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Literature Review: ATh and Neuropsychiatry

Literature Review -
Literature Review - "SPECT"
Literature Review - "SPECT"

Representing and Holding the Person Behind the Diagnosis: The Unique Aspects of Art Therapy Within the Medical Diagnostic Setting of a Neuropsychiatry Unit



This paper presents a critical review of the literature and evidence in support of the use of art therapy as an allied health service within the very specific medical diagnostic environment of a Neuropsychiatric Unit in a major hospital located in one of Australia's capital cities.  In reviewing the literature and arriving at a recommendation as to an appropriate and effective role that art therapy can play, the specific nature of the particular Neuropsychiatric Unit in case is taken into account.  As such, the recommended action cannot be seen as a "blanket" model for all Neuropsychiatric settings particularly those where treatment, as opposed to diagnosis and short term admission, is the central operating premise.

When a patient enters a hospital to undergo medical testing, they often encounter a range of unfamiliar procedures and services.  In the neuropsychiatric setting presented in this paper, many of the procedures undergone by the particular client demographic of the unit are in order establish a diagnosis of one or another progressive or debilitating illness which, in many cases, are terminal.  The patient's physical and mental functioning may have slowly declined in the years or months prior to their admission, or they may be noticing the presence of symptoms they had witnessed in the progressive decline of a close relative, and be only too aware of the implications for themselves.  

To this already latent sense of fear, confusion and disorientation there is added the unfamiliar environment of the hospital ward; encounters with foreign (and noisy) equipment such as the Magnetic Resonance Imaging (MRI) machine (for an example, listen to Audio 1 - MRI below); and extensive sessions undertaking intensive psychological testing.

Audio 1 - MRI

In reviewing the literature related to the application of art therapy within such a setting, the writer will firstly give an overview of the specific Neuropsychiatric Unit's services and function; the typical client demographics; types of diagnostic and daily medical procedures undergone by patients; as well as allied health services and extended support frameworks available within the unit.  The discussion of the patient demographics will address typical presenting issues and illnesses including common symptomatic, neuropsychiatric, psychological and psychosocial presentation.

In order to further inform the subsequent review of the literature, a description of Art Therapy will also be given in order to provide a definition for the reader, within the context of this paper. 

This will lay the foundation for the ensuing discussion of the literature with regard to the implementation of Art Therapy within a Neuropsychiatric setting.  Further to this, it will allow for a comparative review of further literature with respect to the unique role that Art Therapy can play within the specific Neuropsychiatric Unit that the author is presenting. 



2. Description of the Neuropsychiatry Unit, its function and typical

presenting patient demographics  


2.1 The Neuropsychiatry Unit's Team

The Neuropsychiatry Unit presented in this paper has a multifaceted team representing a range of complimentary and interconnected disciplines.  A typical (but not exhaustive) list of the professionals involved in the diagnostic investigations, assessments and services encountered by a patient admitted to the unit would include neuropsychiatrists; neuropsychologists; neurologists; medical doctors; occupational therapists; social workers; psychiatric and general nursing staff; medical imaging services; research fellows; student health professionals representing fields such as psychiatric and general nursing, occupational therapy, and art therapy; and, in addition, the administrative staff, including personal assistants, office managers and medical records management.


2.2 How and why a patient comes to be at the Neuropsychiatry Unit

There are a range of pathways and reasons that may lead to a patient admission to the unit.  The most common reason is in order to investigate and hopefully come to a diagnostic conclusion regarding a patient's cognitive or functional decline as evidenced in symptoms commonly caused by neurologically based disorders.  This includes memory loss; inability to perform daily tasks; confusion; decline in mental acuity; as well as the presence of ataxia, agnosia, dysphagia, and Parkinsonism.  In some cases it is difficult to determine whether the presenting issues are physiological or psychogenetic in their origin.  One of the diagnostic aims may be to determine the balance of such contributing causes.  In other cases it is a matter of providing diagnosis by exclusion, a differential or "working" diagnosis, or providing confirmation as to what the condition is NOT as opposed to arriving at a definitive conclusion as to what it actually is.

Patients are usually referred to the unit by their own health professionals who may wish to have the patient's presenting symptoms investigated further.  This is a psychiatrist or neurologist who has been referred to by the patient's general practitioner.  Patients may also be referred on from the hospital's neuropsychiatry outpatient service, as well as via an online referral form found at the unit's web site.

At times a close parent or sibling of the patient may have received a diagnosis of a genetic condition such as Huntington's Disease (HD) or Young Onset Dementia (YOD) and the patient may be seeking to discount or confirm the presence of the illness in themselves.  Usually these clients have shown some symptomatic indications that they may also have the illness.

Patients with a confirmed diagnosis such as HD, Niemann Pick Type C (NPC), or YOD will typically attend an admission every six to twelve months to review and assess the progress of their condition.


2.3 Typical testing, interview and daily medical procedures

A patient admitted to the Neuropsychiatry Unit will undergo a range of medical testing and diagnostic procedures and have an average admission of ten to fourteen days.  Tests may include Magnetic Resonance Imaging (MRI) (see Figure 1); Computer Axial Tomography (CAT scan);  Single-Photon Emission Computer Tomography (SPECT) (see Figure 2); Positron Emission Tomography (PET scan); blood tests; gene and DNA testing; extensive psychological, cognitive and functional testing; Occupational Therapy assessments, including ability to perform Activities of Daily Living (ADLs) and navigational ability.  In addition, the patient's earlier medical histories are collected and reviewed by the team as well as interviews being undertaken with those of the patient's relatives who may be available to assist in the provision of collateral history and additional information concerning the patient.



Figure 1 - MRI showing significant cerebral atrophy


Figure 2 - SPECT imaging indicating volume of blood within different regions of the brain.  This, in turn, indicates brain function.  Areas of high and healthy brain activity would be indicated by higher volumes of blood as represented in the SPECT by red to white "hot" coloured regions.


When testing and assessment is complete, and some form of a diagnostic picture has been arrived at, a family information meeting is usually undertaken in order to inform the patient and family of any implications and potential courses of treatment pertaining to the patient's illness.  Treatment, per se, is not part of the unit's charter, although certain conditions may result in the implementation of particular treatment and/or medication regimes which would be followed up via outpatients or external services.

2.4 Typical patient demographics for patients admitted to the Neuropsychiatry Unit discussed in this paper

2.4.1 Diagnosis, age and employment status

During the duration of the author's placement and the Neuropsychiatry Unit being discussed in this paper, highest diagnostic group represented were patients assessed with YOD (Younger Onset Dementia).  Other diagnoses included HD, NPC, Parkinson's Disease (PD), Hydrocephalus, Schizophrenia, and a range of Psychogenetic disorders including Psychogenetic Amnesia.  There were some occasions when a definitive diagnosis could not be arrived at.

The age range of patients encountered varied from early twenties to mid eighties.  In most cases, due to the nature of their illness, patients were unemployed, retired or on disability pensions.  Employment history varied significantly, with some having been home makers, students, sales assistants or employed in labouring positions, such as factory hand or "brickie's labourer".  Others had high ranking, high functioning positions including dental technician, architect, computer programmer and teacher.

2.4.2 Typical symptomatic presentations

Patients admitted to the Neuropsychiatry Unit being discussed in this paper have a range of symptoms, many of which, although similar in presentation, are diverse in aetiology.  Loss of or decline in cognitive and functional ability is often accompanied by difficulties with memory, speech and recognition.  Agnosia, the inability to recognise "things" has many forms - such as visual, auditory, touch, parts of the body and written text.  Atrophy or damage to frontal areas of the brain can result in disinhibition, which may manifest in a range of socially unacceptable behaviours.  Difficulties with movement and muscle control are common with ataxia, Parkinsonism, chorea, and incontinence often being present.  Delayed comprehension and latency in speech and/ or reaction responses are also common.

At times, a patient will lack insight into the presence or extent of these symptoms can occur.  This can cause distress for friends and family, as well as creating situations where the patient may put themselves at risk by attempting to perform actions beyond their capabilities.  Patients who do have insight into their symptoms and accompanying implications often experience depression, frustration and personal distress.


3. What is art therapy?

The Art Therapy Credentials Board (2013), Inc. defines art therapy as follows:

Art therapy is a human service profession in which clients, facilitated by the art therapist, use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem. Art therapy practice is grounded in the knowledge of human development, psychological theories, and counselling techniques. (para. 1)

Art therapy can be seen as "a hybrid discipline based primarily on the fields of art and psychology" (Vick, 2012, p. 23), with its history grounded in the merging of the two.  As the discipline of art therapy has grown from its early manifestations of art used both therapeutically and as a diversion in psychiatric hospitals, greater depth of insight into the potency of its application has developed.  Because "[a]rt does not, in the manner of language, describe experience but offers it directly to our senses through iconic forms" (Wright, 2009, p. 8), art therapy enables healing by offering a deeper encounter with life and experience.  Art is a "symbolic rendering of emotional life in a form that enables apprehension of its being rather than comprehension of its meaning" (Wright, 2009, p. 8), providing for added depth and dimension when implemented in the therapeutic encounter. 


4. Literature related to art therapy in a Neuropsychiatry setting

4.1 Introduction

This section of the paper is a critical review of literature related specifically to the use of Art Therapy with client groups experiencing neuropsychiatric diagnostic regimes.  In order to address the situation encountered in the Neuropsychiatry Unit setting as discussed in this paper an overview of literature applying to art therapy with neuropsychiatric patients in general will be initially presented.  

The final section of the literature review will deal specifically with the literature relating to the client demographic of the Neuropsychiatric Unit presented in this paper.  Discussion of the application of art therapy targeting what is unique to art therapy as opposed to other types of therapy, in the context of what has been defined as the patient experience within the medical diagnostic framework of the Neuropsychiatry Unit will also be presented.


4.2 Art therapy and neuropsychiatry literature

Art therapy and neuroscience are both relatively new fields and the concept that they may be complimentary in their practices can be a somewhat novel idea to some, particularly for those looking for empirical, quantitative data to support the use of art therapy in neurological based medical settings.  A review of the literature, unsurprisingly reveals that there is little to nothing of any strength in this area. Elkis-Abuhoff, Goldblatt, Gaydos, and Corrato (2008) are one of the few who present a study of 22 participants with Parkinson's Disease (PD) and a control group of 19 participants without PD.  The aim of the study, as defined in the paper's title, was determine the effects of clay manipulation on aspects such as somatic dysfunction and emotional distress, with a focus "on art therapy as a support for medical treatment and palliative care" (Elkis-Abuhoff, Goldblatt, Gaydos, & Corrato, 2008, p. 122).  Although the study outcomes demonstrated that there "was a decrease in somatic dysfunction and emotional distress" (p. 128), this result was not specific to the PD group.  In addition, in an attempt to standardise the testing process, the process undergone in the clay manipulation was limited in terms of an art therapy intervention.  There is no evidence to indicate that the results are specific to art therapy or that similar results might not be arrived at through the interacting physically within other contexts, such as squeezing and bouncing a tennis ball or planting in a garden.

One of the largest demographics in neuropsychiatry is patients suffering from dementia and Alzheimer's Disease.  Gilroy (2006) discusses a randomised controlled study done by Waller (2001; see also Rusted, J; Sheppard, L; and Waller, D (2006)) with a sample group of 45 participants, each having moderate to severe dementia and with an average age 80.  The study compared two, ten week art therapy groups with two, ten week activity groups and measurements of cognitive ability, depression and attention were undertaking throughout project and one month following.  Areas of improvement were shown in sociability; mental acuity; physical competence; and calmness.  

Much of the remaining literature specific to art therapy and patients with neuropsychiatric illnesses are either case study based or hypothetical explorations as to why art therapy might, or should, be helpful in the treatment of this specific client group.

Stace (2011), for example, presents a case study exploring the use of art therapy with a hospitalised adolescent with paediatric neuropsychiatric Systemic Lupus Erythematosus (npSLE), in terms of art therapy's usefulness in helping to provide containment and reduced impact of the condition.  The study was the result of Stace's "experience as a final year intern art therapist" (p. 52) and Stace believes that art therapy was effective in reducing the severity of symptoms and allowing for a containing space which enabled the client's "self expression and management of feelings" (Stace, 2011, p. 57).  Being a case study, however, there was no quantitative data, or research methodology or framework applied.

Related and linked in with the field of neuropsychiatry is the area of neuropsychology.  In his 1996 paper Garner presents an argument for the development of a Neuropsychological Art Therapy (NAT) model (Garner, 1996).  The basis for his proposal is the linking of functionality in specific areas of the brain with art therapy methods which employ these functions in their implementation, and is aimed at patients who have traumatic brain injury (TBI) in particular.  The argument is that the engagement with art therapy processes that require the employment of these functions and related areas of the brain will provide a means for "diagnosis and retraining" (Garner, 1996, p. 108).

Art therapy and TBI is also discussed by McGuiness and Schnur (2013) in Chapter 17 of Art therapy and health car! (Malchiodi, ed., 2013).  However, rather than developing a Neuropsychological Art Therapy (NAT) model as Garner (1996) did, they  look at the use of art therapy as a means of rehabilitation via creative apperception and development of a renewed or rebuilt image of self for the TBI patient (McGuiness & Schnur, 2013). 

The more recent work, Art therapy and clinical neuroscienc! (Hass-Cohen & Carr, 2008), presents a theoretical argument for the use of art therapy in clinically based areas of neuroscience.  However, once again, the text gives no actual definitive empirical data but, rather, presents information about brain architecture, theories of functionality, and how art therapy might most likely be applicable to the treatment of related neurological disorders as well as the consolidation and development of particular areas of brain functioning.  

Related to these bodies of work, but with a stronger emphasis on understanding the unconscious and its relationship to art, the mind and the brain (what is termed as "neuroaesthetics") is The age of insight: The quest to understand the unconscious in art, mind, and brain : From Vienna 1900 to the presen" by Eric R. Kandel (2012).

Relationship between neurological functioning, wellbeing, treatment, and the application of art therapeutic interventions are one logical extension of explorations undertaken in other works by such authors as Zaidel (2005; 2009); Chatterjee (2006); Seeley, Matthews, Crawford, Gorno-Tempini, Foti, Mackenzie, and Miller (2007); and Hass-Cohen and Clyde Findlay (2009).  

In particular, the literature by Chatterjee (2006); Seeley et al. (2007); as well as Zaidel (2009) employs case studies and anecdotes in which the relationship between art and specific case examples of brain damage are explored. Implicit in these accounts is the hypothesis that changes by artists in their art production is directly related to the areas of the brain damaged. However, as pointed out by Frigg and Howard (2011), there are some inherent assumptions that are made which may not necessarily hold true for a general hypothesis, particularly when working from accounts of situations as experienced by professional artists as opposed to art in general or art therapy in particular with a more broadly benchmarked societal demographic of artistic experience and ability.

As can be seen there is still an obvious need for rigorous forms of research in this area.  The current literature, however, indicates a nascent comprehension that such research would be invaluable, but shows little evidence of any such studies having been undertaken to date.


4.3 Literature related to unique aspects of art therapy within the specific Neuropsychiatry Unit presented within this paper

The author's placement experience within the specific Neuropsychiatry Unit presented in this paper has seen an evolution in the author's practice of art therapy with the patients admitted to the unit.  Initially there was a determination to find ways in which art therapy could be employed as a type of diagnostic tool.  

With this in mind the literature relating to different art therapy assessment tools was revisited and explored - the Expressive Therapies Continuum (Kagin & Lusebrink, 1978; Lusebrink, 1991; Hinz, 2009); Face Stimulus Assessment (Betts, 2003); and the Formal Elements Art Therapy Scale (FEATS) (Gantt, 2001).  In terms of symptomatic diagnosis there is little that these art therapy diagnostic tools can bring to the table that is not already addressed by the medical diagnostic regime already in place within the unit.  Added to this was the lack of evidence for the efficacy of such art therapeutic projective diagnostic tools, specifically with regard to patients suffering from a wide and varied range of neuropsychiatric conditions.

As the previous section on the actual availability of literature of either a quantitative or even qualitative nature concerning art therapy with neuropsychiatric patients demonstrates, there is very little of any real consequence.  

It is also to be noted that, particularly in the area of case studies, the literature that is available often deals conditions that are very specific.  An example of this is Stace's (2011) account of the adolescent client with paediatric neuropsychiatric Systemic Lupus Erythematosus as mentioned previously.  Perhaps the most rigorous research uncovered is that undertaken with Alzheimer's Disease clients by Waller (2001; see also Rusted, J; Sheppard, L; and Waller, D (2006)) as discussed by Gilroy (2006).  The issue for the author with these and other similar studies is that they do not represent the usual demographic of patients admitted to the specific Neuropsychiatry Unit presented in this paper.  



In attempting to find the place for art therapy within the Neuropsychiatry Unit the author sent an email to the staff working at the unit, requesting feedback as to  what they saw as a common factor for admitted patients, regardless of condition, and their thoughts on how art therapy could best be applied within the Neuropsychiatry Unit's setting.  The common theme of replies received was that art therapy could enhance the medical diagnostic picture developed for each patient by "presenting the patient behind the diagnosis" (R. Dewhurst, Personal communication, May 2, 2013).  Additionally, the generous time available for art therapy interventions was considered to be a powerful service for the patients and the team in providing expended opportunity for "unfolding" of information concerning the patients which might not be revealed in time poor or diagnostic interviews.

For the typical patient admitted to the Neuropsychiatry Unit for medical testing and diagnosis there are also many existential, invasive and confronting issues that are very present, but not addressed.  These are encountered within the experience of the illness, the operational infrastructure of the hospital and the procedural machinations of the testing regimes.  Discussion related to the individual's core existential crises hierarchy - death; freedom; isolation; meaninglessness; and embodiedness -  can be found as a general theme in Cooper (2003) and as a specific method employing art therapy in Moon (2009).  In terms of the application of art therapy to the exploration of the embodied and "felt" experience, the seminal reference remains Rappaport (2009).

The author firmly believes that the most powerful, salient and pertinent implementation of art therapy is found in art therapy's unique capacity to provide a space for holding and containment.  

In terms of holding, as a general psychotherapeutic construct, Ogden (2004) writes:

The earliest quality of aliveness generated in the context of a holding experience is aptly termed by Winnicott ‘going on being’ (1956, p. 303), a phrase that is all verb... The principal function of the mother’s early psychological and physical holding includes her insulating the infant in his state of going on being from the relentless, unalterable otherness of time. (p. 1350)


Most of the client's admitted to the Neuropsychiatry Unit are in the midst of experiencing significant deterioration and collapse of their physical, mental and emotional life constructs.  Art therapy is unique amongst the therapies in that it allows for the creation of a specific and enduring object as an ongoing container and medium which gives back to the person creating the art work "the resonating forms for which [they are] searching" (Wright, 2009, p. 148).



Art Therapy Credentials Board. (2013). Art Therapy Credentials Board. Retrieved June 18, 2013, from


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Chatterjee, A. (2006). The neuropsychology of visual art: Conferring capacity. International Review of Neurobiology, 74, 39-49. doi: 10.1016/S0074-7742(06)74003-X


Cooper, M. (2003). Existential therapies. London,: SAGE Publications. Reprinted 2011


Dewhurst, R. (2013, May 2). RE: Art Therapy and Nψ [E-mail to the author]. Personal correspondence from Neuropsychiatry Unit Occupational Therapist.


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