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A Literature Review Exploring how Effective and Compatible Creative Interventions are when Combined with Talking Therapy (Creative Counselling)

14th April 2021

Investigating the importance of ethical considerations and safety measures when working within this approach 

Written and Researched for Creative Counsellors by Lisa Cromar, a Person Centred Counsellor, Trainer and researcher. She is a PhD student at the University of Chester, and is a published author, with a chapter in The Neurodiversity Reader (Pavilion Publishers)

Introduction

This review will focus on professional counsellors who chose to incorporate CIs into their practice (creative counselling), separate from modality based expressive art therapies/creative art therapies, which are a distinct discipline. There has been little focus in the research or training into counsellors of all theoretical modalities who wish to work this way (Rosen & Atkins, 2014; Westergaard, 2013; Rouse, Armstrong & Mcleod, 2015; Sagan, 2018). The review will explore creativity’s place in history, both in human experience and within the field of counselling. Highlighting whether it has been effective in supporting clients with a variety of presenting issues, including trauma, grief and loss and challenges with social and emotional functioning. The review will  address whether working creatively is compatible with neuroscience knowledge, exploring left and right brain functionality and neural pathways, and with a focus on how well CIs ‘fit’ with the core features of the four major theoretical modalities, Cognitive Behavioural Therapy (CBT), Psychodynamic, Transactional Analysis (TA) and Person-Centred (PC). Progressing to explore the ethical considerations of working creatively within talking therapy and how counsellors can ensure clients are being kept safe. The quality of the literature will be explored with recommendations made for future research.

Methodology

A full systematic search was employed, followed by a reference check. Fifty-five pieces of peer-reviewed literature, published between 2009 and 2020 were saved for further scrutiny, with a total of thirty-nine included in the final review. The focus was on combining CIs with face-to-face counselling within the primary talk therapy modalities.

Does creative counselling enhance talking therapy?

History

It would seem creativity and the arts have always been an intrinsic part of human existence. There was no separation in ancient times; ‘Among ancient cultures, there was no word for art’ (Rosen & Atkins, 2014, p. 300). Through cave paintings, ancient folk made sense of the world through their’ mind’s eye,’ communicating with us from beyond and in turn helping with ‘our understanding of the world’ (Stevens & Spears, 2009, p. 5-6). Our creativity has enabled us to solve problems; nothing stands out more than the ‘cultivation of fire.’ Gladding (2008) surmises; ‘this type of creativity was essential. It still is, especially in… counselling’ (p. 98).

In the late 1800s-1900s, came the birth of psychiatry, from the beginning, the limitations of verbal language in the expression of emotions and experience have been recognised (Gladding, 2011; Thomas, 2017). Art has bridged the gap to ‘enable non-verbal self-expression’ which has been useful for ‘patients with severe mental health illness’ (Peterson & Goldberg, 2016, pp. 201-202). Freud appreciated creativity early on; he used photographs in psychoanalysis both when teaching his ‘disciples’ and when evaluating his patients (Loewenthal, 2009). However, as his career progressed, Freud chose to pursue ‘verbal association methods for gaining insights into the unconscious inner dynamics of his patients’ (Thomas, 2017, p. 2).

Other prominent figures progressed creativity in counselling. Carl Jung (1875-1961) ‘lay the ground for imagination-based methods’ (Thomas, 2017, p. 2). Jung believed ‘the fundamental aspects of human experience and psychological life can be expressed through images’ (Lee & Mustaffa, 2011, p. 99); Fritz Perls (1893-1970), humanistic founder of Gestalt Therapy made a ‘significant contribution to… the repertoire of [CIs] in counselling’ (Thomas, 2017, p. 2), incorporating the ’empty chair’ to aid non-verbal communication in therapy (Schimmel & Jacobs, 2013). William Reich (1897-1957) was influential in all Somatic Psychology approaches; incorporating the body in the healing process, including dance/movement as a psychotherapeutic technique (Leseho & Maxwell, 2010). Carl Rogers (1902-1987), humanistic founder of the PC approach recognised; ‘creativity is the desire to communicate,’ postulating; ‘it is doubtful whether a human being can create, without wanting to share his creation’ (1961, p. 356). However, like Freud, Rogers therapeutic approach would be through verbal expression. Natalie Rogers (1928-2015) evolved the PC approach to a type of expressive arts therapy, ‘she applied non-conditional caring as an expressive therapist to her clients and their art, movement, sound, poetry and drama’ (Kim, 2010, p. 94).

Many distinct disciplines in arts-based approaches have been formulated since psychiatry and psychotherapy began, including Art Therapy, Creative Arts Therapy and, many others (Rosen & Atkins, 2014), however, ‘talking therapy’ seemed to stand alone. Another significant therapeutic approach, Aaron Beck’s (1921) Cognitive Behavioural Therapy (CBT) is also recognised as a ‘Talking Therapy’  (“Cognitive behavioural therapy (CBT)”, 2020). Perhaps psychotherapy pioneers feared creativity in psychotherapy would not be taken as seriously? Sydney Levy (1958), a psychoanalyst who ‘originated many projective drawing methods’ who Levy (2014) ‘no relation [describes as] from the old school and unlike many professionals from similar backgrounds was not frightened and sceptical of expressive therapies’ (p. 6). It has been said; creative therapy is ‘one of psychology’s orphans’ (Rouse, Armstrong & McLeod, 2015, p. 4). Side-lined and abandoned for the more prestigious ‘talking therapy,’ However, as (Rosen & Atkins, 2014); profess ‘the art belongs to everyone, it seems appropriate that the arts would be a part of counselling process’ (p. 300).

The Efficacy of Creative Counselling

Talking Therapy is not always enough for some counselling clients, CIs can be used to help access and express emotions and for sharing stories when verbal expression is difficult (Rosen & Atkins, 2014; Holm-Hadulla & Hofmann, 2012). Gladding believes; professional counsellors are trained to be resourceful and encourages those working in the counselling field to embrace their creativity (as cited by Rosen & Atkins, 2014). According to the literature, CIs are limited only by the imagination of the individual. Einstein believed ‘I’m enough of an artist to draw freely on my imagination. Imagination is more important than knowledge. Knowledge is limited. Imagination encircles the world’ (as cited by Lukács, 2019). The literature includes a variety of CIs, including; collage/vision boards (Larsen et al., 2018; Burton & Lent, 2016), symbol/ritual/figures (Canto et al., 2015; Ali, 2017), genogram (Gatfield, 2017), photography (Ginicola, Smith & Tzaska, 2012a, Ginicola, Smith & Tzaska, 2012b; Loewenthal, 2009), literature (including writing, storytelling and poetry) (Edgar-Bailey & Kress, 2010; Stepakoff, 2009), drawing (Peterson & Goldberg, 2016; Hackett & Aafjes-van Doorn, 2019), sculpture/clay (Westergaard, 2013; Brandon & Goldberg, 2016), sandtrays (Westergaard, 2013; Roaten, 2011), stones/rocks (Westergaard, 2013), music/sound (Duffey & Haberstroh, 2013), journaling (Slyter, 2012; Ikonomopoulos et al., 2017), trading cards (Garrett, 2015) and imagery/guided imagery (Binkley, 2013; Kress et al., 2013).

Creativity, huh, yeah. What is it good for? Absolutely everything!’ (Gladding, 2008, p. 98),

The evidence demonstrates CIs have a positive impact with various presenting issues including; depression (Vela et al., 2019; Lee & Mustaffa, 2011) and chronic illness/pain; (Larsen et al., 2018; Kwong, Ho & Huang, 2019). As Gladding’s take on Edwin Starr’s hit single will testify, he is a proponent of creativity in counselling. Believing in its usefulness in many clients presenting issues when verbal expression is difficult.

Trauma

There is growing evidence amongst researchers and practitioners in support of using CIs with clients who have experienced trauma. For example, with populations such as survivors of sexual assault and abuse (Leheso & Maxwell, 2010; Ikonomopoulos et al., 2017; Murray et al., 2017), military combat trauma (Kern & Perryman, 2016; Canto et al., 2015); childhood sexual abuse and trauma (Wright & Thiara, 2019; Loewenthal, 2009).

Research suggests; the brain is severely impacted by trauma. Perryman, Blissard & Moss (2019) report; trauma survivors can experience fragmented memories of their experience, making it hard for them to assign ‘words to describe these implicit memories and feelings’ (p. 92). (Murray et al., 2017) agree; this can make verbalisation difficult and re-traumatising. Communication is disrupted between the right hemisphere ‘where images and negative unconscious emotions are stored, and the left hemisphere which houses logic and language’ (Perryman, Blisard & Moss, 2019, p. 92). Healthy brain functioning to process the trauma occurs once integration between both hemispheres of the brain is restored. Perryman, Blisard & Moss (2019) undertook a case study, offering ‘a model for the assessment and treatment of trauma through the use of creative arts’ (p.80). Their participant, Janet, using sand tray strategies combined with narrative strategies through journaling,  was able to articulate memories which had been hidden, in a ‘continuous narrative with a beginning, middle and end, further providing integration of the left and right hemisphere’ (p. 89-90). A similar strategy and results were found, in a report by (Murray et al., 2017) evaluating arts-based interventions for victims and survivors of intimate partner violence or sexual assault. Participants utilised pots, broken into pieces which they decorated and stuck back together again, to symbolise becoming whole, combined with creative journaling. Creativity and the arts were important in providing survivors of abuse an ability to ‘give voice to their experiences, especially valuable because abuse often serves to silence victims’ (p. 193-194), see also (Sagan, 2018; Wright & Thiara, 2019).

Grief/Loss

A universal trauma in all human life is loss and the grief which follows. Peterson & Goldberg (2016) stress the importance ‘for counsellors to have interventions available to help clients process them and move through grief in healthy, life-affirming ways’ (p. 198). In addition to the grief experienced due to the death of a loved one, evidence has demonstrated; CIs can be useful for people experiencing different types of losses. Including divorce, job loss (Brandon & Goldberg, 2016); survivors of suicide (Stepakoff, 2009); loss of identity as a result of chronic illness (Stuckey & Nobel, 2010; Larsen et al., 2018). Slyter (2012) suggests; CIs can be helpful and developmentally more appropriate for bereaved adolescents than talking therapy alone. They recommend incorporating accessible mediums. One example is a person’s favourite music. The lyrics of the song can help them ‘relate to the deeper parts of themselves. [An alternative way of] finding words to convey their otherwise inaccessible thoughts, emotions and memories. [Helping to] bridge the gap’ (p. 22-23) between nonverbal expression and talking therapy.

Furthermore, Edgar & Kress (2010) suggest; adolescents who have experienced traumatic grief, through the loss of a parent or sibling can feel a loss of control and are ‘often inhibited from progressing through the grieving process due to their trauma-related symptoms’ (p. 162). The authors recommend CIs, such as singing, dancing, journaling, poems and drawings. By giving the adolescent the choice of medium used and topics explored, they can reap a sense of regaining this lost control, resulting in their increased ability to connect with their experiences and to explore painful and complicated feelings more safely than talking therapy alone.

Emotional and Social Intelligence

Talking therapy can also be impacted by challenges found in emotional and social intelligence, which is understood to be an essential factor for mental health and functioning (Ali, 2017). Significant measures of social intelligence are; an individual’s ability to: ‘recognise or perceive emotions; utilise emotions to inform thought; regulate emotions, and; manage emotions’ (Mayer, Caruso & Salovey’s,1999 as cited by Ali, 2017, p. 378). Neurodevelopmental conditions, including autism (Poquérusse et al., 2018); schizophrenia (Winston, Mogrelia & Maher, 2016); and intellectual disabilities (Hackett & Aafjes-van Doorn, 2019) can adversely affect emotional and social intelligence, impacting upon emotional competence (Poquérusse et al., 2018). Ali (2017) asserts; CIs can go ‘beyond talk therapy [and can] be a catalyst for emotional comprehension and competence’ (p. 385). Utilising characters from the well-known children’s film Inside Out (Rivera & Doctor, 2015, as cited by Ali, 2017) they created a ‘framework for the use of [CIs] that focus on emotional intelligence’ (p. 385). This framework guides exploring emotions in therapy using ‘visual aids of important characters, scenes and concepts’ utilising ‘puppets, plush toys, figures and pictures’ (p. 379). The authors believe; ‘expressive modalities have the potential to serve as an outlet for teaching and therapy’ (p. 377).

Access to talking therapy is compromised by a condition known as alexithymia, linked to social and emotional intelligence. This condition can affect an individual’s ability to interpret, respond to and regulate their emotions (Poquérusse et al., 2018). The Greek translation is ‘a = lack, lexis = word, thymos = emotion, mood or feeling’ (Ŝago and Babić, 2019, p. 71). This condition can make it difficult for individuals to find words to verbalise their emotions. A study by Winston, Mogrelia & Maher (2016) of 10(N) alexithymic schizophrenic adults exploring ‘the therapeutic value of expressive writing and asemic writing’ (p. 142) had negative results. Alexithymic participants found expressive writing difficult and distressing because they lacked words for feelings. Although participants found asemic writing to have some benefit, this had only a temporary positive effect on the improvement of the individuals’ moods. Research by (Poquérusse et al., 2018) was favourable towards CIs. They suggest alexithymic autistic individuals can benefit from art, dance/rhythmic movement in therapy as a way to ‘express themselves and potentially access the verbal expression system which they need to process and vent their emotions’ (p. 5). It seems; choosing the right CI to support the client’s individual needs is imperative to its effectiveness towards complimenting talking therapy.

Summary

History demonstrates; art and creativity have been intrinsic to human existence, popular across time and cultures. They have been evident in psychiatry/psychotherapy since inception. Although the great pioneers in the field seemed to favour talking therapy alone, the research suggests; verbal expression can be challenging for some clients. CIs are most helpful in aiding talking therapy when verbal expression is compromised; particularly in the examples of trauma, and when verbalisation is restricted as a result of some conditions impacting upon social and emotional functioning, including autism, schizophrenia and intellectual disabilities. CIs can enhance talking therapy by making it more accessible and more effective for many client groups and a vast range of presenting issues.

Is creative counselling compatible with neuroscience and counselling theory?

Neuroscience

To judge when CIs could enhance talking therapy, Perryman, Blisard & Moss (2019) posit; therapists should ‘consider how their theoretical framework fits with neuroscience knowledge’ (p. 81). A neurological explanation can be a comfort to clients, normalising feelings, particularly concerning trauma. Studies have discovered; the right hemisphere is responsible for; sensations, images, nonverbal multiple meanings of words, autobiographical memory and negative unconscious memories. The left hemisphere is responsible for processing language (for example reading), conscious attention and sequencing narratives, translating personal experiences into verbal communication and is analytical and rational (Stevens & Spears, 2009; Perryman, Blisard & Moss, 2019; Kern & Perryman, 2016). Research by Stevens & Spears (2009) found; integrating photography into counselling, helps to engage both hemispheres, resulting in a ‘more positive, reflective, and complete communication process’ (pp. 8-9). CIs offer a way to ‘foster integration between the emotional nonverbal brain and the rational verbal brain [which can] offer a means of therapy in cases where talking therapies have been limited in their impact’ (Sagan, 2018, pp. 23-24). The brain has an ‘intricate network of neurons (cells that receive and transmit electrochemical signals), [containing an] estimated 100 trillion connections among them’ (Pinel, 2009, p. 2). Creative therapies assist in creating new neural pathways and to keeping existing ones nimble, which helps clients to understand and organise their ‘personal histories’ and narratives, thus improving their chances of forming connections and promote healing (Warner, 2016). Research by Roaten (2011) demonstrates; adolescents can benefit from the use of sand tray and art, as it helps support their developing brain, stimulating ‘the limbic region by sending sensory input and processing data into… emotional meaningful context’ (p. 305). Further research by Duffey & Haberstroh (2013) found; using musical chronology ‘may activate the same neural pathways associated with empathy [which can help] identify words and develop a cognitive complexity around the feelings that music can evoke’ (p. 444). Warner (2016) suggests; for senior citizens, art-making, music and dancing can increase ‘cognitive reserve and increases complexity of neuronal synapses… creating new neural pathways compensating for cognitive decline and increasing options for finding solutions’ (pp. 31-32). CIs appear to be compatible with neuroscience, lending ‘coherence to diffuse cognitions and emotions.… [enhancing] the narrative shaping of present and past experiences [which] is a basic principle [of counselling and psychotherapy] regardless of the specific theoretical background’ (Holm-Hadulla & Hofmann, 2012, p. 132-133).

CBT

Research is supportive of the compatibility of CBT and CIs, in part due to this structured theoretical approach being malleable to being practiced visually (Paxton & Estay, 2007), this combination can help with various presenting issues. CIs such as drawing, writing, commemorating, plays, storytelling, drama, art, sculpture and ritualising have been beneficial in helping rectify cognitive distortions in adolescent trauma survivors (Edgar-Bailey & Kress, 2010; Paylo et al., 2014). There is evidence to suggest CIs can enhance the efficacy of CBT when helping clients who self-injure. Whisenhunt & Kress (2013) purport; a combination of CBT and creative drawing can facilitate the cognitive awareness of the negative consequences of self-injury. A creative drawing activity which visualises a kitchen blender as an analogous metaphor is utilised. Symbolising how the client can see self-injury as their safety ‘container’ for difficult feelings and emotions; the image demonstrates, the blades that are part of this container causes them harm. Kress et al., (2013) advocate the use of guided imagery to support behavioural change by using ‘positive thoughts or images to regulate emotional experiences… used to promote and manage impulses to self-injure’ (p. 35).

Psychodynamic

Various CIs, including, artist trading cards, dance, art, writing, drama, embodied approaches, symbols, and metaphors, have been blended with psychodynamic theory to support the main features of this approach. Including; addressing distortions of internal resistances, dreams, transference, unconscious conflicts – making the unconscious conscious (Holm-Hadulla & Hofmann, 2012; Hackett & Aafjes-van Doorn, 2019; Garrett, 2015; Levy, 2014). This blended approach allows the counsellor to communicate with their client in a way which makes sense of their experience, which helps the counsellor to understand their client, and the client to understand themselves which is a core feature of psychodynamic counselling (Jacobs, 2010). Levy (2014) adds; this integration is vital because people are all different, with a variety of expressive preferences, including auditory, tactile, cognitive or through the body. Knowing these preferences can provide opportunities for communication and growth. Levy (2014) describes a technique used with a female participant, whereby drama, metaphor and imagery are incorporated into the session. The client acts out a tug-of-war with a rope, helping her with conflicted feelings relating to a work promotion. This task brought to the surface an image of her competent adult self, at one end, pulling against a helpless, aggressive and mischievous child part of her self at the other. Seeing this dichotomy, she had only been semi-conscious of, played out so vividly, helped her to realise how her inner child had been impacting upon her life, which led to her being released from its grip. The task facilitated making the unconscious conscious, enabling her to have more awareness and conscious control over her promotion decision, and other elements of her life, than her unconscious reactions, were allowing (Jacobs, 2010).

TA

Research demonstrates; CIs can enhance TA. Concerns of TA are to help a client to know themselves, allowing them to discover discord in their personality. To assist them in understanding how they relate to others. To gain more control of how they operate in interpersonal relationships, it also gives them a way to evaluate old decisions and behaviour, allowing for change (James & Jongeward, 1971). A study by Warren & Garfield Weingartner (2017) utilised a belief in this theory of individuals operating from three stages of self. They designed a poster which gave a visual and written description of these three stages, including ‘closed (I’m ok, you are not ok), absorbent (I’m not ok, you’re ok) and flexible (I’m ok, you’re ok) (pp. 336-337). The poster enables counsellors to help clients creatively ‘understand their ways of being… choose new… ways of being with others by communicating genuine wants, honest feelings, and avoid put-downs of self and others’ (p. 338). A study by Schimmel & Jacobs (2013) outlines; another significant belief within TA, being; ‘each person has three distinct ego states, the ‘parent,’ the ‘adult,’ and the ‘child.’ They help clients to use chairs to demonstrate and experiment with each of these ego states. The chairs are labelled to indicate which state they represent, and the counsellor and client discuss which ego state the client is functioning from when discussing a particular issue. Adams (2009) use a similar approach, but instead, recommend using pictures of characters from “Winnie the Pooh,” (1979) to illustrate the ego states.

PC

PC is a non-directive approach which advocates a client’s self-directed ability to achieve therapeutic change if they are given a supportive, facilitative environment with a counsellor who offers the necessary and sufficient ‘core conditions’ of ‘empathy’, ‘congruence’ and ‘unconditional positive regard (UPR)’ (Rogers, 1951). N. Rogers (as cited by Kim, 2010) applied these principles to the expressive arts, trusting therapists working this way ‘maintain a positive and caring attitude towards clients, helping them to accept any negative feelings [applying] non-conditional caring’ (p. 94). Lee & Mustaffa (2011) empathise the importance of focusing on ‘active and empathic listening while observing… verbal responses and creative artworks’ (p. 103).  In a case study by Kim (2010), PC principles are combined with expressive arts therapy. The female client participant was suffering from depression and seemed afraid to talk about her feelings, expressing fear it might be too painful for her. Art-making would be incorporated into her therapy to help her ‘experience, discover and gain insight [removing the fear of] facing her inner world verbally’ (p. 95). The client was given a supportive environment where she was able to self-direct, free to choose which ‘art materials, subjects, size of canvas and her style of writing’ (p. 96) to use. Whisenhunt & Kress (2013) emphasise; ‘using [CIs] can facilitate a sense of control by allowing clients to have choices in how their… treatment is approached’ (p. 102). Throughout the treatment, the client was able to ‘access the painful parts of her past life in a creative and safe way, and gain insights for her current life’ (Kim, 2010, p. 96). Rogers et al., (2012) agree; ‘individuals have a tremendous capacity for self-healing if given the proper environment’ (p. 13).

Summary

The research seems to demonstrate CIs and talking therapy combined are compatible with how the brain functions. The combination enhances therapy by utilising more parts of the brain than talking therapy alone. The research also suggests CIs are compatible with most theoretical backgrounds with specific examples given demonstrating its enhancement of the core features of theoretical approaches such as CBT, psychodynamic, TA and PC.

What are the ethical considerations when combining CIs into talking therapy?

CIs are combined with talking therapies on an ad-hoc basis, to ensure client safety the research suggests an ethical framework is required to help allow for their deeper integration into counselling practice (Thomas, 2017; Bastemura et al., 2016; Westergaard 2013). Andrew (2019) proposes an ethical framework which evolves from the BACPs “Ethical Framework for the Counselling Profession” (2018). This framework will be utilised to explore the ethical considerations highlighted in the research.

Justice

‘The fair and impartial treatment of all clients and the provision of adequate services’ (Andrew, 2019, p. 2).

The research suggests talking therapy is exclusionary to clients who struggle to verbalise their thoughts, feelings or experiences. Whether due to the impact of trauma (Murray et al., 2017; Whisenhunt & Kress, 2013; Sagan, 2018; Kim, 2010; Stevens & Spears, 2009), developmental stage (adolescence) (Bastemura et al., 2016; Slyter, 2012; Edgar-Bailey & Kress, 2010) or challenges relating to neurodevelopmental conditions (Poquérusse et al., 2018; Winston, Mogrelia & Maher, 2016; Hackett & Aafjes-van Doorn, 2019). The integration of CIs into talking therapy appears to provide for a more adequate and inclusive therapeutic service.

Being Trustworthy

‘Honouring the trust placed in the practitioner. Clients often feel nervous when they begin to do artwork, and we need to create a safe, non-judgmental space for them’ (Andrew, 2019, p. 2).

Working with CI could be unfamiliar territory for clients. They may experience negative emotions towards the process, fearing their creations may be judged; this need not be counterproductive. Instead, it could open up areas of exploration within a safe counselling relationship (Kwong, Ho & Huang, 2019). Stepakoff’s (2009) research with suicide survivors found; in sharing original material, the survivor does ‘not have to bear the pain alone… the therapist will bear… a portion of the pain’ (p. 111). Kim (2010) emphasises the importance of conveying a non-judgmental space, making it clear that clients visual and written expression would be accepted and respected, providing no ‘pictorial interpretation or aesthetic judgment’ (p. 95).

Autonomy

‘Respect for the clients self-governing. We do not force or shame the client’ (Andrew, 2019, p. 2).

Kim (2010) elaborates on the importance of client choice in the CI used and for the counsellor to trust in their client’s process. Edgar-Bailey & Kress (2010) agree; offering this choice can help restore a sense of control previously lost in the client’s life. Research by Binkley (2013) suggests; ‘counsellors should not push clients to discuss [their abuse] as re-traumatisation may occur, creative arts in session can give clients alternative means of exploring their stories in a safe manner’ (p. 312). Levy (2014) emphasises the importance of counsellors learning to ‘listen carefully to [clients] and [to] let them teach [the counsellor] what they need and how to reach them’ (p. 26).

Beneficence

‘Commitment to promoting the clients’ well-being. We offer [CIs] because we genuinely believe this will benefit the client, e.g. in processing unconscious material’ (Andrew, 2019, p. 2).

A counsellor may get a sense or be told by their client that talking therapy is too difficult or ineffective due to, for example, a need to suppress emotions. Research by Kwong, Ho & Huang (2019) using a mask-making activity with people living with HIV (PLHIV), found; a critical problem PLHIV face is the need to suppress and disguise their emotional status, due to the stigma surrounding the disease. The activity helped participants to release ‘relax and stay attuned to their emotional status’ (p. 14). Further research by Edgar-Bailey & Kress (2010) with adolescents who have suffered the death of a parent, found CIs useful to support them identify and process conflicting feelings, such as love for the parent, but anger at feeling abandoned by them. Leseho & Maxwell (2010) advocate for the use of dance to help the body and mind work together to form a connection which ‘would create a sense of safety for the body and mind to process information and emotions previously too difficult to face’ (p. 26).

Window of Tolerance

‘The Window of Tolerance is a term coined by Dr Dan Siegel. It describes a ‘zone’ where a person’s brain can function well, processing and integrating information and emotion without too much difficulty’ (Andrew, 2019, p. 2).

Research suggests greater awareness of a clients window of tolerance is imperative when working with trauma survivors (Kern & Perryman, 2016; Ikonomopoulos et al., 2017; Murray et al., 2017; Paylo et al., 2014; Binkley, 2013;). Perryman, Blisard & Moss (2019) stress the need for counsellors to ‘maintain attunement and resonance, gauging clients’ ability to stay within the window of tolerance, allowing them to express their feelings and to feel heard and understood’ (p. 85-87). They argue; it is useful for a counsellor to have an understanding of neuroscience, enabling the monitoring of ‘hyperarousal, which includes feeling extremely zoned out and numb or feeling frozen in time. Ideally, the client remains focussed, alert and calm while recalling difficult memories’ (p. 89). Chong (2015) suggests; working creatively has the ‘capacity to absorb and slow down… (hypoaroused] impulse emotions… [which helps] communication within the therapeutic relationship [to feel] less confrontational’ (p. 121-123). Whisenhunt & Kress (2013) emphasise the importance of a strong therapeutic alliance and dedicating some time to helping clients’ develop the skills ‘to regulate the intensity of emotions that may emerge [they recommend] incorporating transitional periods into sessions [including] opportunities for clients to reorient and to become grounded to the present moment prior to ending the session’ (p. 132). Edgar-Bailey & Kress (2010) stress the ‘importance of ‘developing emotion-regulation techniques, creating a strong, connected therapeutic bond and facilitating a reasonable measure of safety’ (p. 172-173) when incorporating CIs into counselling practice.

Self-respect

‘Fostering the practitioner’s self-knowledge, integrity and care for self’ (Andrew, 2019, p. 2).

Perryman, Blisard & Moss (2019) explain; working with clients who have experienced trauma can feel overwhelming to the counsellor, CIs can provide a way of both the client and the counsellor to ‘remain within the window of tolerance for a longer period’ (p. 85). Kim (2010) agrees; when ‘facilitating a safe environment for the client… both the client and the [counsellor]… experience integration and transformation [aiding the] therapeutic growth of the [counsellor]’ (p. 98). Whisenhunt & Kress (2013) caution; CIs can be powerful tools which can ‘evoke intense emotions’ (p. 127). Recommending counsellors stay alert to any risk and be ready to support or intervene should the need arise; ‘to hinder the unrestricted expression of anger and destruction when safety is compromised’ (p. 127).

Non-maleficence

‘A commitment to avoiding harm to the client. We don’t offer [CIs] because we are bored, fancy experimenting or can’t think what else to do. We work regularly through supervision’ (Andrew, 2019, p. 2).

CIs can be very powerful and often result in emotions and issues being accessed more quickly than in traditional talking therapy due to defences being bypassed. Protecting clients from harm involves counsellors being trained to be prepared and ready to ‘hold’ their clients safely (Rosen & Atkins, 2014; Edgar-Bailey & Kress, 2010). Rosen & Atkins (2014) stress the importance of working within ethical guidelines, such as the BACPs “Ethical Framework for the Counselling Profession,” (2018) to ensure the counsellor is working within their competence. Ensuring confidentiality extends to any artwork/creations produced by the client, and they engage in supervision to expand the counsellors understanding of these interventions. Westergaard (2013) recommends ‘underpinning knowledge, understanding and experience… before diving into’ (p. 103) using creativity in counselling practice. Whisenhunt & Kress (2013) agree; ‘adequate training and preparation are required [to] determine [which] intervention is appropriate for the client’s unique needs’ (p. 132). The research demonstrates; training in the use of CIs is essential to ensure ethical practice and thus avoid harm to the client (Ginicola, Smith & Tzaska, 2012; Bastemura et al., 2016; Kern & Perryman, 2016).

Westergaard (2013) highlights; CIs are not ‘widely explored in counselling training’ (p. 103). Instead, there is a reliance on counsellors engaging in continuous personal development (CPD) to expand their knowledge. Rouse, Armstrong & Mcleod (2015) add; there is a ‘tension within primary training between addressing and enhancing the potential value of creativity, and the need to establish a sound base of counselling theory and practice’ (p. 177), see also Sagan (2018).

Summary

Training and sound empirical research into how best to incorporate CIs into traditional talking therapy, combined with counsellors following a robust ethical framework (Andrew, 2019) appear to provide a means of providing a safe and effective service to clients. Allowing for a rich source of choice to meet the unique needs of each client provides a safer service and more inclusive offering.

Conclusion

Summary of Main Results

This review demonstrates; CIs are most helpful in supporting talking therapy when verbal expression is compromised, for example, when trauma has been experienced or with populations with neurodevelopmental conditions and adolescents. Due to the sheer choice of CIs available, they have also been found to be able to address a large variety of presenting issues so can offer choice to clients who have a preference to work creatively. The review demonstrates the importance of counsellors being more aware of how neuroscience knowledge can enhance their skills, especially when supporting clients processing traumatic events. The combination of talking therapy (verbal) and CIs (non-verbal) seemed to be useful for forming a connection between the left (verbal) and right (non-verbal) hemispheres of the brain, which brings cohesion to clients fragmented memories of traumatic events. The research demonstrated compatibility of CIs across most theoretical backgrounds, with a broad mix included in the literature, including CBT, psychodynamic, TA and PC. The author agrees with Rosen & Atkins (2014); creativity belongs to us all, and this is apparent within the literature. This review has highlighted the importance of quality training and for the counsellor to pay close attention to ethical considerations as essential to offering a safe and inclusive service which combines talking therapy and CIs.

Quality of Evidence

This review uncovered a variety of research into many different CIs being incorporated into talking therapy. Thirty-five per cent of the studies reviewed had sound empirically-based evidence. Aligning with the expectations of funding bodies ranging from ‘government agencies, health providers, employers to private individuals [to be able to access] concrete evidence for the service they are buying into’ (Vossler & Moller, 2015, p. 6). The rest of the reviews were conceptually based. Together they built a consistent message of how CIs enhanced talking therapy, additionally highlighting the importance of knowledge in keeping clients safe from harm.

Further Research

Further empirical research, detailing the outcomes of the effect of these interventions through the use of qualitative methods, leading to quality research-informed training and practice would make a vital contribution towards the counselling profession keeping clients safe from harm when accessing CIs (Ikonomopoulos et a;., 2017; Whisenhunt & Kress, 2013; Stevens & Spears, 2009).

Further research is warranted to address gaps found in the literature relating to specific populations which can be known to struggle with verbal expression. They therefore would benefit from CIs which are known to favour non-verbal expression, including children (Westergaard, 2013) and neurodivergent people, for example, autistic (Cromar, 2020).

Potential bias

The author of this review undertook the project on behalf of the Creative Counsellors Association. Although the author received no financial award, there was a risk of the influence on the review of funding bias (Booth, Sutton & Papaioannou, 2016). This risk was mitigated by conducting a full and exhaustive systematic approach when searching and reporting on the literature, highlighting both positive as well as negative findings.

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