Arts and psychomotor therapies in the treatment of personality disorders

Abstract

Personality disorders (PDs) are enduring and inflexible patterns of cognitions, emotions, interpersonal functioning or impulse control that lead to significant distress or impairments with an impact on a broad range of personal and social situations (American Psychiatric Association, 2013; National Center for Health Statistics, 2015).

Even though PDs are difficult to treat, both outcome studies and meta-analyses have shown that verbal psychotherapy is effective for reducing PD pathology, though its effectiveness is often incomplete (Budge et al., 2013; Cristea et al., 2017; Stoffers-Winterling et al., 2012, 2022). For example, their symptoms and psychosocial functioning remain impaired even after treatment (Chakhssi et al., 2021; Keuroghlian et al., 2013; Smits et al., 2020), and act as a risk factor for relapse, occurrence or recurrence of symptoms and interpersonal problems. Moreover, state of the art results say that both cognitive and psychodynamic therapies for PD are effective to a similar degree, even if they approach the problems from different angles. Treatments of psychodynamic orientation are mostly focused on changing patterns via conversation only, e.g., Mentalization Based Therapy (Bateman & Fonagy, 2004) and Transference Focused Therapy (Yeomans et al., 2015), though they ask patients to try with and adopt healthy behaviors in between sessions.

Other therapies, mostly from the third wave orientation, such as Dialectical Behavior Therapy (Linehan, 1993), Schema Therapy (Young, 1994) and Metacognitive Interpersonal Therapy (Dimaggio et al., 2020) add an experiential component, which includes mindfulness, skills training and behavioral emotion-regulation strategies, guided imagery and rescripting, role-play and chair work.

As described, PDs feature dysfunctions in multiple domains, e.g., identity problems, problems at work and in romantic relationships, risky behaviors and so on (American Psychiatric Association, 2013). Moreover, core pathology includes multiple elements, such as poor awareness of mental states, poor capacity to regulate emotions, problematic ideas about self and others and resort to maladaptive strategies to cope with psychological pain. Finally, PDs are comorbid with heightened levels of symptom disorders and behavioral problems (e.g., alcohol and substance abuse). We are then facing a complex form of psychopathology for which psychotherapy is only partially effective. It seems therefore necessary to adopt a wide array of strategies to tackle the different problems they present. As a consequence, current psychotherapeutic approaches may benefit from differently oriented therapies than only verbal approaches that may improve upon general treatment efficacy.

In this issue we will suggest that experiential practices such as creative arts therapies, psychomotor therapies and body work can be successfully included in the treatment of PD to increase effectiveness in patients whose treatment response has only been partial.

Arts and psychomotor therapies are forms of treatment for people of all ages with psychosocial and psychiatric problems. Arts and psychomotor therapists methodically use an action- and experience-based approach. Arts and psychomotor therapy includes art therapy, dance therapy, drama therapy, music therapy, body movement or psychomotor therapy, and play therapy. Besides in the mental health sector, arts and psychomotor therapies are also used in addiction care, forensic psychiatry, care for the intellectual disability, youth care, special education, rehabilitation, psycho geriatrics, nursing home care, refugee care, hospital care, welfare work and palliative care (Federatie Vaktherapeutische Beroepen [FVB], 2023). Art and psychomotor therapies use art, body awareness and movement as the primary mode of expression, alongside talking with an art therapist. It aims to reduce distress and improve social, emotional and mental health by promoting insight, self-compassion and a sense of agency and self-worth (British Art Association of art therapists [BAAT], 2023; FVB, 2023). Arts or psychomotor therapists support clients to use art, body awareness and movement to express and articulate often complex thoughts and feelings through art making. This may be difficult or traumatic experiences which may be hard to talk about (BAAT, 2023; FVB, 2023). Art and psychomotor therapists are credentialed mental health professionals. They are trained in a broad range of psychological theory and ways to use art media, creative processes, body awareness and movement to help people cope with mental health challenges (American Art Therapy Association [AATA], 2023; BAAT, 2023; FVB [Dutch Federation of Arts & Psychomotor Therapies], 2023). There is a growing body of evidence that arts and psychomotor therapies are effective interventions (e.g. AATA American Art Therapy Association, 2023; BAAT, 2023; FVB, 2023).

There are many reasons for including arts and psychomotor therapies in the practice of clinicians of any orientation working with PD. Personality pathology is surely sustained by explicit dysfunctional cognitions about self and others, for example: “I am a failure and people will judge me”, or “I am weak and fragile but I cannot ask for help because the others cannot be trusted”. But in parallel, these persons' problems are driven by automatism, patterns of behaviors, and of bodily attitudes they are unaware of. These persons tend to avoid, procrastinate, resort to drugs, compulsive sex, self-harm to sooth heightened levels of arousal they are unable to describe with appropriate emotion words. They are anxious but say “tense”, they act as if they were guilty but just say “I have to do it”. Moreover, their gesture, posture, prosody embody their attitudes: a patient with avoidant PD does not look others in the eyes, controls her emotional display, lowers her head and all these elements are likely to sustain a core image of self as flawed. As psychotherapy is focused mainly on conversation, these elements may be more difficult to address and then change.

Some authors have suggested that experiential work has the potential to tackle these elements of core PD pathology and change them (Centonze et al., 2023; Cheli et al., 2023; Dimaggio et al., 2020). As noted, we focus on the practices of arts and psychomotor therapies that are defined by the targeted use of nonverbal communication of thoughts and feelings by means of the artistic media of art, drama, music, dance and psychomotor elements such as movement and body awareness. Arts and psychomotor therapies have this experiential, action-directed and creative quality and make methodical and targeted use of a wide range of specific working methods or assignments, materials such as paint or clay, instruments like piano or percussion, materials like balls or mirrors, sometimes with a consistent structure, or sometimes in a less structured way. They both ask the person to act differently, the body is always involved in doing something different than usual. Using drawings, play, music, dance, focusing on bodily sensations or movement, provides leads to awareness and introspection which ultimately help discover and name a wide range of feelings, thoughts and reasons for behaviours the person was previously unaware of (Dimaggio et al., 2020; Haeyen, 2018).

These expressive, experience and body focused therapies are guided by a trained arts or psychomotor therapist. Arts and psychomotor therapies are aimed at the regulation of impulses and emotions, by addressing the problematic personal patterns in feelings, thoughts, acting and practicing with new roles and skills as described by the general quality mental health care (Akwa GGz, 2019), the American Art Therapy Association, the British Association of Art Therapists, the Dutch Federation of Arts and Psychomotor therapies (Federatie Vaktherapeutische Beroepen, 2017) and the Dutch multidisciplinary guidelines in the treatment of personality disorders (Federatie Medisch Specialisten, 2022; Haeyen, 2022). Beyond their capacity to foster self-awareness, the active and creative processes that are fueled by arts and psychomotor or body-based therapies, hold the potential to reduce symptoms and promote contact with formerly unexpressed areas of the self, and to enhance patients' well-being. These aspects are often linked to expressive or body processes: patients are invited and stimulated to act, dance, draw and this provides new insights through nonverbal channels. This elicits material the therapist will discuss with the patients and integrate in patients self-concept. Feelings, behaviour or themes can be explored even if they have not being firstly directly expressed in words (e.g., British Association of Art Therapists, n.d.; Haeyen, 2018; Malchiodi, 2012; Moschini, 2005; Schweizer et al., 2009). Sometimes elements of arts and psychomotor therapies can also be implemented in psychotherapy for PD by verbal therapists of other orientations. Elements such as drawings, playing or body-based work may be used as part of their practice (see Dimaggio et al., 2020). This requires certified training as the processes involved are specific, and require attunement skills and integrative knowledge in these domains.

Arts and psychomotor therapies and techniques can be as well implemented in residential treatments, day units or be included in outpatient sessions. They can be delivered to individuals and to groups, in a way that is customized and attuned to the individual or in inside structured programs. They are often embedded in multidisciplinary programs – based for example on Dialectical Behavior Therapy (DBT), Schema Focused Therapy (SFT), Mentalization Based Treatment or Acceptance and Commitment Therapy (ACT). For example, artwork may be used as an add on to SFT to better understand inner functioning. For example, the patient shapes clay figures that represent elements of their inner world. (Haeyen, 2022). When combined with DBT, these interventions are used to practice actively in the here-and-now mindfulness skills, emotion regulation skills or interpersonal skills. For example, the patient practices focused attention working with fluid art materials or practices emotion regulation bringing the tension level up and down again in playing the piano in a specific way (Haeyen, 2018).

In MBT arts and psychomotor therapies are used to practice mentalization which means to understand and make meaning of experiences of self and others by using the art or movement to talk about meaning and interpretations. For example an art object can serve as a symbol or anchor for safety that patients can then bring home and use as a reminder for the positive sensations and thoughts that emerged while creating it in the session. Music making, dancing or playing in dramatherapy can be a safe space for those who have trouble experiencing safe connections with others (Bateman & Fonagy, 2016). Fonagy et al. (2002) observe that patients with PDs greatly appreciate art therapy, particularly because it activates a mode of playfulness and it has the quality of “as-if”, so they feel free and secure to express their inner world and to reason about it. In Metacognitive Interpersonal Therapy (Centonze et al., 2021; Dimaggio et al., 2020) the therapist can also invite patients to adopt different body postures, play instruments or make drawings to let them discover new and healthy aspects of self-experience. The MIT-Group program includes role-play as routinely part of the programme (Popolo et al., 2022).

Haeyen (2022) offered a systematic review of current scientific evidence for arts and psychomotor therapy in regard to PDs. This review categorized the available international scientific studies in different levels of evidence and furthermore described other relevant studies and topics such as patient satisfaction and conditional aspects. These guidelines are to inform daily practice in treatment in The Netherlands.

The papers in this issue and the papers presented here show how arts and psychomotor practices can be suited at reaching different treatment goals and are based on a wide range of experiential orientations. The first paper concerns a case report on art therapy. Hinz (2024) used the Expressive Therapies Continuum (Hinz, 2020) as a guidance in the treatment of a woman with a narcissistic PD. This patient requested art therapy to deal with grief after the death of her partner of 12 years. The therapy process consisted of a gradual progression from cognitively dominated sessions to more effectively open processing. Art therapy encouraged integration of emotion through expressive writing, diagrams, and body mapping. The second case report concerns dance movement therapy (Harty, 2024) which focuses on the integration of different sides of self. The third case report (Kehr & Haeyen, 2024) concerns art therapy with a woman diagnosed with a borderline personality disorder, using the method of Imagery Rehearsal based Art Therapy, previously developed by Haeyen and Staal (2021), focused. on treating posttraumatic nightmares. The fourth case report is about making meaning of one's own life story in words and images (Haeyen et al., 2024), a co-created paper with a client diagnosed with unspecified personality disorder and traits of borderline personality disorder, clinical psychologist and art therapist. This case report focuses on personal recovery from early childhood trauma through the interventions ‘An Empowering Story’ and Art Therapy. The fifth case report focuses on the use of drama therapeutic work with a male offender of domestic violence in a forensic outpatient setting (Van den Broek, 2024). The sixth case report (Van Sprang & Haeyen, 2024) concerns music therapy, how the change through musical interventions is viewed from therapist perspective. The seventh and last case report (Passarella et al., 2024) is on using body-focused work to overcome dependent issues in a woman treated with Metacognitive Interpersonal Therapy (Dimaggio et al., 2020). With these descriptions we hope to have offered a multicolored pallet of options, knowing that there is so much more to know and to explore.