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Occupational Therapy International, 5(1), 4864, 1998 Whurr Publishers Ltd

Creative arts in occupational therapy: Ancient history or contemporary practise?

MELANIE THOMPSON, PANDA Centre, Hawkhead Hospital, Paisley, UK SHEENA E.E. BLAIR, Queen Margaret College, Department of Occupational Therapy, Edinburgh, UK Abstract: This paper is primarily concerned with the use of creative arts by occupational therapists in adult mental health rehabilitation. A review of relevant literature within and beyond occupational therapy suggests that creative arts have therapeutic value. The first section considers the more traditional, psychodynamic framework for creative arts in mental health. This underpinned much therapeutic creative art work between the 1960s and 1980s. The second section draws on a broader, more eclectic framework of theorising and research. This offers a rationale for the use of creative arts in their own therapeutic right. It is hoped that this will stimulate thinking among occupational therapists about retaining and promoting creative arts within their practice. Key words: Creative arts, mental health, frameworks for practice Introduction The use of creative art activities (such as art, pottery, drama, dance, music, creative writing and other related media) is a topic that has been discussed periodically, with varying degrees of interest, in occupational therapy literature since the early days of the profession. It is important to define the term creative art activity from the outset, for clarity. Creek (1996) asserts that many of the activities of daily life, including cookery and choosing clothes or hairstyles, can be approached creatively. However, she also concurs that certain other activities (which are classified as arts, that is drawing/painting, pottery, drama and dance, creative writing, performing music and related activities) are valued as having a specific potential for creative expression, which includes the components of inventiveness and imagination (Stein, 1974; Cynkin and Robertson, 1990; Runco and Robert, 1990). Although routine and daily task activities can be creative, it is appar-

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ent that it is harder for clients and occupational therapists to realize their creative potential, particularly where a clients creative ability is decreased in mental illness (Barfield, 1978; Fulder, 1988; De Witt, 1992). Although early so-called creative occupational therapy groups have been criticized retrospectively for existing simply to keep hospital patients busy or to exploit free labour (Rothman, 1980), some individuals were developing more thoughtful rationales. For example, in 1934 Slavson theorized about the enrichment of individuals through active participation in groups organized around creative pursuits, and others felt that art had soothing and socializing effects on the mentally ill individual. Psychiatry moved from custodial to curative care in line with two key developments. First, the advent of drugs such as major tranquillizers reduced acute symptoms and opened the possibility of behavioural change, rather than simply control (Kendall and Zealley, 1995). Second, the theories of psychoanalysts and humanists advocated a more humane, understanding attitude (Bernstein et al., 1990). As a result, creative arts activities assumed a more central position in the treatment of individuals with mental illness by occupational therapists (Steward, 1996). In 1948, Halle and Landy expressed the opinion that discussions in art groups correlated with and, occasionally, explored in greater depth the subject matter covered in psychotherapy groups led by psychiatrists. Such ideas were exemplary of a growing interest in the therapeutic potential of creative activities for exploration and expression of deeply rooted emotions. Willson (1984) and Busuttil (1990) have suggested that occupational therapists only truly began to facilitate their patients participation in creative arts with the advent of psychodynamic and humanistic models for practice. This is highly questionable, as the use of arts in therapy has its historical antecedents in the moral philosophies of the eighteenth century and the arts and crafts movement of the late nineteenth century. However, psychodynamic models in particular attracted much attention and psychodynamic frameworks for the use of creative arts were extensively explored in psychiatric occupational therapy theory and practice between the late 1950s and the 1970s. Despite the interest and strong theoretical and anecdotal support for practice, it continues to prove extremely difficult to obtain quantitative research support for the psychodynamic/humanistic application of creative arts (for example, Warne, 1993). This could well be because its concern with the subjective experience of individuals (Aldridge, 1996) decreases the validity of using quantitative research techniques (Bruce and Borg, 1987). The agencies that finance health-care services in the UK often demand rational scientific and quantitative evidence of the benefits of therapies (Appelby et al., 1995; National Health Service Executive, 1996). This is possibly one of many reasons for the recent decline in the therapeutic use of creative arts by occupational therapists which has been noted by commentators such as Steward (1996) and which is the motivation for this present review. Increased hospital

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costs, dramatically shorter admissions and the advent of a business-orientated approach to health care have led to pressure for occupational therapists to prove their cost-efficiency and to develop quantifiable, easily packaged and definable, time-limited interventions (Elliot, 1991). As more and more patients are maintained in the community and have shorter periods of contact with therapists in the decreasing number of venues suitable for creative group treatment, it is not surprising that there has been a concomitant decrease in the possibilities for creative therapies which aim for improved self-expression and personal growth for patients, and thus require longer-term interventions. A further significant factor appears to be the rising popularity and availability of specialist creative art therapies, which are gaining an increasing monopoly on the use of creative arts media in treatment of those with mental health problems. Research problems aside, in the past two or three decades a sizeable amount of literature has accumulated which criticizes and questions the validity of key psychodynamic theories and offers alternative explanations (for example, Eysenck, 1986). This has arguably accelerated the decline in adherence to psychodynamic paradigms, perhaps first in clinical psychology, but also more generally in National Health Service mental health services, including occupational therapy. They have been replaced in general by a behavioural skills-orientated, learning approach (Serrett, 1985; Howe and Schwartzberg, 1986). Thus, in clinical practice in the UK, the authors have observed what now seems to be common occupational therapy practice in adult mental health structured discussion- (not activity-) based groups, utilizing cognitive-behavioural theory and techniques, and focusing, for example, on stress and anxiety management and assertiveness or confidence building. A growing body of occupational therapy research reports positive, quantifiable outcomes for such group techniques (Courtney and Escobedo, 1990; Brown and Carmichael, 1992). Separate activity-based sessions stress the importance of occupational competency (Keilhofner, 1993) in survival behaviours which have obvious real-life significance, such as cooking or personal care. Creative art activities are still utilized in the UK, generally under the guidance of technical instructors or occupational therapy assistants. However, it appears that their full potential is seldom realized and they are often offered without any particular structure or specific therapeutic direction being superimposed. Certainly, the author has found little evidence of either formal or informal theoretical rationales in areas where creative arts sessions are facilitated by unqualified staff. In other areas the specialist services of creative therapists (for example, art, music, drama or dance therapists) may be bought in, although this is comparatively rare because of the expense and scarcity of such professionals. In the authors experience, this buying in of creative therapy services seems to be on a somewhat ad hoc basis, with unclear rationales for why one particular creative therapy is chosen over another.

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It appears that a number of therapists regret the decline in the therapeutic use of creative arts by occupational therapists (Harris, 1997; Steward, 1996). The purpose of this paper is to review the literature that supports and highlights the value of creative arts. For this, it is necessary to look both within and beyond occupational therapy. Emphasis will be placed on literature that offers possible justification for occupational therapists using creative arts within cognitive-behavioural, functional-skills orientated paradigms. Such paradigms appear to have increasing dominance in many mental health services (Steward, 1996). The intention is not to dismiss the more traditional psychodynamically driven use of creative arts. Rather it is to try to go beyond this in recognition of the shifting patterns of health care, to try to assemble theoretical support for the use of creative art activities by occupational therapists, whatever the overarching paradigm of the service might be. It is clearly necessary to first set the scene by briefly overviewing the literature that supports the more traditional use of creative activities within psychodynamic and humanistic paradigms for occupational therapy. (For definitions of these paradigms, see Bruce and Borg (1987), for example.) It is recognized that there is a vast amount of literature concerning psychodynamic paradigms, and it will be possible to offer only a very broad outline and to direct the interested reader to areas of the literature that provide more detail. It is then intended to provide a review of the literature that also supports the use of creative activities, but that is more congruent with present functional skills and cognitive-behavioural paradigms (as defined by Bruce and Borg (1987), for example). The hope here is of working towards a more eclectic framework for the use of creative arts by occupational therapists. Obviously, there are difficulties, restrictions and generalizations created by grouping all therapeutic creative arts together, but specialist creative art therapists do agree that the creative arts share an underlying commonality of form and pattern, despite differences in their expressive faculties (Aldridge, 1996). The author also recognizes that a review such as this is perhaps not strictly conventional because it includes a very broad spectrum of literature and therefore can hope only to fully review selected key papers. However, it is felt to be timely and necessary if occupational therapists are to be encouraged to look again at creative activities. The hope here is to outline a framework that will help occupational therapists to recognize and justify the full eclectic extent of possibilities for creative arts with mentally ill adults. As Roberts (1997) stated in her address to the 1997 conference of the British Association of Occupational Therapists in Mental Health:
It is imperative for the profession to do the rigorous research needed to validate creative activities as a therapeutic medium . . . then . . . the profession can cease this fragmentation and borrowing of treatment techniques . . . it can own the activity tradition in OT.

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The use of creative arts within psychodynamic and humanistic theories of OT The early work of the Azimas (1957, 1959), the Fidlers (1963) and a series of papers in occupational therapy journals of the early 1970s (Batchelor, 1970; Drost, 1971; Blair, 1974; Dollin, 1976; Malcolm, 1977) provide clear examples and a useful gateway to understanding the use of creative arts activities within a psychodynamic framework of occupational therapy. They describe the facilitation of groups where patients participated in free-association and comparatively unstructured creative activities using variously the media of art, pottery, psychodrama, music and poetry. The creative objects were seen as an essential catalyst in the group process (Azima and Azima, 1959). They were also viewed as media through or into which participants could project their unconscious or sub-conscious defence mechanisms. In psychoanalytic (Freudian) theory (Jacobs, 1993), projection is a defence mechanism and as such is inaccessible to the conscious awareness of the individual. It involves the individual investing another person (or, in the case of occupational therapy, also an object, piece of music or poetry) with qualities that are either desired or, more commonly, unacceptable within the self. In psychoanalysis and in occupational therapy groups, this defence mechanism is theoretically used to explore and give insight into the personality. The personality is defined as including unconscious attitudes, motivations, defensive manoeuvres, characteristic ways of responding and unresolved emotional conflicts, which often arise in early childhood (Remocker and Storch, 1982; Bruce and Borg, 1987). This is achieved by the therapist, trained in psychoanalytic techniques, interpreting verbally what has been produced, acted out or evoked in the creative part of the group. In the case of occupational therapy, the group leader also assists the individual creator and other members of the group to interpret what has been produced. This provides a basis for therapeutic work aimed at increasing patients self-awareness, understanding of problems within close relationships or at initiating, developing and maintaining social contacts. It may also hopefully lead to the resolution of some of these conflicts. It does this by first re-experiencing the conflicts and working them through (Robinson, 1984) within a safe environment and then transferring the skills and strategies learned within therapy to relevant personal circumstances. Brown and Pedder (1979), in citing Cawleys levels of psychotherapeutic intervention, see such projective techniques and their concomitants as having the potential to reach a deep level of exploration and analysis. Such exploration of the unconscious can clearly be very distressing for patients and thus occupational therapists using such methods stress the importance of pacing intervention (Blair, 1996) and balancing explorative work with more ego-supportive techniques. This highlights the importance of the therapist in anticipating, balancing and therapeutically utilizing group dynamics. It is assumed that the occupational therapist who contemplates using creative art activities has professional knowledge and experience of the principles of group dynam-

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ics. It also raises the important question of whether occupational therapists are presently trained to use psychodynamic techniques appropiately. It may be that further postgraduate training should be a prerequisite for engaging in psychodynamic work. For the interested reader, succinct overviews of the subject of group work and dynamics are provided in Finlay (1993) or Whittacker (1989). Creative art activities also provide possibilities for ego-support, by allowing a safe, non-judgmental environment. Within this environment there is scope for particularly non-verbal, but also verbal, ventilation of feelings and discussion of current problems that may otherwise remain unexpressed. Emphasis is also placed on the pleasure and playful release of tension, which may be gained by participating in meaningful activities that may in addition have a clear, personal end-product (Creek, 1996; Steward, 1996). Both Jung (1954) and Winnicott (1971) (although the latter concentrated more on infant development) stressed the importance of creative activities, and using the active imagination, fantasy and creative potential of the mind as a method of healing. Winnicott felt that the intermediate area between a mother and child, in which reality could be playfully tested, stretched and rejected or accepted as desired, persisted into adulthood where it finds its expression in creative artistic, spiritual or cultural experience. Piergrossi and Gibertoni (1995) feel that the occupational therapy experience can be best understood as taking place in this intermediate area, presumably with the therapist replacing the mother figure. Jung (1971) and Storr (1972) both expressed the theory that human beings are self-regulating entities, not just in terms of biological homeostatic mechanisms such as acidbase balance, but also in terms of psychological mechanisms. They feel that humans are constantly trying to heal the divide between their inner world and their external reality. Storr stated that this tension impels humans to engage in imaginative and creative processes, often utilizing art or music, and that creative arts can, for brief moments, give us a sense of balance and our deepest consolations and greatest glories. Some of the theories and theorists of the existential, humanistic paradigm (especially Rogers, 1951, 1961 and Maslow, 1968) and Gestalt therapy (Perls, 1969) had considerable impact on the development of drama therapy in particular. They share a similar perspective to the psychodynamic approach on the use of creative arts as a safe environment in which group members can ventilate their feelings and gain an understanding of their own needs and difficulties. One of the key differences, however, is that in humanistic approaches to therapy the therapist attempts to be as non-directive as possible (Bruce and Borg, 1987). The lack of research and the difficulties of researching the efficacy of psychodynamic and humanist theories using experimental or quantitative designs has already been mentioned. There have been some attempts to describe the use of narrative in psychotherapy in quantifiable terms, (Fried et al., 1992;

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Luborsky et al., 1992), but quantitative methods still seem to sit uneasily with research into psychodynamic techniques. However, many generally positive anecdotal and qualitative accounts of the use of creative arts have been published in the occupational therapy journals. These are worth noting briefly because they often give extremely detailed, descriptive information and because carefully structured qualitative research is, rightly, gaining credibility. This is particularly notable in the area of occupational science (Clark, 1993;Yerxa, 1991) However, as they are not from an experimental research base they cannot quantifiably prove the clinical efficacy of using creative arts, nor the formal clinical validity of the above theories of its use. Much of the literature focuses on the use of art (painting, drawing and so on), but also covers clay modelling, and using music, poetry and drama. It includes the papers noted above and the more recent papers by Monroe and Herron (1980), Busuttil (1990) and papers examining the use of art with specific diagnostic groups, for example, anorexia nervosa (Harries, 1992), bulimia (Martin, 1991) and multiple personality disorder (Frye, 1990). In virtually all of these papers the client group was reported as responding actively to the opportunities for expression. In many cases, following a series of psychodynamically driven group sessions using creative arts projectively, clients were felt to have increased insight, or at least to have uncovered and communicated defences, conflicts and transferences to some extent (for example, Azima et al., 1957). Interestingly, among the quantity of literature supporting psychodynamic paradigms at that time, Dollin (1976) presented a different perspective in her summary that:
although it has become very fashionable to use art as a projective technique . . . I feel that the actual process of artistic creation itself has been neglected . . . The activity can be curative in itself, as it teaches the patient to play and express himself in a socially acceptable way. (p. 227)

In more contemporary discussions of the use of the psychodynamic approach in occupational therapy (such as Bruce and Borg, 1987), it is widely acknowledged that it very rarely used in isolation. Occupational therapists are not and do not purport to be psychoanalysts. They argue that they use creative arts in a more eclectic way (Bruce and Borg, 1987; Steward, 1996). However, in searching the occupational therapy literature, rationales or justifications for this more eclectic use are not clearly outlined. In some cases, the more humanistic rationales (such as to increase self-expression and personal understanding of problems) are mentioned, but generally in a limited way, within the discussion of psychodynamic approaches (Bruce and Borg, 1987). Kavanagh (1994) remarked that occupational therapists have not yet identified a discrete framework for the therapeutic use of art, and presently just borrow from principles of psychodynamic theory and group dynamics. This seems equally applicable to all the creative arts.

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There have been often complex, specific critiques of psychodynamic theory both within and beyond occupational therapy. Probably the most enduring and comprehensive (if somewhat seditious!) critic of psychodynamic theory is Hans J. Eysenck. Eysencks The Decline and Fall of the Freudian Empire (1986) was the culmination of many years of critical research and thinking. Others have offered more specific criticisms. The overemphasis on the dyadic relationship as a closed system is criticized by some authors, including Karasu (1990), and the patriarchal bias, inadequate conception of gender and age stereotyping in psychodynamic theory is discussed in Person (1983) and Eichenbaum and Orbach (1983). Within occupational therapy, perhaps the most noted critic of psychodynamic models is Gary Kielhofner (1983; 1992). He believes that the psychodynamic approach led to a crisis of identity in the profession because it is extremely reductionist in asserting that only the therapist has the ability to access the clients unconscious. Thus the therapist technically knows more about the patient than he knows about himself. Kielhofner (1992) notes that this is at odds with a client-centred approach and respect for the clients autonomy which is embodied in the philosophy of occupational therapy. Keilhofner (1992) also states that the psychodynamic approach relegates occupation and activity to secondary therapeutic importance, after the key factor of participation in the group setting (for example, Drost, 1971). Keilhofner (1993) highlights task-orientated groups (for example, focusing on cookery, personal care or vocational training) with a conscious motivation as being the key factor leading to change and growth. A counter-argument from those advocating a psychodynamic perspective seems to be that this perspective lacks an emphasis on developing the clients personal and unique understanding of and ability to express their feelings and emotions. For clients with mental-health problems, this, they argue, is as important as, if not more important than, simply participating in activities. Central to the issues presented in this paper is the fact that there has been an overall decline in adherence to psychodynamic paradigms for a number of reasons, including economic ones. Many occupational therapists working in mental health now work in departments where psychodynamic paradigms have been replaced (often by functional skills and cognitive-behavioural paradigms) and where there is apparently little or no clear rationale for using creative arts. As a result, their use has declined or been relegated solely to the provinces of technical instructors, assistants or occasional specialist creative therapists. This was acknowledged in the UK by the governments Attenborough committee report (1985) which highlighted the haphazard (p. xiii) present use of the arts in health care. The authors feels that if occupational therapists are to justify the use of creative arts within such health care environments, they must move on from the primarily psychodynamic rationales and projective uses. To do this, they must examine a broader range of theoretical and research literature. In the authors opinion, this literature reveals that

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the value of creative arts as therapeutic media has only been partially realized in occupational therapy. It is hoped that developing a theoretical and research base will build a stronger foundation for a more flexible use of creative arts in contemporary practice. This should cross theoretical boundaries and allow creative arts to enhance cognitive-behavioural approaches to treatment as well as psychodynamic or humanistic approaches. This will then be the subject of the next section. Towards a more eclectic theory base for the use of creative arts In a discussion of the value of creative arts activities, it seems important to begin by outlining the key points of the ongoing debate concerning the relative value of activity groups per se, relative to discussion groups in mentalhealth occupational therapy. In an editorial in the British Journal of Occupational Therapy in 1986, Stephanie Correia described as disappointing the increase in use of skills not involving activities as treatment media in mental health groups. In the debate in the letters pages that followed, she and Janet Ready proved staunch proponents of activity-based groups, offering the arguments that discussion does not meet the definitional requirements of true activity and that turning to verbal therapies would risk losing the unique perspective and approach of occupational therapists. In response, Stockwell (1986), Horne (1986) and McFeely(1986) stressed the benefits of verbal groups in providing a clearer picture of clients difficulties with interpersonal relationships and a balance to the more practical aspects of occupational therapy. Both arguments clearly have some validity and, in the authors opinion, the case supporting verbal groups was probably more coherently and thoughtfully argued. However, empirically sound research from the USA (DeCarlo and Mann, 1985; Mumford, 1974) was not alluded to in the debate. These studies presented quantitative and some qualitative evidence that activity groups (role-playing sessions, problem-solving games, co-operative creative art and collage work and so on) were significantly more effective in enhancing interpersonal communication skills and self-awareness than discussion-only groups covering the same general topics. The usual problems in research using groups applied to these papers: namely, difficulty in excluding other variables such as group cohesion, individual non-participants, and small sample size. However, both studies were controlled and efforts made to minimize the impact of extraneous variables. From the wider perspective, beyond occupational therapy, a piece of British research (Colgan et al., 1991) gave quantifiable evidence of the benefits of using art activities for mental-health rehabilitation. They found that, following participation in a group art programme, the 26 patients in the study required markedly shorter periods of inpatient and day hospital patient care. More research is clearly needed as these papers highlight only a few benefits of

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activity groups. However, they are still very significant in providing researchbased evidence for the efficacy of activity in groups. So, armed with the evidence that activity has some clear benefits over discussion alone in mental health groups, the next task is to draw on wider theoretical sources to develop an understanding of what the specific advantages of creative art-type activities could be. Creek (1996) listed the benefits of creative arts as: facilitating projection and emotional self-expression, increasing satisfaction and self-esteem, increasing motivation and enhancing learning. However, she did not provide any research evidence to support her claims and only very scant theoretical support. This is clearly a deficit in her argument, as personal opinions, however intuitively appealing, are often not given much credence in the present rational-scientific health-care environment. The intention in the remainder of this article is to try to provide some of the missing theoretical and research support. Creative arts and emotional self-expression The beneficial uses of creative art activities in facilitating projection and emotional self-expression have arguably been demonstrated through a large body of (albeit primarily anecdotal) research and theoretical literature. It has been noted, however, that, in many cases, occupational therapy services in mental health care have tended to move away from the psychodynamic paradigms that underpin the use of creative arts in this way. This is a cause for concern as it is widely accepted by occupational therapists that people have a need to express their feelings, whether positive or painful, and that creative arts are a socially acceptable and controllable forum for the expression of powerful emotions (Creek, 1996; Steward, 1996). Creative arts and play The perceived benefits in increasing self-esteem and motivation seem to be most coherently dealt with together, along with the ideas of play, pleasure and affective meaning. The search for theoretical and research support for the use of creative arts to enhance self-esteem and motivation seems to begin with the work of the psychodynamic theorists, as mentioned briefly in the preceding section. Jung (1954) strongly advocated creative activities for their healing potential, but it was Winnicott (1971) who began to unpack why they might have healing properties when he highlighted the importance of play and the position of creative arts as a legitimate (socially accepted) form of play for adults. Play, by definition, is pleasurable exploration. Trevarthen and Grant (1979) defined it as mutually pleasurable action on an object and Gordon (1961) noted the intrinsic pleasure in play. The enjoyment derived from play where the individual is in control and able to explore the medium active-

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ly without undue anxiety, is seen as being a powerful motivator. Again this idea originates in developmental psychology research. McGarrigle (1990) found that children would engage in otherwise cognitively complex and demanding tasks with much more enthusiasm and energy, when the task was presented in the form of a game or play experience, rather than as work. Creative arts and optimal experiences Over the past three decades, an exciting new line of research and theorizing has been developed worldwide which gives strong support and further develops this line of reasoning in adults as well as children. Csikszentmihalyi (1975, 1982, 1992) and a group of researchers began by interviewing more than 2000 people representing a broad spectrum of social, cultural, age and gender groups, from Hong Kong teenage-biker gangs to Italian grandmothers. They progressed to using an experience sampling method in which people wrote down their thoughts, feelings and the task they were engaged in when a pager went off randomly, about eight times a day. The outcome of this research effort was the discovery that individuals experience during their moments of deepest enjoyment and satisfaction is strikingly universal. From thousands of personal accounts, Csikszentmihalyi developed a description of optimal or flow experience, where individuals experience complete absorption and concentration in an activity so that time seems to flow effortlessly. At such times people are oblivious to external factors, selfconsciousness or concern with the self disappears and there is a clear sense of internal control over actions without anxiety or fear of negative consequences of failing at the task. There are clear benefits to be attained from such flow experiences. The most obvious is enjoyment and a deep sense of satisfaction, but more subtle and perhaps more important are the increase in feelings of self-efficacy, self-esteem and the development of an increasingly secure (differentiated and integrated) self. Csikszentmihalyi theorizes that the self develops because, first, there is recognition that one has overcome a challenge and increased ones capability and skill and, second when concentrating deeply, with thoughts and feelings focused on the same goal, consciousness becomes well ordered. Another benefit of the flow experience is that it seems to create a powerful, enduring memory trace both about the task and the self-experience. This is important in terms of learning and also because it serves as a potent motivator to re-engage in the activity that allowed such optimal experience. The importance of this research and theorizing for the thesis of this paper is that, when engaged in for leisure, creative art activities (as well as games and sports) have apparently evolved historically to enrich life with enjoyable experiences and have maximum potential for producing optimal experiences. This is because they can be participated in successfully at a very wide range of skill levels which prevents them from being boring or tedious, but the conse-

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quences of not achieving a high skill level or performing poorly are not as negative as in tasks which occur in paramount reality such as at work, where poor performance can lead at worst to dismissal. Thus, they are not necessarily anxiety-provoking. As well as its strong support from, and grounding in, research, the theory of optimal experience benefits from the fact that its theoretical basis does not preclude either a cognitive-behavioural or a psychodynamic approach. The idea of an experience that unites and strengthens the self is reminiscent of Storr (and Jungs) ideas of creativity and Csikszentmihalyi accepts that past experiences shape the way we interpret events in consciousness. However, he also firmly believes that outside events appear value-free in consciousness at first, before we interpret them, which is a more cognitive-behavioural tenet. It does seem that if occupational therapists could present creative arts to individuals in a way that is not too challenging or anxiety-provoking, but that none the less stretches them to achieve a slightly higher skill level, there could be a powerful therapeutic benefit. It does depend on the activity being viewed as meaningful by the individual and it must be accepted that there will be some people who will view creative arts as either the exclusive province of experts, or childish, immature and irrelevant-despite the therapists best efforts to break down such stereotypes. In the authors experience, however, this does not reflect the majority view and, as Brienes (1995) states:
Being able to structure experiences so that they are enticing, intriguing and not fear provoking is a special skill that occupational therapists develop. (p. 22)

Creative arts and learning The idea that (optimal) participation in creative activities assists in learning, or certainly is associated with the creation of powerful memory traces could also potentially be harnessed by occupational therapists, to their and the clients advantage. There is support from other theorists for this point. Reilly (1974) believed firmly that a playful approach, aimed at making the activity enjoyable, is an important first step in learning new skills. There is also some research that further reinforces the benefit of creative activity in learning. Conti, Amabile and Polack (1995) discovered that if they gave students a creative task (rather than a non-creative task) before asking them to read and remember a short passage on a related topic, their long-term recall of the material was significantly better and they were also able to display a deeper understanding of it. This fits with a body of research headed by Entwistle (1988, 1995), an educational psychologist, and his colleagues (Rankin, 1984). They have found repeatedly that if students are asked to read a passage for meaning and understanding, rather than simply to recall it, or are actively encouraged to come up with examples and relate them to their own experience, they have a deeper, holistic understanding of the material.

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On a different tack, Dewey (cited in Brienes, 1995), the eminent philosopher, educator and social activist, argued convincingly that learning by doing is developmentally earlier and easier than learning through language. There is a large body of research into learning, including neuroanatomical studies, which supports the idea that there are two distinct systems of learning. They have been assigned different names by different researchers, but are mainly referred to as procedural learning and declarative learning (Carlson, 1991). Procedural learning is a neurologically simpler or more basic type of learning, which seems to create relatively durable memory traces and involves being able to demonstrate a skill, even though it cannot necessarily be accessed consciously or described verbally. Declarative learning, on the other hand, is a more complex, higher level of learning and is more difficult to achieve, but can be reflected on verbally (Squire et al., 1989; Carlson 1991). In general, but especially for individuals whose capacity for learning is reduced by mental ill health, such as excessive anxiety or disordered thinking (Bernstein et al., 1990), it seems that procedural- or activity-based learning is more easily achieved and should therefore be encouraged by occupational therapists. Conclusions To summarize, it appears from the present understanding of the processes of learning and memory formation, that activity or anything that encourages the learner to interact actively and creatively with the material being presented (such as being asked to act out or express artistically a part of it) leads to a deeper understanding and a more enduring memory of it (Conti et al., 1995). This suggests that occupational therapists need to make an effort to present material in a way that is as attractive and as stimulating as possible. As a result their clients will hopefully engage with it and maximize their opportunities for achieving optimal experiences through it. Carefully thought out and presented creative art activities could therefore be an important addition to groups that aim to teach clients more adaptive interpersonal skills, through purely verbal interaction. It is hoped that, with a more eclectic framework to support the use of creative activities, occupational therapists will feel that creative arts are a useful medium, even where therapy has clear cognitive-behavioural, humanoccupational or other underlying paradigms, other than a psychodynamic one. Creative art activities could also be an important addition to the treatment programme in general, because of their effects on motivation, self-esteem and self-expression. However, it is recognized that to achieve their therapeutic potential, creative arts must be used in a way that is meaningful to the client, within a carefully planned and justified treatment programme and a positive, therapeutic relationship between therapist and client. Further research is needed to look at specific practical issues, including finding out which specific creative arts are best used in a particular set of cir-

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cumstances. It is hoped that occupational therapists will be able to apply their skills in activity analysis to begin to provide some answers and that they will be willing to publish the results of such research, for the benefit of the profession as a whole and all those who seek to use creative arts in a therapeutic way. References
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Warne S (1993). A haven of the healing arts. Hospital Doctor 17 October. Whittacker DS (1989). Using Groups to Help People. Tavistock: Routledge. Willson M (1984). Occupational therapy in short term psychiatry. Edinburgh: Churchill Livingstone. Winnicott DW (1971). Playing and Reality. New York: Basic Books. Yerxa EJ (1991). Seeking a relevant, ethical and realistic way of knowing for occupational therapy. American Journal of Occupational Therapy 45: 199204 Address correspondence to Melanie Thompson, PANDA Centre, Hawkhead Hospital, Hawkhead Road, Paisley PA2 7BL, UK.