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Arts-Based Therapies in the Treatment ofEating DisordersMaria J. Frisch a , Debra L. Franko b & David B. Herzog ca University of Minnesota , Minneapolis, Minnesota, USAb Massachusetts General Hospital and Northeastern University ,Boston, Massachusetts, USAc Massachusetts General Hospital and Harvard Medical School ,Boston, Massachusetts, USAPublished online: 21 Aug 2006.

To cite this article: Maria J. Frisch , Debra L. Franko & David B. Herzog (2006) Arts-Based Therapiesin the Treatment of Eating Disorders, Eating Disorders: The Journal of Treatment & Prevention, 14:2,131-142, DOI: 10.1080/10640260500403857

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Eating Disorders, 14:131–142, 2006Copyright © Taylor & Francis Group, LLCISSN: 1064-0266 print/1532-530X onlineDOI: 10.1080/10640260500403857

UEDI1064-02661532-530XEating Disorders, Vol. 14, No. 02, January 2006: pp. 0–0Eating Disorders

Arts-Based Therapies in the Treatment of Eating Disorders

Arts-Based Therapies in TreatmentM. J. Frisch et al.

MARIA J. FRISCHUniversity of Minnesota, Minneapolis, Minnesota, USA

DEBRA L. FRANKOMassachusetts General Hospital and Northeastern University,

Boston, Massachusetts, USA

DAVID B. HERZOGMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA

Arts-based therapies are increasingly being employed, in conjunc-tion with empirically valid traditional therapies, in the residentialtreatment of eating disorders. A systematic database search of arts-based therapies in the treatment of eating disorders was conducted.In addition, program staff at 22 residential eating disorder treat-ment programs were contacted to provide information regardingarts-based therapy utilization rates. Of the 19 programs that par-ticipated in this study, all incorporate arts-based therapies on atleast a weekly basis in the treatment of eating disorders. However,while published narrative reflections on arts-based therapies andeating disorders imply a generally positive outcome, no known,empirically valid studies exist on this experiential form of therapywithin the area of eating disorders.

In the past several decades, a large variety of psychological treatments suchas interpersonal, cognitive-behavioral, family systems, and pharmacothera-peutic therapies have gained popularity in the treatment of eating disorders(Fairburn & Harrison, 2003; Garner & Garfinkel, 1997; Wilson, 2004). Alongwith this trend has come the emergence of multidisciplinary approaches, suchas the incorporation of experiential therapies in combination with one or

This work was in part supported by Matina S. Horner, Phd. Summer Research Fellowship.Address correspondence to Maria J. Frisch, Dept. of Psychiatry, Riverside Prof. Bldg, 606

24th Ave. S., Ste. 602, Minneapolis, MN 55454. E-mail: fris0039@umn.edu

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more traditional forms of therapy in the comprehensive treatment of eatingdisorders. Some programs have even made the incorporation of alternativeand holistic therapies, such as arts-based therapies, part of their core treat-ment philosophy. However, there is currently no published research to sub-stantiate the claim that such therapies are useful in the treatment of eatingdisorders.

In the most basic sense, arts therapy is the medicinal use of creative artssuch as drawing, dance, music, and drama. It is most often implemented by aMaster’s level trained therapist whom, according to the American Art TherapyAssociation (AATA), is trained in both art and therapy through a nationally,regionally, or state accredited program (AATA, 2002). Arts therapists utilizepsychological and developmental theories in combination with a form orforms of creative arts to bring about personal growth and positive change inclients. This distinctive form of therapy presents a unique avenue of adjunc-tive treatment for the eating disordered client.

While arts therapy has been clinically used for over a century (Junge,1994), much of the published work in this area consists of case studies andtheoretical discussions, with little emphasis on outcomes (Reynolds, Nabors,& Quinian, 2000). Moreover, specifically within the area of eating disorders,we were not able to find evidence of empirically valid studies conducted withthis population.

Despite the lack of treatment outcome studies specifically in the area ofeating disorders, some nonrandomized and randomized controlled trials withtrauma survivors and psychiatric patients exist in the area of arts therapy.Chapman and colleagues (2001) looked at the effect of arts therapy on pediat-ric trauma patients up to six months after treatment, but found no significantreductions in post-traumatic stress symptoms between patients receiving artstherapy and those receiving standard hospital treatment. In contrast, Green,Wehling, & Talsky (1987) studied regular therapy versus regular therapy withart therapy every other week in chronic psychiatric patients for 20 weeks andfound significant differences between groups in attitudes towards self andgetting along with others. On a broader scale, Koerlin, Nybaek, & Goldberg(2000) investigated arts therapy in a group of 58 individuals with a wide rangeof mental and behavioral impairments over a period of four weeks. Althoughthere was considerable variation in psychiatric symptom reduction betweenparticipants, 88 percent of participants who completed an arts therapy pro-gram showed significant improvements in symptom reduction, with a sub-group of trauma patients obtaining significantly better results, implying thatresearch on arts therapy and trauma may differ from arts therapy outcomestudies in other areas. However, it is not entirely clear whether the positiveoutcomes found by Koerlin et al. (2000) were the result of arts therapy treat-ment since there was no control group used for comparison. In addition, it isdifficult to generalize the results of these studies to clients with an eating dis-order, because the samples are very different.

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Arts-Based Therapies in Treatment 133

Research exploring arts-based therapy that specifically investigates andaddresses the unique characteristics of clients who have an eating disorder iswarranted. The purpose of this review is to highlight, summarize, and explorethe prevalence of primary types of arts-based therapies commonly used in theresidential treatment of eating disorders and to stimulate discussion regardingfuture research in arts-based therapies and eating disorders treatment.

METHODS

Participants

Program directors at 22 residential eating disorder treatment programs fromacross United States (see Table 1) were contacted. Programs were selectedbased on the following criteria: 1) Offered residential treatment services; 2)Offered treatment for anorexia nervosa (AN), bulimia nervosa (BN), orbinge eating disorder (BED); and 3) Location in North America. The 22selected programs were the only programs that met the above criteria, froma comprehensive national search of all residential treatment programs foreating disorders. The comprehensive search was conducted by searchingthe Internet, national eating disorder treatment referral databases, and on-line yellow pages. Programs were not offered any form of compensation forparticipation in this project.

Materials

An email survey used in a recent descriptive study of residential eating dis-order treatment programs (Frisch, Herzog, & Franko, 2005) was used to col-lect information from program staff regarding the incorporation of arts-based therapies in residential programs. Data were collected during Julyand August of 2004.

TABLE 1 Survey Questions Specifically Pertaining to Incorporation of Arts-based Therapies

•Do you incorporate any arts-based therapies into your program? Please check all that you offer:

_Arts-based Therapy ___Dance Therapy

_Music Therapy ____

__

_Other(s):__________________

•On average, what percentage of your residential clients participates in arts-based therapies while

in treatment?

•On average, do your clients participate in arts-based therapies at least:

___Once p/day ___Once p/wk. ___Once p/mo ___Once in 3/mo ___Never

•Why do you offer/incorporate arts-based therapies into your treatment program?

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134 M. J. Frisch et al.

Procedure

All participating programs were asked to complete a 30-question surveyregarding their residential treatment program (Frisch, Herzog, & Franko, inpress). Of these 30 questions, four were specifically on the topic of arts-based therapies (see Table 1), and an additional question asked aboutweekly schedules for residential clients. The results of these five questionswill be presented here.

Websites and brochures produced by each program also werereviewed as a secondary means of obtaining information.

Additionally, a systematic English-language only database search wasconducted using PsycInfo (1985–2004), PubMed (1966–2004), and AMED(1985–2004) using the keywords eating disorders and arts therapies or artsbased therapies or creative arts therapy or music therapy or dance therapy.Results were limited to only include papers on anorexia nervosa, bulimianervosa or binge eating disorder, excluding obesity. A total of 30 paperswere found, 17 on arts therapy, 8 on music therapy, and 5 on dance. Sixbooks containing chapters pertaining to this topic were also reviewed.

LITERATURE REVIEW RESULTS

What is Arts Therapy?

Arts therapy is an umbrella term for a diverse assortment of sub-specialtyexperiential therapies that cross a wide variety of artistic disciplines. Basedon the literature, three major sub-specialties of arts-based therapies emergedin the treatment of eating disorders: music therapy (MT), dance/movementtherapy (DMT), and creative-arts therapy (CAT).

Music Therapy (MT)

MT primarily utilizes music as a therapeutic tool. Music is used mostoften in the treatment of eating disorders as a tool for self-discovery oras a method for relaxation (Justice, 1994; Parente, 1989; Robarts & Sloboda,1994). Some examples include using background music to facilitatebreathing, positive imagery or meditation. Alternatively, music may beplayed during mealtime to alleviate anxiety. Examples of using music asa tool for self-discovery include listening or singing along with a songand then examining and discussing the lyrics, eventually using theinsight discovered through the lyrics to apply to oneself. For instance, anarts or music therapist could facilitate a discussion on the theme of lov-ing oneself unconditionally from the lyrics of India Arie’s “Supermodel”or the desire to survive a battle with one’s eating disorder from DestinyChild’s “Survivor.” A wide variety of songs may be used with this therapy

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Arts-Based Therapies in Treatment 135

and selection is typically based on the individual characteristics of a per-son or a group.

One residential program employs a unique form of cognitive-behavioralmusic therapy (Hilliard, 2001). Under this model, music therapy is used toaddress “behavioral and cognitive issues in a non-threatening and support-ive manner while challenging long-held cognitive distortions and destruc-tive behavioral patterns” (p. 112). Hilliard (2001) illustrated this techniqueby showing a “recovery rap” that clients had written and performed aboutovercoming their eating disorders and reclaiming their lives. He alsoemphasized the use of lyrics as a tool for personal insight and change.

Dance/Movement Therapy (DMT)

The body is a central battleground in eating disorders, making DMT a prom-ising adjunctive treatment. DMT is often misunderstood because of itsname; this specialized form of therapy is not simply limited to dance andmovement. The majority of dance movement therapists base their therapeu-tic art on the idea that the body and mind are unconsciously (or con-sciously) connected and strive to impact the mind through some type ofdirect work with the body. In other words, positive effects on the body mayoften result in positive changes within the mind. Dance movement therapyis defined in a broader sense by the American Dance Therapy Association(ADTA) as “ . . . a process that furthers the emotional, cognitive, social andphysical integration of the individual” (ADTA 2001). Of the five papersfound on eating disorders and DMT, all were narrative depictions of a spe-cific DMT method (and corresponding theory) and/or treatment modeldeveloped from clinical experience with eating disordered clients. Mostmethods incorporated some form of psychotherapy with DMT. Krueger andSchofield (1986) developed what they termed “preverbal” (p. 326), dance-therapist led DMT techniques developed to be directly followed with verbalpsychoanalysis, led by a trained psychiatrist. Intended for use with inpatientand outpatient clients, the DMT technique was developed as a treatment foremotionally stunted patients who were not yet inherently “.. . insightful[or] verbal...” (p. 324) and included relaxation and centering, mirroringanother’s movement, facing a mirror, creating drawings that reflect theexperiences of the movement session, and videotaping of one’s body andmovement following self-critiquing and reflection. Another technique withties to psychoanalytic theory is that developed by Blanch Evan (Evan, 1991;Krantz, 1999; Levy, 1988) who is known among dance-movement therapistsas a pioneer in the field of dance therapy. Her methods and theories areclosely intertwined with a unified goal of “psychophysical unity,” using thebody to link action with feeling through individualized DMT.

Other authors have incorporated DMT methodology into body imagetherapy (Totenbier, 1994). Totenbier suggests a DMT model in which a

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positive change results from the exploration of one’s body. Specifically, aclient is asked to look in a mirror and draw a picture of herself. She is thenwalked through a series of activities, such as creating an actual body tracingand comparing it to her self-portrait, which encourages clients to challengedistorted beliefs they may have about their body. By examining and experi-encing different aspects of actual versus perceived body images, it is pur-ported that the client is able to reach a more realistic perception. Anothersimilar technique embracing the use of a mirror and a body map was devel-oped by Rice, Hardenbergh, & Hornyak (1989), although their work waslimited to clients with anorexia nervosa.

Creative-Arts Therapy (CAT)

CAT primarily utilizes drama, role-playing, drawing, painting, and sculptureas therapeutic tools. Arguably the most widely employed of the three formsof arts-based therapies, CAT may be found within inpatient units (Wolf,Willmuth, & Watkins, 1986), day treatment programs (Jacobse, 1994), outpa-tient programs (Bloomgarden, 1997), and residential programs for eatingdisorders. Methods widely varied across papers, although a common themeof symbolism as a tool for insight appeared throughout. Additionally, eachauthor stressed the importance of the creative arts as an alternative meansof expression and exploration of feelings. Techniques vary from diagnosticdrawing (Kessler, 1994; Levins, 1995), which is the examination or interpre-tation of the structure and content of drawings, to improvisation (Kaslow &Eicher, 1998). Wooley and Wooley (1985) described an improvisation tech-nique where clients acted out getting fatter and fatter and then getting thinnerand thinner until they were unable to move because they were so thin. Sim-ilar to verbal psychotherapy, improvisation allows free association throughthe body instead of through words (Siegel, 1984).

Arts may be used to explore early developmental stages (Fleming,1989) and root causes of eating disorders. For example, in the early stagesof therapy, the art therapist could focus on Piaget’s (Atherton, 2003) stage ofassimilation by mirroring the actions of a caring authority figure that empa-thizes with the themes found within the client’s art and unconditionallyaccepts the client’s artwork, often praising the client for her efforts. Rabin(2003) pioneered a unique form of arts therapy called Phenomenal andNonphenomenal Body Image Tasks (PNBIT) that addresses self-esteem as aroot cause of eating disorders. Her technique involves participation in aseries of verbal and nonverbal arts-oriented tasks (many focused on bodyimage) designed to bridge the client’s self-image with reality.

Dramatherapy is another form of CAT. The National Association ofDrama Therapy (NADT) describes this treatment as “ . . . the systematic andintentional use of drama/theatre processes and products to achieve the ther-apeutic goals of symptom relief, emotional and physical integration, and

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Arts-Based Therapies in Treatment 137

personal growth” (NADT, 2004). Jacobse (1994) described a Dutch methodof dramatherapy where clients with anorexia nervosa and bulimia nervosawere given theatrical roles in a fictional play. Through the process of acting,they explored expression, imagination, and emotional involvement underthe safety of playing another character. This role-playing also allowed cli-ents to improve means of communicating and functioning within a groupsetting. Under the auspice of acting, clients experimented both “psychologi-cally and physically” (p. 142).

SURVEY RESULTS

Twenty-two residential eating disorder treatment programs were contactedfor this study. Of these 22, 13 programs completed the survey through self-report. Information was obtained about 6 programs through a combinationof publicly available information and verification telephone calls and 3 pro-grams refused to participate.

Arts-therapy is frequently employed in the residential treatment of eat-ing disorders. Of the 19 programs that participated in this study, all pro-grams offered arts-based therapy at least once per week, with an averageweekly client participation rate (CPR) of 90.55% (SD = 26.64%) for BEDtreatment programs and an average weekly CPR of 99.21% (SD = 2.08%) forAN and BN treatment programs. Over twenty-six percent (26.32%) of the 19participating programs offered arts-therapy once per day. These programsboasted an average daily CPR of 99.38% (SD = 1.25%).

Based on a review of daily resident schedules for each program, therewas large variability in the amount of time per week devoted to arts-basedtherapies (see Table 2). Controlling for outliers (two programs dedicatingover 10 hrs to arts therapy per week per patient were removed), programsdevoted an average of 2.8 total hrs (SD = 1.5 hrs, range = 45 min–5 hrs) perweek per patient to arts-therapy, not including dance or music therapy.

Programs offered a wide variety of reasons for incorporating arts-basedtherapies, including self-discovery, self-exploration, and self-expression.Others reported that arts-based therapies allowed clients to face and chal-lenge issues such as self-esteem, body image, depression, and the tendency

TABLE 2 Arts Therapy Utilization: Average Time per Week per Patient Dedicated toArts-based Therapies

Type of therapyAvg. time p/wk,

p/patient (SD) (Range)

Arts therapy 4.5 hrs (6.2 hrs) (45 min–22.2 hrs)Dance therapy 25 min (44 min) (0–2 hrs)Music therapy 32 min (1.1 hr) (0–3 hrs)

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138 M. J. Frisch et al.

to isolate by providing an alternative, healthy outlet for expression of emo-tions and development of positive coping skills. Art activities were viewedas non-threatening, alternative therapies wherein registered art therapistsworked to help clients identify feelings and integrate new awareness intomore positive coping behaviors. Many arts-based therapies were reported tobe particularly effective for patients who had difficulty with more traditionalforms of talk-oriented therapies.

DISCUSSION

While creative arts therapies are by all means intriguing and widelyemployed in the residential treatment of eating disorders, based on a com-prehensive review of the current literature, there are no empirical studies onarts-based therapies with clients who have an eating disorder. Althoughsome studies in the area of trauma and general psychiatric disorders exist,the outcomes are inconsistent between studies, most likely due to differ-ences and problems in study design. Further, the results of these studiesmay not be applicable to the unique characteristics of the eating disorderedclient. It appears that the majority of residential eating disorder treatmentprograms support and employ at least one form of therapy that has not yetbeen shown to be an empirically valid primary, secondary or adjunctivetreatment for eating disorders. However, the concept of empirical validitywith respect to arts-based therapies is complex.

Based on a review of the literature, the practice of utilizing arts-basedtherapies in the treatment of eating disorders has not been standardized.Most narrative depictions offered a case study for illustration of basic con-cepts, but stressed the unique, individualized nature of their process. Mostagree that the field of arts is quite individualized and difficult to measure, letalone standardize. However, if art as therapy is frequently used in the resi-dential treatment of eating disorders, perhaps we should consider scientificstudy of standardized forms, in order to test whether or not arts therapy isan effective adjunctive form of therapy. We suggest that a small series ofrandomized, controlled studies in this area be conducted. In addition, wesupport pursuit of short- and long-term follow-up data from basic outcomestudies.

The question of standardization within arts-based therapies must beaddressed. It is vital for purposes of replication that at least one standard-ized, replicable arts therapy model is tested within a randomized, controlledstudy. However, homogeneity for the sole purpose of “quality” or “correct”scientific research may alienate a core concept in arts therapy, the processof individualized expression. It is possible that standardization of arts-basedtherapies for the purpose of study may undermine the inherent therapeuticbenefits. By requiring the standardization of arts based therapies for the

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purpose of empirical validation, are we in some sense changing the spirit ofthis practice? Perhaps evidence-based practice and best practice are notalways the same (Driever, 2002).

According to the American Psychiatric Association (APA, 2000), type ofcare selection for clients who have an eating disorder is not only based onempirical evidence, but on clinical judgment and availability of care(Vandereycken, 2003). It is possible that arts therapy is not a therapy in atraditional sense, but is in fact a basic standard of care (Aldridge, 2003).Specifically, it may be that arts therapy is an important addition for eatingdisordered patients that allows for an alternative means of expression andcommunication within the context of traditional milieus of therapeutic careand treatment. However, it remains important to better understand theeffectiveness of arts therapy.

This study has some limitations. First, while this review presentedrevealing information regarding arts-based therapies in the treatment of eat-ing disorders, the limited scope of the survey does not allow for generaliza-tion to inpatient, partial or outpatient treatment programs for eatingdisorders, even though generalization may be implied. Second, the surveydid not ask whether each program utilized a standardized curriculum forarts-based therapies. While a review of scientific literature did not reveal awidely accepted or employed, standardized form of arts-based therapy inthe treatment of eating disorders, it is not clear whether any residentialprograms have developed and/or tested effective forms of standardized arts-based therapies. Therefore, it is possible that the standardization problemsoutlined within this discussion are less significant than suggested.

Several questions were raised by the study. How do scientists validateand support the use of such individualized forms of experientially orientedtherapies? If arts therapies are indeed only one small aspect of complex,multimodal client care, does it make a difference whether or not arts ther-apy has a positive impact that leads to progressive client change? Arts ther-apy does not cause any known harm to patients; it has been used oninpatient units at psychiatric hospitals for decades (Junge, 1994), longbefore its application to the treatment of eating disorders. Yet without sys-tematic study, important questions remain unanswered.

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