Arts-based therapies are often used to supplement more “traditional” eating disorder treatment protocols in various different settings, ranging from individual therapy to inpatient units. However, as Frisch, Franko & Herzog (2006) note, no published research provides empirical support for the use of arts-based therapies for eating disorder treatment.
You might be wondering: if there is no empirical support, why are clinicians still using these therapeutic practices? You might also be wondering why I’ve chosen to dissect an article from 2006.
I’ll address the first question in this post (teaser: it’s really hard to say!). As for my delving back into the depths of academia, there is surprisingly little literature that touches on arts-based therapy, despite its continued use. This article provides an overview of why this might be, and where we can go from here.
WHAT IS ARTS-BASED THERAPY?
Arts therapy is an umbrella term used to refer to the “medicinal use of creative arts,” including dance and movement, drama, music, and visual arts. The premise of arts-based therapy is that engaging with the arts will facilitate clients’ achievement of positive change and personal growth.
Arts therapies don’t often stand alone; even at their roots they are linked to a number of psychological or developmental theories, which inform the shape they take. Accordingly, these therapies vary widely in both their underlying assumptions and their implementation. I wrote about dance/movement therapy here; other types of arts therapies include music therapy, creative arts therapy, and drama therapy.
WHAT EVIDENCE DO WE HAVE FOR THE USE OF ARTS-BASED THERAPIES?
In short, not a whole lot. As the authors suggest, what literature does exist on this topic is largely in the form of case studies and theoretical discussions. Fewer articles take an outcome focus, particularly for eating disorders.
There is some support for the use of arts-based therapies for groups of trauma survivors, as well as for psychiatric patients. However, these studies have mixed results. Positive outcomes for psychiatric patients have included better relationships with oneself and with other. For trauma survivors, there has been some encouraging research suggesting improvements in symptoms.
These outcomes are unlikely to generalize to eating disorders. Resultantly, Frisch et al. sought to find out more about the use of arts-based therapies for eating disorders, in an effort to guide further research in this area.
Review of the Literature
The authors used 2 techniques to survey the landscape of arts-based therapies for eating disorders in North America. They sent out a survey of various types of therapy and their use for eating disorder treatment, assessing what treatment programs are currently using; they also conducted a thorough search of the literature.
The authors found 30 papers dealing with the use of arts therapies for AN, BN, or BED. Of these:
- 17 discussed arts-therapies in general
- 8 discussed music therapies
- 5 discussed dance therapies
HOW ARE ARTS-BASED THERAPIES USED IN EATING DISORDER TREATMENT?
Music Therapy (MT)
Articles explored the use of music therapy for self-discovery or relaxation purposes. Some examples include:
- Background music used to facilitate meditation exercises
- Music played during mealtime to alleviate anxiety
I found this second point interesting; I had never considered music during a meal in the treatment context as “therapy,” but I suppose it could qualify.
- Having patients listen and/or sing along with a song, and then examine or discuss the lyrics in relation to oneself
A unique example touched on the combination of CBT and music therapy. In this context, music is used to help clients to challenge cognitive distortions through creating music. For example, in one treatment setting, patients created and performed a “recovery rap” (Hillard, 2001).
Dance/Movement Therapy (DMT)
In dance therapy, movement is used to help patients become more connected to their bodies and (in theory) transcend gaps between body image distortions and reality. The authors suggest that DMT is promising because “the body is a central battleground in eating disorders” (p. 135). The links between body and mind are highlighted, such that work with the body will lead to changes in the mind.
Generally, DMT is linked to psychotherapy; dance therapists may work with patients considered to be in a “preverbal stage” to overcome body issues. To be honest, I didn’t love the way that this was framed in the article; the authors make a statement about eating disorder patients who are “emotionally stunted.”
I also wonder about the body-image focus, and the idea of real vs. ideal self; as I’ve written about before, there are some issues with the idea of body image as a real “thing” that all individuals have. However, it is possible that being in one’s body and exploring it’s potential through movement may have positive effects related or unrelated to body image.
Some examples of DMT exercises include:
- Relaxation and centering
- Mirroring movements of others
- Facing mirrors
- Having clients reflect on experiences of a movement session (often through drawing)
- Videotaping body movement and then reflecting/critiquing
Blanche Evan (1991) created a form of DMT based on psychoanalytic theory that links a sense of the body to feelings, in an effort to establish “psychophysical unity,” or a better sense of linkage between body and mind.
Creative-Arts Therapy (CAT)
“Creative-arts therapy” encompasses a number of arts-based therapies including drama, role-playing, drawing, painting and sculpture. CAT is the most widely employed, but also the most varied, arts-based therapy. Commonly, CAT centers around generating insight through the use of symbolism.
A few examples of CAT include:
- Diagnostic drawing, where patients examine and/or interpret drawing structure and content
- Role playing
In some instances, CAT techniques are based in developmental psychology, and explore the root causes of eating disorders from early childhood using role-play and dramatization in order to help patients develop insight into the development of their disorder. Much like DMT, CAT is often theory-driven (developmental psychology in the case of CAT; body-image based in the case of DMT), which informs the approach it takes.
In another approach to CAT, those using phenomenal and nonphenomenal body image tasks (PNBIT; Rabin, 2003) look at the role played by self-esteem in the development of eating disorders. PNBIT looks very similar to body image interventions employing dance and movement, in that participants perform a number of arts-based tasks to narrow the gap between “real” body image and an internalized sense of one’s body.
Drama therapy has also been used in eating disorder treatment, for example through role-play. Some suggest that this form of therapy may lead to improvements in both communication and functioning (e.g. Jacobse, 1994).
WHO IS USING THESE THERAPIES?
Twenty-two programs met the authors’ criteria: residential treatment programs treating AN, BN or BED in North America. Of these, the authors obtained data from 19 (13 responded to their survey, and data from 6 was found on the Internet via publicly-available information). Surveys assessed the structure and implementation of the treatment program, with 4 of 30 questions asking specifically about arts therapies.
19 programs used arts-based therapy at least once per week
- BED programs had a 90.55% client participation rate (CPR)
- AN/BN programs has a 99.21% CPR
26% of programs had daily arts-therapy; these programs had 99.38% attendance
The amount of time per patient per week spent on arts-based therapy varied widely depending on the treatment program; 2 outliers spent over 10 hours per week on arts therapies, and thus were removed from the data set in order to calculate a representative average. Of the remaining 17 programs, an average of 2.8 hours per week per patient was reserved for arts therapy (not counting dance/music).
Programs endorsed a number of reasons for using arts therapies, including:
- Addressing challenging issues e.g. self-esteem, body image, depression, isolation
- Providing a “healthy outlet for expression of emotions and development of positive coping skills”
- Giving access to non-threatening, alternative therapies
- Facilitating change for those who have difficulty with more traditional forms of therapy
Reviewing these results, it becomes clear that despite lack of empirical studies, many programs still use arts-based therapies. The concept of “empirical validity” is not a simple one, when applied to arts therapies: there is no standard way of using these therapies, and arts-based therapies tend, by nature, to be individualized, and hard to accurately assess and measure.
The authors of this study suggest using several smaller randomized controlled studies assessing arts-based therapies, given the extent to which they are used in residential treatment programs. Given the difficulties associated with measuring these therapies, and the fact that they are almost always used in conjunction with other therapies, I have to wonder whether it would be possible to design a randomized controlled study that both isolates the effects of arts-based therapies and also holds real-life, clinical implications?
Arts-based therapies may themselves be at odds with the very idea of standardization. As the authors note, “standardization of arts-based therapies for the purpose of study may undermine the inherent therapeutic benefits” (p. 138). They raise the question of whether evidence-based and best practice are synonymous, a question I’ve often pondered myself.
While it is obviously not practical in many treatment settings to individualize treatment, it is also incredibly difficult (if not impossible…) to establish a program of treatment that will work for all individuals with eating disorders (see this post for more detail on this point).
So, what is the point of using arts-based therapies, if there is no evidence base to back them up? The service providers’ survey responses in this study speak to the potential value of providing an alternative means of treatment for those who do not respond to more “traditional” approaches.
I certainly think there is value in exploring new and creative ways to engage, but I am torn between an endorsement of the value of individualized treatment and the practicality of group-based, homogenous treatment strategies. The existence and widespread employment of arts-based therapies is in itself encouraging, in a way; providers are eager to reach as many patients as possible, through a multi-disciplinary approach to treating eating disorders.
We are still unsure how best to treat eating disorders, and we need to engage with complex ideas and complex solutions. Why not include the arts among these complex solutions? Nonetheless, there is still a need to better understand and be explicit about the theories and values underlying these approaches.
Frisch, M.J., Franko, D.L., & Herzog, D.B. (2006). Arts-based therapies in the treatment of eating disorders. Eating Disorders, 14 (2), 131-42 PMID: 16777810