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Art therapy in prison

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When one generally thinks of art therapy, the use of it with some of society’s most dangerous individuals does not naturally spring to mind. Prison inmates are a unique cohort living in an unnatural environment. Cognitive or behavioural issues may have contributed to an individual being incarcerated and being confined to a single facility for potentially long periods brings up challenges for rehabilitation.

This Literature review will look at five studies carried out over approximately the last 10 years in chronological order, ranging from reducing depression in inmates to applying art therapy to difficult cases involving schizophrenia. It will conclude with outlining some potential shortcomings arising in the studies; though the overall results are promising with implementing the use of art therapy within the prison environment.

Pearson and Wilson (2009) attest that art therapy provides a mechanism for expressing and communicating personal experiences from the depths of the human soul. Not only does it allow the expression of non-verbal thinking but the act of creating within a therapeutic space is a moment to focus energetic drives, process personal behaviours and seek a unified emotional and mental state (pp. 169-170). Nowhere does this seem more required than in a population that is sometimes forgotten by the general populous; that of inmates in prison.

The history of the use of art therapy within the prison environment can be traced back to the work of Levy (1978) in her work with female inmates displaying aggressive behaviours. Levy discovered the use of art therapy as a non-verbal therapeutic technique successful in realizing “untapped material” (p. 157) which may have explained the source of the inmate’s aggressive behaviour. Within the prison environment, the benefits of art therapy endure with ongoing studies spearheaded by David Gussak.

Gussak’s (2007) study examined the effectiveness of art therapy in reducing depression in prison populations. In an environment where the clients can have an inherent mistrust for verbal disclosure and rigid defenses for basic survival (p. 444), art therapy was seen as an alternative avenue for developing the essential sense of trust and safety required for the therapeutic alliance to flourish (Pearson & Wilson, 2009, p. 170). The study was conducted with male inmates in a North Florida prison in medium to maximum security, and chosen by the mental health counsellor. All participants had Axis I diagnosis such as depression, despondency or manic type bipolar disorder. Gussak utilized the Formal Elements Art Therapy Scale (FEATS); the Beck Depression Inventory-Short Form (BDI-II) (Beck, Rial, & Rickets, 1974, as cited in Gussak, 2007, p.454); and a personally developed 6-point Likert-type survey once before the intervention, and once after. The art tasks began with simple individual exercises such as a name embellishment and self-symbol activity, through to more complex group work such as collaborating to build a paper bridge and group mandala work. These were used in conjunction with an art directive, which consisted of each inmate drawing a picture of a person picking an apple from a tree (PPAT) using standardized art materials, to ascertain any therapeutic change (Gussak, 2007, p. 444-448).

Gussak (2007) found that posttest PPAT drawings reflected increased space used, extensively greater details, and higher compositional integration; thus reflected a greater awareness of their surroundings. Results also showed that inmate participants showed a stronger investment in the therapeutic process, a greater display of compliance of directives with staff, increased socialization skills, and a significant decrease in depressive symptoms with an elevation of mood (pp. 449-456). The results from this study were promising with working in a uniquely difficult environment. A year later, Michael Hanes took an art therapeutic modality one step further in working with greater at risk inmates; those on suicide watch.

Hanes (2008) applied his art therapy modality in an American County Jail where clinicians, with limited availability of resources, were tasked to evaluate an inmate’s risk of suicide solely upon self-reporting of their internal mental state, behavioural patterns and life history. The use of Road Drawings was implemented due to their ease of use with limited safe materials as to lower potential security risks; a 2B pencil (shortened to 3 inches), 8 crayons and paper (pp. 78-80).

Hanes (2008) theorized that the use of drawing a road, which he believed is a universally understood symbol, can function as a metaphor as the inmate’s “road of life” (p. 79); thus bringing forth vital information that the inmate may be reluctant to disclose in a standard verbal therapeutic setting (p. 83). Hanes found that inmates were able to reflect on their Road Drawings as a way to self-assess their capacity for change, transform destructive patterns of thinking and actions, and imbue hope and optimism for their future (p.83). This ‘process drawing’, outlined in Pearson and Wilson (2009), supports ventilation and catharsis by use of colour, lines and shapes to express and release internal feelings (pp. 181-182). This is a projective technique which allows the focus to be on reparative methods instead of beginning with a problem focus approach. It facilitates the opportunity for inmates to create their story and express their unique perception of reality, rather than focusing on established literal facts (p, 172) which may be presented in their case history. Given that depression has been found to be the leading predictor of suicide amongst inmates (Suto & Arnaut, 2010, pp. 294-295, 302-304), a study was done to investigate this further.

Gussak (2009b) revisited his study from 2007 with the inclusion of female inmates, so to advance his previous research base. He simultaneously theorized whether art therapy would assist in improving the inmate’s mood, socialization skills, problem-solving skills, and Locus of Control (LOC) (p. 6). As LOC is the degree of control that an individual feels he or she has over their environment, with external LOC indicating a tendency to believe outside influences control one’s behaviour and internal LOC having a sense that one is in control of one’s destiny (Bayse, Allgood, & van Wyk, 1992); Gussak (2009b) believed inmates may have a tendency towards exhibiting a greater external LOC. This correlated with his findings that there is a direct relationship between LOC and depression; the greater the external LOC, the greater chance of displaying depressive symptoms (p. 6).

Gussak (2009b) followed a similar format to how the therapeutic sessions were run in his 2007 study; beginning with simple individual art work which progressed to group orientated art work, thus facilitating problem-solving skills. The addition of the Adult Nowicki-Strickland Locus of Control Scale (ANSLOC) was utilized to assess interpersonal and motivational areas for a change in LOC. This was achieved by a simple Yes and No questionnaire (p. 6-7).

The results were a significant change in the male and female inmate’s ANSLOC scores from external to internal. Gussak (2009b) concluded that through art therapy, inmates learnt to manipulate the art materials to accomplish their desired effect and learnt cause and effect through this creative therapeutic process; this knowledge then became internalized (p. 10). Gussak (2009a) revisited his results and found a substantial improvement in mood and internal LOC within the female inmate participants compared to males. As it has been shown that female inmates are potentially more susceptible to depression (Harris, 1993), experience more difficulty with depression (Butterfield, 2003), and display a greater external LOC (DeWolfe, Jackson, & Winterberger, 1988); Gussak (2009a) concluded that his results highlighted the notion that female inmates undertaking art therapy had a greater scope to change (pp. 202-207). Up until this point, art therapy had shown flexibility in working with both male and female inmates. Investigating its adaptability with another therapeutic modality was achieved.

Breiner, Tuomisto, Bouyea, Gussak, & Aufderheide (2012) used art therapy within a Cognitive Behavioural Therapy (CBT) framework at the Wakulla Correctional Institution in Florida. It targeted anger management with inmates who previously had a history of anger issues or interpersonal violence. The basic assumptions of CBT are that problematic thinking leads to problematic emotional and behavioural consequences, and this problematic thinking is either learned or is resultant from a lack of learning. The goal of CBT to identify these errors in thinking and to help the client to correct them by acquiring the cognitive skills to assist in eliminating problematic behaviour (pp. 1125-1127).

Breiner et al’s (2012) reasoning for incorporating art therapy was to accommodate the treatment to the individual inmate’s unique characteristics which they believed was beyond the scope of the standard CBT tools. The flexibility and variability in art therapy allowed them to undertake the treatment with clients showing a diverse level of verbal ability and intellectual capacity (pp. 1139-1140). This was achieved with an art therapy directive known as “The Water Contamination Exercise.” A 3 piece drawing of water being contaminated by 3 different sources, and the effect that has on the water being produced at the end of an irrigation system. It was designed to assist the inmates to comprehend how underlying attitudes can generate the thoughts that may occur in response to a trigger (p. 1135-1136). For the inmates it was an easy pictorial way in understanding cognitive restructuring using the ABCD model from CBT developed by Albert Ellis (Ellis, 2006).

Breiner et al (2012) found that art therapy engaged the inmates more in the therapy process by assisting group members to access emotions that may be difficult or troublesome to express. It assisted in calming inmates who were displaying signs or nervousness or distress about being in this particular group setting. They found the art therapy tasks complimented the CBT material which made it more readily accessible to the inmates with different learning styles, intellectual barriers, and personality traits that may have impacted their ability to understand the material (p 1140). These results displayed the adaptability of art therapy to work within another established therapeutic modality. Another challenge was whether art therapy could be successfully applied to inmates with a severe mental disorder.

Qiu et al (2017) examined the effect of an art brut therapy program with prison inmates, on mainland China, that have been diagnosed with schizophrenia. Inmates with schizophrenia display a very rigid self-defense mechanism, which can be externalized through silence or lies. This is due in part for the need for basic survival coping strategies against possible threats from other inmates. Compounding this is the high rate of illiteracy with a decreased level of verbal communication in the prison setting. This is challenging for inmates with schizophrenia to be able to vocalize their emotional and mental issues, such as depression, which has been shown to be prevalent in prisons (p. 1070).

Art Brut, also known as “outsider art” or “raw art”, is art without limitations. Its style, or lack of, is used to describe art created outside the normal boundaries of mainstream art or culture. Qui et al (2017) decision to use this particular art modality was due to the clients they were working with. An art exercise that was directive in nature would not have been received well by the clients with schizophrenia (p. 1069). The format of the sessions began with free process drawing (Pearson & Wilson, 2009, pp. 181-182), followed by a 15-25 minute focus one-on-one interview where the client talked about their art with the therapist giving advice on how to enrich their drawing for future sessions, then group discussion were everyone was allowed to discuss other’s works by giving comments and compliments (Qiu et al, 2017, pp. 1070-1071).

Qiu et al (2017) reported witnessing a decrease in anxiety, depression, anger, and negative psychiatric symptoms with the inmates. They also showed greater compliance with rules and medications, and increased socialization with peers (pp. 1069-1078). Although each study has shown the benefits of using art therapy within the prison environment, there are some notable shortcomings which cannot be dismissed.

Shortcomings

Participants in Gussak’s (2007) initial study were not randomly chosen, instead selected by the counsellor due to previously having worked with them. Cooperation in the study may have also been considered as practicing ‘good behaviour’ in the prison environment, thus deserving the inmates of extra privileges (p. 452-453). Gussak (2009a) rectified this in his follow up study though he acknowledged his random sample sizes were too small (p. 10).

Gussak’s (2007, 2009a), Hanes (2008), and Breiner et al (2012) studies were all conducted in a geographically specific location, Florida. Although this helped with reinforcing results from the studies, it does substantially hinder the applicability to other geographically diverse populations.

The study by Qui et al (2017) appears to break a fundamental rule outlined by Pearson and Wilson (2009) in that an expressive therapist, or other client’s, should avoid analyzing the client’s creations. The goal is transformation through the art instead of educating or instructing so the completed piece can be admired (p. 170-171, 190).

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