The Arts in Psychotherapy

Background and rationale

Art therapy has historically privileged and perpetuated Eurocentric and Western perspectives on art, art media, and psychotherapy (Arslanbek et al., 2022; Kaimal & Arslanbek, 2020; Leone, 2021; Napoli, 2019; Talwar et al., 2004). Art therapists have been taught to interact with clients using art media largely found within the Western definition of fine arts (e.g. painting and drawing materials) (Kaimal et al., 2017; Leone, 2021). As a result, in parallel with Western distinctions between what is considered art vs. craft, non-Eurocentric media including craft materials and processes have been historically devalued and dismissed in the profession (Leone, 2021). These distinctions have also often been related to biases around gender, race, and social class.

How do we distinguish between indigenous and traditional arts practices? Indigenous arts practices refer to artforms rooted within “a specific community located in a geographical region, including those with a heritage of artwork that might be sacred with depictions of belief systems, spirituality, and community history” (Kaimal, 2022, p. 52). Traditional practices may not be tied to a specific cultural community, but rather artforms passed down across time among family or loved ones (e.g. quilting). In clinical practice, encouraging the client’s preferred/self-selected artistic practices in art therapy may provide “a potential point of entry” in forging an authentic therapeutic relationship (Kaimal et al., 2017, p. 88). Such processes may be more approachable, meaningful, and culturally relevant to many with whom art therapists work (Leone, 2021). In the United States, members of the art therapy community have advocated for decolonized, more culturally relevant (not misappropriated) practice (Napoli, 2019; Talwar, 2019). Ethically incorporating heritage arts practices into art therapy services could lead to better care and understanding (Arslanbek et al., 2022). Research on the applications of indigenous and traditional arts to art therapy practice is however scarce.

A key commonality between indigenous and traditional arts prac- tices is that they are shared between generations and exhibit cultural significance. Thus, we assert that both indigenous and traditional arts practices should be conceptualized as valuable heritage arts practices with significance for the discipline of art therapy.

Measures

Participants completed the following measures immediately before and after each session. Interventionists asked participants to respond to the questionnaires based on how they perceived the various constructs in the present moment.

Anxiety. Participants completed the Patient-Reported Outcomes Mea- surement Information System (PROMIS) Anxiety Short Form 4a to self- report indicators of anxiety (PROMIS Health Organization & PROMIS Cooperative Group, 2008–2012). This measure is comprised of 4 ques- tions about symptoms of anxiety on a 5-point Likert scale with answers ranging from 1 “never” to 4 “always.” The PROMIS Anxiety Short Forms appear to exhibit strong reliability, with Cronbach’s alpha ranging from 0.96 to 0.97 when used with diverse respondents (Teresi et al., 2016).

Mood and affect. Participants completed the Positive and Negative Affect Schedule (PANAS) to self-report their mood and affect (Watson et al., 1988). This measure has 20 items, 10 of which indicate positive affect (PA) and 10 of which indicate negative affect (NA). Using this questionnaire, participants self-report mood/affect using a Likert scale ranging from 1 “very slightly or not at all” to 5 “extremely” for each item. Alpha reliability scores indicate reliability between 0.86 and 0.90 for items representing PA and 0.84–0.87 for items representing NA. Items indicate strong factorial validity, and the measure exhibits strong external validity.

Perceived stress. Participants rated their perception of stress using The Perceived Stress Scale (PSS) (Cohen et al., 1983). This 10-item self-report measure asks about the frequency of stress they experience and their ability to cope with those stressors using a Likert scale ranging from 0 “never” to 4 “very often.” When tested with three samples, the PSS’s reliability coefficient alpha ranged from 0.84 to 0.86 and items appear to correlate with constructs representing stress.

Self-efficacy. The General Self-Efficacy (GSE) scale (Schwarzer & Jeru- salem, 1995) is a 10-item self-report measure that allows participants to rate perceived self-efficacy. Each item outlines an aspect of self-efficacy and participants rated their perceptions of each item using a Likert scale ranging from 1 “not at all true” to 4 “exactly true.” The scale exhibits strong validity and internal reliability, with Cronbach’s alpha’s ranging from 0.76 to 0.90.

Creative agency. Researchers adapted the Creative Self-Efficacy and Identity scales (Beghetto, 2006; Tierney & Farmer, 2002) to measure creative agency. This adapted scale consisted of 5 items which asked participants to rate aspects of their creative agency using a Likert scale ranging from 1 “not true” to 5 “very true.” Psychometric properties of this adapted scale are not available.

Arslanbek et al. (2022) conducted a study on art therapists’ perceptions of the value and application of heritage arts practices in art therapy practice using a grounded theory design. The researchers interviewed twenty-one art therapists and expressive arts therapists from around the world who applied indigenous and/or traditional art practices to their clinical work and/or provided art therapy services to indigenous communities. Findings informed an ecological model based on four themes: “1) indigenous and traditional artforms are deeply embedded in the cultures from which they emerge. 2) although not al- ways, indigenous and traditional practices are often familiar and rele- vant to the client who [has] cultural resonance with the artistic practice.

3) there are distinct art media qualities which make traditional arts more suitable in certain settings and for certain therapeutic goals. 4) [these] qualities make indigenous and traditional art practices more suitable to address historical trauma, explore cultural identity, and increase connectedness to one’s roots” (p. 3). The researchers discuss the importance of reflective practices, not making assumptions about artistic preferences based on cultural background, partnering with community leaders, and understanding the trauma of cultural oppres- sion and genocide when considering using such materials and practices in art therapy settings.

Our previous qualitative studies indicate that heritage artforms may offer “strength and inspiration” for communities experiencing oppres- sion in times of stress (Kaimal, 2022, p. 58) and are a potential com- munity and resource for health and well-being (Arslanbek et al., 2022; Kaimal & Arslanbek, 2020). However, much remains unknown about the use of indigenous and traditional artforms in contemporary art therapy practice. This study seeks to address this gap by examining the impact of heritage art practices on psychosocial well-being. The aim is to better understand these artforms’ therapeutic benefits and situate them in an informed, ethical, and respectful contemporary art therapy prac- tice. We conceptualize heritage practices (indigenous and traditional arts practices) as having embedded and implicit psychosocial impact.

Defining Well-being

Definitions of well-being vary according to discipline, though most scholars agree that the concept is multi-dimensional, incorporating various aspects of one’s life (Jarden & Roache, 2023). The American Psychological Association (2018) defines well-being as “a state of happiness and contentment, with low levels of distress, overall good physical and mental health and outlook, or good quality of life” (para. 1). Psychosocial well-being expands beyond physical and mental well- ness and includes social, economic, cultural, and spiritual dimensions of health as well (Kumar, 2020). We recognize that well-being is multi-dimensional and encompasses all such aspects. For this study, we aimed to study the impacts of engaging in heritage artforms and puzzles on aspects of well-being pertaining to mental health (such as levels of anxiety, stress, positive and negative affect, self-efficacy, and creative self-efficacy).

Heritage arts practices for Well-being

Heritage arts practices encompass a rich tapestry of cultural tradi- tions and creative expressions that hold profound significance for in- dividuals and communities worldwide. These practices serve various purposes, including cultural restoration and the promotion of cultural inclusion, and play an integral role in establishing rituals, fostering communication, and promoting mental well-being (Kaimal & Arslanbek, 2020). Engaging in indigenous art practices has been effective at addressing low self-esteem and enhancing identity, reconnecting with memories, promoting mental health, offering tangible and intangible benefits, and, connecting individuals to their personal histories. (Collier, 2011; de Guzman et al., 2010). Basto et al., (2012) underscore the importance of community involvement in indigenous contexts, noting a strong sense of communal connection while engaging in indigenous arts practices. The integration of art and research within indigenous settings has further enhanced the understanding of the effects of participation in traditional art practices on mental health and wellbeing (Basto et al., 2012; Collier, 2011; Huss & Cwikel, 2005; Sjo¨berg & Porko-Hudd, 2019; Warson et al., 2013).

Traditional arts practices such as textile handcrafting, knitting, cro- cheting, and weaving are central to gender roles within some commu- nities (Collier, 2011) and a valuable tool for the transmission of generational stories, emphasizing the inter-connectedness with nature (Nagarajan, 2018) as well as supporting creative agency and spiritual meaning-making, social togetherness, stress management, and a sense of relaxation. (Sjo¨berg & Porko-Hudd, 2019). The repetitive nature of some traditional artforms, such as fiber arts, can be rhythmic, grounding, and soothing (Collier, 2011). Additionally, indigenous and heritage arts practices, support the acknowledgment and integration of indigenous wisdom (Chilisa, 2012) and promote practices that facilitate empower- ment (Huss & Cwikel, 2005) while building therapeutic environments where cultural identity and restoration from cultural oppression can be addressed through indigenous knowledge systems (Arslanbek et.al, 2022; Napoli, 2019).

Art therapist Jhaveri (2021) wrote about her experience applying two indigenous Indian artforms (mehndi and kolam) to her art therapy practice by conceptualizing the physical, mental, emotional, and spiri- tual meaning of these artforms. For example, when using mehndi in her art therapy practice, she considered the media’s physical and sensory qualities such as its scent, temperature, and natural origins; mental as- pects, such as the need to focus on fine motor movements and create symbols; emotional characteristics, such as the media’s connection to the body and ability to “transform/adorn scars and injuries”; and spir- itual meaning, such as its connection to ritual and community (p. 120). Additional empirical research is needed to determine the impact of engaging in indigenous artforms on psychosocial well-being and connect the potential therapeutic qualities of such experiences to art therapy practice.

Preferred/self-selected arts practices for health and well-being

Engaging in an art practice one is familiar with and participates in regularly (which has similarities to heritage arts practices), such as crafts, can activate the brain’s reward system and induce a flow state (Gutman & Schindler, 2007) as well as support well-being (Chaze et al., 2022; Leone, 2021). In their secondary analysis of the National Endowment for the Arts’ Survey of Public Participation in the Arts, Kaimal et al. (2017) found that of a sample of 37,000 adults from 2011 to 2012 in the United States, 13.2 % reported engaging in fiber arts. The next two most popular art forms in the general population were photography at 12.4 % of the population and leatherwork, metalwork, or woodwork, at 8.2 % of the population. When the popularity of fiber arts and leatherwork, metalwork, and woodwork was mapped onto re- ported gender, women overwhelmingly reported engaging in fiber arts, while men overwhelmingly reported engaging in leatherwork, metal- work, or woodwork.

Engaging in fiber arts (especially in group settings) supports well- being emotionally and socially as it increases positive mood and relax- ation while facilitating social connections. In their scoping review on the impact of fiber arts groups (e.g. knitting, crocheting, etc.) on physical, cognitive, emotional, and social aspects of well-being, Chaze et al. (2022) found that these art forms promoted positive mood, relaxation, stress reduction, coping strategies associated with loss, concentration, feelings of pride and control, identity, and connection with others, supporting emotional and social aspects of well-being. In their phenomenological study of a non-clinical knitting guild’s experiences, Brooks et al. (2019) found that engaging in knitting resulted in more positive mood, increased cognitive stimulation, supported social re- lationships and identity, and provided an outlet for artistic expression. As for crocheting, an online survey study (of 8391 participants) exploring the benefits of crocheting (in a non-clinical setting) found that engaging in this artform led participants to feel more relaxed, happy, and helpful (Burns & Van Der Meer, 2021), and an art therapist docu- mented her experience using crochet to contain and express racial stress (Holmes, 2021). In her ethnographic inquiry into quilt-making in North Carolina, Dickie (2011) found that quilt-makers believed quilting to be therapeutic, in “mundane,” everyday ways, or in “exceptional” ways to support them in times of crisis.

Exploring textile arts more generally in a non-art therapy survey study of 821 women who reported engaging in textile arts, Collier (2011) identified that those who engaged in such art forms reported using these practices to access beauty, feel grounded, and cope with stressors and discussed implications for art therapy. Collier et al. (2016) then examined the impact of textile arts (N = 47 women, though authors did not have exclusion criteria on the basis of identified gender) in changing one’s mood and observed that textile arts were effective at increasing positive affect and decreasing negative affect among people who reported a moderate level of familiarity engaging in such practices. This study was not done in the context of art therapy. In a survey study, Hermann (2023) found that respondents (N = 97) who engaged in fiber arts with more frequency and experience reported increased joy and self-regard than respondents who engage in these practices less often. The reviewed research indicates that engaging in fiber arts promotes emotional well-being, such as reduction in negative mood, increase in positive mood, increased self-esteem, and reduced stress, and when engaging in group textile arts settings, social well-being is promoted.

Less is known about the health benefits of engaging in media like woodworking, clay work, metalworking, and leatherworking. The Men’s Shed movement provides free community maker spaces for (mostly) retired men to engage in these crafts in a group setting (Vyas & Quental, 2023). Participants (“shedders”) have reported increased mental health due to the social support among their peers in these spaces, a feeling of vocation, and the sensory engagement with the material, especially wood (Banack et al., 2023; Vyas & Quental, 2023). Gulliksen (2023) autoethnographically documented his experience of woodcarving throughout his terminal cancer diagnosis and treatment, learning that: when woodcarving, his attention was fully immersed, which he found to be a useful coping strategy; deep engagement with the material allowed him to feel grounded and in touch with himself; and woodcarving enabled him to find value and joy in his experience.

Clay has been used as a global artistic and functional medium throughout human history (Staubach, 2013), and there have been various investigations into the effect of working with clay on mental health and well-being. Clay has been used in the field of occupational therapy to support the well-being of people living with disability and chronic illness both physically and psychologically (Timmons & Mac- Donald, 2008). Findings from a pilot study of 30 service users of a healthcare facility with dementia indicate that engaging with clay in a group setting may improve mood and increase self-esteem among people with dementia (Pe´rez-Sa´ez et al., 2020). Research in a laboratory setting with 36 adult participants by art therapy scholars Wong and Au (2019) suggests that the unique tactile experience of engaging with clay (e.g. its temperature) leads to significant mood increases while using this ma- terial, which can be fully realized if using bare hands when working with clay (as opposed to gloves). Sholt and Gavron (2011) conducted a literature review of clay work in art therapy and found that clay is in art therapy settings to “facilitat[e] the expression of emotions,” “facilitat[e] catharsis,” “revea[l] unconscious materials,” “facilitat[e] rich and deep expressions,” “facilitat[e] verbal communication,” and support “concretization and symbolization” (p. 70).

As previously indicated, this study sought to observe the impacts of engaging in heritage arts practices on well-being to determine implica- tions for encouraging such practices and one’s own creative resources in art therapy settings, not to develop a clinical art therapy intervention. To that end, we sought to compare outcomes from engaging in heritage arts practices to a task that exhibited similar cognitive, creative, and kines- thetic attributes but different potential emotional components. We determined that engaging in a puzzle would promote cognitive and kinesthetic activation, without emotional activation. Literature on the activity of solving puzzles and its implications for well-being is as follows.

Puzzles and psychosocial well-being

Participating in a puzzle task evokes a creative (Galvis, 2000) and cognitive response (Fissler et al., 2018). In a quantitative study of 14 participants using fNIRS technology, Mutlu et al. (2020) found that while engaging in an online jigsaw puzzle task, participants used a cognitive task called mental rotation, or the ability to imagine an object turning in space, which activated hemodynamic activity in the right dorsolateral prefrontal cortex. As tasks increased in difficulty, bilateral activity was noted throughout the prefrontal cortex with “a significant increase in left dorsolateral prefrontal cortex activation” (p. 1). In a mixed methods pilot study exploring online jigsaw puzzle solving with older adults (N = 18), puzzle solving elicited a sense of pleasure and self-esteem among participants (Brandt et al., 2023). In her autoethno- graphic exploration of solving jigsaw puzzles, Garcia (2016) spoke of how puzzle solving connects “physical, mental, and emotional aspects of experience” as well as intensifies learning, creativity, and imagination (p. 177). Additionally, Garcia (2013) suggested that rewards and moti- vation play an integral role in completing puzzles and noted that some people find satisfaction in the process alone. In contrast, other people derive satisfaction from completing the puzzle. In a survey of 156 older adults, Lin et. al (2022) found that solving jigsaw puzzles provides emotional and social gains by creating an opportunity to concentrate on the present and lose perception of time (leading to a temporary decrease of stress) and enhancing positive feelings. Although there has been substantial exploration of the cognitive effects of engagement with puzzles, Lin et al. (2022) note that future qualitative research would be impactful in understanding the key components that contribute to the happiness and well-being of puzzlers.

Rationale and hypotheses for the study

There is a significant gap in understanding the potential therapeutic implications of engaging in heritage arts practices on well-being. The purpose of this study was to examine whether there would be any dif- ference in psychosocial outcomes between engaging in two tasks (puzzle making and heritage artmaking) that use attention, cognition, creation, and motor activity. Based on experience in prior studies, outcome var- iables of anxiety, stress, positive and negative affect, self-efficacy, and creative self-efficacy were chosen as measures of psychosocial well- being. The hypothesis guiding the study was that participation in heri- tage artmaking would result in better psychosocial outcomes as compared to participation in the puzzle condition. The rationale un- derlying the hypothesis was that heritage arts practices connected to one’s lineage, creativity, and emotional experiences would result in improved well-being compared with the puzzle task on mainly only engaged structured problem solving and kinesthetic activity.

Materials and methods

Study design

This overall study uses a within-subjects convergent mixed methods design. This paper reports preliminary quantitative results from a larger mixed methods study.

Sample and settings

Participants were eligible for study inclusion if they were above the age of 18, were proficient in English, and self-identified as personally regularly engaging with an indigenous or traditional art practice.

Recruitment occurred at three sites (in India, Japan, and the US) through study flyers and snowball sampling. Study measures were available in either Japanese or English for participants in Japan. A total of 54 people participated in this study across the three sites (n = 29 in India, n = 16 in Japan, and n = 9 in the US). Of these, 52 were women and 2 were men.

Procedures and data collection

Following approval from the University’s Institutional Review Board, a study flyer was posted online and in data collection spaces at each site. When planning data collection at each site, snowball sampling was also used such that recruited participants would share the study with people they thought would be interested.

Participants were asked to participate in the study for two sessions: one involving heritage artmaking and one involving puzzle-making, on two separate days. Since each participant needed to attend two sessions, informed consent was gathered at the first session.

The order of task session completion was randomly assigned to participants by interventionists. Participants in India provided data in a university setting over two days. In Japan, participants provided data in two art studio settings over the course of a week. In the US, participants provided data in a university art therapy research space. The interven- tionist (a member of the research team, which varied between sites) was present at all sites during data collection. Data collection is ongoing in the US and additional sites may be added. Participants worked in both group (India and Japan) and individual (US) settings on their own tasks. Participants were compensated with $10 (USD) for completing each session of the study. Quantitative (measures, scales) and qualitative (written responses, art) data were gathered before and after each of the sessions.

Description of each session

Heritage artmaking session. In this session, study participants engaged in their preferred heritage arts practice for about 45 minutes (Fig. 1). Participants were instructed to bring their preferred materials to the session. Before and after engaging in their heritage arts practice, they completed pre- and post-test surveys. Participants were told they did not need to complete their artwork by the end of the session. Interventionists took photographs of the artwork for later qualitative analysis.

Puzzle-making session. This condition consisted of a puzzle-making ses- sion in which the participants worked on a jigsaw puzzle for about 45 minutes (Fig. 1). Researchers randomly assigned one of three 100- piece jigsaw puzzles depicting nature-based imagery (one puzzle showing an image of birds, one of an underwater scene, and one of floral scene) to each participant. Participants were told that they did not need to complete the puzzle within the allotted time.