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

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Page 1: The treatment of aggression using arts therapies in forensic psychiatry: Results of a qualitative inquiry

The Arts in Psychotherapy 33 (2006) 37–58

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

Henk Smeijsters Ph.D.a,∗, Gorry Cleven RDTb

a KenVaK, Centre of Expertise for the Arts Therapies, Zuyd University, the Universityof 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 recentpractice, 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 ingeneral and more specifically in the Netherlands. It shows that arts therapies can help to decreaserecidivism. 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 beencompared and integrated into consensus-based treatment methods. The research reflects the Dutchtradition 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 ofdestructive 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

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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, todevelop treatment protocols and treatment guidelines based on research. To start with,arts therapists describe their observations, goals, interventions, effects and rationales whenworking 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 therapiesin forensic psychiatry. Because arts therapists had started describing their work individually,the authors decided by means of questionnaires, interviews and focus groups to accumulateand 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 unitedin one national association and arts therapies are developed and researched within the samemethodical formats and compared to each other.

The first part of this article describes the context for forensic psychiatric treatment andthe status of arts therapies in forensic psychiatry. A summary of the published researchis included, which gives an overview of “the state of the arts” in forensic psychiatry. Thesecond 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 patientsare treated in special forensic mental health institutes and will be released to the communitysooner 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 treatmentfirst before they can be released. These offenders are treated as clients in psychiatric hospitalsthat are closed from the community. Patients are imprisoned, but within the institution thereis a psychiatric, not a prison culture.

Although these patients are diagnosed using theDiagnostic and Statistical Manual ofMental Disorders (DSM-IV; American Psychiatric Association, 1994), in several psychi-atric hospitals the focus of treatment is on so-called problem areas. Problem areas arerelated to the DSM-IV and the chain of offense.Broek (2000a, 2000b)distinguishes thefollowing problem areas: lack of impulse control, aggression, grief, lack of empathy, lowsocial functioning and lack of structure.Horschlager (2000a, 2000b), in her follow-up ofthe 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 andnon-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 mostpsychiatric institutions. The number of arts therapists working in forensic institutions is

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about 10% of the working population of arts therapists. However, there is no differencein the relative frequency of art therapists working in forensic and general psychiatry. Ingeneral 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. Basedon their observations, they collect supportive information for the process of diagnosis,which is determined by the psychiatrist. Treatment in a forensic institution is made upas an integrated program in which several professionals—psychiatrist, psychologist, artstherapists, and others—take part. Within the treatment program, arts therapists focus onspecific treatment goals.

In the Netherlands the arts therapies in the last decade developed from insight orientedtherapy that takes the personality as a focus, to changing the way the patient feels, thinks andacts 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 behaviorsrelated to one problem area. This makes arts therapies valuable ingredients in the treatmentof forensic patients. An important rationale for arts therapies in forensic psychiatry istheir orientation to action (Douma, 1994; Hakvoort & Emmerik, 2001). The experientialand 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 thedevelopment of interaction competencies possible.

A general theory of arts therapies, for psychiatry as well as forensic psychiatry, has beenarticulated bySmeijsters (2003a, 2003b, 2003c, 2005). In line with Stern’s developmentalpsychology (Stern, 1985, 1995), Smeijsters describes the “analogy” between the vitalityaffects 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 andform. The therapeutic process is possible because the change of expression in the art formis experienced as a change of vitality affects. By experiencing vitality affects in art formsforensic patients can work through unarticulated layers of experiences and gradually becomeconscious 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 distinguishbetween their own point of view and some else’s 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 isJoe 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 alternativebehavior. 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 byMulder (1995)in drama therapy. Together with the patient she develops a play in whichcrucial moments of the chain of offense are incorporated. The patient reflects on these

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Table 1Recidivism 2 years after patients have been dismissed from supportive treatment

Length of treatment Recidivism (%)

No more than 6 months 677–12 months 5613–18 months 4519–24 months 21More than 2 years 17

Source:Teasdale (1997).

moments with words like “who,” “where,” and “when.” We see that typical aspects of dramatherapy are perfect ingredients to be incorporated in a cognitive–behavioral treatment. Whatmakes drama therapy a strong primary treatment is the fact that the behavior is trained inconcrete play situations.

Landers (2002)starts from the perspective that people who have been victims in societychoose the role of offender because this role is easily available. By means of playing the rolesof offender and victim, by changing scenes, and commenting on scenes patients acquire amore varied role pattern.Cleven (1998a, 1998b, 1999, 2003, 2004)developed interventionsin 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 treatmentmodality” within a forensic therapeutic community in which the whole community andalso smaller groups have group therapy sessions. This community as a whole leads to aremarkable decrease of recidivism (seeTable 1).

This shows that the success of treatment increases with the length of treatment. Althoughit 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 thetherapeutic community: decreasing individual impulsivity and crime.

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

Thompson (1999)takes the similarity between cognitive–behavioral therapy and theprocess of the actor who changes his cognitions to play his role. He tells us that “everydaylife is staged,” and that it is a matter of rehearsing and playing the appropriate role in reallife that saves patients from getting into an offense. A patient can leave the role of thebad 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 inforensic psychiatry is complex,Cleven (2004)uses several rationales adopted from Gestaltpsychology, transactional analysis, self-psychology and developmental psychology.

Music therapy in forensic psychiatry

Flower (1993)andSantos (1996)describe how forensic patients in music therapy areunable to improvise. These patients either control themselves to the extreme or are unable

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to stop their acting out behavior and act aggressively. Anger can be heard in the tempo, thedynamics, and the sound of the patient’s 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, angermanagement, 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, songselection, song parody, song composition, lyric analysis, group singing, drumming, andvocal 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 helplessnessand negative identity. To increase the patient’s control of his or her environment, Flowertakes destructive family situations as a theme and together with the patient explores musicalterritory during which the patient can experiment with levels of control. The patient reachesa balance when he or she is able to take initiatives and lead the improvisation and also isable to give space to another person, which he or she supports and follows. Flower usesthematic 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, fightingbehavior, frustration tolerance, impulse control, attention span, reality perception, awarenessof others, and self-perception (Codding, 2002; Hoskyns, 1988; Thaut, 1989a, 1989b, 1992).A review of session documentation byGallagher and Steele (2002)of 188 patients showedthat 91% actively participated, 82% expressed thoughts and feelings and 68% had a positivechange in affect.

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

Research ofDaveson and Edwards (2001), a self-report study after 12 sessions, showsthat five female delinquents in a prison reported being more relaxed and experiencing lesstension and stress and were able to express themselves better after music therapy. All patientsreported 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 andfrustration.

The effect of music in forensic psychiatry can be explained by referring to its possibilitiesfor interaction, communication, expression and exploration of feelings, as well as its abilityto stimulate goal-oriented behavior and create possibilities for controlling emotions andbehaviors (Codding, 2002; Gallagher & Steele, 2002). Theoretical concepts that are usedmay be related to psychodynamic theories, behavioral approaches, and cognitive procedures

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(Rio & Tenney, 2002). An explanation for the effect of drumming with patients who havethemselves been traumatized is given bySkaggs (1997), who argues that trauma is imprintedin 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 thetheory of analogy (Drieschner, 1997, and inSmeijsters, 2003c, 2005).

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

Art therapy in forensic psychiatry

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

Goals which are used in art therapy in forensic psychiatry are self-expression, self-esteem, coping mechanisms, social competencies, breakthrough of defenses, opennessfor 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 toothers. 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 oilpastels to balance the planning, controlling and expression by means of cognitive andbehavioral instructions. The art therapist (and co-therapist) acts as a model, and togetherwith the patient rules are described that shape behavior. The use of simple steps of progresshelps to minimize the patient’s frustration and to maximize success experiences. Givingpatients the opportunity to make choices prevents opposition.

Art therapy in forensic psychiatry often takes place within the framework ofcognitive–behavioral psychotherapy in which the problem is explored and then the searchfor a solution is undertaken (Kampen, 2001). Artistic expression of emotions instead ofacting 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 intoinner contradictions from the perspective of dialectical–behavioral therapy in line withLinehan (1996). It is possible to integrate these contradictions in a work of art and decreaseaggressive and destructive impulses. By doing this, patients can prevent their levels ofincreasing emotional tension from getting out of control and ultimately culminating in anoffense.

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

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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 areunable to express it verbally and cognitively. After feelings have found an expression inthe 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 resultof 13 months of art therapy. The amount of transgressions requiring disciplinary measuresas a result of art therapy decreased 75–81%. Two years after patients were dismissed 69%of the persons who took part in art therapy did not re-offend compared to the control groupwithout 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 onthe premise that patients can communicate in art in a symbolic way that cannot be verbalized(Liebmann, 1998). This may be linked to Freud’s or Jung’s psychoanalytic concepts of themanifest and latent meaning of images and Winnicott’s concept of symbolic play (Murphy,1998; Winnicott, 1971). In these rationales the patient’s artwork refers to content ‘behind’the image. The goal of therapy is finding these latent meanings to reach insight in fragmentedpsychic content and conflicts (Hagood, 1998).

From a different perspective, the art process and art form as an expression of the patient’sthoughts, emotions and behaviors is used rather than the symbolic meaning of the patient’simages (Baeten, 2001, 2005; McCourt, 1998; Riches, 1998). Important in this perspective ishow the patient uses the brush and color, arranges the space on the paper, works with detailsand the whole, makes transfers, and so on. These actions show how the patient experiencesand 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 mighthave in forensic psychiatry it is included to show its potency.

In dance-movement therapy Laban Movement Analysis (Laban, 1998) forms thebasis for a variety of different assessment measures that can be used to analyze thebody 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 towork with tension increases and decreases. Slow movements, conscious relaxation andeye contact counteract impulsive, brusque, uncontrolled and antisocial behavior. In herstudy DiGiorgio (1988) describes several theoretical perspectives when working withaggression.

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

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Dalessi (1997)describes how in dance-movement therapy movement games can be usedthat show almost no difference from the offensive act. The patient can use his body to huntthe 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 isanalogy because in therapy this is play and not a real offensive act. The dance-movementtherapist by means of rules can offer the opportunity on the one hand to experience thesame physical, emotional and behavioral processes, and on the other hand to put these intoplay where they can be controlled and where there is no harm done to others. Suddenlyincreasing tension in movement followed by releasing this tension is an example how indance-movement therapy tension increase and tension release can be explored and controlled(Milliken, 2002).

Research question and research method

The research reported here focused on finding which problem areas are important inactual clinical practice, how they can be defined, and which observations, indications,goals, interventions, effects and rationales arts therapists use when working with oneparticular problem area with the population of interest. We also addressed the issue ofconsensus about the treatment of any particular problem area within and between the artstherapies.

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 betweenpractitioners 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 memberchecking with respondents, peer debriefing with independent experts, triangulation (multi-ple respondents with different training and experience, multiple data collection techniquessuch as open questionnaires, interviews and panels, multiple theoretical perspectives), con-cept development and categorizing from grounded theory, and content analysis as describedin the work ofLincoln and Guba (1985, 2000),Smeijsters (1997),Strauss and Corbin (1998),Charmaz (2000), andSchwandt (2000).

Problem areas were conceptualized as diagnostic categories. Within these problem areasthe 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 areado you focus on during therapy? What are your goals? Which method, play forms andtechniques 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,

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comparing data from different people, comparing incident with incident, comparing datawith 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 the Netherlands and Germany. As data collectingtechniques questionnaires, interviews, and expert panels were used. Several arts therapistsparticipated in more than one data collecting technique. Nineteen arts therapists receivedby e-mail an open questionnaire with a set of problem areas and the listed framework aboveand 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-analysesof all questionnaires for a specific problem area and modality. There were several cyclesin which the results of analysis went back and forth between (new) respondents and theresearcher.

Because of gaps in the data, five arts therapists were interviewed to fill these gaps using“theoretical sampling” (Charmaz, 2000). The researcher used the sameframework whilediscussing 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 ina dialogical encounter tested the arts therapists’ understandings, and thus critical involve-ment produced understanding on both sides. During the interviews the researcher wrotedown the therapist’s answers into the framework. The transcripts of the interviews werecompared with the results of the questionnaires.

Finally 15 arts therapists participated in expert panels in which they discussed withcolleagues the trustworthiness of the researcher’s cross-analysis of the questionnaires andinterviews. 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 therapistsand 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 increasedcredibility and dependability. Peer debriefing with the members of the KenVaK researchteam was used to secure confirmability.

Results

The project began using the preliminary definitions of 11 problem areas byHorschlager(2000a) were used (see alsoHorschlager & Cleven, 2002). The outcome resultedin seven consensus-based problem areas and treatment models. Within the scope ofthis article it is only possible to describe one problem area. A complete descrip-tion of the research results (in Dutch) can be found inSmeijsters and Cleven(2004).

Table 2gives an overview of treatment possibilities for the problem area of destructiveaggression. This table is the result of the researcher’s content analysis of all open question-naires, interviews and panel discussions as described above.

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Table 2Consensus-based results of the treatment of destructive aggression by means of arts therapies (selection of data)

Drama therapy Music therapy Art therapy Dance-movement therapy

Indications Regular aggressive behaviors Lack of contact with own aggressivefeelings

Being irritated quickly Uncontrolled aggressiveoutbursts during which thepatient cannot control his body

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

Screaming and expressinganger in interaction

Unable to regulate aggression Unable to regulate aggression Unable to regulate aggression Unable to control aggression

Goals Insight into one’s personalaggression history

To make contact with one’saggressive feelings

Insight into the process of aggressiondevelopment

Insight in the process ofaggression development

Insight into stimuli that evokeaggression and the process ofaggression development

To permit and express aggression Recognizing risky events To handle power and lack ofpower, being big and small

Recognition of one’s personalaggression thermometer andone’s non-verbal signals ofaggression

Aggression regulation To handle cognitions and feelingsduring events that might lead to anoffense

To handle frustration, tension,anger, anxiety, aggression,violence

Being able to use techniques ofaggression to decrease aggression

Being able to handle conflicts Developing self control during riskyevents

Being able to reconstruct riskyevents

Being able to handle stimuli thatevoke aggression

To handle aggression To accept that suppressingfeelings leads to uncontrolledoutbursts

Being able to stop aggressionimmediately

Sublimation of destructive aggressioninto constructive aggression

To learn how to expressfeelings without hurting oneselfand other people

Sublimation of destructiveaggression into constructiveaggression

Sublimation of destructiveaggression into constructiveaggression

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

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Reach insight into and changeaggressive behavior

Reach insight into and changeaggressive behavior

Reach insight into and changeaggressive behavior

Reach insight into andchange aggressive behavior

Activities Activities Activities ActivitiesGoing through the aggression

history in several life timesTogether with the music therapist

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

Working with water paint, usinganother color before the first one isdry

Learn how to experience theincrease of aggression throughbody signals

Scene work to explore: Express feelings like anger andaggression; one person is playing, theother is guessing which feeling hasbeen expressed

Alternating between constructingand deconstructing (destroying,burning, tearing apart)

Learn how to decrease theincrease of aggression bymeans of changing bodyreactions

Sorts of aggression Choosing on a scale from 0 to 100which level of aggression the patientwants to express. Rising the levelaggression from 0 to the level thathas been chosen and going back

Exploding within borders When aggression increasesfocusing on functionalmovements

Cognitions and emotions A fight on musical instruments Gradual exposure to materials withresistance (hardness, weight, format):

Using strength in controlledsituations and movements (tugof war) where you can hurtnobody

Role-play of events where thepatient acted aggressively

YES/NO plays Working with stones Thematic techniques: powerand lack of power, big andsmall, anger, aggression,violence, anxiety, hyperactivity,tension, frustrationPlaying:

Using an aggressionthermometer (0–10) to scheduleevents linked to levels ofaggression

Improvisation on percussions Working with strong physicalefforts

“Hunter and hare”

Role-play low risk events fromdaily practice and increasing thetension level, then:

Using words including feelings,destructive coping behavior(aggression, drugs abuse)

Depicting how the patient loosescontrol in the offense (suddenchanges in the art process)

“Defending your territory”

Confronting, looking for themost frustrating stimulus of theevent

Giving structure to aggression bylearning how to play the drums

Painting stop signals “Catch and free”

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Table 2 (Continued )

Drama therapy Music therapy Art therapy Dance-movement therapy

Learn how to stop thebehavioral outburst

Researching the cognitions,feelings and behaviors during theoffense

Painting lack of power “Pretended fights” (hittingat a distance)

Exploring alternativebehaviors

Playing the victim on the musicalinstrument

Painting one’s misfit betweeninner power and outer burdens

“Fighting with sticks”against the wall and withcushions

Connecting the low riskevent with the offense

Painting one’s pitfalls Techniques of distancing

Learn to anticipate high risksituations in the future

Learn how to behave different Using rules during play andstops

The boxing ringScene work with high status

rolesPretended fightsTheatre of statues, tableaux

vivants“Joe Blaggs”

Effects Insight in one’s personalaggression increases

Less experience of stress, angerand frustration

Openness to the offense Admitting one’s anger

Acting differently in conflictsituations outside therapy

A decrease of anger Feeling responsible for the offense To understand and controlone’s anger

For instance: Supporting others Perceive risk factors Expressing power in acontrolled way

Not hitting Insight into one’s cognitivedistortions

Express aggression at theright moment and in the rightway

Staying at a distance Reflecting one’s personaldevelopment and experiences

Being more relaxed

Using a time out (visitingone’s room)

Experiencing the victim asinnocent

To understand one’s bordersand stop behavior at an earlystage

Not slapping with doors Behaving differentlyNot screaming

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The consensus-based rationales that were developed as a result of the research aredescribed below.

Rationales

Drama therapyDrama 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 andreach insight into stimuli and his or her cognitions. The patient can reach insight into hisor her inner conflicts concerning status and respect. Dramatic play gives the opportunityto develop the ability to regulate aggression. This ability can be transferred to realisticrole-play.

Music therapyMusical instruments and parameters offer the opportunity to express aggression in a

constructive way. The aggressive energy can become a part of the musical process. Themusic therapist can take part in the aggressive outburst, contain it and help the patient toexpress and regulate his aggression. Working in the music and being contained by the musictherapist gives the patient a feeling of security when exploring his aggression.

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

Expressing aggression in art material safely helps to explore one’s aggression. Using artmaterials makes it possible to be in contact with one’s cognitions, feelings and behaviors.

Visual art forms make it possible to picture the events, cognitions, feelings and behav-iors that went along with the person’s crime. By reflecting on the image the patient canbe confronted. Behaviors like grasping, hitting or petting can be transformed into artisticbehaviors.

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

therapy works with body and movement and therefore can evoke destructive bodily andmovemental powers. Patients are afraid of their destructive behaviors, which are suppressedbut suddenly can come to an outburst. They did not learn to symbolically express powerless destructively. In dance-movement therapy, dance and movement are used to expresssuppressed destructive aggression in an acceptable way, and to find alternative behaviors.

CommentsAll arts therapists sampled chose a lack of aggression regulation as anindication for treat-

ment. Drama, art, and dance-movement therapists mentioned aggressive behavior. Dramatherapists also focused on a lack of insight, music therapists on a lack of contact withpersonal feelings and avoiding conflicts, and art therapists on the saving up of anger.

All arts therapists used reaching insight as agoal. Learning how to control aggressionstimuli 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

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a goal. Music and dance-movement therapists mentioned accepting and releasing aggres-sion. Drama and art therapists focused on stopping aggression. Drama therapists also choserelaxation as a goal, music therapists handling conflicts, art therapists controlling thoughtsand feelings, and dance-movement therapists handling power and lack of power.

There were manyinterventions. 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 usedstop rules. Drama and music therapists worked with an aggression thermometer. Art anddance-movement therapists worked with control giving way to power. Drama therapistswent into the aggression history, and also played little risk situations from daily life. Musictherapists worked with frustration tolerance training and used play forms to express feelings.

Drama and dance-movement therapy indicated as aneffect the ability to react differently.Music and dance-movement therapy led to a decrease of anger. Music therapy resulted in achange of feeling, art therapy in the decrease of cognitive distortions, and dance-movementtherapy in expressing anger in a more controlled way.

Drama therapists saw as arationale for the effect of drama therapy the possibility toexplore 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 musicalinteraction as an opportunity to express aggression in a social context and to learn howto 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 intheir opinion was a means to decrease cognitive distortions. Dance-movement therapistsstressed the fact that in dance and movement the physical aspect of destructive aggressionare expressed and changed.

Table 3gives a summary of all therapeutic categories for all arts therapies.In Table 3, in most cases a coherent clinical reasoning process can be seen, which means

that all aspects of treatment (indication, goal, intervention, effect, rationale) were connectedto 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 forall 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 andemotions. 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 totheir experiences. This is possible because in arts therapies concrete scenes are explored inwhich it is almost impossible to hide one’s thoughts, emotions, and behavior.

Arts therapies explore the onset and characteristics of the offense and help patients torecognize and influence the thoughts, feelings and behavioral signals that are linked to theoffense. Through structured play forms—with roles, scenes, listening exercises, improvi-sations, art images and forms, body exercises, and movement arrangements—behaviors,

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Table 3Summary of the treatment of destructive aggression by means of arts therapies

Drama Music Art Dance-movement

IndicationsLack of aggression regulation X X X XAggressive behaviors X X XLack of insight XLack of contact with one’s feelings XTo avoid conflicts XSuppressing anger X

GoalsTo reach insight X X X XTo control aggression stimuli X X XTo transform destructive in constructive behavior X X XTo express aggression X XTo stop aggression X XRelaxation XTo handle conflicts XTo control cognitions and feelings XTo handle power and lack of power X

InterventionsPlayforms with power and status X X X XPretended fights X X X XExploring cognitions, feelings and behaviors X X XStop rules X X XAggression thermometer X XControlled strength X XAggression history XLow risk events XFrustration tolerance training XExpression of feelings X

EffectsBehaving differently X XLess anger X XChange of feeling XLess cognitive distortion XExpressing anger differently X

RationalesDistancing in fictive scenes and roles XMusical instruments, parameters and interaction XObstinate art material XImaging XExpression in body and movement X

feelings and cognitions are transformed. Attachment problems, developmental and psychi-atric disturbances are positively influenced by strengthening self-expression, self-esteemand empathy. A shared rationale of arts therapists is that by expressing thoughts, feelingsand actions in art forms it is possible to influence these expressions “hands on” and exploreand develop new thoughts, feelings and actions.

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Table 4Examples of coherent clinical reasoning process

Indication Goal Intervention Effect Rationale

Drama Aggressive behaviors To control aggression stimuli Low risk events Behaving differently Distancing in fictivescenes and roles

Music Lack of contact withone’s feelings

To contact personal feelings Expression of feelings Change of feeling Musical instruments,parameters andinteraction

Art Lack of insight To reach insight Exploring cognitions,feelings and behaviors

Less cognitive distortion Imaging

Dance-movement Lack of aggressionregulation

To transform destructive intoconstructive behavior

Controlled strength Expressing angerdifferently

Expression in body andmovement

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The research resulted in several consensus-based areas of treatment such as patients’limited perception, compulsive control, lack of emotional expression and empathy, highemotional 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 psychoticdisturbances. Other problem areas are related to personality disorders, attention deficithyperactivity disorder, and mental handicaps. When the offense has been committed bya 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, andmovement show the psychological limitations and possibilities of patients. The arts thera-pies confront forensic patients with their lack of emotions, dysfunction of cognitions andbehaviors. By experiencing and acting it is possible to increase tension regulation, impulsecontrol, aggression regulation, empathy, interaction, and the strengthening of boundaries.

This research makes explicit the “tacit knowledge” of a group of arts therapists. Bydoing this it is possible to analyze, compare and integrate the implicit body of knowledgethis group of arts therapists developed while working with their patients. This researchmade a cross-analysis of tacit knowledge of several arts therapists, which resulted in aconsensus-based body of knowledge, the “collective sense of the profession” so to speak.

The effects listed in this research study reflect the effects as perceived by the surveyed artstherapists. 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 controlconditions are precisely observed and correlated with other assessment scales like scalesfor recidivism. The results of this qualitative study will act as an input for the next researchstudy 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 whatthey were doing. For them, this led to empowerment that they hoped would strengthen theirfuture treatment interventions and also their rationales within their multidisciplinary teams.Hopefully, due to this research where respondents at several stages were confronted withanalyses 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 therespondents acted as co-researchers, this may have led to an increase of their scientificcompetencies.

The information gathered by this research can be used in everyday clinical practice whenthe goal is to influence destructive aggression of forensic patients. The body of knowledgeis “consensus-based,” as listed inTable 2. However, this information should not be used as a‘protocol’ without variation. Each individual art therapist should reflect on the transferabilityof 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 themembers of the KenVaK team who were involved with peer debriefing. This research is a

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joint project by KenVaK, and the GGzE, the Institute for Forensic and Intensive Psychiatryin Eindhoven. The research results have been published as a book by the EFP, the nationalCentre of Expertise for Forensic Psychiatry in Utrecht. Thanks to Cheyenne Mize at theUniversity of Louisville for her advice in preparing this article.

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