Art therapy & anxiety - Scholarly Publications Leiden University

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Art therapy & anxiety Abbing, A.C. Citation Abbing, A. C. (2020, January 22). Art therapy & anxiety. Retrieved from Version: Publisher's Version License: Licence agreement concerning inclusion of doctoral thesis in the Institutional Repository of the University of Leiden Downloaded from: Note: To cite this publication please use the final published version (if applicable). Cover Page The handle holds various files of this Leiden University dissertation. Author: Abbing, A.C. Title: Art therapy & anxiety Issue Date: 2020-01-22 “The most beautiful thing a person can experience is to wonder about the mysterious; it is the fundamental emotion that creates true art and true science.” (Albert Einstein) General Introduction Chapter 1 Introduction and aim Anxiety is a major problem for individuals within our society, causing suffering and impairment in daily life. One in every five adults in the Netherlands will face serious anxiety problems during life (Nederlands Kenniscentrum Angst en Depressie, 2019). Frequently used interventions, like Cognitive Behavioural Therapy (CBT) and pharmacotherapy, are not always successful in anxiety treatment. Therefore, many other interventions are offered, with different intensity and different levels of evidence of effectiveness according to the Multidisciplinary Guideline Anxiety Disorders (van Balkom et al., 2013). One of these provided interventions is art therapy, often used as an additional treatment next to CBT and pharmacotherapy. Art therapy uses visual art exercises to elicit ‘experiences’ and ‘insights’, and by using this method it is hypothesized that personal development is stimulated and mental health is improved. Art therapy has several variants, of which anthroposophic art therapy (AAT) is one. Although AAT is used widely in western society, hardly any research has been conducted into the effectiveness of this treatment. Also, the content of the therapy is not well described and working mechanisms are not clear. This is mainly due to the lack of a research tradition within the AAT profession. AAT therapists are not used to provide data for research or to systematically evaluate the effectiveness of their treatment (Abbing & Baars, 2012). The lack of studies on the effectiveness of AAT makes it difficult to evaluate its usefulness and the justification for its application. To gain insight into the possible value of art therapy in anxiety treatment, thorough research is required and two research objectives are obvious: 1) to assess the effectiveness of art therapy in anxiety in adults, and 2) to explore working mechanisms of AAT In this introduction, the concept of anxiety and the supposed working mechanisms of art therapy are described. In addition, the status of evidence of the effectiveness of AAT on anxiety is evaluated, to explore the current knowledge gap that needs to be addressed. GENERAL INTRODUCTION 11 1 Anxiety Anxiety needs to be differentiated from fear. Fear is a normal and functional response to danger or threat (Rosen & Schulkin, 1998). It can be detected in a physical reaction, the so- called stress response, with typical symptoms such as increased heart rate, heart pounding, shortness of breath, trembling or shaking hands, dizziness, dry mouth, light-headedness, increased muscle tone, sweating and increased attention to the dreaded stimuli, depending on the intensity of the stressor and the response. The stress response enables a person to act quickly upon eminent danger. The sensory perception of a stressor, coupled with an emotional association and cognitive framing, causes the stress response. Normally, an individual can downregulate these responses as soon as the stressor disappears. Not only external objective danger or threat can evoke a stress response, psychosocial stressors can cause a stress response as well. Individuals in current western society are known to be frequently exposed to social stressors, which can lead to a chronic stress response with large effects on internal regulation functions due to disrupted hormone balance that also influences the brain function (e.g. Davidson & McEwen, 2012). Chronic stress can dysregulate the immune system (Cole, Hawkley, Arevalo, & Sung, 2007), can influence our DNA by epigenetic mechanisms (Epel, Blackburn, Lin, Dhabhar, Adler, Morrow, & Cawthon, 2004) and is thought to result in many physical and psychological problems, such as arteriosclerosis, diabetes, tumours, intestinal problems, fibromyalgia, pain, chronic fatigue, depression and anxiety disorders (Capel, 2017). The difference between fear and anxiety is that anxiety involves the expectation of future threat (APA, 2013). A fear response has a short duration and is focused on the present situation, whereas anxiety is defined by a longer duration of the emotional state of fear and is typically caused by negative expectations about future events and is usually more generalized, leading to excessive caution, which interferes with adaptive functioning and use of coping skills (Sylvers, Lilienfeld, & LaPrairie, 2011). Clark and Watson (1991) describe that anxiety is characterized by negative affect (NA) and physiological hyperarousal (PH). People with high levels of NA tend to have a negative perception of themselves and their environment, and have negative expectations of the future and of other people (Watson & Clark, 1984; Jeronimus, Riese, Sanderman, & Ormel, 2014). Due to the PH, which is a frequent or ‘constant’ stress response, people with high levels of anxiety often present ‘round up’ or agitated. 12 CHAPTER 1 Anxiety disorders According to the American Psychiatric Association (APA, 2013), typical anxiety responses can accumulate to an anxiety disorder when the anxiety symptoms are disproportionate to the actual danger or threat, are increasing and become permanent. This differentiates an anxiety disorder from the usual fear and anxiety that is experienced by every person in daily life to some degree. Anxiety disorders are believed to arise from specific psychological characteristics that result from genetic and neurobiological factors that interact with social factors (Hassink-Franke et al., 2012). This includes hypersensitivity to stress and the tendency to experience strong negative emotions (nervousness, sadness, anger), which implies high impact on quality of life. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association (APA), 2013) distinguishes between different types of anxiety disorders. The most common anxiety disorders are phobias, followed by social anxiety disorder (SAD), generalized anxiety disorder (GAD) and panic disorder (PD) (Anxiety and Depression Association of America [ADAA], 2018). Phobias refer to anxiety that is related to a specific stimulus, such as heights or spiders, often exist isolated and therefore usually don’t affect daily life in general. Other anxiety disorders usually have an impact on daily life, which is illustrated by the description of the main symptoms, based on DSM-5 classification (APA, 2013): -� People with SAD have a general intense anxiety towards social or performance situations. They worry that actions or behaviours associated with their anxiety will be negatively evaluated by others, leading them to feel embarrassed. This worry often causes people with social anxiety to avoid social situations. Social anxiety disorder can manifest in a range of situations, such as within the workplace or the school environment. -� People with GAD suffer from excessive anxiety or worry about a number of things such as personal health, work, social interactions, and everyday routine life circumstances. The anxiety can cause significant problems in areas of their life, such as social interactions, school and work. -� People with PD experience recurrent unexpected panic attacks. Panic attacks are sudden periods of intense anxiety that occur quickly and reach their peak within minutes. Attacks can occur unexpectedly or can be brought on by a trigger, such as a feared object or situation. People with panic disorder often worry about when the next GENERAL INTRODUCTION 13 1 attack will occur and actively try to prevent future attacks by avoiding places, situations or behaviours they associate with panic attacks. Worry about panic attacks, and the effort spent trying to avoid attacks, cause significant problems in various areas of the person’s life and may e.g. include the development of agoraphobia: fear for situations outside the home where leaving might be difficult or impossible in case they have panic-like reactions or other embarrassing symptoms. Although the anxiety disorders may have different triggers, they share underlying features (Cisler, Olatunji, Feldner, & Forsyth, 2010; Rosellini, Boettcher, Brown, & Barlow, 2015). An important feature that applies to all anxiety disorders is the exaggerated cognitive appraisal that is associated with the threatening situation: hyper-alert cognitive schemas lead to pathological anxiety (Beck & Haigh, 2014). Emotions are functional in daily life, guiding our attention to what is important and function as a signal to take action (Frijda, 1986). Emotions therefore support adaptive functions (Fresco, Mennin, Heimberg, & Ritter, 2013), although the cognitive labelling of the emotion is not always functional. Individuals with anxiety are believed to experience high levels of subjective emotional intensity (Mennin, Heimberg, Turk, & Fresco, 2005). Emotions and the regulation of emotions are part of a larger self-regulation system. Self- regulation, the ability to adapt behaviour to changes in the internal and external environment, is defined by Blair and Diamond (2008) as a dynamic process, influenced by behavioural, cognitive and emotional aspects. The individual uses cognitive processes to adjust and adapt emotions and behaviour, in order to maintain positive social relationships, productivity, achievement, and a positive sense of self (DIjkhuis, Ziermans, Van Rijn, Staal, & Swaab, 2017). Self-regulation is considered to consist of three components: stress regulation, cognitive regulation and emotion regulation (or social regulation). These three components influence each other through the overlap in the neurobiological systems involved. Anxiety disorders are associated with dysfunctions in self-regulation (Mennin, Heimberg, Fresco, & Ritter, 2008; Levine, Fleming, Piedmont, Cain, & Chen, 2016). Prevalence and impact of anxiety disorders Nearly 29% of the population will be affected by an anxiety disorder somewhere in life (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005). It is estimated that 12,5 % of 14 CHAPTER 1 women (one out of eight) and 7,7 % of men (one out of thirteen) in the Netherlands suffer from anxiety disorders (Dutch National Institute for Public Health and the Environment, 2017a). Anxiety disorders rank the second highest in terms of ‘Years Lost’ due to Disabilities (YLDs). The sum of YLDs, for people living with a health condition or its consequences, together with Years of Life Lost (YLL) due to premature mortality in the population, is a measure of Disability-Adjusted Life Years (DALYs). One DALY represents one lost year of "healthy" life and is a measure of the burden of disease; “the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability” (WHO, 2019). In the Dutch DALY order, anxiety disorders are the fifth, behind coronary heart diseases, strokes, diabetes and COPD (Dutch National Institute for Public Health and the Environment, 2018). The presence of an anxiety disorder is associated with a lower quality of life and a negative impact on psychosocial functioning (Cramer, Torgersen, & Kringlen, 2005; Mendlowicz & Stein, 2000). People with high levels of anxiety symptoms often show comorbidity: more than half of the people with anxiety disorders also suffer from symptoms of depression (Dutch National Institute for Public Health and the Environment, 2017b). In 2015, the costs of care for anxiety disorders in the Netherlands amounted to 807 million euro. In reality this amount may be (much) higher, since a considerable part of the costs spent on psychological disorders cannot directly be attributed to a diagnostic group (Dutch National Institute for Public Health and the Environment, 2018) and there are other related societal costs such as sick-leaves, job loss, etc., that are not included in the estimation. From the low percentage of people with GAD that receives treatment, which is only 43,5%, one can conclude that signalling and treatment can be improved. According to the Anxiety and Depression Association of America (ADAA), nearly 36% of people with SAD report experiencing symptoms for 10 or more years before seeking help (ADAA, 2018). In conclusion, the negative impact of anxiety disorders on quality of life is significant. Treatment of anxiety When a patient presents with anxiety symptoms, a general practitioner in the Netherlands follows a stepped-care treatment as prescribed by the Nederlands Huisartsen Genoodschap (NHG) in the NHG Standard for Anxiety treatment (Hassink-Franke et al., 2012). This stepped- GENERAL INTRODUCTION 15 1 care treatment of anxiety consists of successively: psycho-education, CBT, pharmacotherapy or a combination of CBT and pharmacotherapy. CBT is an evidence-based intervention for anxiety, focusing on the cognitive labelling. Originally introduced over 50 years ago by Aaron Beck (Beck, 1963; 1964; 1976), CBT aims to directly alter dysfunctional ways of thinking (e.g. irrational or automatic thoughts) and by that changing dysfunctional behavioural patterns or attitudes (Hofmann, Asmundson, & Beck, 2013; Carpenter, Andrews, Witcraft, Powers, Smits, & Hofmann, 2018). CBT is based on the theory that individuals can become more functional and adaptive by intentionally modifying their cognitive and behavioural responses to the circumstances they face (Dobson & Dobson, 2009; Dobson & Dozois, 2010). CBT is a structured, collaborative process that helps individuals to consider both the accuracy and usefulness of their thoughts through processes of exploration, examination and experimentation (Hollon & Dimidjian, 2009). According to Beck & Dozois (2011, p. 400): “patients learn how to become scientific investigators of their own thinking—to treat thoughts as hypotheses rather than as facts and to put these thoughts to the test. Patients learn to modify their thoughts so that they are congruent with existing evidence. They learn to shift their cognitive appraisals from ones that are unhealthy and maladaptive to ones that are evidence-based and adaptive”. The CBT intervention for anxiety aims to change maladaptive beliefs about the probability and magnitude of the anticipated harms by using behavioural (exposure) and various cognitive techniques (e.g. altering dysfunctional thoughts) (Hofmann & Smits, 2008; Smits, Julian, Rosenfield, & Powers, 2012). A recent systematic review in which the efficacy of CBT for anxiety-related disorders was examined, included 2843 patients (41 placebo-controlled trials) and showed small to moderate effects of CBT on anxiety symptoms and quality of life (Carpenter et al., 2018). Exposure strategies led to higher treatment success compared to cognitive or combined cognitive and behavioural intervention techniques. The authors conclude that since treatment effects are small to moderate, improvement of intervention can possibly be gained by exploring other treatment methods, especially for SAD and PD (Carpenter et al., 2018). Pharmacotherapy encompasses treatment with benzodiazepines, antidepressants, anxiolytics, antipsychotics or antiepileptics, with the overall aim of suppressing the physical sensations and feelings of anxiety and panic. 16 CHAPTER 1 Despite the proven effectiveness of CBT and pharmacotherapy (Hooke & Page, 2006; Pohl, Feltner, Fieve & Pande, 2005; Hofmann & Smits, 2008; Kjenisted & Bleau, 2004), it is estimated that 30%–60% of patients do not benefit from these interventions and still suffer from serious anxiety symptoms after treatment (Heldt, et al., 2003; Tyrer, Seivewright, & Johnson, 2004; Linden, Zubraegel, Baer, Franke, & Schlattmann, 2005; Zou, Ding, Flaherty, & Dong, 2013; Pelissolo, 2008; Katzman et al., 2014). Although generalized anxiety disorder (GAD) is associated with substantial personal and societal costs, the treatment success of GAD is lower than other anxiety disorders (Newman, Llera, Erickson, Przeworski, & Castonguay 2013). Possible explanations for lower treatment success are illustrated by a study on GAD, which showed that protocols are not always followed very well and that evidence-based treatments may not work for all subgroups (Van der Heiden, 2016). Furthermore, anxiety disorders have a recurrence rate of 54.8% within four years, (Scholten et al., 2016). When all steps of the stepped care treatment are taken and have not resulted in sufficient treatment effects, ‘the handicap model’ can be applied (Van Balkom et al., 2013). This includes low-frequency contacts with the emphasis on guidance, explanation and preventing complications in different areas of daily functioning, to support quality of life. Supporting interventions aim at reducing the influence of anxiety on personal functioning and reducing impending factors for psychological and pharmacological interventions (Van Balkom et al., 2013; Hassink-Franke et al., 2012). The arts therapies are classified as supportive interventions, according to the Multidisciplinary Guideline on Anxiety Disorders. Art therapy The domain of arts therapies include visual art therapy (referred to as art therapy), music therapy, dance/movement therapy, drama/speech therapy and psychomotor therapy (Federatie Vaktherapeutische Beroepen [FVB], 2018). The Zorginstituut Nederland (ZiN, National Health Care Institute) concluded in 2015 that the effectiveness of the arts therapies is insufficiently studied and that evidence for effectiveness of the therapies is largely lacking (Borgesius & Visser, 2015). However, the Trimbos Institute, the Dutch institute on mental health research, describes the arts therapies interventions as ‘’potentially effective treatments” that should be evaluated further (Van Balkom et al., 2013). GENERAL INTRODUCTION 17 1 Art therapy, the subtype of the arts therapies that uses the visual arts (e.g. painting, drawing, sculpting, clay modelling), is an experience-oriented therapy and is provided in clinical practice as standalone therapy or in multidisciplinary treatment programs for anxiety disorders. Within the multidisciplinary guideline (Van Balkom et al., 2013), art therapy is not part of the recommended treatments, because the evidence of effectiveness of art therapy for anxiety disorders cannot easily be judged, due to a lack of studies. Art therapy is considered an important supportive, but yet insufficient studied intervention for mental illness in general (Van Balkom et al., 2013). This is one of the reasons that art therapy is currently classified as supporting intervention, although art therapists, based on their clinical experiences, state that art therapy is not only supportive but may also directly reduce anxiety symptoms Perceived working mechanisms Based on clinical experience it is stated by art therapists that, because of its non-verbal character, art therapy can be suitable for individuals with anxiety, especially if they have difficulty in cognitive (re)labelling of their feelings, or if the opposite is the case: individuals that are very focused on cognitive labelling and use rationalizing as a psychological coping mechanism to deal with their anxiety (Gold, Vorack, & Wigram, 2004; Smeijsters, 2008). Moreover, the non-verbal AT approach is considered to be suitable for individuals with high levels of anxiety, since talking about anxiety and traumas can evoke fear and associated physical reactions (Posthuma, 2001). It is stated that ‘distance to the anxiety’ can be provided when creating visual artwork. To ‘distance’ oneself from the emotion during the act of creating art is believed to improve cognitive regulation of emotions (Smeijsters, 2008). The supposed mechanism is that during the process of creating an artwork, one can experience a feeling of being ‘in control’, which helps to counterbalance the overwhelming experience of anxiety (Van Gerven, 1996). Some studies have indicated a possible stress regulating effect of AT, by stimulating a ‘flow-like’ state of mind that is attributed to relaxation (e.g. Kaimal, Ray, & Muniz, 2016; Sandmire, Gorhan, Rankin, & Grimm, 2012). This implies that self-regulating processes may play a role in the reduction of anxiety symptoms through art therapy. However, the assumptions of working mechanisms seem to be merely based on anecdotal evidence and expertise and need further substantiation. 18 CHAPTER 1 Art therapy has a variety of subtypes, that are based on various perspectives from psychoanalysis, cognitive-analytic therapies, compassion-focused therapy, attachment-based psychotherapy and client-centered approaches, like mindfulness and mentalization-based treatments (British Association of Art Therapists [BAAT], 2018). Anthroposophic art therapy One of the AT variants with a client-centred approach and similarities with mindfulness-based treatments is anthroposophic art therapy (AAT). AAT is used in 28 countries (Hamre et al., 2009) and was developed by Dr. Margarethe Hauschka in the beginning of the 20th century as a part of anthroposophic medicine (Box 1) (Hauschka, 2004). The Dutch association of anthroposophic art therapists (Nederlandse Vereniging voor Kunstzinnige Therapieën [NVKT]) describes AAT as follows: “In AAT, specific artistic exercises are used that are supposed to provide new experiences and insights, and create an entrance for working on health and personal development” (NVKT, 2018). AAT (Box 2) is primarily an individual therapy, used in somatic and mental healthcare. The therapy is in line with the concept of ‘positive health’, in which health is not seen as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, as defined by the World Health Organization (WHO, 2006), but as the ability to adapt and self-manage (Huber et al., 2011) or, in other words: the ability of people to self- regulate physical, emotional and social life challenges. In this current definition of health, not only the physical and mental functioning is part of health, but also meaningfulness (a spiritual / existential dimension), quality of life (well-being, experiencing happiness, enjoying, balance) ANTHROPOSOPHIC MEDICINE is an integrative diagnostic and therapeutic concept, developed from 1921 onwards, as an addition to conventional healthcare and is practiced today in over 60 countries. It is based on Rudolf Steiner’s anthroposophy (IVAA, 2018), in which a human being is considered as a whole entity of body, mind/ soul, and individuality (Baars, Kiene, Kienle, Heusser, & Hamre, 2018). AM integrates conventional medicine with additional treatments, such as anthroposophical pharmacotherapy, massage therapy and arts therapies (visual arts, music, speech/drama and dance (eurhythmy)) (IVAA, 2018; Kienle, Albonico, Baars, Hamre, Zimmerman, & Kiene, 2013; Baars & Hamre, 2017). Box 1. Anthroposphic Medicine GENERAL INTRODUCTION 19 1 and social participation (meaningful relationships, social contacts, being accepted, social involve- ment, meaningful work). Although AAT has a long history and is developed through experience and clinical expertise, the evidence of its effectiveness and efficacy is unclear. Evidence based practice Since the 1990s, healthcare has been increasingly influenced by the development of evidence- based medicine (EBM). EBM was defined in 1992 as 'the process of systematically searching, assessing and applying contemporary research outcomes as the basis for clinical decision- making' (Evidence-Based Medicine Working Group, 1992). In 1996, the definition by David Sackett was extended with a role for the clinical expertise of the healthcare professional and with a value judgment by the patient (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Where the term EBM is reserved for medicine, the term evidence-based practice (EBP) is used for all care disciplines (e.g. psychotherapy, occupational therapy, physiotherapy, art therapy and speech therapy). EBP is about decision-making (Kuiper, 2004), and aims to encourage clinicians to make rational decisions based on three pillars (Lucas, 2015): 1) the patient's clinical condition and circumstances, 2) the patient's preferences and his behaviour in relation to the health problem, and 3) the best available external evidence for the treatment of the present clinical problem (Fig. I). The latter often means (but not exclusively) evidence obtained from scientific research. These aspects are integrated in the decision-making process (Lucas, 2015). ANTHROPOSOPHIC ART THERAPY uses an expressive approach (expression of emotions, feelings and thoughts), combined with an ‘impressive’ or inwardly oriented approach (Uitgeest, 2016). The client is guided to (sub- or unconsciously) express feelings and life experiences. The therapist provides structured artistic exercises with the therapeutic aim of improving the health and resilience of the individual. These exercises are often structured and provide ‘’impressions’’: profound experiences of color and shape. The underlying idea is that these impressions have both psychological and physiological effects and activate the self- regulating ability of the client (Christeller et al., 2000; Hauschka, 2004; Rolff & Gruber, 2015). Box 2. Anthroposophic Art Therapy 20 CHAPTER 1

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