The effect of Art Therapy in individuals with Personality Disorders cluster B/C: a RCT.

People with personality disorders are struggling with emotion and
self-regulation issues . Art therapy is often part of the specialized treatment
for clients with personality disorders. In art therapy change, development and
/ or acceptance processes are initiated and strengthened. Art therapy has an
important experiential, action-oriented and / or creative quality. With various
materials, tools and methods emotions, feelings, thoughts and behaviors are
portrayed. This provides clues for impulse and emotion regulation, and focuses
on patterns in feeling, thinking and acting, on the practicing of new roles,
skills and behavior (Haeyen, 2007).
Research has shown that art therapy is largely appreciated by patients with
personality disorders (Karterud & Pedersen, 2004; Shechtman & Perl Dekel,
2000). In the study of Karterud and Pedersen the overall benefit of the entire
day treatment program (n = 319) was even valued higher than all other treatment
groups, including psychodynamic group psychotherapy, cognitive group therapy,
body-oriented therapy group and a problem-solving group (Karterud & Pedersen,
2004). These results showed that the appreciation of AT According to the
researchers this is due to the "as if-situation" (Fonagy et al 2002). This is
a safe method to explore, express and add meaning to their own inner world
(mentalizing ) by means of self-objects in the shape of artpieces. Besides
satisfaction also the experience of the patient during art therapy was
investigated. In an exploratory survey among 48 patients with personality
disorders showed that patients consider art therapy as a means to acquire
(self-) understanding, awareness of own patterns and promote reflection on
themselves (Haeyen, 2007). This is also confirmed by a study that focused on
the experience of patients during art therapy (n = 63) (Haeyen, 2011). Patients
indicate that in art therapy intrapsychic integration is promoted and
corrective (emotional) experience are gained. Experts in the field of art
therapy in a panel discussion conclude that art therapy improves self-control
and self-structuring (Haeyen, 2007).

No empirical research is available focusing on the effects of AT. A lot of
studies, however, some have investigated broader treatment programs, in which
AT is included. Results are positive (Piper et al, 1996; Wilberg et al, 1998;
Bateman & Fonagy, 1999 and 2004, Karterud & Urnes, 2004). Piper for example
found a positive effect in an RCT on a day hospital psychotherapeutic program
in comparison to a waiting list control group (Piper et al, 1993). Also four
cohort studies showed a positive effect of intensive psychotherapy with art
therapy as a part of the intervention (Karterud et al, 1992; Karterud et al,
2003; Krawitz, 1997; Wilberg et al, 1998; Wilberg et al, 1999).
Although literature suggests that AT has positive results we have to conclude
that these are hardly based on sound empirical research. In effect studies the
effect of art therapy for personality disorders is not sufficiently isolated to
make statements about it. There is a need for research that insolates the
effects of art therapy adequately. Although art therapy is recommended in
guidelines (National Committee on Multidisciplinary Guideline Development in
Mental Health, 2008) hardly any empirical support concerning its added value
is available This research aims to evaluate AT as treatment for people with
personality disorders.

In this randomised controlled study, the effects of art therapy is examined on
psychological functioning of patients with a personality disorder. It is
expected that art therapy results in less personality pathology, more
acceptance, and less experiential avoidance of unpleasant inner experiences.

A randomized controlled design. Patients indicated for outpatient treatment
aimed at personality problems are randomly assigned to one of the following
conditions:
1.Art therapy.
2.Waiting list (control condition). This does not change the situation of the
patients. They are only asked to complete questionnaires.

The procedure is as follows: After a general intake for treatment at GGnet,
patients with personality disorder and indicated for treatment are placed on
the waiting list. At this very moment , they will be approached for the present
study. Through a letter patients are informed about the present research and
are invited to participate. Agreement to participate is realized by signing the
consent form.

After agreement, patients will be screened by a semi-structured diagnostic
interview (SCID-II). All patients with a personality disorder (cluster b and
cluster c) will be included in the study. They start immediately with the some
questionnaires (T1). In the first condition patients are directly invited to
start treatment. This treatment will take 10 weeks, one weekly session of Art
therapy (1,5 hours). The participants from the second group only fill in the
questionnaires.
After 10 weeks, measurement 2 takes place for both conditions (T2). After T2
there will be no intervention. After another 10 weeks measurement 3 (T3) takes
place.
The duration of the whole research project is expected to be 48 weeks.

Art therapy. For the present study a protocol is designed for 10 sessions (1.5
hours weekly), based on the theory and methods as described in "Don't act out
but live through" on art therapy for personality disorders (Haeyen, 2007). The
content of the art therapy is aimed at improving mindfulness, emotion
regulation skills and interpersonal functioning. This means: to make contact
with, to express and to limit emotions for a better emotion regulation and
acceptance of (also negative) experiences, feelings and thoughts. It will
include aspects such as making their own choices and making realistic demands
on themselves. This protocol is a closed group with a maximum of 8 to 9
participants.

Completing questionnaires, the interview and 10 weeks participating in an art
therapy group is not expected to include risk. The effort per person in the
experimental condition will be 20 hours, spread over 22 weeks (3 times 45 min.
for questionnaires, 1 interview of a maximum of 2 hours, 10 weekly sessions of
90 minutes, one questionnaire only at the start and after the intervention (2x
10 min.), and a introduction with the art therapist of 20 minutes; total amount
of 20 hours). The controlgroup will spend 4,5 hours.

Art therapy is a common form of treatment in mental health care. Although this
treatment is widely used within the mental health, there is relatively little
research on the effects of this treatment and the existing studies are of
moderate quality. However, the available results seem promising that art
therapy is useful and effective to psychological complaints. The experience in
clinical practice show no heavy effort or risk.