A pilot study of arts therapy techniques to evoke emotional states in forensic patients

Highlights

• This study focused on emotional vulnerability in forensic patients.

• We used a 5-session protocol to evoke emotional vulnerability.

• Participants showed a significant increase in emotional vulnerability.

• The study provides some support for the effectiveness of arts therapies in forensic patients.

Abstract

There is little evidence on the effectiveness of arts therapy interventions in forensic settings. The aim of this study was to explore the effects of arts therapy in evoking emotional vulnerability in forensic patients. Participants received drama, art or psychomotor therapy. For each therapy, we used a 5-session protocol that consisted of an introduction session, an assessment session, an intervention session that deliberately aimed to evoke emotional vulnerability, a regular intervention session, and a wrap-up session. Emotional vulnerability was assessed with the Mode Observation Scale and the Schema Mode Inventory, which is a self-report. Participants showed a significant increase in emotional vulnerability in both intervention sessions. The self-report ratings indicated that there was no significant change in vulnerable emotions. Our hypothesis was only partially supported. The findings provide some support for the effectiveness of arts therapy interventions in forensic patients.

Introduction

Emotions are an important driver of human behavior, whether these emotions are positive (e.g., happiness) or negative (e.g., anger, shame, loneliness). The way we maintain, inhibit, and express emotional experiences contribute to an individual’s well-being and mental health (Balzarotti et al., 2016; Baumeister, 2016; Feldman-Barrett, 2016). Problems in emotional expression and/or regulation are a salient feature of many psychiatric disorders. For example, patients who suffer from mood or anxiety disorders or personality disorders often present difficulties in emotion regulation (Gratz et al., 2009; Kanske et al., 2012; Monson et al., 2004). These disorders are not only prevalent in civil psychiatric settings but also in forensic psychiatric settings. Problems in emotional expression or regulation are not only associated to psychopathology but can also be a result of, the involuntary nature of their admission to a forensic hospital. Patients may perceive their treatment as coercive which can arouse strong negative feelings. Patients may feel constraint of freedom and attacked in their feelings of autonomy and individual dignity, which may result in irritability and defensive aggressive behavior (Petrila, 2004; Sevecke et al., 2009). Forced treatment may exacerbate this. Patients’ perception of coercion may consequently lead to impaired therapeutic relationships and may hinder expression of vulnerable emotions (Levi et al., 2010; Veltkamp et al., 2008).

It has been suggested that difficulties in expression and regulation of emotions may be associated with violent behavior (Roberton et al., 2012; Roberton et al., 2014). For example, a recent study by Keulen-de Vos et al. (2016) showed that criminal behavior is often preceded by frustration and painful feelings (e.g., loneliness, abandonment, and vulnerability). Criminal behavior itself was typically characterized by excessive states of anger involving threats and intimidation (Keulen-de Vos et al., 2016). Given the risk posed by emotions and potential deficits in dealing with these emotions, addressing emotional states should be an essential component of (forensic) treatment.

Several therapeutic approaches, such as Emotion Focused Treatment (Greenberg, 2002), Schema Therapy (Young et al., 2003) and Cognitive Analytic Therapy (Ryle, 1995), focus on emotional states. Arts therapies also offer an outlet for exploration and expression of intense and diverse emotions. The emphasis is on the interplay between emotional expression and regulation with the ultimate goal of mastery of one’s emotions. “Arts therapies” is an umbrella term for drama, music⁵, art, and movement therapies, such as dance therapy and psychomotor therapy. Drama therapy is the intentional use of drama and theater processes by means of elements and techniques such as roleplaying, puppetry and masks (Emunah, 1994). Art therapy makes use of artistic visual expression of emotions by analyzing how an individual uses color, and/or arranges the material or tools at hand (e.g., clay, brush, paper) (Smeijsters & Cleven, 2006). Movement therapies focus on the interplay between emotions and movement (Zwets et al., 2016). Dance therapy makes use of improvisation on music, relaxation and synchronization techniques. Psychomotor therapy focuses more on bodily sensations and body awareness through a range of motion exercises. All kinds of arts therapies use experiential techniques to help patients access and reprocess emotions; they evoke feelings and explore interpersonal interactions using creative media (Malchiodi, 2000). Forensic settings⁶ in the Netherlands often provide various kinds of arts therapy.

Several studies show that arts therapies trigger or modify particular emotional states, such as emotional vulnerability or anger, or that they enhance its regulation. For example, in a study by Blacker et al. (2008), 62 prisoners who were convicted for violent offenses were treated with a 9-day based drama therapy based program in which drama therapy techniques were employed in combination with cognitive behavioral and anger management techniques. The program consisted of nine days that were structured into three 3-day blocks with two sessions per day. The first block focused on aggressive and violent behavior, block 2 on issues such as power and control, and block 3 was focused on exploring alternative behaviors. After treatment, significant reductions in self-reported anger were found with effect sizes ranging from −.79 to 1.13. (Blacker et al., 2008).

In a randomized clinical trial by Hakvoort et al. (2015), 13 primarily (but not exclusively) forensic patients⁷ with cluster B PD (i.e., antisocial, borderline, histrionic, or narcissistic PD) were randomly allocated to a 6-months music therapy anger management program (n = 8) or to 6- months of control therapy (n = 5) that consisted of a regular anger management program without music therapy. Patients were admitted to a high secure hospital. Results showed that the music therapy anger management program outperformed regular anger management therapy with regard to positive coping skills. Patients in both treatment conditions improved with regard to negative coping styles, social dysfunction and aggression, and self-management, however, no effect sizes were reported (Hakvoort et al., 2015).

Koch et al. (2015) evaluated the effects of a movement- and drama therapy based anti violence training in 47 prisoners. Upon completion of the training, participants reported an increase in body awareness but no decrease in anger. Movement analysis, however, did indicate a decreased immediate aggression potential (Koch et al., 2015).

Van den Broek et al. (2011) compared various arts therapies (i.e., drama, art, music, and psychomotor therapy) to psychotherapy over the course of 18 months of individual treatment in ten male forensic patients with personality disorders. In the arts therapy sessions, significantly more healthy emotional states were observed than in the psychotherapy sessions (van den Broek et al., 2011). Similar results were reported in a pilot study by Keulen-de Vos, Bernstein et al. (2017), Keulen-de Vos, Van den Broek et al. (2017). They examined the effects of a 5-session drama therapy program in a comparable sample of nine forensic patients. The program consisted of an introduction section, an assessment session, an experiential session to evoke emotional vulnerability, an experiential session to evoke anger, and a wrap-up session. Participants showed significantly more emotional vulnerability within the two consecutive experiential sessions when post-intervention scores were compared to baseline (pre-intervention) scores of the same session. Patients did not show an increase in anger after induction (Keulen-de Vos, Bernstein et al., 2017, Keulen-de Vos, Van den Broek et al., 2017).

These studies tentatively show the promise of arts therapy (programs) as a therapeutic resource in forensic patients with regard to changing and eliciting emotional states.

In a qualitative study of perceived effects of art therapy in the treatment of personality disorders, patients also reported that they experienced art therapy as an experiential therapeutic entry with a complementary quality to verbal therapy (Haeyen et al., 2015). Furthermore, they experienced art therapy as a more direct way to access emotions, which they attributed to the appeal of arts materials and art making to bodily sensations and emotional responses. Arts therapies may offer a specific pathway to more emotional awareness and constructive emotion regulation in forensic patients.

The current study is a follow-up on the study by Keulen-de Vos, Bernstein et al. (2017) and Keulen-de Vos, Van den Broek et al. (2017). We examined whether arts therapy techniques are able to deliberately evoke emotional vulnerability in the safety of therapy sessions with patients admitted to a high secure hospital. Recent research shows that criminal behaviour is often preceded by emotional states that refer to feelings of vulnerability, abandonment and loneliness (Keulen-de Vos et al., 2016). Also, vulnerable emotions seem to be involved in institutional transgressions in forensic settings (Keulen-de Vos, Bernstein et al., 2017). In line with the previous study, we defined emotional vulnerability as “an emotional state in which one feels vulnerable or overwhelmed with painful emotions such as anxiety, grief, or shame/humiliation” (Keulen-de Vos, Van den Broek et al., 2017, p. 81). We used a five session experimental protocol that consisted of an introduction section, an assessment session, an intervention session to deliberately evoke emotional vulnerability, a regular intervention session and a wrap-up session. Patients either received drama, art, or psychomotor therapy (PMT). We hypothesized a significant increase (i.e., large effect size) in vulnerable emotions (i.e., Vulnerable Child mode) in the session after the emotional vulnerability intervention was initiated. Furthermore, we hypothesized that the change in intensity of Vulnerable Child mode would be greater in this session compared to other sessions. Finally, we were interested in learning about the participants’ experiences with the study protocol. The aim of this study was to add to the literature on the effects of arts therapies in forensic patients.