Smeijsters, H. and Clever, G. (2006). The treatment of aggression using arts therapies in forensi.pdf

8/11/2019 Smeijsters, H. and Clever, G. (2006). The treatment of aggression using arts therapies in forensi.pdf

1/22

The Arts in Psychotherapy 33 (2006) 3758

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

Henk Smeijsters Ph.D. a,, Gorry Cleven RDT b

a KenVaK, Centre of Expertise for the Arts Therapies, Zuyd University, the University

of Professional Education Utrecht, and Saxion University of Professional Education Enschede,

PO Box 69, 6130 AB Sittard, The Netherlandsb GGzE, the Institute for Forensic and Intensive Psychiatry, Eindhoven, The Netherlands

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 31experienced arts therapists working in 12 institutions in the Netherlands and Germany. The arts ther-

apists 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 for-

mats. 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.

2005 Elsevier Inc. All rights reserved.

Keywords: Arts therapies; Forensic psychiatry; Qualitative research; Aggression

Corresponding author. Tel.: +31 46 4207262; fax: +31 46 4207279.

E-mail address:[email protected] (H. Smeijsters).

URL: www.smeijsters.nl, www.kenvak.hszuyd.nl.

0197-4556/$ see front matter 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.aip.2005.07.001


2/22

38 H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758

Introduction

In the Netherlands health care system, arts therapies are a regular part of treatment inpsychiatric 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 psychiatric treatment in the Netherlands

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, forinstance psychosis, personality disorder or addiction, it is agreed that they need treatment

first before they canbe released.These offenders aretreated 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 psychi-

atric 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, 2000b)distinguishes the

following problem areas: lack of impulse control, aggression, grief, lack of empathy, low

social functioning and lack of structure. Horschlager (2000a, 2000b), in her follow-up of

the research byDamen (2000, 2001), mentions problem areas such as tension, aggression,

impulsivity, power, control, lack of boundaries, lack of structure, lack of expression andinadequate perception. Factor analytic research with theBehavioural 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.

Arts therapies in forensic psychiatry in the Netherlands

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


3/22

H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 39

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 professionalspsychiatrist, psychologist, arts

therapists, and otherstake 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 bySmeijsters (2003a, 2003b, 2003c, 2005).In line with Sterns developmental

psychology (Stern, 1985, 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 formsforensic patients can workthrough unarticulated layers of experiences and graduallybecome

conscious of cognitive schemes (Johnson, 2002; Kampen, 2004; Timmer, 2004).

Drama therapy in forensic psychiatry

Forensic patients in dramatherapy are unable to improvise, to take roles and to distinguish

between their own point of view andsome elses point of view (Thompson,1999). Thompson

(1998, 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. Thestory 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, 2000b, 2000c, 2003, 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


4/22


Table 1

Recidivism 2 years after patients have been dismissed from supportive treatment

Length of treatment Recidivism (%)No more than 6 months 67

712 months 56

1318 months 45

1924 months 21

More than 2 years 17

Source:Teasdale (1997).

moments with words like who, where, and when. We see that typical aspects of drama

therapy are perfect ingredients to be incorporated in a cognitivebehavioral 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 societychoose the role of offenderbecause 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, 1998b, 1999, 2003, 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 (seeTable 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 psy-

chodrama, 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 cognitivebehavioral 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 rehears-ing 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.

Music therapy in forensic psychiatry

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


5/22


to stop their acting out behavior and act aggressively. Anger can be heard in the tempo, the

dynamics, and the sound of the patients play (Hakvoort, 1996, 2002a, 2002b).

There are many goals that are listed by music therapists working in forensic psychiatrysuch 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, 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 patients 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),andPeeters (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,attentionspan, reality perception, awareness

of others, and self-perception (Codding, 2002; Hoskyns, 1988; Thaut, 1989a, 1989b, 1992).A review of session documentation byGallagher 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 ofDaveson 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 andstress andwere able to express themselves betterafter music therapy. Allpatients

reported that music therapy was pleasant and helpful. Song composition and song parodyled 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


6/22


(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. Drieschnerdescribes that the effect of the drum improvisation can be explained by referring to the

theory of analogy (Drieschner, 1997, and inSmeijsters, 2003c, 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, 1998). By changing the parameters of the

musical expression, the behavioral, emotional and cognitive parameters of the offense can

be changed.

Art therapy in forensic psychiatry

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 byLev-

Wiesel and Hershkovitz (2000) with theMachover Draw-A-Person Testshows a statistically

significantdifference in signsof violent behavior between violent and non-violent offenders.

Lopez and Carolan (2001)with theHouse-Tree-Person Testfound 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 thecognitive distortions in the artwork.

Bennink et al. use collages that are constructed with journals, objects trouves 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 patients 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

cognitivebehavioral 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)showsthat it is possible for patients to express emotional polarities in art, and gain insight into

inner contradictions from the perspective of dialecticalbehavioral 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


7/22


their personal thoughts, beliefs and behaviors as well as the thoughts, beliefs and behav-

iors of others (Gussak, 1997; Gussak & Cohen-Liebmann, 2001; Gussak & Virshup,

1997; Liebmann, 1996a, 1996b, 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 7581%. 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 Freuds or Jungs psychoanalytic concepts of the

manifest and latent meaning of images and Winnicotts concept of symbolic play (Murphy,

1998; Winnicott, 1971).In these rationales the patients artwork refers to content behind

the image.The goal of therapy is findingthese latentmeanings 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 patients

thoughts, emotions and behaviors is used rather than the symbolic meaning of the patients

images (Baeten, 2001, 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 andacting.

Dance-movement therapy in forensic psychiatry

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 move-

ment increases individuation. Moving synchronously in the same rhythm increases socialbehavior 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).


8/22


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 andbehavioral 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-movementtherapy tension increase and tension release can be exploredand controlled

(Milliken, 2002).

Research question and research method

The research reported here focused on finding which problem areas are important in

actual clinical practice, how they can be defined, and which observations, indications,

goals, interventions, effects and rationales arts therapists use when working with one

particular problem area with the population of interest. We also addressed the issue of

consensus about the treatment of any particular problem area within and between the arts

therapies.

The aim was to develop treatment methods with a sufficient amount of clinical trust-

worthiness. The research methodology was based on qualitative data, naturalistic (on site)

inquiry, and dialectical knowledge-building. This implies an authentic dialogue between

practitioners and researcher, in which treatment methods are developed, by reconstructing

tacit knowledge of experienced arts therapists (Polanyi, 1967).The outcome representssubjective meanings that have been negotiated.

Specific research techniques used were repeated analysis of transcripts, iterative member

checking with respondents, peer debriefing with independent experts, triangulation (multi-

ple respondents with different training and experience, multiple data collection techniques

such as open questionnaires, interviews and panels, multiple theoretical perspectives), con-

cept development and categorizing from grounded theory, and content analysis as described

intheworkofLincoln andGuba (1985,2000), Smeijsters (1997), Strauss and Corbin (1998),

Charmaz (2000), andSchwandt (2000).

Problem areas were conceptualized as diagnostic categories. Within these problem areas

the researcher asked questions such as: How would you describe this problem area?

Do you have a diagnostic theory about the problem area? How is the problem behaviorreflected in drama, music, art, dance or movement? Which aspects of the problem area

do you focus on during therapy? What are your goals? Which method, play forms and

techniques do you use? Which effects did you see? Do you have a rationale why drama,

music, art, dance or movement has a positive effect? These questions reflect the fol-

lowing framework: problem area, observation, diagnosis, indication, goal, intervention,

effect, and rationale, which can be understood as a way of axial coding (Strauss &

Corbin, 1998). Within the framework concepts were developed by means of the con-

stant comparative method: comparing data from the same individuals with themselves,


9/22


comparing data from different people, comparing incident with incident, comparing data

with category, and comparing a category with other categories (Charmaz, 2000; Glaser,

1992).Respondents were 31 members of the network of arts therapists in forensic psychiatry.

They were working in 12 forensic clinics in theNetherlands and Germany. As data collecting

techniques questionnaires, interviews, and expert panels were used. Several arts therapists

participated in more than one data collecting technique. Nineteen arts therapists received

by e-mail an open questionnaire with a set of problem areas and the listed framework above

and were asked to write down their tacit knowledge.

All written descriptions were analyzed by comparing, selecting, relocating, combining,

and integrating content (Mayring, 1990). Smeijsters acted as the researcher, Cleven as co-

reader. The researcher analyzed each individual questionnaire and also made cross-analyses

of all questionnaires for a specific problem area and modality. There were several cycles

in which the results of analysis went back and forth between (new) respondents and the

researcher.

Because of gaps in the data, five arts therapists were interviewed to fill these gaps using

theoretical sampling (Charmaz, 2000).The researcher used the same frameworkwhile

discussing the tacit knowledge of the therapist when working with specific problem areas.

During these interviews, by taking his own understanding into the dialogue, the researcher in

a dialogical encounter tested the arts therapists understandings, and thus critical involve-

ment produced understanding on both sides. During the interviews the researcher wrote

down the therapists answers into the framework. The transcripts of the interviews were

compared with the results of the questionnaires.

Finally 15 arts therapists participated in expert panels in which they discussed with

colleagues the trustworthiness of the researchers cross-analysis of the questionnaires and

interviews. Some people participated in several stages of the research process, but in total31 different persons were involved (11 drama therapists, 9 music therapists, 8 art therapists

and 3 dance-movement therapists).

During all stages in the research process member checking, peer debriefing, the triangu-

lation of theoretical perspectives, and the use of several data collection techniques increased

credibility and dependability. Peer debriefing with the members of the KenVaK research

team was used to secure confirmability.

Results

The project began using the preliminary definitions of 11 problem areas byHorschlager(2000a) were used (see also Horschlager & Cleven, 2002). The outcome resulted

in seven consensus-based problem areas and treatment models. Within the scope of

this article it is only possible to describe one problem area. A complete descrip-

tion of the research results (in Dutch) can be found in Smeijsters and Cleven

(2004).

Table 2gives an overview of treatment possibilities for the problem area of destructive

aggression. This table is the result of the researchers content analysis of all open question-

naires, interviews and panel discussions as described above.


10/22

Table 2

Consensus-based results of the treatment of destructive aggression by means of arts therapies (selection of data)

Drama therapy Music therapy Art therapy D

Indications Regular aggressive behaviors Lack of contact with own aggressive

feelings

Being irritated quickly U

o

p

Lack of insight in own aggression Avoiding conflicts Suppressed anger that explodes in

uncontrolled destructive aggression

S

a

Unable to regulate aggression Unable to regulate aggression Unable to regulate aggression U

Goals Insight into ones personal

aggression history

To make contact with ones

aggressive feelings

Insight into the process of aggression

development

I

a

Insight into stimuli that evoke

aggression and the process of

aggression development

To permit and express aggression Recognizing risky events T

p

Recognition of ones personal

aggression thermometer and

ones non-verbal signals of

aggression

Aggression regulation To handle cognitions and feelings

during events that might lead to an

offense

T

a

v

Being able to use techniques of

aggression to decrease aggression

Being able to handle conflicts Developing self control during risky

events

B

e

Being able to handle stimuli that

evoke aggression

To handle aggression T

f

o

Being able to stop aggression

immediately

Sublimation of destructive aggression

into constructive aggression

T

f

a

Sublimation of destructive

aggression into constructiveaggression

S

aa

Interventions General line of treatment: General line of treatment: General line of treatment: G


11/22

Reach insight into and change

aggressive behavior


aggressive behavior


aggressive behavior c

Activities Activities Activities A

Going through the aggression

history in several life times

Together with the music therapist

play The cat that hunts, and kills themouse, exchanging roles

Working with water paint, using

another color before the first one isdry inb

Scene work to explore: Express feelings like anger and

aggression; one person is playing, the

other is guessing which feeling has

been expressed

Alternating between constructing

and deconstructing (destroying,

burning, tearing apart)

in

m

r

Sorts of aggression Choosing on a scale from 0 to 100

which level of aggression the patient

wants to express. Rising the level

aggression from 0 to the level that

has been chosen and going back

Exploding within borders

f

m

Cognitions and emotions A fight on musical instruments Gradual exposure to materials with

resistance (hardness, weight, format): s

o

nRole-play of events where the

patient acted aggressively

YES/NO plays Working with stones

a

s

v

te

P

Using an aggression

thermometer (010) to schedule

events linked to levels of

aggression

Improvisation on percussions Working with strong physical

efforts

Role-play low risk events from

daily practice and increasing the

tension level, then:

Using words including feelings,

destructive coping behavior

(aggression, drugs abuse)

Depicting how the patient looses

control in the offense (sudden

changes in the art process)

Confronting, looking for the

most frustrating stimulus of the

event

Giving structure to aggression by

learning how to play the drums

Painting stop signals


12/22

Table 2 (Continued)

Drama therapy Music therapy Art therapy D

Learn how to stop the

behavioral outburst

Researching the cognitions,

feelings and behaviors during theoffense

Painting lack of power

a

Exploring alternative

behaviors

Playing the victim on the musical

instrument

Painting ones misfit between

inner power and outer burdens a

c

Connecting the low risk

event with the offense

Painting ones pitfalls

Learn to anticipate high risk

situations in the future

Learn how to behave different

s

The boxing ring

Scene work with high status

roles

Pretended fights

Theatre of statues, tableauxvivants

Joe Blaggs

Effects Insight in ones personal

aggression increases

Less experience of stress, anger

and frustration

Openness to the offense

Acting differently in conflict

situations outside therapy

A decrease of anger Feeling responsible for the offense

o

For instance: Supporting others Perceive risk factors

c

Not hitting Insight into ones cognitive

distortions r

w

Staying at a distance Reflecting ones personal

development and experiences

Using a time out (visiting

ones room)

Experiencing the victim as

innocent a

s

Not slapping with doors

Not screaming


13/22


The consensus-based rationales that were developed as a result of the research are

described below.

Rationales

Drama therapy

Drama therapy allows distancing so it is possible to analyze cognitions before and during

aggression. Because of fictive dramatic play the patient can explore aggressive scenes and

reach insight into stimuli and his or her cognitions. The patient can reach insight into his

or her inner conflicts concerning status and respect. Dramatic play gives the opportunity

to develop the ability to regulate aggression. This ability can be transferred to realistic

role-play.

Music therapy

Musical instruments and parameters offer the opportunity to express aggression in a

constructive way. The aggressive energy can become a part of the musical process. The

music therapist can take part in the aggressive outburst, contain it and help the patient to

express and regulate his aggression. Working in the music and being contained by the music

therapist gives the patient a feeling of security when exploring his aggression.

Art therapy

In art therapy materials and techniques can be used to evoke and release aggression.

Expressing aggression in art material safely helps to explore ones aggression. Using art

materials makes it possible to be in contact with ones cognitions, feelings and behaviors.

Visual art forms make it possible to picture the events, cognitions, feelings and behav-

iors that went along with the persons crime. By reflecting on the image the patient canbe confronted. Behaviors like grasping, hitting or petting can be transformed into artistic

behaviors.

Dance-movement therapy

Aggressive behaviors have strong body and movement characteristics. Dance-movement

therapy works with body and movement and therefore can evoke destructive bodily and

movemental powers. Patients are afraid of their destructive behaviors, which are suppressed

but suddenly can come to an outburst. They did not learn to symbolically express power

less destructively. In dance-movement therapy, dance and movement are used to express

suppressed destructive aggression in an acceptable way, and to find alternative behaviors.

Comments

All arts therapists sampled chose a lack of aggression regulation as an indication for treat-

ment. Drama, art, and dance-movement therapists mentioned aggressive behavior. Drama

therapists also focused on a lack of insight, music therapists on a lack of contact with

personal feelings and avoiding conflicts, and art therapists on the saving up of anger.

All arts therapists used reaching insight as a goal. Learning how to control aggression

stimuli was used in drama, art, and dance-movement therapy. Drama, art, and dance-

movement therapists also took the transfer of destructive into constructive aggression as


14/22


a goal. Music and dance-movement therapists mentioned accepting and releasing aggres-

sion. Drama and art therapists focused on stopping aggression. Drama therapists also chose

relaxation as a goal, music therapists handling conflicts, art therapists controlling thoughtsand feelings, and dance-movement therapists handling power and lack of power.

There were many interventions. All modalities used playforms for power and status, pre-

tended fights and quarrel in the art form. Drama, music and art therapists explored thoughts,

feelings, and behaviors during the offense. Drama, art, and dance-movement therapists used

stop rules. Drama and music therapists worked with an aggression thermometer. Art and

dance-movement therapists worked with control giving way to power. Drama therapists

went into the aggression history, and also played little risk situations from daily life. Music

therapists worked with frustration tolerance training and used play forms to express feelings.

Drama and dance-movement therapy indicated as an effectthe ability to react differently.

Music and dance-movement therapy led to a decrease of anger. Music therapy resulted in a

change of feeling, art therapy in the decrease of cognitive distortions, and dance-movement

therapy in expressing anger in a more controlled way.

Drama therapists saw as a rationale for the effect of drama therapy the possibility to

explore by distancing and fictive role cognitions and to explore and train alternative behav-

iors. Music therapists saw the musical instruments, the musical parameters, and the musical

interaction as an opportunity to express aggression in a social context and to learn how

to control it. Art therapists mentioned the characteristics of the art material as a possibil-

ity to experiment with the expression of aggression. Depicting the offense in an image in

their opinion was a means to decrease cognitive distortions. Dance-movement therapists

stressed the fact that in dance and movement the physical aspect of destructive aggression

are expressed and changed.

Table 3gives a summary of all therapeutic categories for all arts therapies.

InTable 3, in most cases a coherent clinical reasoning process can be seen, which meansthat all aspects of treatment (indication, goal, intervention, effect, rationale) were connected

to each other. Sometimes, however, the link between treatments aspects was not manifest.

Table 4based onTable 3, shows how the clinical reasoning process can become explicit for

all treatment aspects. The authors additions have been put in italics.

Discussion

From the literature it can be seen that arts therapies strongly focus on behavior and

emotions. The play forms are aimed to go into life history, to express emotions, to interact,

and to strengthen social, emotional, physical and cognitive competencies. Arts therapieswork with a combination of experiencing and acting; with a stable structure in the art form.

Patients learn how to think, feel and act differently as well as give different meanings to

their experiences. This is possible because in arts therapies concrete scenes are explored in

which it is almost impossible to hide ones thoughts, emotions, and behavior.

Arts therapies explore the onset and characteristics of the offense and help patients to

recognize and influence the thoughts, feelings and behavioral signals that are linked to the

offense. Through structured play formswith roles, scenes, listening exercises, improvi-

sations, art images and forms, body exercises, and movement arrangementsbehaviors,


15/22


16/22

Table 4

Examples of coherent clinical reasoning process

Indication Goal Intervention Effect

Drama Aggressive behaviors To control aggression stimuli Low risk events Behaving differently

Music Lack of contact with

ones feelings

To contact personal feelings Expression of feelings Change of feeling

Art Lack of insight To reach insight Exploring cognitions,

feelings and behaviors

Less cognitive distortion

Dance-movement Lack of aggression

regulation

To transform destructive into

constructive behavior

Controlled strength Expressing anger

differently


17/22


The research resulted in several consensus-based areas of treatment such as patients

limited perception, compulsive control, lack of emotional expression and empathy, high

emotional tension, impulsivity, lack of interpersonal boundaries, and destructive aggres-sion. These problem areas form a bridge between disturbances and offensive behaviors.

Impulsivity for instance is related to addiction; limited perception is related to psychotic

disturbances. Other problem areas are related to personality disorders, attention deficit

hyperactivity disorder, and mental handicaps. When the offense has been committed by

a patient with a particular disturbance, the problem areas that are connected to this dis-

turbance will be the focus of treatment. Interventions in drama, music, art, dance, and

movement show the psychological limitations and possibilities of patients. The arts thera-

pies confront forensic patients with their lack of emotions, dysfunction of cognitions and

behaviors. By experiencing and acting it is possible to increase tension regulation, impulse

control, aggression regulation, empathy, interaction, and the strengthening of boundaries.

This research makes explicit the tacit knowledge of a group of arts therapists. By

doing this it is possible to analyze, compare and integrate the implicit body of knowledge

this group of arts therapists developed while working with their patients. This research

made a cross-analysis of tacit knowledge of several arts therapists, which resulted in a

consensus-based body of knowledge, the collective sense of the profession so to speak.

The effects listed in this research study reflectthe effects as perceived by the surveyed arts

therapists. These effects are consensus-based, but not experimentally researched. Therefore,

we are planning another research study of effects that is closely linked to clinical practice,

but is more experimentally oriented, in which baseline phases, treatment phases and control

conditions are precisely observed and correlated with other assessment scales like scales

for recidivism. The results of this qualitative study will act as an input for the next research

study and we hope to transform these data into an assessment scale and treatment plan.

The arts therapists reported experiencing this interaction with the researcher as veryfruitful because they were stimulated to reflect on their experiences and conceptualize what

they were doing. For them, this led to empowerment that they hoped would strengthen their

future treatment interventions and also their rationales within their multidisciplinary teams.

Hopefully, due to this research where respondents at several stages were confronted with

analyses of data, the reflective practitioner could develop into a scientific practitioner

who not only acts as an individual respondent, but also as a co-researcher. Because the

respondents acted as co-researchers, this may have led to an increase of their scientific

competencies.

The information gathered by this research can be used in everyday clinical practice when

the goal is to influence destructive aggression of forensic patients. The body of knowledge

is consensus-based, as listed in Table 2. However, this information should not be used as aprotocol without variation. Each individual art therapistshould reflect on the transferability

of these data to his or her own setting and patients.

Acknowledgements

Thanks to all arts therapists and students who participated in this research. Thanks to the

members of the KenVaK team who were involved with peer debriefing. This research is a


18/22


joint project by KenVaK, and the GGzE, the Institute for Forensic and Intensive Psychiatry

in Eindhoven. The research results have been published as a book by the EFP, the national

Centre of Expertise for Forensic Psychiatry in Utrecht. Thanks to Cheyenne Mize at theUniversity of Louisville for her advice in preparing this article.

References

Argante, R. (1999). Muziektherapie ten behoeve van het dagprogramma seksueel delinquenten [Music therapy

for a day treatment program of sexual delinquents]. Workshop gehouden tijdens de SCRET-studiedag Dag-

behandeling van zedendelinquenten [Workshop during the SCRET Symposium Day treatment of sexual

delinquents]. Eindhoven: GGzE.

Baeten, N. (2001).Observatie en analyze van beeldend werk[Observation and analysis of art work]. Workshop

tijdens de StudiedagCreatief Therapeuten binnen de Forensische Psychiatrie [Workshop duringthe Symposium

Arts Therapies in Forensic Psychiatry]. Utrecht: Dr. F.S. Meijerskliniek.

Baeten, N. (2005).Beeldende therapie creatieve therapie in de praktijk[Creative art therapy in practice]. Utrecht:Flevo Future.

Bennink, J., Gussak, D. E., & Skowran, M. (2003). The role of the art therapist in a Juvenile Justice Setting. The

Arts in Psychotherapy,30(3), 163173.

Brewster, L. G. (1983). An evaluation of the arts-in-corrections programme of the California Department of

Corrections. Prepared for the William James Association, Santa Cruz, California and California Department

of Corrections.

Broek, R. van den (2000a). Inleiding over de Pompekliniek[Introduction about the Pompe clinic]. Studiedag Dra-

matherapeuten in de Forensische Psychiatrie [Symposium Dramatherapists in Forensic Psychiatry], Nijmegen.

Broek, R. van den (2000b). Workshop empathie[Workshop empathy]. Studiedag Dramatherapeuten in de Foren-

sische Psychiatrie [Symposium Dramatherapists in Forensic Psychiatry], Nijmegen.

Buck, J. N. (1987). House tree person test. Los Angeles, CA: Western Psychological Services.

Chandler, M. (1973). Egocentrism and antisocial behaviour: The assessment and training of social perspective

taking skills.Developmental Psychology,44, 326333.

Charmaz, K. (2000). Grounded theory objectivist and constuctivist methods. In N. K. Denzin & Y. S. Lincoln(Eds.),Handbook of qualitative research(pp. 509535). London: Sage Publications.

Cleven, G. (1998a).De toepassing van vaktherapieen in de daderbehandeling[Arts therapies in the treatment of

offenders]. Eindhoven: GGzE FPC.

Cleven, G. (1998b). Van inspiratie naar integratie. Over observatiemethodiek in dramatherapie [From inspiration

to integration. Assessment in drama therapy]. Tijdschrift voor Creatieve Therapie, 17(4), 2023.

Cleven, G. (1999).Dramatherapie ten behoeve van het dagprogramma seksueel delinquenten [Drama therapy as

part of the day treatment program for sexual delinquents]. Workshop gehouden tijdens de SCRET-studiedag

Dagbehandeling van zedendelinquenten [Workshop during the SCRET Symposium Day treatmentof sexual

delinquents]. Eindhoven: GGzE.

Cleven, G. (2003). Het rollenrepertoire van cli enten met een persoonlijkheidsstoornis. Het rollenrepertoire is

driedimensionale actie [The role repertoire of clients with a personality disturbance. The role repertoire is

three-dimensional action]. In I. Graumans (Red.). Storing verplicht?! Overhet onvermogenemotieste hanteren

(pp. 2128) [Disturbance obliged?! About the helplessness to handle emotions]. Eindhoven: GGzE.

Cleven, G. (2004). In Scene. Dramatherapie en ervaringsgerichte werkvormen in hulpverlening en begeleiding

[In scene. Drama therapy and experiential play forms in treatment and support]. Houten: Bohn Stafleu van

Loghum.

Codding, P. A. (2002). A comprehensive survey of music therapists practicing in correctional psychiatry: Demo-

graphics, conditions of employment, service position, assessment, therapeutic objectives, and related values

of the therapist.Music Therapy Perspectives,20(2), 5668.

Cogan, K. B., & Paulson, B. L. (1998). Picking up the pieces: Brief report on inmates experiences of a family

violence drama project.The Arts in Psychotherapy,25(1), 3743.

Cruz, R. F., & Sabers, D. L. (1998). Dance/movement therapy is more effective than previously reported.The Arts

in Psychotherapy,25(2), 101104.


19/22


Dalessi, A. (1997). Roofdieren in een kooi. Danstherapie in de behandeling van een groep zedendelinquenten

[Animalsin a cage. Dance therapy in thetreatment of a group of sexual delinquents]. Tijdschrift voor Creatieve

Therapie, 16(3), 2631.

Damen, M. (2000). Indicatiestelling bij de non-verbale therapieen van het forensisch psychiatrisch circuit van

de GGzE. Een concept mapping project ter ontwikkeling van een indicatieschaal [Indications for nonverbal

therapies in the forensic psychiatric unit of the GGzE. A concept mapping project for the development of an

indication scale]. Eindverslag, Eindhoven: GGzE.

Damen, M. (2001). Een indicatieschaal voor de non-verbale therapieen [An indication scale for nonverbal thera-

pies].Tijdschrift voor Creatieve Therapie, 20(1), 2023.

Daveson, B. A., & Edwards, J. (2001). A descriptive study exploring the role of music therapy in prisons.The Arts

in Psychotherapy,28(2), 137141.

Diagnostic and Statistical Manual of Mental Disorders(DSM-IV). (1994). American Psychiatric Association.

DiGiorgio, D. (1988). Three theoretical perspectiveson aggressionwith implicationsin thefield of dance/movement

therapy. Philadelphia: Hahnemann University.

Douma, N. (1994). Kreatieve therapie onder dwang? [Creative therapy under pressure].Tijdschrift voor Kreatieve

Therapie, 13(4), 126128.

Drieschner, K. (1997). Vermindering van boosheid door muziektherapie: een gecontroleerd effectonderzoek metforensisch psychiatrische cli enten [The reduction of anger by means of music therapy: A controlled effect

study with forensic psychiatric clients]. Amsterdam: Universiteit van Amsterdam.

Flower, C. (1993). Control and creativity. Music therapy with adolescents in secure care. In M. Heal & T. Wigram

(Eds.),Music therapy in health and education(pp. 4045). London: Jessica Kingsley Publishers.

Fulford, M. (2002). Overview of a music therapy program at a maximum security unit of a state psychiatric facility.

Music Therapy Perspectives,20(2), 112116.

Gallagher, L. M., & Steele, A. L. (2002). Music therapy withoffenders in a substanceabuse/mental illness treatment

program.Music Therapy Perspectives,20(2), 117122.

Gerber, J. (1994). The use of art therapy in juvenile sex offender specific treatment. The Arts in Psychotherapy,

21(5), 367374.

Glaser, B. G. (1992).Basics of grounded theory analysis: Emergence versus forcing. Mill Valley, CA: Sociology

Press.

Gussak, D. (1997). Breaking through barriers: Art therapy in prisons. In D. Gussak & E. Virshup (Eds.), Drawing

time: Art therapy in prisons and other correctional settings. Chicago, IL: Magnolia Street.

Gussak, D., & Cohen-Liebmann, M. (2001). Investigation versus intervention: Forensic art therapy and art therapy

in forensics settings.American Journal of Art Therapy,40(2), 123135.

Gussak, D., & Virshup, E. (Eds.). (1997). Drawing time: Art therapy in prisons and other correctional settings .

Chicago, IL: Magnolia Street.

Haeyen, S. (2004). Verbindend werk. Beeldende therapie met borderline-clienten op basis van de dialectische

gedragstherapie van Linehan [Work that connects. Art therapy with borderline clients based on the dialectical

behaviortherapy of Linehan].Tijdschrift voor Creatieve Therapie, 23(1), 510.

Hagood, M. (1998). Group art therapy with adolescent sex offenders. An American experience. In M. Liebmann

(Ed.),Art therapy with offenders(pp. 197219). London: Jessica Kingsley Publishers.

Hakvoort, L. (1996).Patterns between indication for music therapy and characteristics of musical improvisation

of forensic patients. Paper presented at the 8th World Congress of Music Therapy, Hamburg.

Hakvoort, L. (2002a). A music therapy anger management program for forensic offenders. Music Therapy Per-

spectives,20(2), 123132.Hakvoort, L. (2002b).Observation and treatment criteria in music therapy for forensic patients. Paper presented

at the 10th World Congress of Music Therapy, Oxford.

Hakvoort, L. & Emmerik, J. van (2001). Diagnostiek en observatie in de Dr. F.S. Meijerskliniek[Diagnosis and

observation in the Dr. F.S. Meijers clinic]. Presentatie tijdens de Studiedag Creatief Therapeuten binnen de

Forensische Psychiatrie [Presentation during the Symposium Arts Therapies in Forensic Psychiatry]. Utrecht:

Dr. F.S. Meijerskliniek.

Horschlager, K. (2000a). Indicatiestelling bij de non-verbale therapieen van het forensisch psychiatrisch circuit

van de GGzE. Deel II Work in progress. Operationalisatie van probleemgebieden ter ontwikkeling van een

indicatieschaal [Indications for nonverbal therapies in the forensic psychiatric unit of the GGzE Part II Work


20/22


in progress. Operationalization of problem areas for the development of an indication scale]. Eindverslag,

Eindhoven: GGzE.

Horschlager, K. (2000b). Indicatiestelling bij de non-verbale therapieen van het forensisch psychiatrisch circuit

van de GGzE. Deel III. Op weg van een individuele waarneming en beschrijving naar een gemeenschappelijke

waarneming en beschrijving van probleemgebieden [Indications for nonverbal therapies in the forensic psy-

chiatric unit of the GGzE. Part III. From individual perception and description to the collective perception and

description of problem areas]. Eindverslag, Eindhoven: GGzE.

Horschlager,K., & Cleven, G. (2002).Indicatiestelling bij non-verbale therapieen van het forensischpsychiatrisch

cirquit van de GGzE[Indications for nonverbal therapies in the forensic psychiatric unit of the GGzE]. Lezing

tijdens het NVCT Symposium, 7 juni [Paper presented during the NVCT Symposium].

Hoskyns, S. (1988). Studying group music therapy with adult offenders: Research in progress. Psychology of

Music,16, 2541.

Johnson, D. R. (2002). Creatieve therapie bij getraumatiseerde mensen [Creative therapy for traumatized peo-

ple]. Lezing tijdens het Symposium Tijdsbesef van de NVCT [Paper presented during the Symposium Time

consciousness of the NVCT].

Kampen, E. (2001). Module creatieve therapie beeldend. Zorgprogramma 3 Seksuele stoornissen: delictketen

groep [Treatment module creative art therapy. Treatment program 3 sexual disturbances: Chain of offensegroup]. Venray: De Rooyse Wissel.

Kampen, E. (2004). De innerlijke observator als bewaker van delinquent gedrag. De reflectieve functie als aan-

grijpingspunt en maat voor behandeling [The inner perspector as guard of delinquent behavior. Reflection as

indication and measure for treatment]. Tijdschrift voor Creatieve Therapie, 23(2), 813.

Laban, R. (1998).The mastery of movement. Plymouth: Northcote House Publishers.

Landers, F. (2002). Dismantling violent forms of masculinity through developmental transformations.The Arts in

Psychotherapy,29(1), 1929.

Lev-Wiesel, R., & Hershkovitz, D. (2000). Detecting violent aggressive behavior among male prisoners through

the Machover Draw-A-Person Test.The Arts in Psychotherapy,27(3), 171177.

Liebmann, M. (1996a).Arts approaches to conflict. London: Jessica Kingsley Publishers.

Liebmann, M. (1996b). The violent illusion: Drama therapy and the dangerous voyage to the heart of change. In

M. Liebmann (Ed.),Arts approaches to conflict(pp. 92117). London: Jessica Kingsley Publishers.

Liebmann, M. (Ed.). (1998). Art therapy with offenders. London: Jessica Kingsley Publishers.

Lincoln, Y. S., & Guba, E. G. (1985).Naturalistic inquiry. Newbury Park, CA: Sage Publications.

Lincoln, Y. S., & Guba, E. G. (2000). Paradigmatic controversies, contradictions, and emerging confluences. In N.

K. Denzin& Y. S. Lincoln (Eds.),Handbook of qualitative research (pp. 163188). London: Sage Publications.

Linehan, M. M. (1996). Borderline persoonlijkheidsstoornis. Handleiding voor training en therapie[Bordeline

personality disorders. Manual for training and therapy]. Lisse: Swets & Zeitlinger.

Lopez, J. R., & Carolan, R. (2001). House-tree-person drawings and sex offenders: A pilot study. Art Therapy,

18(3), 158165.

Lusebrink, V. B. (1990).Imagery and visual expression in therapy. New York: Plenum Press.

Mayring, P. (1990).Qualitative Inhaltsanalyse. Grundlagen und Techniken[Qualitative content analysis. Funda-

mentals and techniques]. Weinheim: Deutscher Studien Verlag.

McCourt, E. (1998). Building up to a sunset. In M. Liebmann (Ed.), Art therapy with offenders (pp. 3956).

London: Jessica Kingsley Publishers.

Milliken, R. (2002). Dance/movement therapy as a creative arts therapy approach in prison to the treatment of

violence.The Arts in Psychotherapy,29(4), 203206.Mulder,J. (1995).Het terugvalpreventiemodel alsbehandelingsmethodiek in eenforensische dagbehandelingsklin-

iek [The prevention of recidive model als treatment method in a forensic day treatment clinic].Tijdschrift voor

Psychotherapie, 21(2), 119133.

Murphy, J. (1998).Mistsand darkness.Art therapy withlong termprisoners in a highsecurityprisonAtherapeutic

paradox? In M. Liebmann (Ed.),Art therapy with offenders(pp. 1438). London: Jessica Kingsley Publishers.

Peaker, A., & Vincent, J. (1990, December). Arts in prisons: Towards a sense of achievement. Home Office

Research and Planning Unit and the Arts Council.

Peeters, R. (2003). Workshop persoonlijkheidstoornissen en zedendelinquenten. Emoties binnen de themas

ontwikkelingsgeschiedenis, delictscenario en slachtofferempathie van een eendaagse deeltijd [Workshop per-


21/22


sonality disorders and sequal delinquents. Emotions within the themes developmental history, offense scenario

andvictim empathy of a oneday parttimetreatment]. In I. Graumans (Red.). Storingverplicht?! Overhet onver-

mogen emoties te hanteren [Disturbance obliged?! About the helplessness to handle emotions]. Studiedag

SCRET, Eindhoven: GGzE.

Poel, T. van der (1997). Musiktherapie mit personlichkeitsgestorten sexualstraftatern in der Forensischen Psychi-

atrie [Music therapy in the treatment of sexual delinquents with personality disorders in forensic psychiatry].

InHast du Tone? Musik und Musiktherapie im Rheinland[Do you have sounds? Music and music therapy in

the Rheinland]. Koln: Landschaftverband Rheinland.

Poel, T. van der (1998).Musiktherapie mit pers onlichkeitsgestorten sexualstraftatern in der Forensischen Psychi-

atrie[Music therapy in the treatment of sexual delinquents with personality disorders in forensic psychiatry]

(p. 5). WsFPP.

Polanyi, M. (1967).The tacit dimension. London: Routledge Kegan Paul.

Reed, K. J. (2002). Music therapy treatment groups for mentally disordered offenders in a state hospital setting.

Music Therapy Perspectives,20(2), 98104.

Riches, C. (1998). The hidden therapy of a prison art education programme. In M. Liebmann (Ed.), Art therapy

with offenders(pp. 77101). Jessica Kingsley Publishers: London.

Rio, R. E., & Tenney, K. S. (2002). Music therapy for juvenile offenders in residential treatment. Music TherapyPerspectives,20(2), 8997.

Santos, K. (1996). Woman patients in forensic psychiatryThe forgotten ones? In I. Nygaard Pedersen & L. Ole

Bonde (Eds.).Music therapy within multidisciplinary teams. Proceedings of the 3rd European Music Therapy

Conference(pp. 121127). Aalborg: Aalborg Universitetsforlag.

Schwandt, T. A. (2000). Three epistemological stances for qualitative inquiry. Interpretivism, hermeneutics, and

social constructionism. In N. K. Denzin & Y. S. Lincoln (Eds.),Handbook of qualitative research (pp.189213).

London: Sage Publications.

Silver, R., & Ellison, J. (1995). Identifying and assessing self-images in drawings by delinquent adolescents. The

Arts in Psychotherapy,22(4), 339352.

Skaggs, R. (1997). Music-centered creative arts in a sex offender treatment program for male juveniles. Music

Therapy Perspectives,15(2), 7378.

Smeijsters, H. (1997). Multiple perspectives. A guide for qualitative research in music therapy. Gilsum, NH:

Barcelona Publishers.

Smeijsters, H. (2003a). Analogie als Kernkonzept der Musiktherapie. Eine psychologische und empirische Betra-

chtung [Analogy as the core concept of music therapy. A psychological and empirical essay]. Zeitschrift fur

Musik-, Tanz- und Kunsttherapie, 14(1), 918.

Smeijsters, H. (2003b). Forms of feeling and forms of perception. The fundamentals of analogy in music therapy.

Nordic Journal of Music Therapy: Theory Building in Music TherapyAn International Archive,12(1), 7185.

Smeijsters, H. (2003c).Handboek creatieve therapie [Handbook of the creative arts therapies]. Bussum: Coutinho.

Smeijsters, H. (2005). Sounding the self: Analogy in improvisational music therapy. Gilsum, NH: Barcelona

Publishers.

Smeijsters, H., & Cleven, G. (2004). Vaktherapieen in de forensische psychiatrie [Arts therapies in forensic

psychiatry]. Utrecht: EFP.

Stern, D. N. (1985). The interpersonal world of the infant. A view from psychoanalysis and developmental psy-

chology. New York: Basic Books.

Stern, D. N. (1995). The motherhood constellation: A unified view of parent-infant therapy . New York: Basic

Books.Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Grounded theory procedures and techniques .

London: Sage Publications.

Teasdale, C. (1997). Art therapy as part of a group therapy programme for personality disordered offenders.

Therapeutic Communities: The International Journal for Therapeutic and Supportive Organizations , 18(3),

209221.

Thaut, M. (1987). A new challenge for music therapy: The correctional setting. Music Therapy Perspectives,4,

4450.

Thaut, M. (1989a). Music therapy, affect modification, and therapeutic change. Music Therapy Perspectives, 7,

5562.


22/22


Thaut, M. (1989b). The influence of music therapy interventions on self-rated changes in relaxation, affect, and

thought in psychiatric prisoner-patients.Journal of Music Therapy,26, 155166.

Thaut, M. (1992). Music therapy in correctional psychiatry. In W. Davis, K. Gfeller, & M. Thaut (Eds.), An

introduction to music therapy: Theory and practice(pp. 273284). Dubuque, IA: W.C. Brown Publishers.

Thompson, J. (Ed.). (1998).Prison theatre: Perspectives and practices. London: Jessica Kingsley Publishers.

Thompson,J. (1999).Drama workshops for angermanagement and offending behaviour. London: JessicaKingsley

Publishers.

Timmer, S. (2000a). Delict-keten denken binnen dramatherapie. Dramatherapie in een forensisch psychiatrische

polikliniek [The use of the concept of the chain of offense in drama therapy. Drama therapy in a forensic

psychiatric poly-clinic].Tijdschrift voor Creatieve Therapie, 19(1), 1218.

Timmer, S. (2000b).Inleiding over Kairos. Studiedag Dramatherapeuten in de Forensische Psychiatrie [Introduc-

tion about Kairos. Symposium Dramatherapists in Forensic Psychiatry]. Nijmegen.

Timmer, S. (2000c). Workshop agressieregulatie. Studiedag Dramatherapeuten in de Forensische Psychiatrie

[Workshop aggression regulation. Symposium Dramatherapists in Forensic Psychiatry]. Nijmegen.

Timmer, S. (2003). Werkwijzen dramatherapie in de forensische psychiatrie [Treatment modalities of drama

therapy in forensic psychiatry]. Nijmegen: Kairos-Pompestichting.

Timmer, S. (2004). Zanger gezocht. Dramatherapie binnen een schemagerichte behandeling voor zedendelin-quenten [To find a singer.Drama therapy within a scheme oriented treatment for sexual delinquents]. Tijdschrift

voor Creatieve Therapie, 23(1), 1116.

Wagner, M. (1997). Aanbod Kreatieve Therapie Muziek in de seksualiteitsgroep polikliniek. Interne publicatie

[Creative music therapy in thegroup of sexual delinquents in the poly-clinic. Internal publication]. Eindhoven:

GGzE.

Watson, D. M. (2002). Drumming and improvisation with adult male sex offenders. Music Therapy Perspectives,

20(2), 105111.

Winnicott, D. W. (1971). Playing and reality. London: Tavistock Publications.

Woods, P., Reed, V., & Collins, M. (2001). Measuring communication and social skills in a high security foren-

sic setting using the Behavioural Status Index (BSI). London: Florence Nightingale School of Nursing and

Midwifery, Kings College.

Wyatt, J. G. (2002). From the field: Clinical resources for music therapy with juvenile offenders. Music Therapy

Perspectives,20(2), 8088.

Documents

Smeijsters, H. and Clever, G. (2006). The treatment of aggression using arts therapies in forensi.pdf