The treatment of aggression using arts therapies in forensic psychiatry: Results of a qualitative inquiry

Abstract

The article describes the body of knowledge of arts therapies in forensic psychiatry based on recent practice, theory and research. The first part gives an overview of observational details, interventions, effects and rationales of drama therapy, music therapy, art therapy and dance-movement therapy in general and more specifically in the Netherlands. It shows that arts therapies can help to decrease recidivism. In the second part the results are presented of a qualitative naturalistic inquiry with 31 experienced arts therapists working in 12 institutions in the Netherlands and Germany. The arts therapists have been involved by means of semi-structured questionnaires, interviews and focus groups. Their implicit knowledge about indications, goals, interventions, effects and rationales have been compared and integrated into consensus-based treatment methods. The research reflects the Dutch tradition where all arts therapies are developed and researched within the same methodological formats. The results of one of the problem areas that have been researched, destructive aggression, are presented. Finally a comparison has been made between all arts therapies for the treatment of destructive aggression.

Introduction

In the Netherlands’ health care system, arts therapies are a regular part of treatment in psychiatric and forensic psychiatry. Nowadays there is strong pressure to become evidence-based. For this reason there is a need for arts therapists, and other therapists as well, to develop treatment protocols and treatment guidelines based on research. To start with, arts therapists describe their observations, goals, interventions, effects and rationales when working with specific problems. What prompted this research, which lasted several years, was the lack of a research-based overview of these aspects of treatment for all arts therapies in forensic psychiatry. Because arts therapists had started describing their work individually, the authors decided by means of questionnaires, interviews and focus groups to accumulate and analyze this material further.

All arts therapies (drama therapy, music therapy, art therapy, dance-movement therapy) were included. The research reflects the Dutch tradition where all arts therapies are united in one national association and arts therapies are developed and researched within the same methodical formats and compared to each other.

The first part of this article describes the context for forensic psychiatric treatment and the status of arts therapies in forensic psychiatry. A summary of the published research is included, which gives an overview of “the state of the arts” in forensic psychiatry. The second part of the article describes the research method and results.

Forensic psychiatry is an important concern in the Netherlands. Many forensic patients are treated in special forensic mental health institutes and will be released to the community sooner or later. For offenders who, at the time of the crime, had a psychiatric disturbance, for instance psychosis, personality disorder or addiction, it is agreed that they need treatment first before they can be released. These offenders are treated as clients in psychiatric hospitals that are closed from the community. Patients are imprisoned, but within the institution there is a psychiatric, not a prison culture.

Although these patients are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), in several psychiatric hospitals the focus of treatment is on so-called problem areas. Problem areas are related to the DSM-IV and the chain of offense. Broek, 2000a, Broek, 2000b distinguishes the following problem areas: lack of impulse control, aggression, grief, lack of empathy, low social functioning and lack of structure. Hörschläger, 2000a, Hörschläger, 2000b, in her follow-up of the research by Damen, 2000, Damen, 2001, mentions problem areas such as tension, aggression, impulsivity, power, control, lack of boundaries, lack of structure, lack of expression and inadequate perception. Factor analytic research with the Behavioural Status Index (Woods, Reed, & Collins, 2001) shows that there are factors for social perception, assertiveness and non-verbal behavior as problem areas for this population.

In the Netherlands arts therapies are a regular part of multidisciplinary treatment in most psychiatric institutions. The number of arts therapists working in forensic institutions is about 10% of the working population of arts therapists. However, there is no difference in the relative frequency of art therapists working in forensic and general psychiatry. In general and forensic psychiatry arts therapists from different modalities (drama, music, art, dance-movement) work together in teams and take part in the overall treatment plan. Based on their observations, they collect supportive information for the process of diagnosis, which is determined by the psychiatrist. Treatment in a forensic institution is made up as an integrated program in which several professionals—psychiatrist, psychologist, arts therapists, and others—take part. Within the treatment program, arts therapists focus on specific treatment goals.

In the Netherlands the arts therapies in the last decade developed from insight oriented therapy that takes the personality as a focus, to changing the way the patient feels, thinks and acts in concrete, here-and-now situations. The arts therapies became more “re-educative,” which means that the patient is trained to change specific cognitions, feelings and behaviors related to one problem area. This makes arts therapies valuable ingredients in the treatment of forensic patients. An important rationale for arts therapies in forensic psychiatry is their orientation to action (Douma, 1994; Hakvoort & Emmerik, 2001). The experiential and active nature of the arts therapies makes concrete goals like regulation of tension, impulse control, regulation of aggression, the planning and structuring of behavior and the development of interaction competencies possible.

A general theory of arts therapies, for psychiatry as well as forensic psychiatry, has been articulated by Smeijsters, 2003a, Smeijsters, 2003b, Smeijsters, 2003c, Smeijsters, 2005. In line with Stern's developmental psychology (Stern, 1985, Stern, 1995), Smeijsters describes the “analogy” between the vitality affects of the psyche and the dynamic processes during the expression in the art form, which both are characterized by equal basic parameters like dynamics, tempo, rhythm and form. The therapeutic process is possible because the change of expression in the art form is experienced as a change of vitality affects. By experiencing vitality affects in art forms forensic patients can work through unarticulated layers of experiences and gradually become conscious of cognitive schemes (Johnson, 2002, Kampen, 2004, Timmer, 2004).

Forensic patients in dramatherapy are unable to improvise, to take roles and to distinguish between their own point of view and some else's point of view (Thompson, 1999). Thompson, 1998, Thompson, 1999 developed workshops like “Joe Blaggs” and “The Pump.” The “Joe Blaggs” workshop involves a fictitious offender about whom the patients ask questions like: “Who is Joe Blaggs?”, “What is he doing?”, “What are his thoughts?”, “Who is influenced by him?”. By means of these questions the patients develop a story with characters and events. The story is played, and by means of stop-rules, it is possible to reflect and explore alternative behavior. The Pump is a workshop in which patients learn to distinguish between “Knocks” (facts that cannot be changed), “Wind-ups” (provocations, threats by others) and “Pumps” (inner thoughts and interpretations that increase anger). Patients are trained how to decrease “pumping thoughts” and to manage their anger.

Timmer, 2000a, Timmer, 2000b, Timmer, 2000c, Timmer, 2003, Timmer, 2004 uses the chain of offense developed by Mulder (1995) in drama therapy. Together with the patient she develops a play in which crucial moments of the chain of offense are incorporated. The patient reflects on these moments with words like “who,” “where,” and “when.” We see that typical aspects of drama therapy are perfect ingredients to be incorporated in a cognitive–behavioral treatment. What makes drama therapy a strong primary treatment is the fact that the behavior is trained in concrete play situations.

Landers (2002) starts from the perspective that people who have been victims in society choose the role of offender because this role is easily available. By means of playing the roles of offender and victim, by changing scenes, and commenting on scenes patients acquire a more varied role pattern. Cleven, 1998a, Cleven, 1998b, Cleven, 1999, Cleven, 2003, Cleven, 2004 developed interventions in which patients play different stages of life, including the stages that lead to the offense.

Teasdale (1997) describes psychodrama and art therapy as part of a “supportive treatment modality” within a forensic therapeutic community in which the whole community and also smaller groups have group therapy sessions. This community as a whole leads to a remarkable decrease of recidivism (see Table 1).

This shows that the success of treatment increases with the length of treatment. Although it is not possible to infer from this data the specific contribution of art therapy and psychodrama, the characteristics of these therapies are closely connected to the rationale of the therapeutic community: decreasing individual impulsivity and crime.

In drama therapy playing situations form daily life and using role changes to enhance the ability to see things from the perspective of another person led to a decrease in offenses of 50% during the follow-up measurement of a treatment group compared to a placebo and control group (Chandler, 1973). Therapeutic theater for persons who committed armed robbery and abuse led to the decrease of anxiety, the increase of empathy and the ability to handle conflicts (Cogan & Paulson, 1998).

Thompson (1999) takes the similarity between cognitive–behavioral therapy and the process of the actor who changes his cognitions to play his role. He tells us that “everyday life is staged,” and that it is a matter of rehearsing and playing the appropriate role in real life that saves patients from getting into an offense. A patient can leave the role of the bad guy and choose the role of the good guy. The combination of reflecting and rehearsing the performance of the good guy is how drama therapy works. Because pathology in forensic psychiatry is complex, Cleven (2004) uses several rationales adopted from Gestalt psychology, transactional analysis, self-psychology and developmental psychology.

Flower (1993) and Santos (1996) describe how forensic patients in music therapy are unable to improvise. These patients either control themselves to the extreme or are unable to stop their acting out behavior and act aggressively. Anger can be heard in the tempo, the dynamics, and the sound of the patient's play (Hakvoort, 1996, Hakvoort, 2002a, Hakvoort, 2002b).

There are many goals that are listed by music therapists working in forensic psychiatry such as relaxation, self expression, mood change, emotional development, self-esteem, respect for others, social interaction and adjustment, release of tension and anxiety, anger management, decrease of aggressive behavior, self-control and coping skills (Codding, 2002, Fulford, 2002; Gallagher & Steele, 2002; Rio & Tenney, 2002; Thaut, 1987, Thaut, 1992, Watson, 2002). Thaut mentions that for these patients short-term therapy in the here-and-now with realistic goals is appropriate.

The music therapist can use the monochord, background music, music listening, song selection, song parody, song composition, lyric analysis, group singing, drumming, and vocal and instrumental improvisation with themes “your competencies,” “your beliefs,” “your identity” (Daveson & Edwards, 2001; Gallagher & Steele, 2002; Hakvoort, 2002a, Reed, 2002, Watson, 2002, Wyatt, 2002; Poel, 1997).

Flower (1993), in her work with delinquent adolescents, focuses on their helplessness and negative identity. To increase the patient's control of his or her environment, Flower takes destructive family situations as a theme and together with the patient explores musical territory during which the patient can experiment with levels of control. The patient reaches a balance when he or she is able to take initiatives and lead the improvisation and also is able to give space to another person, which he or she supports and follows. Flower uses thematic improvisations like “The giant and the dwarf” and “The spider and the fly.” Wagner (1997), Argante (1999), and Peeters (2003) developed interventions based on three themes: the development history, the offense and empathy for the victim.

Music therapists report effects of music therapy on anxiety, tension, hostility, fighting behavior, frustration tolerance, impulse control, attention span, reality perception, awareness of others, and self-perception (Codding, 2002, Hoskyns, 1988, Thaut, 1989a, Thaut, 1989b, Thaut, 1992). A review of session documentation by Gallagher and Steele (2002) of 188 patients showed that 91% actively participated, 82% expressed thoughts and feelings and 68% had a positive change in affect.

The drum improvisation between patient and music therapist leads to a control of anger (Drieschner, 1997). Watson (2002) reports the following effects of drumming: self-expression and awareness of emotions, appropriate social interaction and cooperation, and coping skills.

Research of Daveson and Edwards (2001), a self-report study after 12 sessions, shows that five female delinquents in a prison reported being more relaxed and experiencing less tension and stress and were able to express themselves better after music therapy. All patients reported that music therapy was pleasant and helpful. Song composition and song parody led to more self-expression. Listening to songs and singing songs led to more relaxation. Singing, song composition, song parody and listening to songs decreased stress, anger and frustration.

The effect of music in forensic psychiatry can be explained by referring to its possibilities for interaction, communication, expression and exploration of feelings, as well as its ability to stimulate goal-oriented behavior and create possibilities for controlling emotions and behaviors (Codding, 2002; Gallagher & Steele, 2002). Theoretical concepts that are used may be related to psychodynamic theories, behavioral approaches, and cognitive procedures (Rio & Tenney, 2002). An explanation for the effect of drumming with patients who have themselves been traumatized is given by Skaggs (1997), who argues that trauma is imprinted in the body, and that drumming by influencing the body can evoke emotions. Drieschner describes that the effect of the drum improvisation can be explained by referring to the theory of analogy (Drieschner, 1997, and in Smeijsters, 2003c, Smeijsters, 2005).

Other music therapists also stress the analogy between offensive and manipulative impulses and behaviors, and the behavior during the musical improvisation (Hakvoort, 2002a; Hakvoort & Emmerik, 2001; Poel, 1997, Poel, 1998). By changing the parameters of the musical expression, the behavioral, emotional and cognitive parameters of the offense can be changed.

In art therapy assessment instruments are used, such as the House-Tree-Person Test (Buck, 1987), the Expressive Therapy Continuum and the Media Dimension Variables (Lusebrink, 1990), and the Draw a Story Test (Silver & Ellison, 1995). Research by Lev-Wiesel and Hershkovitz (2000) with the Machover Draw-A-Person Test shows a statistically significant difference in signs of violent behavior between violent and non-violent offenders. Lopez and Carolan (2001) with the House-Tree-Person Test found a similar difference.

Goals which are used in art therapy in forensic psychiatry are self-expression, self-esteem, coping mechanisms, social competencies, breakthrough of defenses, openness for the offense, insight in thoughts, feelings and actions that triggered the offense, self-control, alternative behaviors and empathy for the victim (Bennink, Gussak, & Skoran, 2003; Gerber, 1994, Kampen, 2001). The patient can work through childhood experiences; compare thoughts and feelings while being a victim and offender, and express feelings to others. The patient can reflect on the form, the content, the emotional expression and the cognitive distortions in the artwork.

Bennink et al. use collages that are constructed with journals, objects trouvés and oil pastels to balance the planning, controlling and expression by means of cognitive and behavioral instructions. The art therapist (and co-therapist) acts as a model, and together with the patient rules are described that shape behavior. The use of simple steps of progress helps to minimize the patient's frustration and to maximize success experiences. Giving patients the opportunity to make choices prevents opposition.

Art therapy in forensic psychiatry often takes place within the framework of cognitive–behavioral psychotherapy in which the problem is explored and then the search for a solution is undertaken (Kampen, 2001). Artistic expression of emotions instead of acting out aggressive behavior can serve as a coping mechanism. Haeyen (2004) shows that it is possible for patients to express emotional polarities in art, and gain insight into inner contradictions from the perspective of dialectical–behavioral therapy in line with Linehan (1996). It is possible to integrate these contradictions in a work of art and decrease aggressive and destructive impulses. By doing this, patients can prevent their levels of increasing emotional tension from getting out of control and ultimately culminating in an offense.

There are few research results of art therapy in forensic psychiatry (Bennink et al., 2003). Several authors report that art therapy increases the insights patients have into their personal thoughts, beliefs and behaviors as well as the thoughts, beliefs and behaviors of others (Gussak, 1997; Gussak & Cohen-Liebmann, 2001; Gussak & Virshup, 1997; Liebmann, 1996a, Liebmann, 1996b, Liebmann, 1998). The case vignettes described by Bennink et al. show that patients, by drawing a volcano, express their anger symbolically if they are unable to express it verbally and cognitively. After feelings have found an expression in the artwork patients are enabled to talk about it. The feedback of others increases self-esteem.

Riches (1998) reports a 29% reduction of disciplinary measures in a prison as a result of 13 months of art therapy. The amount of transgressions requiring disciplinary measures as a result of art therapy decreased 75–81%. Two years after patients were dismissed 69% of the persons who took part in art therapy did not re-offend compared to the control group without art therapy, which in 42% did not re-offend (Brewster, 1983; Peaker & Vincent, 1990).

Art therapists in forensic psychiatry have used two prominent rationales. One is based on the premise that patients can communicate in art in a symbolic way that cannot be verbalized (Liebmann, 1998). This may be linked to Freud's or Jung's psychoanalytic concepts of the manifest and latent meaning of images and Winnicott's concept of symbolic play (Murphy, 1998, Winnicott, 1971). In these rationales the patient's artwork refers to content ‘behind’ the image. The goal of therapy is finding these latent meanings to reach insight in fragmented psychic content and conflicts (Hagood, 1998).

From a different perspective, the art process and art form as an expression of the patient's thoughts, emotions and behaviors is used rather than the symbolic meaning of the patient's images (Baeten, 2001, Baeten, 2005, McCourt, 1998, Riches, 1998). Important in this perspective is how the patient uses the brush and color, arranges the space on the paper, works with details and the whole, makes transfers, and so on. These actions show how the patient experiences and acts. The goal of therapy is then to help the patient find new ways of experiencing and acting.

In Europe dance-movement therapy is not very well represented in forensic psychiatry. Although this section does little justice to the possibilities dance-movement therapy might have in forensic psychiatry it is included to show its potency.

In dance-movement therapy Laban Movement Analysis (Laban, 1998) forms the basis for a variety of different assessment measures that can be used to analyze the body and movement parameters of forensic patients. Presenting yourself through movement increases individuation. Moving synchronously in the same rhythm increases social behavior and bonding (Milliken, 2002). Dance-movement therapy makes it possible to work with tension increases and decreases. Slow movements, conscious relaxation and eye contact counteract impulsive, brusque, uncontrolled and antisocial behavior. In her study DiGiorgio (1988) describes several theoretical perspectives when working with aggression.

Currently, there are no published studies of the effect of dance-movement therapy with the forensic psychiatric population. However, there are meta-analyses that show that dance-movement therapy is effective with psychiatric populations (Cruz & Salbers, 1998).

Dalessi (1997) describes how in dance-movement therapy movement games can be used that show almost no difference from the offensive act. The patient can use his body to hunt the therapist or another patient into a corner of the room. The same physical, emotional and behavioral processes are evoked as have been experienced in the offensive act. But there is analogy because in therapy this is play and not a real offensive act. The dance-movement therapist by means of rules can offer the opportunity on the one hand to experience the same physical, emotional and behavioral processes, and on the other hand to put these into play where they can be controlled and where there is no harm done to others. Suddenly increasing tension in movement followed by releasing this tension is an example how in dance-movement therapy tension increase and tension release can be explored and controlled (Milliken, 2002).