put things, like say you were sorting out a
load of stuff and you put it in piles to make sense of it
all, using that structure to do that then you can make
sense of it but not in a way so you are ignoring the
point when bottling stuff up and ignoring what is actu-
ally going on is not healthy at all but you can use a
INTERNATIONAL JOURNAL OF ART THERAPY 123
structure or a way of putting things into piles and
addressing one thing at a time.
Amie showed a handprint she had made which she
described as asserting a new identity:
Figure 3. Amies selected image. Acrylic on paper. 21 30cm.
Amie: the handprint was like putting my stamp
I am feeling better and more positive.
Accepting and understanding feelings
3. Helping people to accept and understand feelings
that may have emerged during the creative process
(including, in some cases, how they came to have
these feelings) at a pace suited to the person. (NICE,
2014, p. 221)
Jed was offered both the art therapy and later in the
year individual CBT. He said that he found both helpful
and saw them as offering different things at a different
pace. He does not describe so clearly the benets of
CBT because this was an interview about art therapy,
but he is clear that he appreciated being offered
both. He describes art therapy moving at a more
relaxed pace.
Art therapy is different to CBT because CBT is a one to
one situation and you are forced to talk about what is
going on and you are not really given time to slowly
build up to something you want to talk about
whereas art therapy you dont have to talk about any-
thing, you can just get on with what you want to do
and you know, you dont have to talk about what is
 124 S. PARKINSON AND C. WHITER

troubling you. In a group we have talked about what is
on TV, why we watch scary lms but it brings the con-
versation out in an easier way
Jeds use of the word forced is possibly confusing.
Elsewhere he also talks about being forced to stay
with people he doesnt know in the art therapy
group as positive.
In contrast, Amie is explicit in her interview and in
her early artwork about violence and trauma she has
experienced, including the further distress or trauma
of her psychosis, for example experiencing insects
crawling everywhere that other people could not see.
Amie attempts to use the art to put her experiences
into a different form and to look at that together
with the group:
Amie: obviously I was dwelling on everything, all
my issues were going round and round in my head. I
wasnt able to address them and to accept them or
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Open Dialogue, which places mental distress within a
systemic context by engaging with a persons wider
social network. We set up the friends and family
group to meet these needs and in doing so learnt
more about the benets of a group like this. Service
users were enthusiastic to share the therapy available
to them with their friends, to inform their friends and
introduce them to the mental health service they
were involved in. Our observation was that service
users were also keen for their friends and family to
receive some support in kind. Inviting friends and
family members every 10 weeks provided the opportu-
nity for supporters and carers to create their own art
and share another perspective.
Questions about where CBT and where art therapy is
most appropriate were thought about. NICE guidelines
distinguish CBT as an individual and art therapy as a
group intervention, and these guidelines were kept

to make any sense of them. So by putting it on paper
I was able to sort of address it and look at the situation
and face up to it I suppose rather than bottling it all up
which is what I am used to doing.
Discussion
This article documents what we learnt from setting up
and running an art therapy group with the EI service. It
includes a limited amount of service user evaluation in
the form of transcriptions from audio image recordings
completed by two service users from the groups rst
year.
Integrating art psychotherapy with EI philosophy
informed our therapeutic approach (IRIS, 2012). It was
important to think creatively about engagement and
to generate optimism and expectations of positive
outcomes and recovery (IRIS, 2004, p. 2). Our
approach emphasised accessibilityfun, creativity,
social issues and group work balanced and integrated
with psychological intervention. There was a strong
socio-political theme in the group and in EI philosophy,
which focused on challenging stigma and encouraging
social inclusion, and individuals identied strongly with
this social issue. Challenging social views alongside
personal views about mental health was seen as an
important role for the group.
Moving the group to a venue in the community and
away from the hospital was greeted positively by group
members, who conrmed that meeting in a clinical
setting as well as, for some, returning to the place
where they had had an acute inpatient admission
was unwelcome.
Our aim to action service user needs and ideas
included extending the time available in the group
and introducing a friends and family group. We learnt
that some service users needed the active support
and participation of their friends and family to help
them get to therapy. This echoes the approach of
to. Art therapy as a recommended treatment for nega-
tive symptoms was also kept in mind, with the empha-
sis on group work and social interaction. The question
of whether the two approaches can be used simul-
taneously in individual instances was referred to by
one of the service users, who said that he appreciated
having two different approachesand particularly the
way the two approaches, as he experienced them,
complement each other. He contrasted the individual
and group setting, and the difference in pace.
If the two therapies run concurrently, we have ident-
ied making time to coordinate aims and review pro-
gress with the therapists and service user together as
best practice.
Making active use of NICE guidelines in our planning
and practice was key to organising service user reec-
tions into themes and understanding the feedback
further, e.g. experiencing yourself differently. The
feedback we have indicates that these two service
users were both able to use art therapy to work with
the therapeutic aims identied in NICE and some of
our understanding drawn from the feedback is set
out below.
Within the group, making and looking at the artwork
together was spoken about as central to expressing
themselves and sharing experience of each other.
Both meaning and aesthetics are referred to. Partici-
pants commented on the trust built up among them-
selves. Being open and knowing that you have done
it together so you have got rights together was pre-
sented as an important precursor to talking openly
about each others artwork, including challenging
each others work. A non-judgemental attitude and
condentiality within the group setting was important
to building up trust between participants and feeling
free to express oneself and learn from others.
The benet of working in a group and the sense of
community and support they felt came across clearly.
One participant spoke about feelings of alienation

which the safety of the group helped alleviate. Another
participant spoke about taking in what other members
of the group say as distinct from previously held fearful
perceptions about other peoples thoughts. He links
this change of perception to the condence he has
developed in talking and showing his artwork with
others inside and outside of the group.
There are a number of references to the signi-
cance of sharing non-verbal and verbal language in
the group and how that impacts on individual self-
expression and relating with others. The groups
development beyond its rst year is beyond the
scope of this article but the rst year makes clear
that activities such as looking together at the art
objects and listening to different perspectives in the
group are highly valued . Both service users refer to
changing their beliefs about themselves and other
people because of, and in relation to, working,
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looking and talking with others.
Making art and working with the art piece towards
a satisfying aesthetic form was seen as helpful in
managing difcult feelings and experiences. These
thoughts were expressed in phrases such as putting
a full stop, adding that little bit of colour, looking
through a window at how I feel, using a structure
to make sense of it, putting my stamp. Organising
your own thinking into satisfying aesthetic form was
also key to individuals sense of achievement and con-
dence. We understood this both as the enjoyment of
putting colour on paper and also using the process to
organise thinking, e.g. Amies manageable piles of
stuff.
Service users spoke about using art therapy in differ-
ent ways and at a different pace. One participant com-
mented on the benet of using art practice to
externalise her thoughts, put them on paper in order
to look at the situation and address difculties.
Another participant commented on the un-intrusive-
ness of the psychological intervention in art therapy,
noticing that he didnt have to talk about anything.
Talking in a social context, for example whats on TV.
Why we watch scary lms , was important in bring-
ing the conversation out in an easier way. This
suggests that the art therapy group can accommodate
participants moving in different directions and at a
different pace from one another.
Not feeling rushed and working at his own pace was
helpful to the participant above, though feeling chal-
lenged (or forced in his words) was also helpful. This
challenge was cited in relation to CBT rather than the
art therapy group and this was recognised as some-
thing we needed to consider further. This participant,
however, also referred to being forced to work
within a group setting for art therapy as important,
suggesting that service users appreciate feeling chal-
lenged, including some of the demands presented by
working in a group.
INTERNATIONAL JOURNAL OF ART THERAPY 125
The experience of psychosis is now widely recognised
as traumatic in itself (IRIS, 2012), including the experience
of treatment within the mental health system (Cooke
et al., 2014). Members of the group made art about
seeing, hearing or believing things that other people
didnt. They occasionally spoke about experiencing feel-
ings of paranoia, fear or terror. In recovery from trauma,
Herman (1992) emphasises the power of bearing
witness to experiences that may often feel unspeakable.
The experience of feeling heard and validated represents
a source of strength and hope for recovery. In the group
feelings and experiences are brought into a visual, tangi-
ble form and are witnessed by the group. In this way we
feel that the group, on one level, was working with the
trauma of psychosis in the act of sharing and talking
about their artwork with each other, with or without
explicitly naming it.
We suggest that the act of sharing and talking about
artwork within the group mirrors the process Herman
describes in a way that feels, for some service users,
more manageable or safe.
Keeping a meaningful balance between making art,
joint attention, social interaction and introspection
(Baron-Cohen, 2004; Isserow, 2008; Springham et al.,
2012) are key roles for art psychotherapy practice.
Maintaining a therapeutic environment that is non-
threatening while also offering an opportunity to look
and think with others and take some risks was seen
as important to that balance.
Our general experience in the group has helped us
understand that service users manage difculties in
different ways, including avoidance and distraction.
Allowing service users to build up their sense of trust
at their own pace is seen as important. At the same
time it will be important for us as therapists not to
collude with avoidance of the work and to maintain a
therapeutic balance between validation and challenge
as the group develops (Bateman & Fonagy, 2006;
Euster, 2013).
We didnt set out to use a mentalising approach in
this group and are not aware of guidelines for using
mentalisation in early intervention in psychosis art
therapy. We suggest, however, that the outcome sup-
ports investment in mentalising literature, training
and enquiry to help understand the mechanisms of
change in more detail and to develop practice guide-
lines with this client group.
Implications for practice
Some of the implications for practice in addition to rec-
ommendations from NICE include benets in:
. fostering a collaborative relationship with referring
teams to promote understanding of art therapy
. utilising guidance from IRIS/early intervention
declaration such as generating optimism and
 126 S. PARKINSON AND C. WHITER
expectations of positive outcomes and recovery
(IRIS, 2004)
. identifying a community location for this client
groupaway from clinical settings and particularly
hospital settings that patients have been admitted
to as a result of rst episode psychosis
. using warm ups in the form of drawing games and
exercises
. nding ways of including friends of service users
. supporting participants to work at their own pace
while also considering challenges to avoidant or dis-
sociative patterns when sufcient trust in the group
is available
. offering an individual reect interview towards the
end of therapy using the audio image recording
format (AIR).
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Implications for research
Implications for research include more understanding
of the balance between the service users need to set
their own pace and their need to understand and
gently challenge dissociative or avoidant patterns of
relating where these are a problem.
We suggest further exploration of the mentalising-
based approach, which has been developed to meet
specic attachment problems for people with a diagno-
sis of BPD. MBT includes a psycho-educational approach
which could be usefully developed to ground the work in
a shared understanding of art therapy, mentalising and
psychosis. Together with its roots in attachment and an
emphasis on an active and not knowing stance. We
believe MBT offers a number of helpful practice guide-
lines that could be adapted to work with the recovery
of social and imaginative states of mind interrupted by
rst episode psychosis.
Conclusion
To conclude, the art therapy group for people with rst
episode psychosis has proved a valuable resource to
the EI team. The specic aims of art therapy for
people living with psychosis recommended in NICE
(2014) guidelinesexperiencing yourself differently;
expressing yourself; accepting and understanding feel-
ingswere found to be helpful and relevant to this
group, as evidenced by the two service users inter-
viewed. The audio image recordings also helped us
identify how the different aspects of the art therapy
group helped to bring about change.
Much was learnt from this group about the impor-
tance of group work and peer support. Making and
looking at art together is seen as a vital way of learning
about each others thinking, connecting with each
other and protecting individuals from isolating
thoughts.
As a result of our learning from the group, we are
further interested in how a mentalising approach
could be used to underpin the mechanisms of
change and recovery in rst episode psychosis.
Acknowledgement
The authors are grateful to the group members who gave
permission for their words and images to be used and to
Dr Chris Wood for her help and encouragement.
Disclosure statement
No potential conict of interest was reported by the authors.
Note
1. All identifying features, names and locations have been
changed or removed in the interest of condentiality.
Notes on contributor
Sarah Parkinson is a painter, Art Therapist, Group
Analyst and MBT Practitioner working with Avon &
Wilts Partnership NHS Trust. She has a special interest
in social inclusion and was a founder member of the
Community Arts Therapies Project in 2005 and Fresh
Art@ in 2013. She is currently involved in a new
project exploring observational drawing as an interven-
tion in psychosis. Email: sarah.parkinson4@nhs.net
Claire Whiter is currently a trainee clinical psychologist
at Plymouth University. Prior to training, she worked in
the voluntary sector for womens mental health and
was a core group member of Bristol Self-injury Self-
help (SISH). She co-facilitated the EI art therapy group
when working as a mental health worker within an
early intervention for psychosis service. Claire has an
interest in embodied distress, psychosis, trauma and
dissociation. She is currently conducting research
with early intervention teams looking at how staff
talk about the meaningfulness of psychosis.
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