May/June 2015 Issue

Beyond Talk — Creative Arts Therapies in Social Work
By Kate Jackson
Social Work Today
Vol. 15 No. 3 P. 22

When words fail, these therapies are often a conduit to the hearts and minds of clients who cannot verbalize their emotions.

There's no human endeavor that can't be improved with a little creativity, and social work is no exception. While social workers can draw upon any number of talk therapy techniques to help their clients, there are times when talk isn't helpful or can't be summoned. In such cases, the arts can open a back door to the psyche, drawing from individuals that which they cannot yet put into words, thus catalyzing subsequent therapeutic conversations. Creative arts therapies involve the use of the arts—visual art, music, dance and movement, drama, and poetry—to facilitate therapeutic goals.

According to photographer Marianne Gontarz York, MSW, LCSW, "Eighty percent of sensory stimuli enters through our eyes and goes into our brains where it is retained visually, nonverbally. Most of us think, feel, and recall memories not in words but in imagery. These images become a verbal language when we attempt to communicate what is going on in our mind to someone else." The creative arts, Gontarz York says, "offer our social work clients a nonverbal way of expressing themselves and communicating their needs. These adjunctive therapies are invaluable in allowing people to express themselves when words cannot."

In addition to facilitating communication, the arts also help clients forge relationships. "Creative arts therapies are wonderful starting grounds for building a verbal and nonverbal trusting relationship between a client and therapist and in group therapy between members of the group," says Sally Bailey, MFA, MSW, RDT/BCT, a professor and director of the drama therapy program in the School of Music, Theatre and Dance at Kansas State University. "Working together on a project—whether that is a drama game, a mural, a song, or a group poem—creates connections that gently allow clients to reveal parts of themselves to others for a richer interpersonal knowledge."

While creative arts therapies aren't necessarily or entirely nonverbal, they recognize that talking isn't always the best way to communicate, and, as a result, encourage and facilitate self-expression and active participation without depending entirely on a verbal articulation of issues. "The arts therapies provide a complement to traditional 'talk therapies' because they can address the full range of human experience—cognitive, behavioral, and affective domains," says Nicholas F. Mazza, PhD, dean and Patricia V. Vance professor of social work in the College of Social Work at Florida State University. These approaches, he says, are being increasingly used in social work practice because the evidence for their usefulness has grown and been demonstrated by clinical reports and by qualitative and quantitative studies.

Though there's growing interest in creative arts therapies among social workers, the techniques are not new. Arts therapies are "old human technology that has been used as long as there's been art," observes Shelly Goebl-Parker, MSW, LCSW, ATR-BC, program director of the art therapy counseling program in the department of art and design in the College of Arts and Sciences at Southern Illinois University Edwardsville. Indeed, the healing power of the arts was well known in ancient Rome and Greece.

"The arts have a long history in the practice of social work going back to the settlement house movement in the late 19th century," Mazza says. "Through the years, the arts have been incorporated as adjunctive techniques in individual, family, group, and community practice."

Any of the creative arts modalities may be used as a primary form of therapy or an adjunct to other modalities to improve the physical, cognitive, and psychosocial well-being of individuals with psychiatric disorders, developmental disabilities, neurological diseases, physical disabilities, and medical conditions, and may be practiced in the entire spectrum of therapeutic settings.

Art Therapy
According to the American Art Therapy Association, art therapy is "the therapeutic use of art making, within a professional relationship, by people who experience illness, trauma, or challenges in living, and by people who seek personal development. Through creating art and reflecting on the art products and processes, people can increase awareness of self and others; cope with symptoms, stress, and traumatic experiences; enhance cognitive abilities; and enjoy the life-affirming pleasures of making art." Registered art therapists are credentialed by the Art Therapy Credentials Board of the American Art Therapy Association after obtaining a master's degree in art therapy and gaining supervised postgraduate clinical experience.

There's no client who can't be helped by art therapy, Goebl-Parker says—not even the blind. That, she suggests, is because art is felt as well as seen. "Art therapists really can be anywhere; any setting in which it would make sense that there would be a therapist or a counselor is where art therapy can be helpful. For example, it's increasingly used, she says, in substance abuse, where it can help provide the motivation for treatment." Goebl-Parker uses it "as a way to crystalize for clients what they can get out of therapy so they can stay committed to something and to help people locate their own impetus for change."

One of the leading strengths of art therapy rests in its ability to harness the power of the metaphor. "There's a huge range in how it's used," Goebl-Parker says, noting it might be "a metaphor of the material engagement—what it feels like to have your hand in the clay bucket—or the story of the object one makes." Children in a session may be nonverbal, but in the process of "messing around with materials" they create clear metaphors for what they're experiencing that can later be discussed. "So people who would have a hard time doing that work verbally can work in metaphor and the materials become an adjunctive way for them to have language, to have a different kind of voice," Goebl-Parker says.

An offshoot of art therapy that's increasingly popular is phototherapy. "Photo therapy techniques can be used for most psychotherapy situations, and there are numerous applications for different age populations and diagnostic groups, such as adolescents, people with schizophrenia, abuse survivors, and bereavement groups," explains Gontarz York, who describes herself as a "lifelong gerontological social worker" who finds photographs to be powerful therapeutic tools.

While phototherapy can be useful with any population, Gontarz York uses it chiefly to elicit memories for reminiscence and life review work with older adults.

"Everyday photographs, found in albums and boxes, framed by the bedside, mounted on walls, posted on mirrors and refrigerators, offer social workers wonderful opportunities to begin conversations, develop relationships, and offer older adults the opportunity to engage in meaningful interactions through reminiscence and life review." Every photograph, she explains, is a self-portrait, a window into the inner world of the client. "As clients discuss their photographs, we receive a fuller understanding of who that person is and how they perceive their world," Gontarz York says. "Besides being a lasting memory of lives and actions, photographs document the past and contain valuable information regarding relationships and personal values," she adds.

Drama Therapy
Drama therapy relies on a range of techniques to meet numerous therapeutic goals and outcomes, including, according to the Drama Therapy Association, the ability of clients to tell their stories, rehearse desired behaviors, practice relationship skills, set goals, improve interpersonal skills, achieve catharsis, appropriately express feelings, and perform the change they wish to be and see in the world. Among the drama techniques yoked to other methods of therapy to achieve these goals are storytelling, role-playing, improvisation, performance, and the use of puppetry and masks.

Among its many uses, "Drama therapy is spot-on for working with recovering addicts," Bailey says. "Addicts are afraid of feelings and have been numbing their feelings out for years with their substances of choice. Drama therapy is all about experiencing and expressing feelings, but it tends, especially in the beginning, to be fun, so addicts can work on slowly learning how to feel again, and feel with other people, without becoming stressed and feeling the urge to get high." As with other creative arts therapies, an especially powerful aspect of drama therapy rests in its ability to promote relationship building, and its nonthreatening nature encourages participation. "Drama therapy, because it generates strong bonds of trust, helps addicts work on their fears of getting close to others, asking for help, and wanting to give and take in a relationship," Bailey says.

Another group of clients for whom drama therapy can be particularly helpful are those on the autism spectrum who have difficulty understanding and expressing emotion, Bailey says. "Drama therapy," she adds, "provides lots of practice on these nonverbal as well as verbal communication skills. It creates trusting relationships and provides training in give and take as well as flexibility—very needed abilities for people on the spectrum." What's more, she says, it's fun, so it's easy to motivate people to participate.

A registered drama therapist is a master's-level credential administered by the North American Drama Therapy Association (NADTA) to individuals who have completed courses in psychology and drama therapy as well as two clinically supervised internships and 1,500 hours of work experience coupled with theater experience. Candidates have either attended an accredited drama therapy master's program or completed the NADTA Alternative Training Program under the mentorship of a board certified trainer.

Poetry Therapy
Mazza, founding (1987) and continuing editor of the Journal of Poetry Therapy, who is working on the second edition of his book, Poetry Therapy: Theory and Practice (2003), defines poetry therapy as "the use of language, symbol, and story in therapeutic, educational, and community building capacities." It's effective, he says, "with a wide range of populations, from children to elders, and with a broad range of problem areas, including family violence, homelessness, death and loss, and suicide." For example, it's used within social work practice, he explains, when therapists employ poetry and creative writing to work on positive youth development with middle school children or when working with veterans and their families. A collaborative poem may be a helpful tool in gerontological social work, he observes, while a dyadic poem may help facilitate couples/marital therapy.

Poetry therapy, which, according to the National Association for Poetry Therapy (NAPT)—established in 1969 as the Association for Poetry Therapy and formally incorporated as NAPT in 1981—has been a recognized healing art in the United States for more than 200 years, is a means through which individuals—such as those navigating grief or living with depression or cancer—can find voice for their feelings and a medium through which to participate in the therapeutic process.

Among its strengths, says Mazza—the reasons poetry therapy may succeed where other traditional therapies may not—is that it is culturally sensitive and nonthreatening and thus able to "break through resistance, validate, and promote interaction." Through practice and research, Mazza identified three major domains of poetry therapy—introducing a poem into the practice session (bibliotherapy tradition), promoting focused expressive writing (well documented health benefits), and utilizing symbolic or ceremonial activities to aid in life transitions. Furthermore, he says "it's consistent with the strengths perspective but easily adaptable to a wide range of theories, e.g., cognitive-behavioral, narrative, systems, and psychodynamic."

The International Federation for Biblio-Poetry Therapy provides credentials for poetry therapists. Certified poetry therapists and registered poetry therapists are master's-level credentials obtained after completion of an approved program of didactic training, experience, and supervision.

Music
Of all the creative arts therapies, music therapy may be most familiar to the public, having received the lion's share of media attention. It's been widely acknowledged as an especially useful therapeutic modality ever since it was used to help World War II veterans with brain injuries. More recently, a spotlight shone on the successful marriage of music and therapy in the months after the tragic shooting of former Arizona Congresswoman Gabrielle Giffords. Because the injury damaged the left side of her brain—the part of the brain that controls speech—the shooting rendered the congresswoman aphasic. Thanks in large part to music therapy, which research has shown can help rewire the pathways in the brain, Giffords was able to progress gradually from singing to speaking once again. It's a phenomenon highlighted as well in the Oscar-winning film "The King's Speech," in which music therapy helped King George VI of England, a lifetime stutterer, find his fluent voice.

Oliver Sacks, perhaps the most well-known proponent of music therapy, observes that music, like scent, can not only tap long-buried memories but also help propel locomotion, thus making it an especially a valuable tool in the treatment of aphasia, Parkinson's disease, and dementia. In his 2007 book Musicophilia: Tales of Music and the Brain, Sacks points to the healing power of music in cases of Tourette's and Williams syndromes, seizures, and more.

Board certified music therapists are required to have completed a bachelor's degree or higher in music therapy from a program approved by the American Music Therapy Association and 1,200 hours of clinical fieldwork.

Dance/Movement Therapy
Dance/movement therapy, defined by the American Dance Therapy Association (ADTA) as the "psychotherapeutic use of movement to further the emotional, cognitive, physical, and social integration of the individual," and reflects a core social work value in its emphasis on meeting clients where they are. Everyone can meaningfully participate, regardless of his or her level of physical or cognitive functioning, and it's not necessary for clients to be able dance to reap the benefits.

"Movement is the medium of dance/movement therapy the way water is the medium for swimming," says Donna Newman-Bluestein, BC-DMT, adjunct instructor of dance/movement therapy at Lesley University in Cambridge, MA, and official spokesperson for the ADTA. Dance/movement therapists, she says, use dance, expressive movement, and words as the means to engage, interact, and heal. This type of therapy, she says, is healing chiefly because it "engenders a feeling of connectedness to another person; call it bonding or a sense of belonging—this is essential for health and well-being."

The arts, says Newman-Bluestein, "teach us a great deal about values, about life, about getting along, about balance, and health. The dominant culture has values that I would consider upside-down. Even though no more than 35% of what we express when we speak is verbal, the nonverbal is ignored. For people with cognitive issues, the nonverbal is of the utmost importance. The expressive arts therapies in general are something they can excel at and grow in."

The entry-level credential, R-DMT (registered dance/movement therapist), is based on completion of a graduate-level dance therapy program approved by the ADTA and 700 hours of supervised clinical fieldwork and internships. Board certification requires an additional two years of paid clinical employment supervised by a licensed/registered mental health professional.

A Role for Social Workers
"Social workers may want to explore these approaches because they are consistent with the values and principles of the profession. There is no question about the need for scientifically validated and evidence-based approaches to practice," Mazza says. "However, it is equally important to recognize that social work is an art and it is imperative for social workers to recognize their clients' unique history, strengths, and culture. The arts offer the means to reach and validate clients by allowing them to, "tell their stories," in a variety of ways. "This is a respectful and strengths-based approach."

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.

RESOURCES

Training
Based on continuing education programs/workshops, social workers can learn to use arts-based techniques in adjunctive capacities and integrate them within their own theoretical orientations and professional boundaries. While some social workers may refer clients to credentialed arts therapy practitioners, they may also consider further education to allow them to obtain credentials to broaden their skill sets and use these therapies in their own practice. In many cases, it isn't necessary to obtain a second degree in order to become a certified arts therapist. Many degree programs approved by the American Music Therapy Association, for example, offer a degree equivalency program so that those with bachelor's degrees in other fields can become certified without obtaining a second bachelor's degree. And the North American Drama Therapy Association offers an Alternative Training Program that allows individuals with related master's degrees, such as social work degrees, to complete individualized learning programs leading to credentialing. The American Dance Therapy Association's Alternate Route similarly gives master's-level individuals a simpler path to gaining credentials. Further information about education and credentialing is available from the organizations listed below.

Organizations

• National Coalition of Creative Arts Therapies Associations: www.nccata.org

• American Art Therapy Association: www.arttherapy.org

• American Music Therapy Association: www.musictherapy.org

• North American Drama Therapy Association: www.nadta.org

• American Dance Therapy Association: www.adta.org

• National Association for Poetry Therapy: www.poetrytherapy.org

• International Federation for Biblio/Poetry Therapy: www.ifbpt.org

Publications

• American Journal of Art Therapy

• American Journal of Dance Therapy

• Arts & Health: An International Journal for Research, Policy and Practice

• The Arts in Psychotherapy

• The Drama Therapy Review

• International Journal of Arts Medicine

• Journal of the American Art Therapy Association

• Journal of Creativity in Mental Health

• Journal of Music Therapy

• Journal of Poetry Therapy

• Phototherapy Journal

• PhotoTherapy Techniques: Exploring the Secrets of Personal Snapshots and Family Albums, by Judy Weiser